Special

Article

Anthropometric reference data for international use: recommendations from a World Health Organization Expert COmmittee13
Mercedes de Onis and Jean-Pierre Habicht (WHO) conof anthropometry and and
For fetal

ABSTRACT vened an Expert at for different The ages being.

guidelines

The World Committee for assessing task indexes

how the data

Health Organization to reevaluate the use health, included when

should be

only health

for individual status and Consequently, WHO Nutrition of anthropometric charge to the for anthropometric
guidelines

social

assessments but and economic an Expert to reevaluate

also for circumstances was the in use subjects identifying appropriate,

data

reflecting of convened and of

the popuby

nutrition, identifying appropriate,

used.

social

well-lations. datathe

Committee

Committees
on

reference
growth,

Unit

interpretaall ages. reference and proused. be

anthropometnic recommended view of

Center

providing tion The the of ref-data the viding

.

measurements Committee included indicators

on how these

Downloaded from www.ajcn.org by guest on April 30, 2012

Committee erence.
current

In

the
for

an existing significant
Health

sex-specific technical
Statistics

multiracial drawbacks
(NCHS)/WHO refer-

when
reference

should

National

Anthropometry inexpensive,

is

the

single and

most noninvasive

portable, method

universally available of the predicts it and their are to is

apto human perforused nutrition for and

ence
infants,

and
the

its

inadequacy
Committee

for weight

assessing
the

the length/height

growth for

of
of

breast-fed plicable,
a new

recommended

development

reference children,
interpretation

concerning which
of

and
arm

infants

assess body. and

the proportions, It reflects both health, individuals as well and

size, health survival. and as

and composition and nutrition and For these for monitoring values in relation reasons health

will

be a complex reference Committee

and data.

costly
for

undertaking.
preschoolers

midupper

circumference

Proper mance, selecting adolescent interventions, In across set of reference of werewithout andences NCHS/ nutrition.

populations for

requires height-for-age,

age-specific the Use of percentile goals; for and

To

evaluate the current

health compared an acceptable

recommended

WHO reference. with their upper for setting health recommended elevated BMI provisionally triceps
adjusting status.

the NCHSbody elevations however,

mass index and skewness, these data were

(BMI) data, is undesirable provisionally

practical individuals reference values making between

terms, or

anthropometric populations

defining obesity high subcutaneous as reference Guidelines thicknesses.

anthropometric there is no need

based on a combination fat. The NCHS values data were

for reference adult

values. Previous presentations of the WHO (3, 5) have claimed that they are to be used value judgements about the observed differthe reference and the measured are used as of populations, adequate values of and a thus need value. This may basis most mdias a a common but for growth are norm or involves to be An in used

recommended skinfold
adolescent

for

subscapular also provided

data for maturational

comparisons for

be reference values for true whenthe for purely descriptive comparisons screening and and populations, which a level that embraces ought to monitoring the the be from issues are used

Currently,

interpretation the for

tions

should noted
status,

be based that few for

function.

on

pragmatic y of

BMI anthropometnic age.

cutoffs. Proper
age

BMI; uses in Finally, viduals

of reference notion met, them. that

Committee the
of

normative those 80 >

and

data definiremain

exist standard, target,

to judgement be

desirable a value

elderly,
health

especially this group. Reference

biologic

developed KEY tional tional

for WORDS assessment, disorders,

Am

J C/in standards, status, stunting,

Nutr 1996;64:650-8. anthropometry, growth, wasting. obesity, nutninutri-

There when the

about deviations are certain general reference values

considered important

as a standard.

nutritional world health,

From

the Nutrition
Nutritional of the and

Unit,

World

Health

Organization.

Geneva,
Ithaca, Habicht, Italy: JC WHO NY. C

and
Garza,

the

Division of 2 Members Haas, I Himes,

Sciences, Cornell University. WHO Expert Committee: J-P R Yip, India: Brazil: and United 0 ML States: Ransome-Kuti. Wahlqvist. A Ferro-Luzzi, Nigeria: Australia.

A Pradilla, NethSecretariat:

INTRODUCTION Over sought pretation focused vulnerability, izing the 650 growth relevance the years, to provide of largely and and of on the World guidance infants on the well-being. anthropometry and value Health on the indexes young of However, throughout
Am

Colombia: erlands;

L Raman, C Victora,

Seidell,

Organization appropriate (1-5). children anthropometry recent the

(WHO) use and Initially, because advances life cycle, of

M de Onis, G Clugston, J Villar, and P Sizonenko, Switzerland: has United States: M Kramer, Canada: and J Tuomilehto, Finland. intertatives of other organizations: requests Avenue 13. publication in USA. 0 I Csete, de United States Weisell,
3

P Eveleth,
Represenand Health R

anthropometric

attention in charactershow

(UNICEF): World

Italy

(FAO). reprint 20 February for to Appia. 1996. June 1996 3. 1996. American Society for Clinical Nutrition M Onis. Nutrition 27, Unit. Switzerland. I 2 1 1 Geneva

their

Address

Organization. Received

not Accepted

J C/in

Nuir l996;64:650-8.

Printed

ANTHROPOMETRIC one the the at the mo of for-age always deviation malnutrition, ages. Another nonpathologic populations pared identify. sets The error of reference with In reference data it causes For that some such however, as possible judgements for used Expert in needs, the be relevant issue is the magnitude the that where practical is determined judgements the effect of data differentiate about sex of the effect factors that influence from which the reference the public should of the in interpreting instance, reference pathologic health values not influence effects settings, is more reflect normal growth values are drawn, anthropometry use than of the by one use the or of is the standard individual are norm context in and different which population for a 6-mo deviation context of malnutrition. of the on deviations the The meaning implications level old of than of the for a same for deviation most deviation a 6-y or old.

REFERENCE not from ing been the

DATA possible differences to distinguish in mean groups, that and to the periods These of altitude, births, is methods would contrary, of differences assessing slower nature birth it is lead growth gestation from difficult to faster later seem are, gestational or on. in however, nurture to

651 in explainimagine growth Unless the likely age, compared of infants responsible reference rate to small. sociowith with than curves on birth genetic and with any early eviof be

is interpreted.

decisions

weight-for-gestational-age

different racial frombetween influence At environmental 6 third is at trimester produced different determined. in status, and of multiple the anomalies differences

age a substantial norm, in the means may ongoing be depending

from the a deprived At previous 6

weightpopulation, y of but age not

height- in the almost dence growth the same

differences

a reflection

of

observed

at younger

current genetically Differences economic exclusion of

and inclusion of stillbirths, far the is a does among the use where nutrition single, of I I more existing

of the congenital com-race for seeks (15). to weight, a few therefore reference of from other status. such Alreference risk In

probably between

summary, but current in does curves factors, the is Thus, birth not in

fetal sex knowledge weight support situations as poor of a such use

major influence not confirm large various of separate, race or sex-specific fetal reviewed references Despite the growth currently many is low populations

many, differences

inconsequential

influences. margin deviations

race-specific associated socioeconomic international

importance

the norm. importance though in and severe, combined-sex settings, ences right treatment, may (eg. The be used clinical summarizes parental

is usually of between them. is only (6). as account effects many

recommended. characteristics the early also 1950s considered. In addition, references by the under differwere two in detail

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situations in which as in emergencies, reference usually need when instance. to values clinical be taken monitoring this the different above

malnutrition the use of situations, into the purpose,

The prevalent one set published of In

relevant since

is recommended

Committee. otherExpert were influ-development

For to

ences in calendar time, population characteristics, to make the of hormonal and methods of estimating gestational age, the different standards among the various references are more striking determinants reference also This fill ones. data differences. or under to many (16), article the come most Although development close. recent at low The (17), and one, none meet best but Canada there ages

exclusions, similarities than their

according height). Committee public but health not

specific all on data

of the reference curves published all desirable criteria, several appear are probably (18). are The because those Canadian no irregularities smoothing from California reference in extreme techis

focused settings. the more

These specialized existing

Sweden

recommended

anthropometnic

refer- percentiles

gestational

ence data from infancy to old age, discusses its adequacy for nique was used. The Swedish reference is slightly dated, but universal applicability, and proposes the development of more the statistically smoothed curves and presentation of means useful references when necessary. Recommended reference plus and minus multiples of the SDs make it useful for the values in tabulated and graphic format are available in the diagnosis of small-for-gestational age (SGA) and large-forCommittees report (7). gestational healthy value THE The most influence edged neonatal gestation lished based fetal effects common mental or ing fetuses. 34-36 infants; early curves that FETUS AND NEWBORN INFANT development cycle, It important the constitutes a lasting universally indicator product Any of (or of the a of one a high international period of intrauterine vulnerable in the on size subsequent at birth life with is when level age population a growth of its comparison. (LGA). (of chart growth Because mothers from potential The Williams The size at the et this and is based that for represents is end with well of the many known, gestational other candiconsidered on has a selected be of of the best it is achieved that the newborns) is needed al (16) lower it could purposes

a population Committee reference

multiracial reference of of the profound option presently available. on a large sample and fetal and age distribution,

growth. is an at birth is fetal growth. references

acknowl- based duration recently

it is comparable

health. Size and rate of early-gestation

date curves. A distinctive of relation between birth pub-

feature is that it provides weight for gestational age for diagnosis rather than for are future singleton provided reference curves is needed of gestational at a given risks for born using in the curves recommended large age to weight of on boys

data on the and neonatal LGA can statistical as well

curves

meta-analysis

on several of them) could growth standard up to on fetal growth of growth-promoting influences do not third trimesters. differ female Several wk of thereafter, to some fetuses within-country gestation, the pattern black and appear In later

be used for developing 24-26 wk (8-10), sex, race, and growth-inhibiting to diverge until gestation, Starting average, have are (I 1-14). infants reverses on at shown larger

mortality. a single be based because cutoffs. the as for to report second the than To exist- specific use, third before infants white age are outcomes. it has male ultrasound

Thus, the criteria on perinatal risk Reference multiple (7). curves births, whether the research confirmation of different at races substantially Similar research

SGA and arbitrary and Expert need girls,

different

exposure

Committees to for populations assess for gestational health to mothbe more and whether

environthe late the about that, than

decide than additional

however, smaller

sex-specific

present

degree. are, studies

trimester,

Although

different is needed

for important infants born

652

de of different are born stature are parity small at the and because same stature their risk are small cigarettes. to determine mothers for adverse because are

ONIS

AND infants or of as those have

HABICHT

ers who short

whether primiparous sequelae their mothers

of equivalent preeclampsia

size who or smoke

INFANTS Growth fines

ogy,

AND assessment the health in

CHILDREN is the and health

affect

single nutrition,
growth.

measurement status
The

that children of

best their

deetiol-

nutritional and
child

of
most

because

disturbances
invariably

regardless child growth and to has The

commonlyused

anthropometric for-height, circumference The the erable reference the then healthy
surprisingly

indexes height-for-age, (MUAC). of of which growth in the

for

assessing weight-for-age,

are midupper

weightarm FIGURE US children.

using the NCHS

Age

(mo) of low of the for height-for-age 24-mo children disjunction younger (7). than for low-income as a result of and 2 y of age

1. Change
illustrating Fels

in prevalence the curves effect curves for

issue attention

reference during last

population childhood decades.

use

in assessing adopted (3) of

length-based

children

adequacy curves growing preschool

received WHO

consid- the the

height-based

older

of the NCHS for international evidence that the growth children

(19).

from

diverse
of

similar

Differences

evident relatively in growth account

NCHS/WHO

for

some minor related

comparisons; compared to historical charts, scientific growth health with

however, the and background together issues, reference set of with

based on ness reflects an unhealthy characteristic well-fed, and may result in the misclassification ethnic backgrounds are normal. as However, because there genetic origin are of the normality of weight distribution these variations are ages, the issue of skewness should worldwide (20). the be served growth different data sets A of currently found variation detailed research.

use patterns

of the of

reference

sample

Downloaded from www.ajcn.org by guest on April 30, 2012

overweight

children knowledge of different of further

is insufficient in children he the subject

large nutrition

of

the growth

a discussion can has

of
(21).

the The

contemporary international by providing comparison in part

Concern has also been expressed that the NCHS/WHO used curves are inappropriate for healthy, breast-fed infants. As part of some of the preparatory work for the Expert Committee. a Working elsewhere Group on Infant Growth was established to assess the growth
patterns of infants following current WHO feeding recommen-

many references

purposes permit However,

a single

useful dations that opment breast-fed to ditions

(23), of

and

the

relevance

of

such

patterns

to

the

devel-

of growth data from because two distinct

populations. were used

growth infants in different

reference who live parts

data. In reviewing the growth of under favorable environmental conof the world, the Working Group

the international growth refer- found significant differences between the growth patterns of limitations that complicate the these infants and the patterns reflected in the NCHS/WHO from nutrition surveys and surreference. Infants fed according to WHO recommendations and veillance. In essence. for children younger thany of age the 2 living under conditions that favor the achievement of genetic data used are from the Fels Research Institute in Yellow growth potential grew less rapidly than, and deviated signifiSprings, OH, and come from studies of a white, middle-class cantly from, the international reference (Figure 2). Concerning population. For older children the data come from nationally the clinical and public health significance of these differences, representative surveys of children in the United States and the Working Group placed particular emphasis on the risks include the the older child, the measurement. height status the two curves an underestimation Fels sample height at 24 imately the The the status mo of one-half all younger ethnic children children length groups were and social measured classes supine (22). Furthermore, (length) associated with both the premature introduction whereas tary foods and their undue delay. and concluded For any growth reference has limited value as a tool the height
0.6

construct ence has interpretation

the reference curves, important technical of growth data

of complementhat for the the current optimal

were measured standing (height). measurement is always greater than is a marked before and This height represents status curves of effect of with and curves this the discrepancy after 24 mo the combined of

Thus, there immediately merge. of length-based with age. an the The SD. of low of these

in estimated age, where effect of sample

!

_._
.--

.--......

of the of

--/u..:

-A..-...

Length-for-age Weight-for-age Weight-for-length

0

0.4
0.2

interpretation an overestimation from disjunction 24-mo the US

S a

. -

height-based magnitude The height-for-age deviations to

is approxdisjunction

on

;
1 I I i

prevalence magnitude international

is illustrated Figure in 1. warrants caution when using interpret the growth this higher
The

reference

status disjunction. and weightend, reflect-

of
1 2 3 4 Age 5 (mo) in the breast-fed reference set. (7). relative to the 6 7 8 9 10 11 12

children covering a range of ages that includes In addition, the distributions of weight-for-age for-height
ing

are

markedly
level of

skewed
childhood

toward

the
obesity.

FIGURE

2. Mean
Center for

Z scores Health

of infants Statistics/WHO

a substantial

upward

skew-National

ANTHROPOMETRIC nutritional the growth vious However, current tion-based future an entirely groups After its management analyses evaluation can of the Expert of using of the significant growth an one, undertaking. sound lasting be used 1). value, exceptionally some in the Applying of conducted countries country. that pattern Committee Until point-generally that MUAC 4 does and the use among older ones. age-dependent 59 mo younger in both children also Mean y of not of age. reflect a fixed younger have as also now, of the and be must to of on from from be (Table of is an of be infants. found present A complete (24, knowledge reaffirmed international drawbacks for in or inherent growth it is clear well-prepared. desirable development of the Committees a might This arisen a worldwide reviewed a low 12.5 or is ageHowever, the true cutoff children values 2 cm nonaffluent likely to MUAC truly surveys covering be more procedure from using a that The characteristics especially replacement complex, description 25). about

REFERENCE

DATA after to or It was with data

of this

653 adjustment mortality based concluded to nutritional requires

MUAC-for-age

elsewhere

MUAC declined significantly of the ability of the MUAC infant- with that of for age, age) of the relation reference
basis

for was on

age. fixed that

In fact, cutoffs proper status the of or use findon first Surtables are of prelow to and certain

predict weight therefore

comparable

height, (7). MUAC

assessment, WHO position because NCHS/WHO applications, was recommended. new statistically To

Committee a single reference, update or

(unadjusted the prereference. interpretation of to the its etiologic

regard permit for

technical

to functional to

outcomes

Updating extremely The

a reference, difficulties

popula- of age-specific ings. On the the near reference data developing costly, in curves the children and gen-and veys are next and second (NHANES curves based for elsewhere aged

interpretation use for Examination Reference combined interpretation of value for

recommendation,

were 6-60 National I and boys. (26). on a

developed mo II) girls, fixed from Health in the and cutoff Nonetheless, the and

international collected States. sexes the is still Nutrition

based the

samples United both

time-consuming erating many. reference Committee data sets population dation based tions data political trys

appropriate therefore,

identified

Expert sented MUAC for

new reference applications, recommenyounger reference mortality. broad popula-

especially children who

when it is desirable are more vulnerable

to give priority to morbidity

the carefully

formulation

international

several a single difficulties

acceptable will avert a single for and been

than the ADOLESCENTS counoptiAdolescence unique during is a significant changes this for and from the age,
of

Downloaded from www.ajcn.org by guest on April 30, 2012

child-growth

standard the use has

period occur and In and adult are into age adulthood groups, begins with

of many

human adult the health are

growth patterns proximity may problems. processes, not are abrupt. defined the provide

and are of Huand In by earapsecond in hu-

mal growth. The Expert tation a fixed general tween independence growth, overdiagnosed among definite 6 and Thus, Younger completely why heightstudies. Committee of MUAC. cutoff notion I and

maturation; interpre- established based on adolescence on the beof final man growth age transitions with

period. maturity preventing

addition, adulthood

to biological maturation childhood previous adolescence

of

13.0 cm-based and sex-independent this pattern results and across between assumption of in

opportunities

continuous which
sexual

midupper wasting ages the underdiagnosed

arm contrast beingchronologic

liest signs

development

secondary

pubescence, characteristics, changes of the end

MUAC increase of and more higher that

affluent are have to those

a continues and until morphologic of proximate adult status, usually populations (7). decade of life. have low MUACs. Whereas adolescence is clearly it has periods interpretations in somatic with risks, variation normal have knowledge it directly Committees information for future indexes all separating often in

show ages

and near an failed

physiologic the

important to receive with

period the to regard

mortality rates for reasons man development, affect MUAC. This explains given to earlier the MUAC predicts childhood mortality better than related uses and and weight-age adjusted indicators in community-based the rapid changes Analysis carried out in preparation for the Expert lems of dealing showed that this superior performance of the ties ciated involved with in health

children unrelated

attention health-

childhood

of anthropometry. growth in adolescence, in maturation. variations discouraged and from

Historically, the probthe those difficulassofrom and to

researchers

TABLE
Desirable

I
characteristics of a new from them for anthropometric growth geographical ones with unconstrained whole population): in deciding modes into adequate whether account the or growth definition not the populations of the feeding data reference regions should be to be used in the international different

developing etry that outcomes. bring

a body of would link The Expert available

about adolescent anthropomto health determinants intention on work and recommended adolescent discussion. for and has was therefore anthropomadolescents subscapular made no referyounger through consid-

development
Several included.

together to

countries among

etry The

less-developed

form a basis anthropometric

Data should be (not necessarily of healthy choice should

based on healthy representative take infant

populations

is important

are height-for-age, BMI-for-age, skinfold thicknesses-for-age. Until specific recommendations for

and triceps now, the WHO

adolescent

anthropometric data for of height therefore or Although the Committee included population. in It reference whether

Sample sizes and procedures should be Raw data should be available The age range from birth to adolescence
sources Quality For Secular the control adolescents, trends presence of and measurements should of should inhibiting sexual be should be small

should
be

be covered most data by

standardized should be and available they suggest

ence data, but advocated the NCHS reference children, which include SDs and percentiles the adolescent years. The Expert Committee ered were reference able essential ence data whether the most data reference that be all the international appropriate should data the measured are be different on the for NCHSIWHO adolescents

data other reliit referalso

standardization

procedures measures in growth growth

documented or absent because

recommended. available, variables same

other deemed the was

maturity factors

in a population

654 considered from were desirable On that this for there be continuity

de

ONIS

AND

HABICHT be required than the before provisional. recommended age for and that maturational how scheme. status anthropometry differ adolescent should can also then from values In are the of popbe be of stadata account interpreting anthropometric gave recommendations on in the evaluation of maturational medians for that or for that of The median an mean for ages 2. these recommendations can be con-

in reference reference some cases, local

levels would sidered data Finally,

age to age. recommended

basis, the NCHSIWHO height-for-age. In or other local in the context The NCHSIWHO

more

Committee

reference considered; in the ever, Expert height the height provided no other Considerable international adolescents tile levels age-specific with many lack minants, are are

data may be required these are discussed Committees available Committee of and in the appropriate comparison in the at any other United given well-nourished report only did up not (7).

factors must tus be taken be into of specific uses based on chronologic values, (4). data variation, data at if there how- to incorporate The essence, for available, may be

maturational when population age-specific adjusted data (Table variables chronologic population with those median in for 2).

status estimates means or rates are age Table of When

to 1 8 y of recommend of of to ages reference focused the genetic intervene. 1 8-24 reference on [wt wide

age in each sex any reference international and y, may data the (kg)Iht2 very high marked values were environmental If reference the be available. appropriateness (m2)] upper skewing when of values used

in adulthood understanding the required

because inability for local discussion of

maturation calculated

deter- reference for anthropometnic 1 8ulation, y are calculated; compared data for median fromNCHS

mean

sample maturation population

NCHS/WHO

estimates

BMI

maturational estimates,

age are subtracted from the corresponding and, on the basis of that difference, the years subtracted sample. with correct indicators the as the rates, used from) the Age-specific reference for differences give adjustment slightly should for mean data for in

States. The age and the toward higher

percen- or fractions of the chronologic compared particular for that variant be for in the the age. sample The

of 1 y are added to (or age of the population can resultant rate. If and in the then different maturation average be compared maturity comparisons

distributions the median less variation selected 29) percentiles percentiles (28, upper 85th

data

populations BMI-for-age among age-specific

Downloaded from www.ajcn.org by guest on April 30, 2012

concern. At there is much

(27).

and lower well-nourished BMI with are those evident

percentiles, populations for

maturation averaged

differences

differences

For children

example, (30)

percentiles

US children skew values.

are Major

compared differences for US of BMI

French maturation.

in Figure 3.

boys and in their absolute for US boys exceeded the ADULTS 90th percentiles for the French boys, and approximate the 97th percentiles. These differences mean that between two and five The nutrition and health of adultsis particularly important times more US boys than French boys have a BMI greater than because it is this age group that is primarily responsible for the the US 85th percentile. Comparisons of BMI distributions for economic support of the rest of the society. In nonindustrialUS and French girls during adolescence yielded similar results, ized societies, where agricultural work is the dominant ecoalthough the age patterns of population differences changed nomic activity, physical capacity and endurance are critical to somewhat. the ability of adults to sustain the socioeconomic and cultural and Little is known their relations and regarding specific with concurrent Nevertheless, the the BMI values in adolescence or future risk or response Committee concluded that upper percentiles and for children did as a healthy specifying it was published until better basis by reporting data not goal purposes, optimum that data longitudiuse. Must recommended reference integrity recognized to the turn in of was to its that values that from different similar the of reflects their as being community. linked with environmental The applied generally term to Variability variation underweight individuals in evidence, need for to rely recommendation of to and country, with the attributable thinness and same there risks degrees depending as there with BMIs shift as the is an of on in adult weight in adult height, which active of terms in low of throughout adult body BMI. for evivaries indications of morbidity overweight on the of This BMI and and populathe popa conBMI assessweight is

of the The

interventions. elevated distributions patterns able cents and values BMI-for-age 29) be used adolescent nal reference The and ular ues data high and as pattern in the for

several

factors

skewed levels of for US children, developed should For of in for US be other children that absence BMI data on growth data

of the BMImuch with similar ment provide for a desir- relative adoleshowever, After cluded

childhood. therefore height;

in other internationally.

countries, used uniform

expressed

review of current there is no obvious it would of BMI. prevalence country populations relative be This best

the Committee reference data pragmatically is based and are distributions of no on overweight

cutoffin adults, the cutoff for widely that have et al (28,dence

and

derived

adolescence,

a provisional

are available. No were recommended considered the fat-determined thicknesses-as obesity for and skinfold and subcutaneous by

incremental or for international measuring a provisional

Committee

combination

of elevated subscaprecomNCHS available

subcutaneous triceps skinfold for reference for s and defining data BMI

BMI mortality thinness. tions valulation increase tendency in the with

associated BMI values assessed low the for in (Figure BMI

with different vary widely 4). Also, decreases,

proportion almost 25.

mendation tables

recommended are the from as in

symmetrical indicates condi-

fat , 32). 1 Reference (3 thickness requirement the same and childhood, for reference so

proportion

a population-wide

socioeconomic

Committee anthropometric population, are recommended

report (7). variables the same during

This meets to be derived source adolescence one age evidence questions

population

reference Nonetheless, applicability, the Committee

tions improve, with overweight all If sufficient data are collected data or even standards could dataence

replacing thinness. in the future, however, referbe developed. To understand population reference set from populations overfeeding), and of in

there is continuity from because of inadequate full answers to research

group to another. of its universal identified by

the distribution of BMI values in a healthy that collect appropriate data for generating a weights, it is important that data are derived with no nutrition problems (underfeeding and

ANTHROPOMETRIC

REFERENCE

DATA

655

95

30#{149}

97 28 85 90
26
%.

24-

50
50

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ccS

22#{149}

E
C)
.

15 20 10
5 3
-0-I.-.

18

16

14

12

10

_T

25

11

13

15

17

19

21

23

Age FIGURE 3. Selected percentiles

of

(y)
for US and French boys (7).

BMI-for-age

whom and the disease Data at least

childrens young

growth individuals

is unimpaired in the population of age,

by

recurrent are reference and race.

infections, largely data free

and do not smoke. for the potential development include weight, height,

ADULTS of The elderly a very

60

Y OF represent the

AGE the world, group; fastest-growing with the a healthy segment distinctive 80-y-old of popuof is

sex,

should lations Socioeco- being

throughout

feature person

heterogeneous

not comparable with a healthy 60-y-old person, nor are two nomic status and smoking habits may be necessary to adjust for 80-y-old persons necessarily comparable with each these influences. Information would also need to be included healthy in biological age. Indeed, the concept of functional or that would permit the exclusion of persons with abnormal other age should gain more consideration in the elderly. weight relative to healthy well-nourished nonpregnant individ- biological uals, eg, the presence of disease, dieting, and weight history. Within any single population, individual variation is increased

656 TABLE
Estimated

de 2
median ages for maturational events in the

ONIS

AND

HABICHT patterns. For those to groups. the period individuals with age pertinent purposes, no group ie, countries develop III The 1988-1991 (equal upper (33). to age exclusively compare limit data that them, for NHANES (phase numbers and be as means It should of have the no local data between survey 1 ) on whites, with emphasized reference and SDs data a collected sample blacks, oversampling that for across these and of comparpopulaof or that lack

National

Center

the the

resources use

Committee III

recommended different data 600 Histhe data

for Health
Maturational

Statistics/WHO
stage

reference

population
Median age

of NHANES

comparisons

population over elderly panics)

Boys Genitalia Peak Adult Girls voice 2 stage 3 12.4 13.5 14.5 10.6 height velocity

oldest are ison

if used

Breast stage Peak height Menarche , From

velocity

1 1.7 12.8

tions. They should not particularly important, concern regarding the able The metric surveys data to other Committee data on conducted of the health

be used as standards. This and the Committee expressed applicability as a standard countries y through status to

distinction is particular of any avail-

reference

7.

populations. encouraged adults aged at and regular functional should samples. the may elderly affect 60 collect anthropoanthropometric with this segment the moniof the

intervals

coupled of be paid taking and nutritional

because from

of

variable

rates system There or

of to

aging

from

person system groups of

to

person within

toring and

physiological

physiological

same individual. as those bedridden Currently old persons.

are also special institutionalized. anthropometric II, not the most include include people people developing normal for for,
>

elderly, include data set

population. the suchin choosing ation the hence, the veryof chronic years for review Ca-

Special attention population-based heterogeneity conditions that of

to selection criteria into consider-

Downloaded from www.ajcn.org by guest on April 30, 2012

the

high status.

prevalence Several WHO new research in to

available NHANES does data

data people people 80 y,

rarely

comprehensive older up to and

anthropometry, nadian normative data United exist evidence United country. Different ethnic reflects course, ences in Committee variations differences genetic from Japan

include

than 74 y. Furthermore, the age of 70 data. y, for improving data from the normative and there man in a developing geographic much over extent, of variation, various of the data is no in the CONCLUSION elderly.

a consultation should current recommendations the the use Committee and

be organized in light of identified of

by the available areas of anthropometry

interpretation

Kingdom include for the elderly in that States what is also elderly in is normal

64 y. Few countries, say, a 75-y-old man large and to an this BMI, uncertain environment worldwide the validity the and by older that to a 75-y-old show

populations height, in lifestyle and, (7). Given with caution weight,

and The which isting the life each of differ- viduals the health dataextensive

recommendations need to identify the and specific age populations

of

the Expert Committee reference data when groups. to at greatest achievement. reference the WHO. be

fill an appropriate,

exfor mdiand been the

and

differences,

used in assessing risk for nutritional the data For its the be the report sets out an that have not and universal data, full Committee considered Committee of data. more Special

health status considered

problems. series

In a key of tabular by lack of questions For other foster

sets for use as reference data, should be presented in l0-y age SDs, and should in their and age be 60s percentiles group; included should and available that because not be population-based and living to contain people that data for

applying groups for each people

criteria that data distributed sex; with means, elderly, index bility 80 from in free individuals or more their from although y of age to 80s. than mends priate bephasis people quired than data

previously because of and inadequacy crucial before these the be WHO placed

adolescents

anthropometric

of evidence of available reference raised age the infants groups, by can

applicaanswers are more recomapproempresent of is of least is addition of the and on it The and curto re-

several

it is thought extrapolated sample in a healthy some probably of multiple very few, the have

recommendations

those

provisional. that should international

Moreover, the major disabilities

it

should be environment, unhealthy one

development reference and children

anthropometric on

would most the

be

likely elderly

because

cause Given elderly completely select There the from ence across After the and mittee but

high and

prevalence the fact of be today will or of and

disease conditions if any, individuals of health reference in the

diseases. reference data do not correspond with the growth patterns in the infants who are fed in accordance with WHO recommendations. are The need for a new international growth reference used becoming to a matter in whom young of urgency, the children infections. to develop the acceptable should data. and more should The concentrate way in which optimal is key especially nutritional to survival, data. that for in use be based reference. screening international in underprivileged management or effort at

free the sample may also

disease,

definition

has a major significant grew be over available numerous the of up elderly

influence on the cohort differences under 40 on time. reference gaps data use data of in in data knowledge the quite y hence. different

elderly those of

of who differential

data. populations elderly: infants and conditions preventing the may influ-rently vary Most

Finally,

severe underway important,

An international such reference recognized reference on the values

survivorship

anthropometty and elderly, reference local

Committee

populations its review limitations interpreting did rather not the

to recommending recognizing when the levels use, Com- the data,are efforts clinical often usingreference

appropriate will of for

a reference that choice guide

is interpreted

anthropometry recommend collection

universal

public health decisions important than the be used as a general

describing

reference and

ANTHROPOMETRIC Peru Tunisia Colombia Brazil Costa Rica Cuba Morocco Chile Mexico Togo Zimbabwe China Mali Ghana Haiti Senegal Ethiopia India
50

REFERENCE

DATA

657

__________

40

30

Thinness

Overweight
18.5) (BMI
adult populations of both

(BMI
FI(;URE 4. BMI distribution

<

25)
sexes worldwide (7.

of

various

Downloaded from www.ajcn.org by guest on April 30, 2012

monitoring rigid nomic. individual-based as a screening fashion

and to

not

as fixed a individuals and health

standard
with different

that

can ethnic,
For

be

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dicators or 6. WHO. Alexandria. Eastern

Working
of Field

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nutritional guide on World

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1986:64:929-41. rapid Health 1995. interpretation of anthropometry. nutritional Organization assessment Regional emergencies. Office for the Egypt: Mediterranean.

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tool to detect

reference
individuals

values

should

be

used as

or
tions,

nutritional
the

disorders. diagnostic
reference values

and tool.

they For
should

at greater risk of health should not be viewed population-based

be used for

self-sufficient

applicacomparison

7. WHO.

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1995:854. JA. of WE. United Babu Ann of A. Hum Billewicz gestation. Edelman States Chopra Biol WZ. Ann DA. Thomson Hum of SKR. Academy DC: CR, age. I 974:29:65 Salzano population. Factors Stat RL, JC. Intrauterine Gynecol RL, M. C. Creasy growth 1G. Fetal Fryer values TE, age IP, Wilkins in Canada. R, for growth In: London: R. The WHO Martorell standards in to in M, Yip growth health. man. R. Child associated 1211 Cutter GR. growth 1989:161:271-7. RK. Cunningham and Karlberg for R, size at perinatal Lundin and I-S FM. Hum with fetal 1. Parental Biol low National FE

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10. 9.

Biol America. Fetal

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consultation clinicians, review, recomandI 3.

14. the 15.

worldwide, professionals recommendations the stimulate future also for

appreciative and contributed the Conimittees activities would

scientists,

Medicine/National Washington. HI. Stark

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We individuals, major and edgments institutions section

authoritative and interpreting The and present research

throughout should the

deeply

cycle. discussion

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characteristics 1975:47:37-43. birthweight. publication Foster

as
are

basis

A
from many All in the numerous of individuals Acknowl16.

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institutions, preparatory who of

governments.

which

1980:37.1DHEW Hoffman HI. retardation:

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