obesity reviews doi: 10.1111/j.1467-789X.2010.00748.

Diagnostic in Obesity and Complications obr_748 295..300

Defining overweight and obesity in pre-school

children: IOTF reference or WHO standard?

L. Monasta1, T. Lobstein2, T. J. Cole3, J. Vignerová4 and A. Cattaneo5

1
Epidemiology and Biostatistics, Institute for
Maternal and Child Health IRCCS Burlo
Garofolo, Trieste, Italy; 2International
Association for the Study of Obesity, London,
UK; 3MRC Centre of Epidemiology for Child
Health, UCL Institute of Child Health, London,
UK; 4Department of Children and
Adolescents, National Institute of Public
Health, Prague, Czech Republic; 5Health
Services Research, Epidemiology and
International Health, Institute for Maternal and
Child Health IRCCS Burlo Garofolo, Trieste,
Italy
Received 25 January 2010; revised 5 March
2010; accepted 9 March 2010
Summary
Two international datasets are used to define overweight and obesity in pre-school
children: the International Obesity Task Force (IOTF) reference and the WHO
standard. This study compares the performance of the two datasets in defining
overweight and obesity in 24–60 months old children. This was done by plotting
the IOTF cut-offs against WHO curves and by comparing the prevalence of
overweight and obesity, as defined by the IOTF reference and by the WHO
standard, using 2001 data from the Czech Republic. The IOTF cut-off for over-
weight in 24–60 months old children goes from 1.7 to 1.1 z-scores on the WHO
chart, and for obesity it shifts with age from 2.7 to 2.2 z-scores. As a consequence,
at 5 years of age the prevalence of overweight in Czech girls is 3.4% using the
WHO and 15.3% using the IOTF definition. These discrepancies are due to the
choice of cut-offs and to the different criteria used to select the sample for
the IOTF reference and the WHO standard. Research is urgently needed to
identify, for the WHO standard, BMI cut-offs associated with an increased risk of
overweight and obesity, and associated health outcomes later in life.

Address for correspondence: L Monasta, Keywords: Cut-offs, obesity, overweight, pre-school children.
Epidemiology and Biostatistics, Institute for
Maternal and Child Health IRCCS Burlo obesity reviews (2011) 12, 295–300
Garofolo, Via dell’Istria 65/1, 34137 Trieste,
Italy. E-mail: monasta@burlo.trieste.it

were tracked back to define BMI values for overweight and

Introduction
Overweight and obesity in children are a growing problem
worldwide (1,2). Increasing attention is being given to
obesity in children under 5 years of age (3,4). Two inter-
national datasets are used to define overweight and obesity
in pre-school children in terms of body mass index (BMI):
the International Obesity Task Force (IOTF) reference and
the WHO standard. The former, used for children and
adolescents 2–18 years old, was developed from a database
of 97 876 boys and 94 851 girls from birth to 25 years
from six countries (Brazil, Great Britain, Hong Kong, the
Netherlands, Singapore and the USA) (5). Centile curves
were constructed using the LMS method (6), and BMI
values of 25 and 30 at 18 years of age for boys and girls
obesity at younger ages. The WHO standard is used for
children 0–59 months of age and is based on a sample of
888 (longitudinal sample, birth to 24 months) plus 6697
(cross-sectional sample, 18–71 months of age) healthy
breastfed infants and young children raised in environ-
ments that do not constrain growth (7,8). The sample
includes infants and young children from sites in six
countries (Brazil, Ghana, India, Norway, Oman and the
USA).
Despite some discussion, there is general agreement on
the appropriateness of BMI to define overweight and
obesity and on the need to replace national reference curves
with an international standard (9–11). However, during a
review on the prevalence of overweight and obesity in

© 2010 The Authors 295

obesity reviews © 2010 International Association for the Study of Obesity 12, 295–300
296 Overweight and obesity in pre-school children
pre-school children in Europe (12), it became clear that
using the IOTF reference as opposed to the WHO standard
on the same dataset yielded widely different rates. We thus
decided to carry out additional analysis to better explore
this issue. The objective of this study is to compare the
performance of the IOTF reference and that of the WHO
standard, using different cut-offs, in defining overweight
and obesity in children under 5 years of age.
Methods
To compare the cut-offs for overweight and obesity for
age and sex, we plotted IOTF cut-offs for children 24–60
months of age against WHO curves on graphs having age
in months on the x-axis and BMI values or WHO z-scores
on the y-axis. We also compared the prevalence of over-
weight (including obesity) and obesity, as defined by the
IOTF reference, with the results obtained using the 1SD,
2SD and 3SD cut-offs in the WHO standard. These are
the cut-offs suggested by WHO in its training course on
assessment of child growth (Module C: Interpreting
growth indicators) (13) to label children as at risk of over-
weight, overweight and obese, respectively. For these com-
parisons, we used the data from our review on the
prevalence of overweight and obesity in pre-school chil-
dren in Europe (12). We selected the data from the 6th
Czech Republic national survey on children and adoles-
cents (2001), this being the largest available survey (5456
children from 2 to 5 years of age) with measured height
and weight (14). Exact ages were used to calculate BMI
z-scores for the WHO standard. For the IOTF reference
children from 24 to less than 27 months were included in
the 24 months category, from 27 to less than 33 months
were included in the 30 months category, and so on with
the 60 months category including children from 57–60
months old.
21.5
21.0
20.5
20.0
19.5
IOTF obesity
BMI
19.0
18.5
18.0
17.5 IOTF overweight
17.0
16.5
24 36 Age (months)
L. Monasta et al. obesity reviews
Results
Figures 1 and 2 compare the IOTF and WHO cut-offs for
overweight and obesity for boys and girls, respectively (age
in months on the x-axis and BMI values on the y-axis). The
1SD line is included in both figures because, as mentioned
above, WHO defines 1SD as the cut-off for risk of over-
weight. In these figures, the IOTF and WHO cut-offs tend
to diverge with age, the difference between the two curves
being more pronounced in the chart for girls. Also, the
differences between the IOTF and WHO cut-offs for over-
weight and obesity are greater in girls than in boys. If we
calculate IOTF values for overweight and obesity in terms
of WHO z-scores, the IOTF cut-off for overweight in boys
between 24 and 60 months of age goes from approximately
1.7–1.5 z-scores on the WHO chart, while the IOTF cut-off
in girls goes from 1.6–1.1 z-scores. The IOTF cut-off for
obesity in boys shifts with age from 2.7–2.5 z-scores on the
WHO charts, while the cut-offs for obesity in girls goes
from 2.6–2.2 z-scores.
To help us determine the magnitude of the difference in
prevalence based on the IOTF reference as compared to the
WHO standard, data from the Czech Republic are shown
in Figs 3–6. The difference between the prevalence of over-
weight as defined by the IOTF and by the WHO standard
(cut-off at 2SD) appears to be fairly constant throughout all
ages in boys and to increase with age in girls. The same
pattern can be seen if we look at the difference between
rates of obesity as defined by the IOTF reference and by the
WHO standard (cut-off at 3SD). For example, at 5 years of
age Czech data can be interpreted as a prevalence of over-
weight in girls of 3.4% using the WHO standard at 2SD, or
of 15.3% using the IOTF cut-off. With the same Czech
data, the prevalence of obesity in boys at 5 years of age is
double if we use the IOTF cut-off compared with the WHO
standard at 3SD (3.1% vs. 1.5%, respectively).
WHO 3SD
WHO 2SD
WHO 1SD
Figure 1 The International Obesity Task Force
(IOTF) cut-offs for overweight and obesity in
48 60 boys plotted against the WHO standard.
© 2010 The Authors
obesity reviews © 2010 International Association for the Study of Obesity 12, 295–300
obesity reviews Overweight and obesity in pre-school children L. Monasta et al. 297

21.5
WHO 3SD
21.0

20.5

20.0

19.5
IOTF obesity

BMI
19.0

18.5 WHO 2SD

18.0

17.5 IOTF overweight

17.0
Figure 2 The International Obesity Task Force
WHO 1SD
(IOTF) cut-offs for overweight and obesity in 16.5
girls plotted against the WHO standard. 24 36 Age (months) 48 60

30%
WHO 1SD

25% IOTF overweight

WHO 2SD
20%

15%

10%

5%
Figure 3 Prevalence of overweight in the
Czech Republic (2001 data, measured, girls)
using the WHO standard and the International 0%
Obesity Task Force (IOTF) reference and 24 30 36 42 48 54 60
cut-offs. Age (months)

10%
WHO 2SD
IOTF obesity
8% WHO 3SD

6%

4%

2%
Figure 4 Prevalence of obesity in the Czech
Republic (2001 data, measured, girls) using
the WHO standard and the International 0%
Obesity Task Force (IOTF) reference and 24 30 36 42 48 54 60
cut-offs. Age (months)

© 2010 The Authors

obesity reviews © 2010 International Association for the Study of Obesity 12, 295–300
298 Overweight and obesity in pre-school children L. Monasta et al. obesity reviews

30%
WHO 1SD
IOTF overweight
25%
WHO 2SD
20%

15%

10%

5%
Figure 5 Prevalence of overweight in the
Czech Republic (2001 data, measured, boys)
0% using the WHO standard and the International
24 30 36 42 48 54 60 Obesity Task Force (IOTF) reference and
Age (months) cut-offs.

10%
WHO 2SD
IOTF obesity
8%
WHO 3SD

6%

4%

2%
Figure 6 Prevalence of obesity in the Czech
Republic (2001 data, measured, boys) using
0% the WHO standard and the International
24 30 36 42 48 54 60 Obesity Task Force (IOTF) reference and
Age (months) cut-offs.

weight, is the same everywhere in the world. It is difficult,

Discussion
The IOTF reference and the WHO standard yield different
results in terms of prevalence of overweight and obesity in
children 24–60 months of age in the same population. This
is due to the different approaches used to define cut-offs
and to the different criteria used to select the samples. The
IOTF reference is based on children from cross-sectional
surveys designed to be representative of the whole popula-
tion. The WHO standard is based on samples of children
selected to represent optimal growth (no environmental or
economic constraints, exclusive or predominant breastfeed-
ing for at least 4 months, single birth, non-smoking mother
and absence of significant morbidity in the newborn). The
IOTF approach is based on the idea that the BMI-based
definitions of overweight and obesity at 18 years of age,
which are considered to be associated to health conse-
quences in adults, can be tracked back to younger ages. The
WHO approach is based on the concept that, under ideal
circumstances, average child growth, in terms of height and
and it is not an objective of this paper, to express a prefer-
ence for one or the other approach. One of the reasons for
this is the paucity of evidence of an association between
overweight and obesity in children under 5 years of age and
health outcomes later in life (15). Stronger evidence of later
health outcomes is associated with obesity in children
between 5 and 18 years of age (16,17). A second reason is
the uncertainty as to whether the exposure to obesogenic
factors translates immediately into higher BMI at such a
young age, i.e. whether the BMI of children under 5 years
of age responds to obesogenic factors in the same way as
the BMI of older children and adults, or through indirect
mechanisms such as changes in growth velocity (18), or
anticipation of the adiposity rebound (e.g. from a mean age
of 6 years to 4 or 5 years) (19).
Some considerations on the differences between the two
approaches seem, however, necessary. As clearly shown in
the Figures, the two procedures tend to overestimate or
underestimate the prevalence of overweight and obesity by

© 2010 The Authors

obesity reviews © 2010 International Association for the Study of Obesity 12, 295–300
obesity reviews
sex and age, when used on the same population. This may
be interpreted as a consequence of using higher and lower
cut-offs, but may also depend on some intrinsic features of
the two datasets. The problem is more noticeable when one
compares data for girls. Chinn and Rona have already
shown how IOTF curves for girls tend to overestimate
overweight and obesity as a result of a problem with the
backward tracking of the BMI centiles from 18 years of age
(20). This is probably due to a sex bias at 18 years, because
the BMI plateaus earlier in girls than in boys, so that from
18–20 years the BMI rises more in boys than in girls. This
problem could perhaps be solved by tracking back BMI
centiles from other ages. Regarding the WHO standards,
Roelants and colleagues showed, in a study on a represen-
tative sample of 0–3 years old children from Flanders, how
growth of exclusively breastfed infants resembles more
that of the reference Flemish group than that of the WHO
standard (21). They suggest that, despite the relevance of
breastfeeding for appropriate growth, other factors may be
important, such as shared physical and social environments
and genetics. The Flemish sample, however, was not
selected with the strict criteria used by WHO. An addi-
tional problem with the WHO cut-offs for overweight and
obesity is the transition at 5 years between the standard for
children 0–5 years of age and the one for children and
adolescents 5–19 years of age. Overweight and obesity are
defined with 2SD and 3SD cut-offs in the former, and with
1SD and 2SD cut-offs in the latter (22), and in the transi-
tion between 60 and 61 months of age the prevalence
of overweight and obesity will be dramatically different
depending on whether the first or the second dataset and
cut-offs are used (Table 1).
The use of strict selection criteria by WHO implies that
none of the children in the sample were unhealthy. With
this assumption, the tails of the distribution, in the WHO
sample, would only represent children that are much
heavier (or much lighter) than the average, but not obese
(or severely underweight). Using the WHO standard, one
could classify a proportion of infants and young children as
Table 1 Prevalence of overweight and obesity for 59.5–60 months old
boys and girls in the Czech Republic (2001 data) according to the
International Obesity Task Force (IOTF) reference and the WHO
standards for 60 (WHO standard 0–5 years) and 61 (WHO standard
5–19 years) months old children
WHO 60 months IOTF WHO 61 months
Girls, n = 129
Overweight 4 (3.1%) 24 (18.6%) 27 (20.9%)
Obesity 1 (0.8%) 4 (3.1%) 4 (3.1%)
Boys, n = 157
Overweight 9 (5.7%) 13 (8.3%) 31 (19.7%)
Obesity 2 (1.3%) 3 (1.9%) 9 (5.7%)
© 2010 The Authors
obesity reviews © 2010 International Association for the Study of Obesity 12, 295–300
Overweight and obesity in pre-school children L. Monasta et al. 299
obese only in the presence, at a later age, of signs of obesity,
i.e. in the presence of the well-known health consequences
of overweight and obesity. Using the IOTF reference, on the
contrary, children over the established cut-off are consid-
ered as obese on the assumption that they will be obese at
18 years of age and beyond, an assumption that has not
been fully demonstrated.
To conclude, the use of two different international
methods to define overweight and obesity in pre-school
children generates uncertainty by yielding different results.
At the moment, the IOTF reference and cut-offs could be
preferable for the identification of overweight and obesity
both at individual and population levels because they are at
least based on a crude association with ill health later in
life, namely the definition of overweight and obesity at age
18 years. The WHO standard represents children that are
by definition healthy at 24–60 months of age. Research is
urgently needed to identify, for the WHO standard, BMI
cut-offs associated with an increased risk of overweight and
obesity, and consequent health outcomes later in life. For
example, research could be carried out to identify which
BMI cut-offs would identify pre-school children that, at
later ages (e.g. at school age and during adolescence), are
still classified as obese and present comorbidities such as
high blood pressure, impaired glucose metabolism or signs
of a fatty liver. This kind of research could be undertaken
also with the IOTF reference and cut-offs and would help
define a global standard to be used.
Conflict of Interest Statement
No conflict of interest was declared.
Authors’ contribution
• Lorenzo Monasta carried out the analysis and wrote
the different drafts of the manuscript.
• Tim Lobstein and Tim J Cole reviewed several drafts
of the manuscript and contributed with corrections, com-
ments and suggestions.
• Jana Vignerová provided data from the 6th Nation-
wide Anthropological Survey (2001) in the Czech Republic,
and commented on several drafts of the paper.
• Adriano Cattaneo was in charge of the overall project,
contributed substantially to the analysis and to the writing
of different drafts of the manuscript.
Acknowledgements
The project this paper is part of is being carried out with
financial support from the Commission of the European
Communities, SP5A-CT-2006-044128 ‘Health-promotion
through Obesity Prevention across Europe (HOPE): an
integrated analysis to support European health policy’. The
300 Overweight and obesity in pre-school children L. Monasta et al.
study does not necessarily reflect the Commission’s views
and in no way anticipates the Commission’s future policy
in this area. The 6th nationwide anthropological survey
2001, Czech Republic, was supported by Internal Grant
Agency of Ministry of Health CR, grant No. NJ/6792-3
and NR/7857-3. Tim J Cole is funded by UK Medical
Research Council grant G0700961.
References
1. Lobstein T, Baur L, Uauy R. Obesity in children and young
people: a crisis in public health. Obes Rev 2004; 5(Suppl. 1):
4–104.
2. Wang Y, Lobstein T. Worldwide trends in childhood over-
weight and obesity. Int J Pediatr Obes 2006; 1: 11–25.
3. Wells JC, Chomtho S, Fewtrell MS. Programming of body
composition by early growth and nutrition. Proc Nutr Soc 2007;
66: 423–434.
4. Dunger DB, Salgin B, Ong KK. Early nutrition and later health
early developmental pathways of obesity and diabetes risk. Proc
Nutr Soc 2007; 66: 451–457.
5. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a
standard definition for child overweight and obesity worldwide:
international survey. BMJ 2000; 320: 1240–1243.
6. Cole TJ. The LMS method for constructing normalized growth
standards. Eur J Clin Nutr 1990; 44: 45–60.
7. WHO Multicentre Growth Reference Study Group. WHO
Child Growth Standards based on length/height, weight and age.
Acta Paediatr Suppl 2006; 450: 76–85.
8. WHO Multicentre Growth Reference Study Group. Enrolment
and baseline characteristics in the WHO Multicentre Growth Ref-
erence Study. Acta Paediatr Suppl 2006; 450: 7–15.
9. Reilly JJ, Dorosty AR, Emmett PM. Identification of the obese
child: adequacy of the body mass index for clinical practice and
epidemiology. Int J Obes Relat Metab Disord 2000; 24: 1623–
1627.
10. Cole TJ, Faith MS, Pietrobelli A, Heo M. What is the best
measure of adiposity change in growing children: BMI, BMI%,
BMI z-score or BMI centile? Eur J Clin Nutr 2005; 59: 419–
425.
obesity reviews © 2010 International Association for the Study of Obesity 12, 295–300
obesity reviews
11. de Onis M, Habicht JP. Anthropometric reference data for
international use: recommendations from a World Health Organi-
zation Expert Committee. Am J Clin Nutr 1996; 64: 650–658.
12. Cattaneo A, Monasta L, Stamatakis E, Lioret S, Castetbon K,
Frenken F, Manios Y, Moschonis G, Savva S, Zaborskis A, Rito
AI, Nanu M, Vignerová J, Caroli M, Ludvigsson J, Koch FS,
Serra-Majem L, Szponar L, van Lenthe F, Brug J. Overweight and
obesity in infants and pre-school children in the European Union:
a review of existing data. Obes Rev 2010; 11: 389–398.
13. WHO. Child Growth Standards: Training Course on Child
Growth Assessment. WHO: Geneva, 2006.
14. Vignerová J, Bláha P. 4th, 5th and 6th Nation-wide Anthro-
pological Survey of Children and adolescents, Czech Republic.
National Institute of Public Health (and additional analysis):
Prague, 2007.
15. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH.
Predicting obesity in young adulthood from childhood and paren-
tal obesity. N Engl J Med 1997; 337: 869–873.
16. Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D,
Stewart L, Kelnar CJ. Health consequences of obesity. Arch Dis
Child 2003; 88: 748–752.
17. Baker JL, Olsen LW, Sorensen TI. Childhood body-mass index
and the risk of coronary heart disease in adulthood. N Engl J Med
2007; 357: 2329–2337.
18. Monteiro PO, Victora CG. Rapid growth in infancy and child-
hood and obesity in later life – a systematic review. Obes Rev
2005; 6: 143–154.
19. Taylor RW, Grant AM, Goulding A, Williams SM. Early
adiposity rebound: review of papers linking this to subsequent
obesity in children and adults. Curr Opin Clin Nutr Metab Care
2005; 8: 607–612.
20. Chinn S, Rona RJ. International definitions of overweight and
obesity for children: a lasting solution? Ann Hum Biol 2002; 29:
306–313.
21. Roelants M, Hauspie R, Hoppenbrouwers K. Breastfeeding,
growth and growth standards: Performance of the WHO growth
standards for monitoring growth of Belgian children. Ann Hum
Biol 2010; 37: 2–9.
22. de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C,
Siekmann J. Development of a WHO growth reference for school-
aged children and adolescents. Bull World Health Organ 2007; 85:
660–667.
© 2010 The Authors