Diagnosing unhealthy weight in children
Why is it important for health professionals to identify pre-school child weight issues?
With the prevalence of childhood obesity increasing in England (see module on unhealthy weight at pre-school age), society’s perception of what a “healthy weight” looks like has shifted. As such, it is becoming increasingly difficult for parents to identify whether their child is a healthy weight1. Understandably, if a child looks similar to their peers (who may also be overweight) parents are less likely to be concerned. It is not only parents who struggle with identifying unhealthy weight, evidence shows health professionals are also poor at recognising child weight issues from visual assessment alone2.
If parents are not aware of or concerned about their child’s weight issue, they are less likely to seek support and their child’s future health risk increases. This can be particularly so for younger children where excess weight might be perceived as “puppy fat”, with a view the child will grow out of it3. Health professionals therefore have an important role to play in identifying pre-school child weight issues and providing parents with objective information about their child’s weight status.
What is BMI?
BMI stands for Body Mass Index. BMI indicates how heavy a child is relative to their height, and is recommended by the World Health Organisation (WHO) as a better indicator of over- or under-weight than weight alone.
BMI is calculated as weight (kg) / height (m2). For example, if a 3-year old child weighs 15kg and is 96cm tall, their BMI would be calculated as follows:
15 / (0.96 X 0.96) = 16.3
In can be fiddly to work this out on a calculator, since you first need to calculate 0.96 X 0.96 then remember this figure to divide the weight by. But by changing the equation around, you can work out BMI easily on a calculator:
- Enter the weight (kg)
- Divide by height (remember this is in metres not centimetres)
- Divide the result by height
Try this calculation out for a child who weighs 15kg and is 96cm tall, you will see your result is the same as above (BMI 16.3).
|ACTIVITY: Try out the above calculation for your own weight and height. What is your BMI?|
For adults, WHO provides clear BMI classifications to determine if someone is underweight (<18.5), healthy weight (18.5-24.9), overweight (25-29.9) or obese (30+). Because children are still growing however, their BMI needs to be converted to a centile to determine if their weight is healthy for their age and sex. This is because BMI varies throughout childhood, and depending on whether children are male or female.
How do I work out if a child's BMI is healthy for their age and sex?
BMI centile charts can be used to work out if a child’s BMI is healthy for their age and sex. The attached charts show BMI centiles for boys and girls aged 2-20 years, based on a large database of UK children from 19904. You will notice the charts are curved rather than linear. This is because after their first year, children naturally lose body fatness up until the age of 5-6 years, when children are at their leanest (this time is called ‘adiposity rebound’). After 5-6 years, BMI starts to increase gradually through to adulthood. Therefore a healthy BMI range for a 4-year old girl (approximately 13.5-18.5) will be much lower than a healthy BMI range for a 16-year old girl (approximately 16.5-24.5).
The following BMI cut-offs are used to diagnose overweight:
> 91st centile = overweight
> 98th centile = obese
> 99.6thcentile = severely obese
The following BMI cut-offs are used to diagnose underweight:
< 2nd centile = this is unusual and may reflect undernutrition, but may also be due to the child having a small build
< 0.4th centile = likely to have additional issues that require medical or dietetic attention
|ACTIVITY: Look at the BMI centile charts for girls and boys aged 2-20 years and answer the following questions. Once you have completed these yourself you can check your answers here. These questions are focused on older children to help you understand how healthy BMI varies with age and sex.
To make it easier for health professionals, The Royal College of Paediatrics and Child Health (RCPCH) have recently produced growth charts that include BMI conversion charts (see figure 1 for an example of how to use these charts). These charts do not require professionals to calculate the actual BMI of the child, but an approximate BMI centile (accurate to quarter of a centile space) can be determined from the corresponding height and weight centiles.
Which chart should I use to assess the BMI of a child aged 2-4 years?
The charts in this section are provided by The Royal College of Paediatrics and Child Health (RCPCH) and can be freely downloaded for clinical use. If you wish to purchase hard copies or download high resolution images of the charts please e-mail firstname.lastname@example.org
a) For routine growth assessment
The recommended charts for plotting pre-school child growth are the UK WHO Growth Charts for 0-4 years:
For children 2 years and older, an alternative option is to use the UK Growth Chart for 2-18 years:
Both the 0-4 years and the 2-18 years charts include height and weight centiles, plus BMI conversion charts. The following factors will help you decide which is the most appropriate chart to use:
- Your professional role and standard protocols within your service. For example, if you are a health visitor your team may routinely use the 0-4 charts, whereas for GPs the 2-18 charts may be more relevant.
- Frequency and intended longevity of support. The 0-4 chart is more sensitive for frequent monitoring, whilst the 2-18 chart will last throughout childhood.
- Age at which you start monitoring the child. If monitoring from birth the 0-4 chart should be used. If however you start monitoring after 2 years or have previously monitored on the Neonatal and Infant Close Monitoring chart, the 2-18 years chart may be appropriate.
b) If severe over- or underweight is a concern or if you wish to plot BMI over time
Whilst the 0-4 and 2-18 years growth charts include a BMI conversion chart, these charts do not allow BMI to be accurately monitored over time. Therefore if a child is identified as having a weight issue their BMI can be monitored over time by using the BMI chart for children aged 2-20 years. This chart contains additional centile cut-offs for very high and very low BMIs to allow more sensitive monitoring of children with severe over- or underweight.
Note – If using the BMI chart to track change over time, it is important to continue to monitor height and weight on either the 0-4 or 2-18 years growth chart.
- Lundahl, A., Kidwell, K.M., & Nelson, T.D. (2014). Parental underestimates of child weight: a meta-analysis. Pediatrics, 133, 1-15. DOI: 10.1542/peds.2013-2690.
- Smith, S.M., Gately, P., & Rudolf, M. (2008). Can we recognise obesity clinically? Archives of Disease in Childhood, 93, 1065-1066.
- Turner, G.L., Owen, S. & Watson, P.M. (2016) Addressing childhood obesity at school entry: qualitative experiences of school health professionals. Journal of Child Health Care, 20 (3), 304-313. DOI: 10.1177/1367493515587061
- Cole, T.J., Freeman, J.V., & Preece, M.A. (1995). Body mass index reference curves for the UK, 1990. Archives of Disease in Childhood, 73,25-29.