Childhood Obesity assessment - influence on policy, practice and public perception
Submitting InstitutionLondon Metropolitan University
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Summary of the impact
With childhood obesity now of global public health and clinical
importance, attention had to be directed toward how best to identify the
condition and more importantly those who are at further risk of serious
obesity-related conditions. This case study illustrates how assessment has
moved beyond the simple crude measure, challenging the accepted approach
and developed more sensitive and specific assessment tools. Described is a
new range of clinical assessment charts which allow practitioners and
epidemiologists to evaluate a range of body characteristics known to be
linked to morbidity, make a fuller assessment of individual risk and
target better and specific intervention.
The underpinning research encompasses the work lead by Prof. David
McCarthy beginning in 1998. This unit broadened across disciplines
encompassing dietetics and exercise science. Prof. McCarthy strategically
repositioned his research from basic obesity science to an applied and
population-based approach, pre-empting the need for improved assessment
tools given the impending dramatic rise in (childhood) obesity prevalence
both nationally and globally. His earlier research on the developmental
origins of adult obesity had identified the capacity for abdominal obesity
(the more risky type of body fat distribution) to develop early in
childhood — at the time considered to be a phenomenon of adulthood. This
lack of understanding was reflected in the body mass index (BMI) being the
childhood obesity assessment tool — a crude weight-height relationship. He
recognised that more sensitive tools were essential which challenged
thinking and practice in childhood obesity assessment. In 2001 he
published the first (and only) set of UK waist circumference percentile
charts (McCarthy et al. 2001). Across a period of 10 years, more than 25
countries including major global populations of USA, Australia and Canada
produced national waist circumference references. His charts and
associated software were immediately adopted by the Child Growth
Foundation (responsible for producing national clinical growth charts) and
made available to clinicians, epidemiologists and other healthcare
professionals working in obesity assessment and management. These charts
are used in clinical practice in paediatric obesity where they determine
baseline abdominal adiposity and then used longitudinally to track changes
across growth and obesity intervention. They give information in changes
in risk for obesity-related morbidity including dyslipiaemia, and type 2
diabetes. He then demonstrated that in contrast to generalised obesity,
abdominal obesity had increased in UK children and youths at a far greater
rate, thus demonstrating the true extent of obesity-related disease risk
in the UK childhood population (McCarthy et al. 2003, McCarthy et al.
His research extended to develop further sets of childhood clinical
charts — specifically to assess total body fatness — the component of body
composition directly associated with morbidity. This contrasted with BMI
charts which simply assess total body weight in relation to height.
Published in 2006, these new charts substantially reduced the risk of
misclassifying children compared with BMI whilst at the same time focusing
attention away from excess weight.
This research questioned the validity of current assessment guidelines as
well as thinking on the relationship between growth and development and
body fat accumulation. Additionally it provided an opportunity to further
develop and refine the assessment tools in light of new knowledge on body
composition-related risk for cardiometabolic diseases in adults and
children. This research then addressed the influence of socioeconomic
status, ethnicity and weight management intervention on the validity and
application of obesity assessment tools. He developed new national
references for skeletal muscle mass in children. Sarcopenia (age-related
loss of muscle mass) is an emerging important clinical and public health
issue. These new muscle charts will allow the tracking of individuals who
show early signs of sarcopenia.
References to the research
McCarthy HD & Ashwell M (2006). A study of central fatness using
waist: height ratios in UK children and adolescents over two decades
supports the simple message — `keep your waist circumference to less than
half your height'. Int J Obesity 30: 988-992.
Details of the impact
The research findings have impacted to varying extents concerning obesity
assessment and intervention in children and public and commercial
perception of children's body shape and size.
i) Clinical practice. Impact is evidenced through clinical
assessment charts published alongside other growth charts used in
healthcare practice. Evidence of their use is their widespread
incorporation into routine paediatric and dietetic assessment, and routine
GP and school nurse usage. Nationwide child obesity intervention
programmes including MEND and More Life assess abdominal fatness using
these national references. The clinical assessment charts and their
scientific rationale are included in the major global textbook `Principles
of Nutritional Assessment' by Rosalind Gibson, published in 2005. This is
impact upon teaching beyond that delivered at this institution and is a
text that underpins professional practice in nutrition, dietetics and
ii) Health policy. NICE clinical guidelines now formally recognise
that waist measurement in children gives additional information on risk of
developing chronic health problems. This can only be interpreted and
guidance offered through use of the national references generated in this
case study Recent NICE guidelines on psychosis and schizophrenia in young
people (CG155), recommend the monitoring of waist through WC centile
charts in patients receiving anti-psychotic drugs due to their effect on
weight gain. The International Diabetes Federation now support waist
measurement as the "sine qua non" for the diagnosis of metabolic
syndrome in children, based on the data relating WC with components of the
metabolic syndrome. It states the WC>90th centile as the
diagnostic criterion, which can only be determined using the charts
produced in this case study.
iii) Public Health and surveillance. The National Obesity
Observatory endorsed waist measurement in children via a briefing paper
titled `Measures of central adiposity as an indicator of abdominal
obesity' in 2009. This paper was largely based upon the research output
from this case study and most of the content of the report was provided by
iv) Public and professional awareness. The impact of this
underpinning research is strengthened through high-profile dissemination
routes, including national daily newspapers (including on-line material).
Examples include: The Observer (2007, The changing shape of British
children), The Guardian (2006, The BMI myth) and Times Higher (London
Metropolitan University, Fat is a class issue, July 2010).
Dissemination to specialist audiences include invited presentations at
the following conferences:
- The Nutrition Society, summer, 2013 - Childhood nutrition and obesity:
current status and future challenges
- 2012 IFST/Leatherhead Food Research, Nutrition for Olympians,
nutrition for all.
- Weight Concern 2011, Primary Care 2011.
- Health and wellbeing@work 2010.
- Obesity & Health 2009.
- Association for the study of obesity 2009
A further related example of impact included collaborative activity with
the City University of New York to address childhood obesity in the two
global cities. One end result was a report `ObesCities', with a high
profile launch at City Hall, London and in New York. The report was
endorsed by the Mayor of London.
An additional opportunity was the on-screen expert input into 2 series of
the Sky1 programme Fat Families where abdominal obesity and its metabolic
consequences was brought to a national TV audience.
v) Industry/commercial The body fat charts were produced through
collaboration with MRC Human Nutrition Research, Cambridge, London School
of Hygiene & Tropical Medicine, Institute of Child Health, London and
the Child Growth Foundation, London. Industrial funding from Tanita Eu
facilitated this collaboration and also brought this tool into domestic
usage through incorporation into home body fat monitors (see link). This
industrial impact has extended to include the new children's skeletal
muscle reference charts. The manufacturers state that they have almost 50%
of the domestic market share. Additional commercial impact is demonstrated
through the incorporation of the children's body fat references into a
dual X-ray absorptiometry (DXA) scanner.
An innovative impact occurred through consultancy for a UK doll
manufacturer. Arklu produced a new doll at the end of 2012 whose shape and
dimensions were based on the reference measurements for a healthy 9 year
old girl generated from Prof. McCarthy's research. This product was
manufactured in response to calls for a more age-appropriate body shape in
dolls, including waist, leg length and chest size, It has sold worldwide
with enormous global publicity. The impact of this worldwide health
message is beyond anything achievable through conventional health
promotion routes and illustrates the power of innovative health and
Sources to corroborate the impact
i. Clinical practice — The sources below corroborate the
commercial availability of the waist charts and the body fat charts which
are used in clinical practice.
ii) Health policy - The documents below indicate the role of waist
measurement in the general assessment of children and adolescents,
particularly in cases of psychosis and schizophrenia — see section 1.3.15
and table 1, p47.
Identification, Assessment and Management of Overweight and Obesity in
Adults and Children)
NICE: psychosis and schizophrenia: recognition and management in children
and young people. January 2013. http:www.nice.org.uk/cg155
iii) Public health practice — This briefing document published by
the National Obesity Observatory describes the importance of central
adiposity in disease risk. More importantly it also describes the tools
for assessing central adiposity in children and adolescents which have
been developed from the research which underpins the impact for public
health practice in this case study.
iv) Public and professional awareness — The following links
corroborate how the research in this case study has been brought to a
v) Industry/commercial impact — The following links are to site
where the waist charts and waist reference data are used in commercial
contexts — as part of domestic and clinically body composition analysers —
bioimpedance systems and dual energy x-ray absorptiometry scanner.
— This link indicates the contribution made by the case study in
developing the new doll based on his data on children's body dimensions