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. 2015 Jul 15;10(7):e0132891. doi: 10.1371/journal.pone.0132891

Percentile Curves for Anthropometric Measures for Canadian Children and Youth

Stefan Kuhle 1,*, Bryan Maguire 1,2, Nicole Ata 3, David Hamilton 2
Editor: Pedro Tauler4
PMCID: PMC4503699  PMID: 26176769

Abstract

Body mass index (BMI) is commonly used to assess a child's weight status but it does not provide information about the distribution of body fat. Since the disease risks associated with obesity are related to the amount and distribution of body fat, measures that assess visceral or subcutaneous fat, such as waist circumference (WC), waist-to-height ratio (WHtR), or skinfolds thickness may be more suitable. The objective of this study was to develop percentile curves for BMI, WC, WHtR, and sum of 5 skinfolds (SF5) in a representative sample of Canadian children and youth. The analysis used data from 4115 children and adolescents between 6 and 19 years of age that participated in the Canadian Health Measures Survey Cycles 1 (2007/2009) and 2 (2009/2011). BMI, WC, WHtR, and SF5 were measured using standardized procedures. Age- and sex-specific centiles were calculated using the LMS method and the percentiles that intersect the adult cutpoints for BMI, WC, and WHtR at age 18 years were determined. Percentile curves for all measures showed an upward shift compared to curves from the pre-obesity epidemic era. The adult cutoffs for overweight and obesity corresponded to the 72nd and 91st percentile, respectively, for both sexes. The current study has presented for the first time percentile curves for BMI, WC, WHtR, and SF5 in a representative sample of Canadian children and youth. The percentile curves presented are meant to be descriptive rather than prescriptive as associations with cardiovascular disease markers or outcomes were not assessed.

Introduction

Childhood obesity is associated with adverse health, psychosocial, and economic outcomes in childhood and adulthood [1]. Body mass index (BMI) is the most commonly used method to assess a child's weight status. The drawbacks of BMI are that it cannot differentiate between lean and fat mass and does not provide information about the distribution of body fat [2–4]. Since the cardiovascular disease (CVD) risks associated with obesity are related to the amount and distribution of body fat [5–8], measures that assess visceral or subcutaneous fat may provide a better risk assessment than the BMI. Waist circumference (WC) and waist-to-height ratio (WHtR) have both been shown to be associated with CVD risk in children and adults [6,9–11]; skinfolds thickness (SF) can potentially better identify children and adults with excess total body fatness or adverse CVD risk factor levels than BMI [12–14]. As body composition in childhood is dependent on age, sex, and ethnicity, no single universal cut-off point exists for either of these measures in children and youth. Percentile curves have been developed for WC, WHtR, and SF in different populations [15–18] but, with the exception of waist circumference in youth aged 11 to 18 years [19], there are no Canadian reference data available. Therefore, the objective of the present paper was to develop percentile curves for anthropometric measures in a representative sample of Canadian children and youth using the LMS method [20].

Materials and Methods

The current study used data from the Canadian Health Measures Survey (CHMS) Cycles 1 and 2. The CMHS is a representative, cross-sectional survey assessing indicators of health and wellness in Canadians between 3 and 79 years [21,22]. The survey consisted of a household interview to obtain sociodemographic and health information, and a visit to mobile examination centre to perform a number of physical measurements and tests. The sampling frame of the Canadian Labour Force Survey was used to identify the collection sites for the mobile examination centres. Within each collection site, households were selected using the 2006 Census as the sampling frame. Interviews and examinations for the CHMS Cycle 1 and 2 were performed between 2007 and 2009, and 2009 and 2011, respectively. The overall response rate in the two cycles was 51.7% and 55.7%, respectively. Data from the two cycles was combined as per Statistics Canada guidelines [23]. A total of 11,999 persons participated in physical examination part of the survey. The present analysis uses data from 4115 children and adolescents (2089 males and 2026 females) between 6 and 19 years of age.

Anthropometric measures

All anthropometric measurements were performed by trained health professionals at the mobile examination centres. Body mass index was calculated from measured weight and height using the formula weight/height2 [kg/m2]. Weight was measured using a calibrated digital scale (Mettler Toledo, Mississauga, ON, Canada) to the nearest 0.1 kg. Standing height was measured using a fixed stadiometer with a vertical backboard and a moveable headboard to the nearest 0.01 cm. Waist circumference measurement was based on the Canadian Physical Activity, Fitness, and Lifestyle Approach (CPAFLA) protocol [24] using a 150 cm or a 200 cm Gulick tape measure. The WC was measured at the mid-point between the bottom of the rib cage and the top of the iliac crest at the end of a normal expiration to the nearest 0.1 cm. Waist to Height Ratio was calculated as waist circumference over height. Sum of 5 skinfolds (SF5) was determined using the five site method of the CPAFLA protocol [24] with a Harpenden skinfold caliper and a 150 cm Gulick tape measure to the nearest 0.2 mm. Each SF was measured twice. Triceps SF was measured on the midline of the back of the arm at the mid-point level between the acromium process and the tip of the olecranon process. Biceps SF was measured over the biceps at the same level as the midpoint for the triceps. Subscapular SF was measured below the inferior angle of the scapula at an angle of 45 degrees to the spine. Iliac crest SF was measured in the mid-axillary line above the crest of the ilium. Medial calf SF was measured at the medial side of the calf at the point of the largest circumference. Body mass index and WC were not measured in pregnant women, and SF measurements were not done on individuals with a BMI ≥ 30 kg/m2. Height was based on self-report for participants who were unable to stand unassisted.

Statistical analysis

The data were stratified by sex and summarized using the LMS method by Cole and Green [20]. This method assumes that the data are normalized after the Box Cox transformation

z=(y/μ)λ−1λσ  λ≠0 (1)
z=loge(y/μ)σ  λ=0 (2)

The age-specific distribution expresses the mean, coefficient of variation, and skewness as parameters that change smoothly as a function of age by modeling them as cubic splines. These functions can be plotted as smooth curves over age and are referred to as the M (mean μ), S (variance σ), and L (skewness λ) curves. Centiles are computed by using the values of the three parameters curves for a corresponding age with the formula

C100α=M(1+L×S×zα)1/L (3)

where zα is the upper α quantile for the truncated standard normal distribution.

The LMS method allows us to assess the likelihood of an individual observation with the formula

z=(y/M)L−1L×S (4)

The 3rd, 10th, 25th, 50th, 75th, 90th, and 97th centile curves were computed for BMI, WC, SF5, and WHtR. To avoid unusual behaviours of the spline functions near the end of the age range, data from respondents up to age 30 years was used to fit the models. This modification produced smoother curves that more accurately reflect the population characteristics. In addition, the z-score and percentile that intersects the adult cutpoints for BMI (18.5, 25, and 30 kg/m2) [25,26], WC (102 cm for males and 88 cm for females) [27], and WHtR (0.5 for both sexes) [28] at age 18 years were determined. Residual quantile plots ("worm plots") [29] were used to assess the goodness of fit of each component of the LMS models.

All calculations were performed using the sampling weights provided by Statistics Canada [23] to account for design effect and non-response bias. The CHMS uses a multistage sampling design with two sampling frames to select its sample. The probability of an individual to be selected for the survey is determined as the product of the probability of selection at each stage. To correct for non-response the weight of non-respondent households and individuals is redistributed to respondents within homogeneous response groups based on characteristics that are available for both respondents and non-respondents as determined from the Census of Canada (such as dwelling type or household income). A detailed description of the weighting procedure can be found elsewhere [22].

The statistical software package R [30] with the gamlss package [31] was used to perform the statistical analyses.

Ethics statement

All processes used for cycles 1 and 2 of the CHMS were reviewed and approved by the Health Canada Research Ethics Board to ensure that internationally recognized ethical standards for human research were met and maintained. Written informed consent was obtained from all participants; parents or guardians gave consent on behalf of children aged 6 to 13 years, while the child provided his or her assent to participate [21,22]. The current project was approved by the IWK Health Centre Research Ethics Board, Halifax, NS, Canada (File # 1014413).

Results

Descriptive statistics for BMI, WC, SF5, and WHtR by age and sex are shown in Table 1. The prevalence of overweight and obesity in the sample based on the IOTF (International Obesity Task Force) growth reference [32] was 17.0 and 9.6%, respectively. Characteristics of the sample are shown in S1 Table.

Table 1. Sample size, mean, and standard deviation for body mass index [kg/m2], waist circumference [cm], waist-to-height ratio, and sum of 5 skinfolds [mm] for Canadian children and youth aged 6 to 19 years.

BMI WC WHtR SF5
Sex Age [years] n Mean SD Mean SD Mean SD Mean SD
Female 6 155 15.9 2.0 53.1 4.8 0.44 0.04 39.6 13.9
7 140 16.3 2.4 54.6 6.6 0.44 0.05 44.1 19.6
8 165 17.4 3.3 59.0 8.9 0.45 0.06 51.9 23.8
9 177 18.1 3.3 61.1 9.0 0.45 0.06 60.0 29.7
10 194 18.1 3.0 62.1 8.0 0.43 0.05 57.0 22.8
11 216 19.4 3.6 65.7 10.4 0.44 0.06 60.4 25.3
12 131 20.3 3.8 68.9 10.1 0.44 0.06 61.5 24.3
13 132 20.5 3.5 69.8 9.0 0.43 0.05 68.9 30.5
14 122 21.9 3.7 71.9 8.7 0.45 0.05 74.9 28
15 129 23.7 5.5 77.0 14.1 0.47 0.08 77.1 31.6
16 121 22.9 4.5 73.6 9.8 0.45 0.06 72.9 21.1
17 125 23.3 4.7 75.8 13.0 0.46 0.08 77.2 26.1
18 118 23.4 4.7 76.2 11.8 0.46 0.07 76.1 24.8
19 101 23.4 4.2 75.9 9.3 0.46 0.06 78.5 23.4
Male 6 152 16.1 1.7 53.8 4.9 0.45 0.04 37.5 17.4
7 165 17.9 3.7 59.3 10.1 0.47 0.07 47.6 28.7
8 168 17.6 2.8 60.3 7.5 0.45 0.05 47.1 24.7
9 166 18.7 3.5 63.4 9.9 0.46 0.06 52.2 28.1
10 208 19.3 4.2 66.2 10.6 0.46 0.06 60.5 32.6
11 193 19.1 3.7 66.1 9.7 0.45 0.06 53.2 29.9
12 155 20.1 5.0 69.4 13.6 0.45 0.07 56.1 33.8
13 145 20.5 4.0 71.9 11.3 0.44 0.06 55.0 30.8
14 144 21.6 5.8 74.6 13.8 0.44 0.08 47.2 22.3
15 130 22.4 4.8 76.1 12.6 0.44 0.07 44.7 21.9
16 147 23.2 5.5 79.0 14.1 0.45 0.08 45.3 22.0
17 123 23.6 4.7 80.4 11.6 0.45 0.07 46.5 19.0
18 101 24.7 4.7 83.3 12.2 0.47 0.07 50.2 21.0
19 92 25.1 5.2 83.7 12.1 0.47 0.07 53.4 20.5
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Abbreviations: BMI Body Mass Index; WC Waist circumference; WHtR Waist-to-height ratio; SF5 Sum of 5 skinfolds; SD Standard deviation.

Body mass index and WC increased throughout childhood and percentile cutpoints were consistently higher in males compared to females, albeit the differences were small (Tables 2 and 3, Figs 1 and 2). The adult cutoffs for overweight and obesity approximately corresponded to the 72nd and 91st percentile, respectively, for both sexes. The 75th percentile and lower for WHtR in girls showed a slight decline until 12 years, after which it increased, while the 90th and 97th percentile increased throughout childhood and adolescence; a similar pattern was observed for boys (Table 4 and Fig 3). The adult WHtR cutoff of 0.5 corresponded to the 81st and 78th percentile in males and females, respectively. Sum of 5 skinfolds increased until puberty in girls and plateaued afterwards. Among boys, the 50th percentile for SF5 increased slightly until puberty and remained fairly constant afterwards, while percentile levels above the median exhibited a sharp increase with a peak around 11 years of age and subsequent drop (Table 5 and Fig 4). All three components of the models for females showed extremely good fit for every measure and a good fit for males with the exception of SF5, where the worm plots showed a moderate fit due to some kurtosis that the model could not account for.

Table 2. L, M, and S values, and percentiles of body mass index [kg/m2] by age and sex for Canadian children and youth aged 6 to 19 years.

Sex Age [years] L M S 3rd 10th 25th 50th 75th 90th 97th
Female 6 -2.2473 15.5148 0.1134 13.03 13.68 14.46 15.51 16.87 18.50 20.74
6.5 -2.1695 15.7339 0.1186 13.12 13.80 14.62 15.73 17.18 18.92 21.34
7 -2.0918 15.9561 0.1240 13.20 13.91 14.77 15.96 17.49 19.36 21.97
7.5 -2.0148 16.1864 0.1296 13.28 14.03 14.93 16.19 17.82 19.81 22.63
8 -1.9397 16.4293 0.1351 13.36 14.15 15.11 16.43 18.16 20.29 23.31
8.5 -1.8678 16.6871 0.1405 13.46 14.29 15.29 16.69 18.52 20.78 24.01
9 -1.8015 16.9617 0.1455 13.58 14.44 15.50 16.96 18.90 21.29 24.72
9.5 -1.7419 17.2531 0.1500 13.72 14.62 15.72 17.25 19.28 21.80 25.43
10 -1.6907 17.5612 0.1539 13.87 14.81 15.96 17.56 19.68 22.32 26.13
10.5 -1.6492 17.8863 0.1572 14.06 15.03 16.22 17.89 20.10 22.85 26.82
11 -1.6173 18.2266 0.1599 14.26 15.27 16.50 18.23 20.52 23.38 27.51
11.5 -1.5959 18.5779 0.1620 14.49 15.53 16.80 18.58 20.95 23.91 28.20
12 -1.5861 18.9357 0.1635 14.74 15.80 17.11 18.94 21.38 24.43 28.86
12.5 -1.5876 19.2958 0.1645 15.00 16.09 17.42 19.30 21.80 24.94 29.52
13 -1.6007 19.6537 0.1649 15.28 16.38 17.74 19.65 22.21 25.44 30.16
13.5 -1.6265 20.0053 0.1650 15.56 16.68 18.06 20.00 22.62 25.92 30.81
14 -1.6649 20.3473 0.1650 15.84 16.98 18.37 20.35 23.01 26.40 31.47
14.5 -1.7134 20.6753 0.1648 16.12 17.26 18.67 20.67 23.39 26.87 32.14
15 -1.7672 20.9855 0.1648 16.39 17.54 18.96 20.98 23.75 27.32 32.82
15.5 -1.8208 21.2746 0.1648 16.64 17.79 19.23 21.27 24.08 27.76 33.50
16 -1.8696 21.5409 0.1650 16.86 18.02 19.47 21.54 24.40 28.17 34.15
16.5 -1.9106 21.7842 0.1654 17.06 18.23 19.69 21.78 24.69 28.56 34.78
17 -1.9430 22.0064 0.1661 17.24 18.41 19.88 22.00 24.96 28.92 35.39
17.5 -1.9666 22.2105 0.1671 17.39 18.57 20.06 22.21 25.21 29.28 35.98
18 -1.9809 22.3996 0.1685 17.52 18.71 20.21 22.39 25.46 29.63 36.57
18.5 -1.9861 22.5752 0.1701 17.62 18.83 20.35 22.57 25.69 29.97 37.15
19 -1.9830 22.7388 0.1722 17.71 18.93 20.48 22.73 25.92 30.31 37.75
Male 6 -3.0597 15.5312 0.1150 13.16 13.75 14.48 15.53 16.96 18.85 21.90
6.5 -2.9522 15.8204 0.1198 13.31 13.94 14.71 15.81 17.33 19.36 22.66
7 -2.8446 16.1117 0.1248 13.46 14.12 14.94 16.11 17.72 19.89 23.44
7.5 -2.7365 16.4056 0.1299 13.61 14.30 15.16 16.40 18.12 20.43 24.24
8 -2.6273 16.7017 0.1351 13.75 14.48 15.39 16.69 18.52 20.98 25.06
8.5 -2.5167 16.9981 0.1403 13.88 14.65 15.61 16.99 18.92 21.53 25.88
9 -2.4055 17.2928 0.1455 14.01 14.82 15.83 17.29 19.32 22.08 26.69
9.5 -2.2935 17.5845 0.1506 14.14 14.99 16.05 17.58 19.72 22.63 27.47
10 -2.1809 17.8738 0.1555 14.25 15.15 16.26 17.87 20.12 23.16 28.21
10.5 -2.0696 18.1628 0.1600 14.37 15.31 16.47 18.16 20.51 23.68 28.88
11 -1.9615 18.4536 0.1640 14.50 15.47 16.69 18.45 20.90 24.17 29.48
11.5 -1.8592 18.7487 0.1675 14.63 15.65 16.92 18.75 21.28 24.63 30.00
12 -1.7656 19.0503 0.1702 14.78 15.84 17.16 19.05 21.65 25.08 30.46
12.5 -1.6836 19.3586 0.1723 14.95 16.05 17.41 19.36 22.03 25.50 30.88
13 -1.6157 19.6726 0.1737 15.13 16.27 17.67 19.67 22.40 25.91 31.27
13.5 -1.5631 19.9897 0.1745 15.34 16.50 17.94 19.99 22.76 26.31 31.65
14 -1.5283 20.3079 0.1747 15.56 16.75 18.22 20.31 23.12 26.71 32.04
14.5 -1.5133 20.6252 0.1745 15.80 17.01 18.51 20.62 23.48 27.10 32.45
15 -1.5157 20.9386 0.1738 16.06 17.28 18.80 20.94 23.82 27.48 32.87
15.5 -1.5315 21.2443 0.1729 16.32 17.56 19.08 21.24 24.15 27.84 33.30
16 -1.5546 21.5386 0.1717 16.58 17.83 19.36 21.54 24.47 28.19 33.71
16.5 -1.5799 21.8184 0.1703 16.84 18.09 19.63 21.82 24.77 28.51 34.08
17 -1.6043 22.0812 0.1689 17.08 18.34 19.89 22.08 25.04 28.80 34.41
17.5 -1.6267 22.3250 0.1674 17.31 18.57 20.13 22.32 25.29 29.06 34.68
18 -1.6444 22.5488 0.1659 17.53 18.79 20.35 22.55 25.52 29.29 34.91
18.5 -1.6535 22.7515 0.1646 17.72 18.98 20.55 22.75 25.72 29.49 35.09
19 -1.6519 22.9341 0.1636 17.88 19.16 20.72 22.93 25.90 29.66 35.23
19.5 -1.6385 23.0988 0.1628 18.02 19.30 20.88 23.10 26.07 29.82 35.33
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Table 3. L, M, and S values, and percentiles of waist circumference [cm] by age and sex for Canadian children and youth aged 6 to 19 years.

Sex Age [years] L M S 3rd 10th 25th 50th 75th 90th 97th
Female 6 -3.3915 51.6141 0.0838 45.5 47.1 49.0 51.6 55.0 59.0 64.6
6.5 -3.3430 52.6017 0.0882 46.1 47.8 49.8 52.6 56.2 60.6 66.9
7 -3.2914 53.5964 0.0928 46.7 48.5 50.6 53.6 57.5 62.3 69.4
7.5 -3.2316 54.6083 0.0975 47.3 49.2 51.4 54.6 58.8 64.0 71.9
8 -3.1579 55.6442 0.1022 47.9 49.9 52.3 55.6 60.1 65.8 74.5
8.5 -3.0675 56.7060 0.1067 48.5 50.6 53.1 56.7 61.5 67.6 77.1
9 -2.9629 57.8014 0.1108 49.1 51.3 54.0 57.8 62.9 69.4 79.6
9.5 -2.8507 58.9362 0.1142 49.8 52.2 55.0 58.9 64.3 71.1 81.8
10 -2.7428 60.1069 0.1168 50.6 53.0 56.0 60.1 65.7 72.8 83.8
10.5 -2.6492 61.3069 0.1187 51.4 54.0 57.0 61.3 67.1 74.4 85.7
11 -2.5761 62.5198 0.1199 52.3 54.9 58.1 62.5 68.4 76.0 87.4
11.5 -2.5319 63.7243 0.1206 53.3 55.9 59.2 63.7 69.8 77.5 89.1
12 -2.5216 64.9012 0.1207 54.2 57.0 60.3 64.9 71.1 78.9 90.7
12.5 -2.5425 66.0347 0.1202 55.2 58.0 61.3 66.0 72.3 80.2 92.2
13 -2.5913 67.1044 0.1194 56.2 59.0 62.4 67.1 73.4 81.5 93.7
13.5 -2.6659 68.0931 0.1186 57.2 59.9 63.3 68.1 74.5 82.7 95.2
14 -2.7635 68.9946 0.1179 58.0 60.8 64.2 69.0 75.4 83.8 96.8
14.5 -2.8772 69.8066 0.1175 58.8 61.6 65.0 69.8 76.3 84.9 98.5
15 -2.9977 70.5274 0.1175 59.5 62.3 65.7 70.5 77.1 86.0 100.3
15.5 -3.1135 71.1599 0.1179 60.1 62.9 66.3 71.1 77.9 87.0 102.0
16 -3.2154 71.7150 0.1184 60.6 63.4 66.8 71.7 78.5 87.9 103.6
16.5 -3.2974 72.2120 0.1192 61.0 63.8 67.2 72.2 79.1 88.7 105.2
17 -3.3559 72.6752 0.1200 61.4 64.2 67.6 72.6 79.7 89.5 106.5
17.5 -3.3867 73.1266 0.1210 61.8 64.5 68.0 73.0 80.2 90.3 107.8
18 -3.3842 73.5772 0.1221 62.1 64.9 68.4 73.5 80.8 91.0 109.0
18.5 -3.3482 74.0258 0.1234 62.3 65.2 68.7 73.9 81.4 91.8 110.1
19 -3.2813 74.4653 0.1251 62.5 65.4 69.1 74.4 82.0 92.6 111.3
Male 6 -3.7503 51.7546 0.0923 45.3 46.9 48.9 51.7 55.5 60.4 68.0
6.5 -3.6725 53.0313 0.0959 46.2 47.9 50.0 53.0 57.1 62.3 70.7
7 -3.5935 54.3204 0.0996 47.1 48.9 51.1 54.3 58.6 64.3 73.4
7.5 -3.5104 55.6184 0.1035 47.9 49.9 52.2 55.6 60.2 66.3 76.2
8 -3.4188 56.9091 0.1075 48.8 50.8 53.3 56.9 61.8 68.3 79.0
8.5 -3.3145 58.1754 0.1116 49.6 51.7 54.4 58.1 63.4 70.4 81.9
9 -3.1969 59.4078 0.1158 50.4 52.6 55.4 59.4 64.9 72.4 84.7
9.5 -3.0695 60.6104 0.1199 51.1 53.4 56.4 60.6 66.4 74.3 87.5
10 -2.9409 61.7915 0.1237 51.8 54.2 57.3 61.8 67.9 76.2 90.0
10.5 -2.8230 62.9574 0.1268 52.5 55.1 58.3 62.9 69.4 78.0 92.3
11 -2.7237 64.1126 0.1292 53.2 55.9 59.3 64.1 70.8 79.7 94.4
11.5 -2.6472 65.2622 0.1308 54.0 56.8 60.3 65.2 72.1 81.3 96.2
12 -2.5944 66.4153 0.1316 54.9 57.7 61.3 66.4 73.4 82.7 97.9
12.5 -2.5650 67.5713 0.1318 55.8 58.7 62.4 67.6 74.7 84.2 99.4
13 -2.5593 68.7228 0.1314 56.7 59.7 63.4 68.7 75.9 85.5 100.9
13.5 -2.5777 69.8591 0.1306 57.8 60.8 64.5 69.8 77.2 86.8 102.3
14 -2.6227 70.9692 0.1294 58.8 61.8 65.6 71.0 78.3 88.1 103.7
14.5 -2.6936 72.0456 0.1279 59.8 62.9 66.7 72.0 79.4 89.3 105.2
15 -2.7826 73.0804 0.1264 60.9 63.9 67.7 73.1 80.5 90.4 106.6
15.5 -2.8750 74.0609 0.1249 61.9 64.9 68.7 74.0 81.5 91.5 108.0
16 -2.9565 74.9781 0.1236 62.8 65.8 69.6 74.9 82.4 92.5 109.3
16.5 -3.0201 75.8236 0.1225 63.7 66.7 70.4 75.8 83.3 93.4 110.4
17 -3.0677 76.5926 0.1215 64.4 67.4 71.2 76.6 84.1 94.2 111.3
17.5 -3.1045 77.2835 0.1205 65.1 68.1 71.9 77.2 84.8 95.0 112.1
18 -3.1311 77.8966 0.1198 65.7 68.7 72.5 77.9 85.4 95.6 112.7
18.5 -3.1447 78.4340 0.1192 66.2 69.2 73.0 78.4 85.9 96.2 113.3
19 -3.1459 78.9050 0.1189 66.6 69.7 73.4 78.9 86.4 96.7 113.8
19.5 -3.1359 79.3258 0.1188 67.0 70.0 73.8 79.3 86.9 97.2 114.3
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Fig 1. Percentile curves for body mass index for male and female Canadian children and youth aged 6 to 19 years.

Fig 1

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Fig 2. Percentile curves for waist circumference for male and female Canadian children and youth aged 6 to 19 years.

Fig 2

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Table 4. L, M, and S values, and percentiles of waist-to-height ratio by age and sex for Canadian children and youth aged 6 to 19 years.

Sex Age [years] L M S 3rd 10th 25th 50th 75th 90th 97th
Female 6 -3.1268 0.4445 0.0793 0.39 0.41 0.42 0.44 0.47 0.50 0.54
6.5 -3.0890 0.4423 0.0831 0.39 0.40 0.42 0.44 0.47 0.50 0.55
7 -3.0498 0.4402 0.0871 0.39 0.40 0.42 0.44 0.47 0.50 0.55
7.5 -3.0066 0.4382 0.0912 0.38 0.40 0.41 0.44 0.47 0.51 0.56
8 -2.9570 0.4363 0.0954 0.38 0.39 0.41 0.44 0.47 0.51 0.56
8.5 -2.9005 0.4345 0.0994 0.37 0.39 0.41 0.43 0.47 0.51 0.57
9 -2.8404 0.4328 0.1030 0.37 0.39 0.41 0.43 0.47 0.51 0.57
9.5 -2.7793 0.4313 0.1062 0.37 0.38 0.40 0.43 0.47 0.51 0.58
10 -2.7248 0.4299 0.1087 0.37 0.38 0.40 0.43 0.47 0.51 0.58
10.5 -2.6817 0.4288 0.1108 0.36 0.38 0.40 0.43 0.47 0.51 0.58
11 -2.6476 0.4280 0.1125 0.36 0.38 0.40 0.43 0.47 0.51 0.58
11.5 -2.6226 0.4276 0.1137 0.36 0.38 0.40 0.43 0.47 0.51 0.58
12 -2.6075 0.4276 0.1144 0.36 0.38 0.40 0.43 0.47 0.51 0.59
12.5 -2.6030 0.4280 0.1147 0.36 0.38 0.40 0.43 0.47 0.51 0.59
13 -2.6132 0.4288 0.1148 0.36 0.38 0.40 0.43 0.47 0.52 0.59
13.5 -2.6397 0.4300 0.1148 0.36 0.38 0.40 0.43 0.47 0.52 0.59
14 -2.6814 0.4314 0.1149 0.36 0.38 0.40 0.43 0.47 0.52 0.59
14.5 -2.7347 0.4331 0.1153 0.37 0.38 0.40 0.43 0.47 0.52 0.60
15 -2.7938 0.4349 0.1158 0.37 0.38 0.41 0.43 0.47 0.53 0.61
15.5 -2.8502 0.4369 0.1165 0.37 0.39 0.41 0.44 0.48 0.53 0.61
16 -2.8972 0.4389 0.1174 0.37 0.39 0.41 0.44 0.48 0.53 0.62
16.5 -2.9315 0.4410 0.1184 0.37 0.39 0.41 0.44 0.48 0.54 0.63
17 -2.9518 0.4432 0.1194 0.37 0.39 0.41 0.44 0.49 0.54 0.63
17.5 -2.9586 0.4455 0.1205 0.37 0.39 0.41 0.45 0.49 0.55 0.64
18 -2.9522 0.4481 0.1217 0.38 0.39 0.42 0.45 0.49 0.55 0.65
18.5 -2.9344 0.4507 0.1229 0.38 0.40 0.42 0.45 0.50 0.56 0.65
19 -2.9065 0.4533 0.1245 0.38 0.40 0.42 0.45 0.50 0.56 0.66
Male 6 -2.5598 0.4441 0.0876 0.39 0.40 0.42 0.44 0.47 0.51 0.55
6.5 -2.7150 0.4434 0.0901 0.39 0.40 0.42 0.44 0.47 0.51 0.56
7 -2.8691 0.4428 0.0926 0.38 0.40 0.42 0.44 0.47 0.51 0.56
7.5 -3.0197 0.4422 0.0951 0.38 0.40 0.42 0.44 0.47 0.51 0.57
8 -3.1652 0.4416 0.0977 0.38 0.40 0.42 0.44 0.48 0.52 0.58
8.5 -3.3039 0.4409 0.1003 0.38 0.40 0.41 0.44 0.48 0.52 0.59
9 -3.4350 0.4402 0.1029 0.38 0.39 0.41 0.44 0.48 0.52 0.60
9.5 -3.5583 0.4393 0.1054 0.38 0.39 0.41 0.44 0.48 0.53 0.61
10 -3.6735 0.4384 0.1079 0.38 0.39 0.41 0.44 0.48 0.53 0.62
10.5 -3.7799 0.4373 0.1102 0.38 0.39 0.41 0.44 0.48 0.53 0.62
11 -3.8765 0.4362 0.1123 0.37 0.39 0.41 0.44 0.48 0.53 0.63
11.5 -3.9622 0.4349 0.1142 0.37 0.39 0.41 0.43 0.47 0.53 0.63
12 -4.0348 0.4337 0.1160 0.37 0.39 0.40 0.43 0.47 0.53 0.64
12.5 -4.0930 0.4325 0.1176 0.37 0.38 0.40 0.43 0.47 0.53 0.64
13 -4.1341 0.4314 0.1191 0.37 0.38 0.40 0.43 0.47 0.53 0.64
13.5 -4.1552 0.4306 0.1203 0.37 0.38 0.40 0.43 0.47 0.53 0.64
14 -4.1548 0.4301 0.1214 0.37 0.38 0.40 0.43 0.47 0.53 0.65
14.5 -4.1327 0.4299 0.1222 0.37 0.38 0.40 0.43 0.47 0.53 0.65
15 -4.0898 0.4300 0.1228 0.37 0.38 0.40 0.43 0.47 0.53 0.65
15.5 -4.0283 0.4306 0.1231 0.37 0.38 0.40 0.43 0.47 0.54 0.65
16 -3.9500 0.4316 0.1232 0.37 0.38 0.40 0.43 0.47 0.54 0.65
16.5 -3.8599 0.4329 0.1230 0.37 0.38 0.40 0.43 0.47 0.54 0.65
17 -3.7677 0.4346 0.1225 0.37 0.38 0.40 0.43 0.48 0.54 0.65
17.5 -3.6821 0.4366 0.1218 0.37 0.39 0.41 0.44 0.48 0.54 0.65
18 -3.6020 0.4388 0.1209 0.37 0.39 0.41 0.44 0.48 0.54 0.65
18.5 -3.5230 0.4412 0.1200 0.37 0.39 0.41 0.44 0.48 0.54 0.65
19 -3.4418 0.4436 0.1192 0.38 0.39 0.41 0.44 0.49 0.55 0.65
19.5 -3.3555 0.4461 0.1185 0.38 0.39 0.42 0.45 0.49 0.55 0.65
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Fig 3. Percentile curves for waist to height ratio for male and female Canadian children and youth aged 6 to 19 years.

Fig 3

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Table 5. L, M, and S values, and percentiles of sum of 5 skinfolds [mm] by age and sex for Canadian children and youth aged 6 to 19 years.

Sex Age [years] L M S 3rd 10th 25th 50th 75th 90th 97th
Female 6 -0.8001 36.4877 0.3200 22.3 25.6 29.9 36.5 46.2 60.0 82.9
6.5 -0.7432 38.0983 0.3315 22.8 26.3 31.0 38.1 48.7 63.5 88.0
7 -0.6868 39.7213 0.3433 23.3 27.0 32.0 39.7 51.1 67.1 93.2
7.5 -0.6321 41.3740 0.3551 23.7 27.7 33.1 41.4 53.6 70.8 98.5
8 -0.5792 43.0677 0.3663 24.1 28.4 34.2 43.1 56.2 74.5 103.7
8.5 -0.5273 44.7916 0.3764 24.5 29.1 35.3 44.8 58.8 78.2 108.7
9 -0.4769 46.5333 0.3851 25.0 29.9 36.4 46.5 61.4 81.7 113.2
9.5 -0.4282 48.2768 0.3920 25.4 30.6 37.6 48.3 63.9 85.0 117.1
10 -0.3824 50.0088 0.3967 25.9 31.4 38.8 50.0 66.3 88.0 120.4
10.5 -0.3403 51.7288 0.3994 26.5 32.3 40.0 51.7 68.6 90.8 123.2
11 -0.3019 53.4382 0.4002 27.1 33.2 41.2 53.4 70.8 93.3 125.5
11.5 -0.2677 55.1324 0.3995 27.8 34.1 42.5 55.1 72.9 95.6 127.6
12 -0.2384 56.8117 0.3971 28.6 35.1 43.8 56.8 74.9 97.7 129.3
12.5 -0.2142 58.4805 0.3933 29.4 36.2 45.2 58.5 76.8 99.7 130.8
13 -0.1952 60.1312 0.3881 30.4 37.4 46.6 60.1 78.7 101.5 132.2
13.5 -0.1811 61.7488 0.3819 31.4 38.6 48.0 61.7 80.4 103.1 133.3
14 -0.1711 63.3203 0.3748 32.5 39.9 49.4 63.3 82.0 104.5 134.2
14.5 -0.1632 64.8268 0.3672 33.7 41.2 50.9 64.8 83.5 105.8 134.9
15 -0.1556 66.2454 0.3596 34.8 42.5 52.2 66.2 84.8 106.9 135.4
15.5 -0.1468 67.5584 0.3523 35.9 43.6 53.5 67.6 86.0 107.8 135.7
16 -0.1357 68.7533 0.3458 36.9 44.7 54.6 68.8 87.1 108.6 135.8
16.5 -0.1223 69.8262 0.3401 37.7 45.7 55.7 69.8 88.1 109.3 135.9
17 -0.1066 70.7856 0.3355 38.4 46.5 56.6 70.8 89.0 109.9 136.0
17.5 -0.0893 71.6414 0.3319 39.0 47.2 57.4 71.6 89.8 110.5 136.2
18 -0.0704 72.3989 0.3292 39.5 47.8 58.1 72.4 90.6 111.1 136.4
18.5 -0.0505 73.0634 0.3275 39.8 48.2 58.7 73.1 91.2 111.7 136.6
19 -0.0302 73.6442 0.3266 40.1 48.6 59.1 73.6 91.9 112.2 136.9
Male 6 -2.3230 38.7422 0.7465 20.3 22.5 25.7 31.4 41.9 60.9 100.7
6.5 -2.2059 39.3403 0.7137 20.6 23.0 26.4 32.5 43.8 64.6 109.5
7 -2.0893 39.9486 0.6823 21.0 23.4 27.1 33.6 45.8 68.6 119.4
7.5 -1.9737 40.5630 0.6521 21.3 24.0 27.8 34.7 47.9 73.1 130.7
8 -1.8589 41.1632 0.6236 21.7 24.5 28.6 36.0 50.1 77.8 143.3
8.5 -1.7449 41.7239 0.5969 22.1 25.0 29.3 37.2 52.4 82.7 157.2
9 -1.6319 42.2178 0.5723 22.4 25.5 30.1 38.4 54.6 87.7 172.0
9.5 -1.5210 42.6277 0.5499 22.6 25.9 30.8 39.5 56.7 92.3 186.9
10 -1.4144 42.9405 0.5294 22.9 26.3 31.4 40.5 58.5 96.2 200.4
10.5 -1.3138 43.1455 0.5108 23.0 26.6 31.9 41.4 59.9 98.9 210.5
11 -1.2209 43.2441 0.4938 23.1 26.8 32.3 42.0 60.8 100.1 215.0
11.5 -1.1370 43.2479 0.4782 23.2 27.0 32.6 42.4 61.1 99.8 212.7
12 -1.0626 43.1711 0.4639 23.2 27.1 32.8 42.6 61.1 98.0 204.0
12.5 -0.9971 43.0229 0.4510 23.2 27.2 32.9 42.7 60.6 95.3 190.8
13 -0.9398 42.8208 0.4393 23.2 27.2 32.9 42.6 59.9 92.1 176.0
13.5 -0.8895 42.5825 0.4289 23.2 27.2 32.9 42.5 59.1 88.9 161.8
14 -0.8448 42.3307 0.4197 23.1 27.2 32.8 42.3 58.3 85.9 149.2
14.5 -0.8044 42.0880 0.4118 23.0 27.1 32.7 42.1 57.5 83.3 138.9
15 -0.7672 41.8827 0.4053 23.0 27.0 32.7 41.9 56.9 81.1 130.5
15.5 -0.7323 41.7453 0.3999 22.9 27.0 32.6 41.7 56.4 79.3 124.0
16 -0.6987 41.6987 0.3955 22.9 27.0 32.6 41.7 56.0 77.9 118.9
16.5 -0.6656 41.7543 0.3922 22.9 27.1 32.7 41.8 55.9 77.0 115.1
17 -0.6326 41.9139 0.3897 23.0 27.2 32.9 41.9 55.9 76.4 112.2
17.5 -0.6000 42.1743 0.3878 23.0 27.3 33.1 42.2 56.1 76.1 110.1
18 -0.5676 42.5227 0.3866 23.1 27.5 33.3 42.5 56.4 76.1 108.6
18.5 -0.5358 42.9398 0.3860 23.3 27.7 33.7 42.9 56.8 76.3 107.7
19 -0.5045 43.4095 0.3860 23.4 27.9 34.0 43.4 57.4 76.7 107.2
19.5 -0.4735 43.9177 0.3867 23.5 28.1 34.3 43.9 58.0 77.3 107.1
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Fig 4. Percentile curves for sum of 5 skinfolds for male and female Canadian children and youth aged 6 to 19 years.

Fig 4

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Details on the percentiles of BMI, WC, and WHtR by age and sex that intersect adult cutpoints at age 18 years can be found in Table 6 and S2 Table.

Table 6. Z-scores and percentiles that intersect the adult cutpoints for body mass index, waist circumference, and waist-to-height ratio at age 18 years.

Adult cutpoint z-score Percentile
Body mass index—Thinness Grade 1
 Male 18.5 kg/m2 -1.41 7.9
 Female 18.5 kg/m2 -1.38 8.4
Body mass index—Overweight
 Male 25 kg/m2 0.57 71.6
 Female 25 kg/m2 0.59 72.1
Body mass index—Obesity
 Male 30 kg/m2 1.37 91.5
 Female 30 kg/m2 1.32 90.6
Waist circumference
 Male 102 cm 1.52 93.6
 Female 88 cm 1.10 86.4
Waist-to-Height ratio
 Male 0.5 0.86 80.6
 Female 0.5 0.77 77.9
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Discussion

The current study has presented for the first time percentile curves for the most commonly used anthropometric measures for body composition assessment based on a representative sample of Canadian children and youth aged 6 to 19 years. The percentile curves presented are meant to be descriptive rather than prescriptive as associations with cardiovascular disease markers or outcomes were not assessed. The data may be used by researchers as reference data for future studies.

The general shape of the BMI centile curves in males and females was comparable to existing growth curves from the IOTF [32], WHO (World Health Organization) [33], and CDC (Centers for Disease Control) [34] with the BMI increasing steadily until puberty, after which the slope begins to level off. Since the data for the CHMS were collected during the obesity epidemic, the percentile cutpoints are higher than those from the IOTF, WHO, and CDC curves, which were based on data that were for the most part collected before the 1980s. While the 72nd and 91st percentiles for both sexes in our sample intersected the adult cutpoints for overweight and obesity at age 18 years, the corresponding percentiles were 88th (females) and 90th (males) for overweight, and 99th for obesity (both sexes) using the IOTF reference [32], and 82nd (females) and 81th (males) for overweight, and 95th (females) and 96th (males) for obesity using the CDC reference [34]. These differences underline the importance of relating percentile curves and cutoffs to actual health outcomes as the associated health risks of distribution-based cutoffs may change considerably with the reference population.

Waist circumference has been found to be a better predictor of CVD risk factors in children than BMI [6,10,35] but the method still has not seen widespread use, neither clinically or for research purposes. Percentiles for WC in children have been published for more than 20 countries but there is no universally accepted WC cutoff that is based on health outcomes or CVD risk markers in children. Establishment of WC cutoffs is further hampered by the use of different method to measure WC between studies. While the CHMS and other recent studies consistently measured the WC at the midpoint between the lower end of the rib cage and the iliac crest at the end of an expiration [16,18], studies in samples from the pre-obesity epidemic era often used the umbilicus or the point of maximum waist narrowing [17,19,36]. For this reason, comparison of WC percentiles determined in this study with existing Canadian reference data [19] from the 1981 Canadian Fitness Survey (which measured WC at "the point of noticeable waist narrowing") was not possible. The shape of the WC curves in boys and girls in the present study is similar to previously published centile curves [16], including the Canadian reference curves [19]. The intersection of the WC curves at age 18 years with recommended cutoff points for adults suggested the 94th percentile (males) and 86th percentile (females), respectively, as WC cutoffs in childhood. The only other study that related their centile curves to adult cutoffs was a German study using data collected between 2003 and 2006; the investigators found that the 98th and 97th percentile corresponded to the adult cutoffs in males and females, respectively [16].

A WHtR greater than 0.5 has been proposed as an indicator of CVD risk in adults [28] and two recent meta-analyses concluded that WHtR provides a better discrimination for CVD outcomes in adults than WC or BMI [9,11]. The same cutoff has been suggested for use throughout childhood [37,38], which would offer the great advantage of obviating the need for age-related reference values and providing the simple universal public health message "keep your waist circumference to less than half your height" [38]. Centiles for WHtR in the present study, with the exception of the higher percentiles, decreased slightly until around puberty and increased again thereafter as reported previously in samples from other countries [18,39]. The median WHtR varied by less than 3% throughout childhood for both sexes. The percentiles that corresponded to the 0.5 cutoff at age 18 years were comparable between males and females (81st and 78th percentile, respectively). These cutoffs were lower than those found in representative samples of Norwegian [18] and German children and youth [39], where the cutoffs fell above the 90th percentile.

Compared to the other methods of body fat measurement discussed above, skinfold thickness has the highest measurement error [40], which may further increase with the degree of adiposity [41]. This shortcoming makes interpretation of skinfolds thickness challenging and, along with the need for specialized measurement equipment (calipers), may account for its limited use. In the largest study to date, Addo and Himes determined reference curves for triceps and subscapular skinfold thickness based on five large representative samples of US children between 1963 and 1994 [15]. They found a distinct difference in skinfold trajectories between sexes, with boys exhibiting a dramatic increase in the percentile levels above the median before puberty while girls showed a more steady increase throughout childhood and adolescence. Sex differences were also evident for SF5 in the current study: Percentile levels above the 75th percentile showed a steep increase before puberty for boys followed by a sharp decline as result of an increase and decline in the μ parameter that is amplified by a large variance and large negative value of the skewness curve in this age range. The percentiles for girls increased slightly until age 12 years and then remained fairly constant. Almost identical sex-specific patterns for triceps and subscapular skinfold thickness were found in a large representative sample of German children (n = 17,158) [42].

The strengths of the current study include the nationally representative sample of children and youth, and the use of sample weighting to account for non-response and design effect. Due to the physical burden of the assessments used in the survey, and the need to travel to the mobile examination clinics, there may have been a self-selection toward more mobile, healthier and fitter individuals. Our study is limited by the relatively small sample size, and the cross-sectional nature of the data; longitudinal data may more accurately reflect how body fatness changes with age. Lastly, while the LMS method provides a very flexible and powerful tool to model data whose dispersion and skewness change over age, it lacks a mechanism for modeling kurtosis, an issue addressed by extensions of the LMS method [43,44]. Its flexibility also means that the curves may differ considerably based on the parameter choices made by the researcher; e.g., the choice of a higher smoothing parameter allows the elimination of features that are not representative of the underlying population. While choice of smoothing parameters and model selection adds some arbitrariness to the process it allows the researcher to balance mathematical rigidity with clinical usefulness.

Conclusions

This study has presented percentile curves for measures of body fatness in a representative sample of Canadian children and youth. Our findings indicate a substantial upward shift of the percentile curves for all measures compared to data from the pre-obesity epidemic era. Since we did not examine any relationships with health outcomes or disease markers, the data should be considered as a reference for future studies not as a growth standard.

Supporting Information

S1 Table. Characteristics of 4115 Canadian children and youth aged 6 to 19 years in the Canadian Health Measures Survey Cycles 1 and 2.

(DOCX)

Click here for additional data file. (59.7KB, docx)
S2 Table. Percentiles of body mass index, waist circumference, and waist-to-height ratio that intersect adult cutpoints at age 18 years.

(DOCX)

Click here for additional data file. (120.9KB, docx)

Acknowledgments

The analysis presented in this paper was conducted at the Atlantic Research Data Centre, which is part of the Canadian Research Data Centre Network (CRDCN). The services and activities provided by the Atlantic Research Data Centre are made possible by the financial or in-kind support of the SSHRC, the CIHR, the CFI, Statistics Canada, and Dalhousie University. The views expressed in this paper do not necessarily represent the views of the CRDCN or its partners.

Data Availability

Due to ethical restrictions and to protect participant privacy, data are available through the Statistics Canada Research Data Centres for researchers who meet the criteria for access to confidential data.

Funding Statement

This work was supported by an IWK Health Centre (http://www.iwk.nshealth.ca) Establishment Grant awarded to Dr. Stefan Kuhle (#09020). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Table. Characteristics of 4115 Canadian children and youth aged 6 to 19 years in the Canadian Health Measures Survey Cycles 1 and 2.

(DOCX)

Click here for additional data file. (59.7KB, docx)
S2 Table. Percentiles of body mass index, waist circumference, and waist-to-height ratio that intersect adult cutpoints at age 18 years.

(DOCX)

Click here for additional data file. (120.9KB, docx)

Data Availability Statement

Due to ethical restrictions and to protect participant privacy, data are available through the Statistics Canada Research Data Centres for researchers who meet the criteria for access to confidential data.

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