DOI: 10.1542/peds.2010-0242; originally published online July 5, 2010; 2010;126;e306Pediatrics

Malviya and Kevin K. TremperOlubukola O. Nafiu, Constance Burke, Joyce Lee, Terri Voepel-Lewis, Shobha

Body Mass IndexNeck Circumference as a Screening Measure for Identifying Children With High

  

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of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Neck Circumference as a Screening Measure forIdentifying Children With High Body Mass Index

WHAT’S KNOWN ON THIS SUBJECT: BMI is a poor descriptor ofcentral adiposity, a well-described risk factor for poorcardiometabolic phenotype. Other surrogates of body fatness arebeing investigated.

WHAT THIS STUDY ADDS: The authors provide data on theusefulness of neck circumference measurements for identifyingchildren with high BMI. They provide age- and gender-specificneck circumference cut points for identifying children who areoverweight or obese.

abstractOBJECTIVES: Overweight in children is most commonly described byusing BMI. Because BMI does not adequately describe regional (cen-tral) adiposity, other indices of body fatness are being explored. Neckcircumference (NC) is positively associated with obstructive sleep ap-nea, diabetes, and hypertension in adults. NC also has positive corre-lation with BMI in adults. The possible role of NC in screening for highBMI in children is not well characterized. The aims of this investigationwere to examine the correlation between BMI and NC in children and todetermine the best NC cutoff that identifies children with high BMI.

METHODS: Children who were aged 6 to 18 years and undergoing elec-tive noncardiac surgeries were the subjects of this study. Trained re-search assistants collected clinical and anthropometric data from allpatients. We calculated Pearson correlation coefficients between NCand other indices of obesity. We then determined by receiver operatingcharacteristic analyses the optimal NC cutoff for identifying childrenwith high BMI.

RESULTS: Among 1102 children, 52% were male. NC was significantlycorrelated with age, BMI, and waist circumference in both boys andgirls, although the correlation was stronger in older children. OptimalNC cutoff indicative of high BMI in boys ranged from 28.5 to 39.0 cm.Corresponding values in girls ranged from 27.0 to 34.6 cm.

CONCLUSIONS: NC is significantly correlated with indices of adiposityand can reliably identify children with high BMI. NC is a simple tech-nique that has good interrater reliability and could be used to screenfor overweight and obesity in children. Pediatrics 2010;126:e306–e310

AUTHORS: Olubukola O. Nafiu, MD,a Constance Burke,BSN,a Joyce Lee, MD, MPH,b Terri Voepel-Lewis, MSN,a

Shobha Malviya, MD,a and Kevin K. Tremper, MDa

Departments of aAnesthesiology and bPediatric Endocrinology,University of Michigan, Ann Arbor, Michigan

KEY WORDSneck circumference, childhood obesity, body mass index, centraladiposity

ABBREVIATIONSWC—waist circumferenceNC—neck circumferenceROC—receiver operating characteristicAUC—area under the curveLR�—positive likelihood ratioLR�—negative likelihood ratio

www.pediatrics.org/cgi/doi/10.1542/peds.2010-0242

doi:10.1542/peds.2010-0242

Accepted for publication Apr 8, 2010

Address correspondence to Olubukola O. Nafiu, MD, 1500 EMedical Centre Dr, University of Michigan Health System, RoomUH 1H247, Ann Arbor, MI 48109-0048. E-mail:onafiu@med.umich.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2010 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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Childhood overweight and obesity re-mains a worldwide public health con-cern.1 The most widely used tool fordefining overweight and obesity inboth adults and children is BMI, whichis defined as an individual’s weight inkilograms divided by the square oftheir height in meters (BMI� kg/m2).2

Despite the ease of use and popularityof BMI as an anthropometric tool, it isbecoming increasingly clear that it isnot a good proxy for regional adipos-ity.3 Regional deposition of fat, espe-cially in the upper body segment, is abetter predictor of some obesity-related complications, such as hyper-tension, diabetes, and heart disease.4

Many studies have demonstrated thevalue of waist circumference (WC) asan index of central obesity.5,6 Other in-vestigators have shown that WC, eithersingly or in combination with BMI, mayhave a stronger relation to somehealth outcomes than BMI alone.7,8

Neck circumference (NC) has alsobeen used as a potential proxy for obe-sity and cardiovascular disease inadults.9,10 Very few investigators11 haveattempted to use NC to screen for highBMI in children; therefore, the objec-tives of this study were to examine thecorrelation between NC and BMI inchildren, to examine the ability of NC toidentify correctly children with highBMI, and to determine the best NC cutpoint for identifying children of variousages as overweight/obese. Our a priorihypothesis was that a significant pro-portion of children with high NC wouldalso be overweight or obese.

METHODS

After institutional review board ap-proval, we prospectively recruited1102 children who were aged 6 to 18years and undergoing elective, noncar-diac surgical procedures at the MottChildren’s Hospital, University of Mich-igan, for inclusion in this study. Wechose a lower cutoff age of 6 years be-

cause of increased difficulty withcompliance while measuring anthro-pometric parameters in younger chil-dren. In addition, previous investiga-tors12 showed that landmarking ismore difficult in children who areyounger than 5, leading to poor inter-rater and intrarater reliability of NCmeasurements. Childrenwith goiter orother neck masses, neck deformity, ortracheostomy or cervical collar wereexcluded from this study.

Measurements

Trained research assistants took allclinical and anthropometric measure-ments. Height was measured to thenearest 0.1 cm by using a wall-mounted stadiometer with the pa-tients shoeless and head held in Frank-furt horizontal plane. Body weight wasmeasured, to the nearest 0.1 kg, by us-ing a calibrated electronic weighingscale with patients lightly clad in hos-pital gowns. NC was measured by us-ing a flexible tape, with the children inthe standing position, head held erect,at the level of the thyroid cartilage. WCwas measured (to the nearest 0.1 cm)with the children standing, at the endof normal expiration, by using an in-elastic tape at a point midway betweenthe inferior margin of the lowest riband the iliac crest. Measurementswere obtained with the tape snug butnot compressing the skin. BMI was cal-culated for all patients and was con-verted to age- and gender-specific per-centiles according to the 2000 Centersfor Disease Control and Preventiongrowth curves.13

Operational Definition of Terms

Children with a BMI �85th percentilewere classified as having normalweight, whereas children with BMI�85th percentile were classified asbeing overweight/obese.13 We alsostratified children into 2 age groups:young children (age �10 years) andolder children (age�10 years).

Statistical Analysis

Data analyses were performed withSPSS 17.0 for Windows and MedCalc7.4.1.1 (written by Frank Schoonjans,Mariakerke, Belgium). Means and SDsof age and anthropometric variableswere compared along gender lines.Pearson correlation coefficient wasused to explore the association be-tween NC and other continuous vari-ables, such as age, WC, BMI, and base-line blood pressure.

Receiver operating characteristic(ROC) analyses14 were used to deter-mine the predictive validity of NC aswell as evaluate optimal cutoff valuesfor identifying overweight or obesechildren. ROC curves determine thediscriminatory power of a screeningmeasure for correctly identifying indi-viduals on the basis of their classifica-tion by a reference test. The ROC curveis a plot of true-positive rate (sensitiv-ity) against the false-positive rate (1�specificity). A good test will have itsROC curve skewed to the upper left cor-ner.15 The area under the curve (AUC)describes the probability that a testwill correctly identify a pair of patientswho do and do not have a disease andwere randomly selected from a popu-lation; a perfect score will have an AUCof 1, whereas an AUC of 0.5 means thatthe test performs no better thanchance. For this study, patients withtrue-positive results were those withhigh BMI and high NC. Patientswith false-positive results were thosewith high NC and low BMI. Patients withfalse-negative results were those withlow NC and high BMI. Sensitivity wascalculated as true-positive results/(true-positive results� false-negativeresults); specificity was calculated astrue-negative results/(true-negativeresults � false-positive results). Cut-off values and the corresponding AUCas well as the likelihood ratios (posi-tive [LR�] and negative [LR�]) for NCthat were predictive of overweight/

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obesity were computed along age andgender lines. The LR� of a positive testresult is sensitivity divided by 1 �specificity and indicates howmuch theodds of a disease increase when a testis positive. Conversely, the LR� indi-cates 1 � sensitivity divided by speci-ficity and indicates howmuch the oddsof a disease decrease when a test isnegative.

RESULTS

A total of 1102 childrenmet the criteriafor inclusion in this study; the majority(70.6%) underwent outpatient surgery.The distribution of surgical specialtieswere as follows: orthopedics, 22.6%;urology, 12.7%; general surgery,13.8%; otorhinolaryngology, 19.4%;ophthalmology, 6.7%; and others,24.8%. The mean age of patients in thisseries was 10.7� 3.6 years. The meanNC in young boys with normal BMI wassignificantly greater than for younggirls with normal BMI (28.1 � 1.9 vs26.9� 2.0 cm; P� .001). Similarly, NCin overweight/obese young boys was�2 cm greater than for young girls ofcomparable BMI category (31.2 � 4.4vs 29.9 � 3.0 cm; P � .001). Table 1

details the remaining baseline charac-teristics of the study population strat-ified according to age group, BMI cate-gory, and gender. As expected, all ofthe anthropometric parameters weresignificantly higher in overweight/obese children than in their normalweight peers. Similarly, baseline sys-tolic blood pressure was significantlyhigher in overweight/obese childrenthan their lean peers in both youngand older children.

Table 2 presents the Pearson correla-tion coefficients between NC and someclinical and anthropometric parame-ters for boys and girls. NC showed astrong positive correlation with age,BMI, WC, and height and weight in bothboys and girls. In addition, NC was pos-

itively correlated with blood pressurein both genders. There was a strongpositive correlation between all of theanthropometric parameters in bothyoung and older children, although thecorrelation coefficients were higher inolder children (Table 3). In addition, NCseems to correlate better with BMI andWC in boys than in girls. Similarly,there was a closer correlation be-tween NC and the other anthropomet-ric indices in older than in youngerchildren (Table 3).

Table 4 shows the AUC for each 1-yearage group including the optimal NCcutoffs and the corresponding sensi-tivities and specificities for classifyingchildren into high BMI groups in boys.The likelihood ratios for each cutoffpoints are also shown. For example,LR� for a 6-year-old boy with NC�28.5cm indicates that he is 3.6 times morelikely to be overweight or obese than a6-year-old boy with NC values below

TABLE 1 Baseline Characteristics of the Children According to Age Group, BMI Category, andGender

Variable Young Children (Age�10 y) Older Children (Age�10 y)

Normal BMI(n� 404)

High BMI(n� 248)

P Normal BMI(n� 282)

High BMI(n� 168)

P

BoysAge, y 7.7� 1.5 7.6� 1.4 .510 14.0� 2.1 13.7� 1.9 .236Weight, kg 26.6� 9.3 37.6� 13.2 �.001 51.4� 12.2 77.6� 21.4 �.001Height, cm 127.0� 14.4 130.7� 14.2 .029 163.2� 13.7 164.4� 12.9 .199BMI, kg/m2 16.4� 1.4 23.1� 4.7 �.001 19.1� 2.4 28.9� 5.8 �.001WC, cm 59.1� 6.3 73.7� 15.0 �.001 73.4� 8.6 96.9� 14.6 �.001NC, cm 28.1� 1.9 31.2� 4.4 �.001 33.1� 3.1 37.6� 4.1 �.001SBP, mm Hg 101.3� 14.2 108.4� 14.2 �.001 115.2� 13.0 118.7� 14.8 �.041DBP, mm Hg 60.9� 8.3 63.4� 9.3 .022 64.9� 9.3 66.5� 8.7 .172GirlsAge, y 7.8� 1.4 7.7� 1.4 .967 14.3� 2.1 13.7� 2.1 .050Weight, kg 25.5� 6.3 36.9� 13.4 �.001 48.9� 10.6 69.3� 17.7 �.001Height, cm 126.9� 11.8 130.0� 13.9 .062 156.1� 13.5 158.6� 11.0 .118BMI, kg/m2 15.7� 1.6 22.8� 4.4 �.001 19.4� 2.6 28.4� 5.7 �.001WC, cm 58.2� 6.0 73.3� 13.4 �.001 72.2� 8.0 93.3� 15.8 �.001NC, cm 26.9� 2.0 29.9� 3.0 �.001 30.9� 2.3 34.3� 3.5 �.001SBP, mm Hg 103.0� 11.9 109.0� 14.2 �.001 110.7� 12.7 118.0� 11.7 �.001DBP, mm Hg 61.7� 8.3 63.8� 8.1 .055 65.7� 8.8 67.9� 9.6 .078

SBP indicates systolic blood pressure; DBP, diastolic blood pressure.

TABLE 2 Relationship Between NC and OtherAnthropometric Variables by Gender

Variable NC, cm

Boys Girls

r P r P

Age 0.66 �.001 0.61 �.001Weight 0.81 �.001 0.84 �.001Height 0.66 �.001 0.63 �.001BMI 0.71 �.001 0.78 �.001WC, cm 0.77 �.001 0.83 �.001

TABLE 3 Pearson Correlation Coefficients ofthe Anthropometric Indices by Ageand Gender

Age, y BMI-WC BMI-NC WC-NC P

Boys6 0.77 0.59 0.59 �.0017 0.76 0.57 0.57 �.0018 0.84 0.66 0.69 �.0019 0.89 0.83 0.85 �.00110 0.88 0.73 0.74 �.00111 0.71 0.68 0.68 �.00112 0.89 0.75 0.73 �.00113 0.92 0.67 0.65 �.00114 0.84 0.74 0.76 �.00115 0.89 0.76 0.75 �.00116 0.92 0.74 0.82 �.00117 0.94 0.84 0.86 �.00118 0.88 0.87 0.86 �.001Girls6 0.57 0.47 0.50 �.0017 0.86 0.82 0.82 �.0018 0.86 0.87 0.83 �.0019 0.78 0.76 0.64 �.00110 0.84 0.82 0.74 �.00111 0.94 0.88 0.7 �.00112 0.85 0.75 0.77 �.00113 0.88 0.72 0.68 �.00114 0.88 0.58 0.62 �.00115 0.91 0.56 0.65 �.00116 0.94 0.74 0.71 �.00117 0.91 0.81 0.85 �.00118 0.83 0.70 0.74 �.001

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this cut point. Corresponding ROC datafor girls are detailed in Table 5.

DISCUSSION

In this prospective study of childrenaged 6 to 18 years, NC, WC, and BMI allwere highly correlated with each otherwithin each gender–age group. NCalso performedwell as an index of highBMI in young children and adolescentsof both genders.

Obesity is arguably the most seriouschronic health problem facing chil-dren in the United States and has beenaptly described as a potential causefor the decline in life expectancy dur-ing the 21st century.16 Many studieshave linked increased adverse healthoutcomes with BMI �85th (over-weight) and 95th (obese) percen-tiles.12,17 One of the first steps toward

controlling the childhood obesity epi-demic is to make available monitoringtools that are low-cost, quick and easyto use, and generally acceptable toboth patients and health practitioners.Various methods are available for as-sessing obesity in adults and children.Some techniques such as height,weight, WC, and hip girths and compu-tations waist-to-hip ratio and BMI areapplicable in physician clinics or pri-mary health care facilities. WC hasbeen shown to be especially useful asan index of central adiposity and per-forms better than BMI in predicting ab-normal cardiometabolic phenotypes18;however, WC measurement may betime-consuming and culturally or envi-ronmentally problematic, especially inthe winter months because clotheshave to be removed for its accurate

measurement. In addition, WC may beaffected by postprandial abdominaldistension.

Several adult studies have docu-mented the value of NC as a simplescreening tool for identifying individu-als with high BMI.10 The association ofNC with central obesity and abnormalmetabolic profile in adults has alsobeen documented.19 Very few pediatricinvestigators have explored the poten-tial value of NC measurement as an in-dex of high BMI.11,12 Consistent withprevious findings in Turkish children,11

the results of this investigationshowed that NC performed well as anindex of high BMI in young and olderchildren of both genders; therefore, NCcould be a useful screening instru-ment for identifying overweight or

TABLE 4 AUCs, Optimal Cutoff Values, Sensitivities, and Specificities for NC Associated With Overweight/Obesity in 6- to 18-Year-Old Boys

Age, y n AUC (95% CI) Cutoff Sensitivity (95% CI) Specificity (95% CI) LR� LR�

6 95 0.84 (0.77–0.92) 28.5 68.8 (54.3–82.8) 81.8 (69.1–90.1) 3.60 0.427 62 0.80 (0.79–0.89) 28.7 79.3 (63.3–92.0) 69.7 (51.3–81.4) 2.60 0.308 61 0.92 (0.79–0.96) 29.0 72.4 (53.0–87.3) 90.6 (75.0–98.0) 7.70 0.309 49 0.97 (0.88–0.99) 30.5 89.6 (79.4–98.2) 87.8 (71.8–96.6) 7.20 0.0110 49 0.94 (0.82–0.98) 32.0 85.7 (57.2–98.2) 94.2 (80.8–99.3) 15.00 0.1511 39 0.92 (0.79–0.98) 32.2 75.3 (47.2–92.6) 95.6 (78.1–99.1) 17.30 0.2612 36 0.96 (0.84–0.99) 32.5 93.7 (69.9–99.8) 80.0 (56.3–94.3) 4.60 0.0813 50 0.79 (0.66–0.89) 33.5 81.8 (59.7–94.8) 67.9 (47.6–84.9) 2.60 0.2714 52 0.79 (0.66–0.89) 36.0 60.0 (36.1–80.9) 93.8 (79.2–99.2) 9.60 0.4315 37 0.91 (0.77–0.98) 37.0 78.9 (48.8–90.9) 94.4 (72.7–99.9) 14.20 0.2216 24 0.89 (0.69–0.98) 38.0 75.0 (34.9–96.8) 81.3 (54.4–96.0) 4.00 0.3117 21 0.84 (0.62–0.96) 38.6 66.7 (32.4–95.5) 93.3 (68.1–99.8) 10.00 0.3618 17 0.98 (0.81–1.00) 39.0 100.0 (47.8–100.0) 100.0 (73.5–100.0) NC 0.00

CI indicates confidence interval.

TABLE 5 AUCs, Optimal Cutoff Values, Sensitivities, and Specificities for NC Associated With Overweight/Obesity in 6- to 18-Year-Old Girls

Age, y n AUC (95% CI) Cutoff Sensitivity (95% CI) Specificity (95% CI) LR� LR�

6 59 0.79 (0.69–0.88) 27.0 62.9 (42.6–80.6) 84.8 (71.1–93.7) 4.10 0.447 49 0.92 (0.80–0.98) 27.1 87.5 (61.7–98.4) 87.9 (71.8–96.6) 7.20 0.148 60 0.86 (0.75–0.94) 27.9 86.7 (69.3–96.2) 70.0 (50.6–85.3) 2.90 0.199 48 0.87 (0.73–0.94) 29.3 72.7 (39.0–94.0) 85.1 (74.6–97.0) 6.70 0.3110 46 0.86 (0.72–0.94) 30.5 79.9 (54.9–93.4) 70.3 (49.8–86.2) 2.70 0.3011 35 0.94 (0.80–0.99) 31.0 80.0 (78.2–95.6) 90.0 (68.3–98.8) 8.00 0.2212 31 0.86 (0.69–0.96) 31.1 68.6 (41.3–89.0) 100.0 (78.2–100.0) NC 0.3113 51 0.86 (0.73–0.94) 31.3 82.4 (56.6–96.3) 76.5 (58.8–89.3) 3.50 0.2314 29 0.85 (0.67–0.96) 32.0 83.3 (35.9–99.6) 86.9 (66.4–97.2) 6.40 0.1215 30 0.64 (0.45–0.81) 33.0 66.7 (34.9–90.1) 55.6 (30.8–78.5) 1.50 0.6016 28 0.85 (0.67–0.96) 33.4 81.8 (48.2–97.7) 70.5 (44.0–89.7) 2.80 0.2617 28 0.92 (0.75–0.98) 34.5 83.3 (35.9–99.6) 100.0 (84.6–100.0) NC 0.1718 16 0.77 (0.50–0.88) 34.6 60.0 (48.2–93.4) 83.3 (51.6–97.6) 3.00 0.60

CI indicates confidence interval.

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obese children as well as children whoare at risk for central fat distribution,an important predictor of poor cardio-vascular health. NCmeasurement is in-expensive, is easier to obtain thanother markers of adiposity (WC andBMI), and has good interrater reliabil-ity. In addition, NC measurement maybe predictive of obstructive sleep ap-nea, especially in obese children.

Certain limitations exist in this studyand should be considered in interpret-ing the data. The cross-sectional na-ture of the study to some extent limitsits interpretation as to causality of as-sociations. Also, single NC measure-

ment could be considered a small lim-itation; however, NCmeasurementwaspreviously12 shown to have good inter-rater and intrarater reliability in theage group included in our study. Fi-nally, analyses that are based on ROCcalculations, predictive values, andlikelihood ratios depend on the overalldisease prevalence14; therefore, con-clusions reached in this study may notbe applicable to a population with farlower childhood overweight/obesityprevalence. Nonetheless, our data, thefirst to show the clinical relevance ofNC measurement in a large sample ofUS children, could prove immenselyuseful to practitioners who care for

children when it comes to screeningfor high BMI.

CONCLUSIONS

NC correctly identified a high proportionof young children and adolescents whowereoverweight or obese. NC is a simpletechnique that has good interrater reli-ability and could be used to screen foroverweight and obesity in children. OurNC cutoffs, which correctly identified themajority of children with high BMI, couldbe used as a reference for boys and girlswho are aged 6 to 18 years. Additionalstudies to evaluate the usefulness of NCas an index of adiposity in younger chil-dren are warranted.

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DOI: 10.1542/peds.2010-0242; originally published online July 5, 2010; 2010;126;e306Pediatrics

Malviya and Kevin K. TremperOlubukola O. Nafiu, Constance Burke, Joyce Lee, Terri Voepel-Lewis, Shobha

Body Mass IndexNeck Circumference as a Screening Measure for Identifying Children With High

  

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