Waist circumference values in Spanish children Genderrelated differences

European Journal of Clinical Nutrition (1999) 53, 429±433 ß 1999 Stockton Press. All rights reserved 0954±3007/99 $12.00 http://www.stockton-press.co.uk/ejcn

Waist circumference values in Spanish childrenÐGender related differences LA Moreno1*, J Fleta1, L Mur1, G RodrõÂguez2, A SarrõÂa2 and M Bueno2 1

E.U. Ciencias de la Salud, and 2 Departamento de PediatrõÂa, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain

Objective: To obtain reference values of the waist circumference in Spanish children, and to investigate their dependence on age and gender.

Design: Cross-sectional study.

Setting: General school-age population.

Subjects: A representative sample of the schools in Zaragoza, Spain, was drawn from seven schools. The population selected comprised 1728 children with ages ranging from 6.0±14.9 y. Of the original sample, 368 children (21.29%) were excluded because of chronic diseases or refusal. Finally, 1360 children and adolescents: 701 boys and 659 girls, were studied.

Interventions: Waist and hip circumferences were measured with an unelastic tape.

Results: Waist circumference tended to be higher in males than in females and this difference was signi®cant after 11.5 y. In general, hip circumference was higher in females than in males (statistically signi®cant differences at 7.5, 10.5, 12.5 and 13.5 y). In general, percentile values of waist circumference were higher in males than in females, especially after 12.5 y. Difference between males and females on percentile 95 at 14.5 y was 7.6 cm. Hip was greater than waist in both sexes, and the two curves run nearly parallel in males. In females, while hip enlarges continuously, waist shows the reverse tendency between 11.5 and 14.5 y.

Conclusions: Waist circumference showed higher values in boys than in girls, especially after 11.5 y, and waist values increase with age both in males and females. These ®ndings justify the use of age and gender speci®c reference standards.

Sponsorship: This work was supported by grant 216-02 from Universidad de Zaragoza, Zaragoza, Spain.

Descriptors: waist circumference; reference standards; body composition; child; hip circumference; anthropometry; nutritional surveys

Introduction The metabolic abnormalities associated with excess weight and adverse fat distribution, and secondary disorders, especially cardiovascular diseases and non-insulin-dependent diabetes mellitus have been increasingly recognized in the past two decades (Krotkiewski et al, 1983; Lapidus et al, 1984; Larsson et al, 1984; Ohlson et al, 1985). In children, it has been also shown a signi®cant relation between adipose tissue distribution and some metabolic complications of obesity (Legido et al, 1989; Caprio S et al, 1996; Gower et al, 1998; van Lenthe et al, 1998).

In adults, waist measurement re¯ects total and abdominal fat accumulation (Lean et al, 1995) and people with large waist circumference have excess burden of ill health (Lean et al, 1998). In children, some evidence supporting

*Correspondence: Dr LA Moreno Aznar, E.U. Ciencias de la Salud, Universidad de Zaragoza, Avda. Domingo Miral s/n, 50009 Zaragoza, Spain.

Contributors: L Moreno: study design, analysis, writing; J Fleta: study design, writing; L Mur: ®eld work, discussion and signi®cative comments; G RodrõÂguez: ®eld work, discussion and signi®cative comments; A SarrõÂa: conception and design, signi®cative comments; M Bueno: conception and design, signi®cative comments. All the authors read and revised the manuscript.

Received 1 October 1998; revised 6 December 1998; accepted 11 December 1998

this is now emerging. Flodmark et al (1994) have shown that the simple measurement of waist circumference correlates to a potentially atherogenic lipoprotein pro®le in obese children. Moreover, variations in distribution of fat are evident as early as 2 y in childhood (Kaplowitz et al, 1988), and children with centralized obesity have an increased risk of centralized obesity at adult age (Rolland-Cachera et al, 1990).

In children, body fat distribution may be described by a variety of anthropometric procedures (Moreno et al, 1998b). Percentiles of waist-to-hip circumference ratio and extremity-to-trunk skinfolds ratios for children and adolescents are now available in different populations (MartõÂnez et al, 1994; Moreno et al, 1997). The simplicity of measurement and its relation to both body weight and fat distribution would be major advantages for waist circumference over body mass index and waist-to-hip circumference ratio (Lean et al, 1995). Concerning waist circumference percentiles, there is only data on Italian children (Zannolli & Morgese, 1996). However, there are no data on the effect of age and gender in changes in waist measurement during childhood.

In Spain, we had no available reference values of waist circumference derived from our own population at school age. The aim of this study is to obtain such reference values, and to investigate their dependence on age and gender.

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430

Subjects and method Subjects The subjects of this study were all Caucasian children living in the central part of Spain (Provincia de Zaragoza).

A representative sample of the schools from this area was drawn (seven schools). A listing of schools provided by the Ministry of Education were used to construct the sampling frame. We selected 速ve urban schools (one of medium-high socioeconomic status; two of medium socioeconomic status; and two of medium-low socioeconomic status) and two rural schools (one of medium socioeconomic status; and one of medium-low socioeconomic status). This represents socioeconomic status of children in the Provincia de Zaragoza (Moreno et al, 1998a). The population selected comprised of 1728 children with ages ranging from 6.0賊 14.9 y. Parents or supervisors of the children were informed by letter of the nature and purpose of this study. After receiving their written consent, the children were considered for inclusion in the study. Of the original sample, 368 children (21.29%) were excluded because of chronic diseases or refusal. Finally, 1360 children and adolescents: 701 boys and 659 girls, were studied. Participation rates were similar in the seven schools. All the children were measured at school and the protocol was approved by the ethical committee of the University Hospital of Zaragoza, Spain.

Anthropometric method All the measurements were performed by a well trained anthropometrist. Beside height, weight, and several skinfolds (which were used as part of a broader investigation) (Fleta et al, 1997) waist and hip circumferences were measured in all individuals.

Waist and hip circumferences were measured with an unelastic tape. For these measurements, the subject was in a Table 1

standing position. To measure the waist circumference, the tape was applied horizontally midway between the lowest rib margin and the iliac crest about the level of the umbilicus. The hip circumference measurement was taken at the point yielding the maximum circumference over the buttocks, with the tape held in a horizontal plane.

Statistical analysis The waist and hip circumferences were described as mean and standard deviation, by sex and age groups. The 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles were also computed by sex and age groups. Comparisons between mean waist and hip circumferences, in both sexes, by age group, were carried out using the unpaired t-test.

Results Table 1 shows the descriptive statistics on weight and height. Tables 2 and 3 summarize the descriptive statistics on waist and hip circumferences by age and sex and the comparisons between both sexes on waist and hip circumferences. Waist circumference was always higher in males than in females, but differences were only signi速cant after 11.5 y. In general, hip circumference was higher in females than in males (statistically signi速cant differences at 7.5, 10.5, 12.5 and 13.5 y).

In Figures 1 and 2, we showed percentiles 5, 25, 50, 75, and 95 for waist circumference, in both sexes. Waist measurement increases with age in both sexes. In general, percentile values were higher in males than in females, especially after 12.5 y. Difference between males and females on percentile 95 at 14.5 y was 7.6 cm.

Hip circumference was greater than waist in both sexes, and the two curves run nearly parallel in males. In females,

Mean and standard deviations for weight and height by age and sex Weight (kg)

Age (y)

Males Mean (s.d.)

6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5

23.81 26.17 30.16 33.48 37.25 42.07 44.26 51.05 56.76

Height (cm) Females Mean (s.d.)

(4.09) (4.00) (5.64) (7.05) (7.47) (9.28) (7.60) (10.08) (10.27)

23.12 26.35 29.81 33.34 38.40 41.89 45.22 50.28 51.27

Males Mean (s.d.)

(3.69) (5.39) (6.50) (6.33) (8.37) (8.42) (5.98) (8.51) (7.91)

121.78 126.86 132.25 136.87 142.97 148.03 152.45 160.66 165.97

(5.49) (5.34) (5.75) (6.55) (5.88) (6.01) (7.68) (8.36) (7.52)

Females Mean (s.d.)

119.75 125.76 132.18 137.90 143.19 149.35 154.13 158.26 159.74

(4.92) (5.73) (6.48) (6.21) (6.22) (6.93) (5.99) (6.58) (6.72)

Table 2 Mean and standard deviations for waist circumference by age and sex Males

Females

Age (y)

Mean

s.d.

Mean

s.d.

P

6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5

55.95 57.27 60.57 63.16 65.41 67.97 68.00 70.62 72.75

4.88 4.29 6.21 6.88 7.31 8.17 6.46 7.65 6.78

54.87 56.59 59.04 61.39 64.05 64.90 65.32 67.29 66.81

6.26 5.35 6.41 6.47 8.18 6.98 4.86 6.44 5.02

0.198 0.350 0.138 0.068 0.257 0.021 0.012 0.010 0.000

Waist circumference values in Spanish children LA Moreno et al

Table 3

431

Mean and standard deviations for hip circumference by age and sex Males

Females

Age (y)

Mean

s.d.

Mean

s.d.

P*

6.5 7.5 8.5 9.5 10.5 11.5 12.5 13.5 14.5

63.98 66.57 69.92 72.67 75.82 79.54 81.18 84.59 86.68

5.69 4.88 5.79 6.94 6.79 8.13 6.46 7.35 6.71

64.24 68.35 70.90 74.16 78.48 81.27 84.51 87.87 88.49

5.52 6.64 6.87 6.40 7.62 7.69 5.58 7.18 6.03

0.752 0.043 0.340 0.124 0.017 0.209 0.003 0.012 0.157

Figure 1 Waist circumference (5, 25, 50, 75 and 95 percentiles) in males.

Figure 2 Waist circumference (5, 25, 50, 75 and 95 percentiles) in females.

Waist circumference values in Spanish children LA Moreno et al

432

Figure 3 Waist and hip circumferences (median) in both males and females.

while hip enlarges continuously, waist shows the reverse tendency between 11.5 and 14.5 y (Figure 3).

Discussion Obviously, the waist-to-hip ratio is the anthropometric variable that has been the most widely assessed in epidemiologic studies on body fat distribution. However, in adults, waist girth alone seems to be a good indicator of both the degree of obesity and the accumulation of visceral adipose tissue, better than the waist-to-hip ratio (Pouliot et al, 1994). The relations between anthropometric variables to visceral adipose tissue accumulation are age-speci®c.

However, in adults, waist girth is likely to be a more convenient anthropometric correlate of visceral adipose tissue than the waist-to-hip ratio because threshold values of waist girth corresponding to critical amounts of visceral adipose tissue do not appear to be in¯uenced by sex or by the degree of obesity (Lemieux et al, 1996). In adult women, waist circumference was also signi®cantly better than waist-to-hip ratio at screening for regional fat distribution, accurately classifying 83% of subjects (Taylor et al, 1998).

In male and female 11 y old children, waist circumference and some skinfolds alone or skinfolds ratios were the best indicators of intraabdominal fat, as measured by magnetic resonance imaging (Fox et al, 1993). In pubertal girls, circumferences at the trunk was indeed superior to waist-to-hip ratio as markers of intraabdominal fat measured by magnetic resonance imaging (de Ridder et al, 1992). In obese children, waist circumference showed signi®cant correlations with high density lipoprotein cholesterol, triglycerides and apolipoprotein B, but regression coef®cients for waist circumference were as strong as those for waist-to-hip ratio (Flodmark et al, 1994).

Therefore, current knowledge seems to indicate that, both in adults and in children, waist circumference is related with intraabdominal fat deposition and some metabolic complications of obesity. This consideration justi®es the interest of studying changes in waist circumference

during childhood. Values observed in our sample are very similar to those published by MartõÂnez et al (1994); however, at all ages, values showed by Zannolli & Morgese (1996) were very much higher than our results (for example, at 13.5 y, differences were 12.7 cm in males and 19.1 cm in females). We do not ®nd any explanation for these differences, but this ®nding emphasizes the need for using local reference standards. We have observed that waist circumference was higher in boys than in girls, especially after 11.5 y, and that waist measurement increases with age in both sexes. These ®ndings seem to justify, in children, the use of age and gender speci®c standards for waist circumference.

Concerning hip circumference, values observed by us at different ages were also similar to those obtained in Cuban scholars (MartõÂnez et al, 1994), and values were higher in females than in males, especially after 9.5 y, as was also observed in Cuban children (MartõÂnez et al, 1994).

For health promotion, action levels have been proposed in adults, on the basis of anthropometric statistics (Lean et al, 1995), and to provide a simple and practical way to identify groups with increased risk to health (Lean et al, 1998). Slight waist reductions (5±10 cm) can result in improvements in several cardiovascular risk factors (Han et al, 1997). Action levels for waist circumference could be the basis on which health promotion might raise awareness or urge action on weight reduction. In adults, the lower action level of waist circumference (94 cm for men and 80 cm for women) represents a threshold above which health risks are increased, particularly for young men.

The upper action level (102 cm for men and 88 cm for women) corresponds with the point at which health risks are such that medical consultation and weight loss should be urged (Lean et al, 1995). In a similar way, and taking into account that waist circumference reference values depend on age and gender, we propose to use 75 and 95 percentiles, as cutoff values for screening of moderate and severe waist values. However, more studies are needed to adjust these values, taking into consideration the relations between waist circumference, total and intraabdom-

Waist circumference values in Spanish children LA Moreno et al

inal fat measured with reference methods, and health outcomes (SarrõÂa et al, 1998; Dwyer & Blizzard, 1996).

Conclusion In this study the waist circumference showed higher values in boys than in girls, especially after 11.5 y, and waist values increase with age both in males and females. These ®ndings justify the use of age and gender speci®c reference standards. In terms of public health and clinical practice, the aims should be to prevent progression into the highest waist-circumference categories.

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