Articles

Height and body-mass index trajectories of school-aged

children and adolescents from 1985 to 2019 in 200 countries
and territories: a pooled analysis of 2181 population-based
studies with 65 million participants
NCD Risk Factor Collaboration (NCD-RisC)*

Summary
Background Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We Lancet 2020; 396: 1511–24
aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures See Comment page 1465
weight gain beyond what is expected from height gain, for school-aged children and adolescents. *Members listed at the end of
the Article, and affiliations listed
in the appendix
Methods For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable
Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in Correspondence to:
Prof Majid Ezzati, School of
mean height and mean BMI in 1-year age groups for ages 5–19 years. The model allowed for non-linear changes over Public Health, Imperial College
time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including London, London W2 1PG, UK
periods of rapid growth during adolescence. majid.ezzati@imperial.ac.uk
See Online for appendix
Findings We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million
participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height
of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia,
and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and
those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and
Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest
mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both
boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and
Chad for boys and girls; and in Japan and Romania for girls) was approximately 9–10 kg/m². In some countries,
children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as
the best performing countries, but they became progressively less healthy compared with their comparators as they
grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or
gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls
in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators
(eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late
childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam,
Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and
western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric
status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a
much larger gain in height than they did in BMI. The unhealthiest changes—gaining too little height, too much
weight for their height compared with children in other countries, or both—occurred in many countries in sub-
Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys;
and in Mexico for girls.

Interpretation The height and BMI trajectories over age and time of school-aged children and adolescents are highly
variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and
risks.

Funding Wellcome Trust, AstraZeneca Young Health Programme, EU.

Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Introduction community. During school ages (typically 5–19 years),

Growth and development through childhood and these factors amplify or mitigate adversity in infancy and
adolescence are affected by social, nutritional, and early childhood and, if healthy, can help consolidate
envir­onmental factors at home, at school, and in the gains from early childhood and correct some nutritional

www.thelancet.com Vol 396 November 7, 2020 1511

 Articles
Research in context
Evidence before this study
We searched MEDLINE (through PubMed) for articles published
from inception up to Aug 2, 2020, with no language restrictions,
using the following search terms: (“body size”[mh:noexp]
OR “body height”[mh:noexp] OR “body weight”[mh:noexp] OR
“birth weight”[mh:noexp] OR “overweight”[mh:noexp] OR
“obesity”[mh] OR “thinness”[mh:noexp] OR “Waist-Hip
Ratio”[mh:noexp] OR “Waist Circumference”[mh:noexp] OR
“body mass index”[mh:noexp]) AND (“Humans”[mh]) AND
(“Health Surveys”[mh] OR “Epidemiological Monitoring”[mh]
OR “Prevalence”[mh]) NOT Comment[ptyp] NOT Case
Reports[ptyp]. Articles were screened according to the inclusion
and exclusion criteria described in the Methods section.
We found global or multicountry studies on trends over time in
height for adults and for children younger than 5 years, but not
for school-aged children and adolescents. One multicountry
study used cross-sectional height data in 53 community-based
samples and reported height differences in children aged
10–17 years. We found three studies on trends in body-mass
index (BMI) or overweight in children and adolescents, but only
one of these studies separately reported trends for children aged
5–19 years. We found multiple studies in individual or small
groups of countries on trends in height, BMI, or both. In terms
of considering combined changes in height and BMI, the Lancet
Series on the double burden of malnutrition used data on
inadequacies and imbalances.1–3 Therefore, investing in
the nutrition of school-aged children and adolescents is
crucial for a healthy transition to adulthood.
Height and body-mass index (BMI) are anthropometric
measures of the quality of nutrition and healthiness of
the living environment during childhood and adolescence
and are highly predictive of health and developmental
outcomes throughout life.4–7 Having low height and
excessively low weight for one’s height, represented by
low BMI, increases the risk of morbidity and mortality,
impairs cognitive development, and reduces educational
performance and work productivity in later life.4,5,7 High
BMI is associated with higher risk of disability and
premature death in adulthood and with poor mental
health and educational outcomes.6,8
Much of global health and nutrition research and
policy has focused on the period from preconception to
age 5 years.9,10 For school-aged children and adolescents,
global information is available only for BMI11 and, to our
knowledge, no study has reported global trends in height
for these ages. In this study, we present consistent and
comparable global estimates of height and BMI for
school-aged children from 1985 to 2019 and assess how
countries perform in terms of children and adolescents
growing taller without excessive weight gain. We also
evaluate height and BMI trajectories by age to understand
when growth is more or less healthy and to identify the
need for intervention.
1512 www.thelancet.com Vol 396 November 7, 2020
stunting in children younger than 5 years together with data on
various measures of underweight and overweight at different
ages, but did not have data on height in older children and
adolescents, nor did it analyse trends.
Added value of this study
To our knowledge, this study presents the first comparable
estimates of height in school-aged children and adolescents for
all countries in the world and does so alongside estimates of
BMI, which together are pathways from nutrition and
environment during childhood and adolescence to lifelong
health. We also analysed age trajectories of mean height and
BMI to investigate ages when growth in different countries was
more versus less healthy and to identify the need for
intervention.
Implications of all the available evidence
Age trajectories and time trends in mean height and BMI of
school-aged children and adolescents were highly variable
across countries and indicated heterogeneous nutritional
quality and life-long health advantages and risks. Global and
national nutrition and health programmes should extend to
children and adolescents in school years to consolidate gains in
children younger than 5 years and enable healthy growth
through the entire developmental period.
Methods
Data sources
For this pooled analysis, we used a database of cardio­
metabolic risk factors collated by the Non-Communicable
Disease Risk Factor Collaboration (NCD-RisC). The data­
base and its criteria for data inclusion and exclusion are
described in the appendix (pp 39–42). We used data from
the NCD-RisC database from 1985 to 2019 for analysis of
BMI and from 1971 to 2019 for analysis of height. Children
aged 5 years in data from 1971 were born in 1966, and
hence were 19 years old in 1985, as were children aged
6 years in data from 1972 through to 19-year-old adolescents
in data from 1985. Additionally, for analysis of height,
participants aged 20–30 years were included and assigned
to their corresponding birth cohort, because mean height
in these ages would be at least that when they were aged
19 years, given that the decline of height with age begins
in the third and fourth decades of life. The inclusion of
data from different years provided multiple observations
of each birth cohort during their life course, which in turn
helped to estimate the relevant parameters in the height
model that used birth year as its time scale. A list of the
data sources we used in this analysis and their charac­
teristics is provided in the appendix (pp 49–89).
Primary outcomes
Our primary outcomes were population mean height
and mean BMI from ages 5 to 19 years. BMI accounts for

the weight gain that is simply due to becoming taller, and
hence measures being underweight or overweight for a
person’s height. When presenting results, we refer to
gains in height as a healthy trend because the relationship
between height and health is positive and continuous.
We refer to BMI gain as unhealthy except in countries
where mean BMI was more than 1 SD lower than the
median of the WHO reference (ie, lower than 18·7 kg/m²
for girls and 19·6 kg/m² for boys at age 19 years). We also
compared mean height and BMI with the median of the
WHO growth reference12 (appendix pp 90–93) at each age
from 5 to 19 years. We used the WHO reference because
it provides growth curves for both height and BMI and is
used for monitoring in most countries. We started our
analysis from age 5 years because children enter school
at or around this age, and their nutrition, physical activity,
and health are influenced by food and environment at
their homes, schools, and communities.
Statistical analysis
We used a Bayesian hierarchical model to estimate
mean height and mean BMI by country, year, sex, and
age. The model is described in detail in a statistical
paper13 and related substantive papers11,14 and is sum­
marised in the appendix (pp 43–45). Briefly, the model
had a hierarchical structure in which estimates for each
country and year were informed by its own data, if
available, and by data from other years in the same
country and from other countries, especially those in
the same region and super-region, with data for similar
time periods. The extent to which estimates for each
country-year were influenced by data from other years
and other countries depended on whether the country
had data, the sample size of the data, whether they were
national, and the within-country and within-region
variability of the available data.
The model allowed for non-linear time trends and non-
linear changes in mean height and BMI with age,
including periods of rapid growth during puberty, and
the earlier age of these growth spurts in girls than in
boys. We used observation year—the year in which data
were collected—as the time scale for the analysis of BMI
and birth year as the time scale for the analysis of height,
consistent with previous analyses.11,14 For BMI, substantial
societal changes that affect nutrition and physical activity
might affect children of different ages simultaneously,
whereas for height, these effects accumulate in each
birth cohort and a cohort’s height-for-age monotonically
increases from childhood to late adolescence.
The computer code for the model is available online, as
are our country and regional estimates both in numerical
format and as interactive visualisations. All analyses
were done with R (version 3.5.1).
Role of the funding source
The funders of the study had no role in study design,
data collection, analysis, interpretation, or writing of the
www.thelancet.com Vol 396 November 7, 2020 1513
Articles
paper. Country and Regional Data Group members,
ARM, BZ, and MS had full access to the data in the study.
The corresponding author had final responsibility for the
decision to submit for publication.
Results
We pooled 2181 population-based measurement surveys
and studies, with anthropometric measurements on
50 million people aged 5–19 years and 15 million people
aged 20–30 years. We used at least one data source for
193 of 200 countries and territories for which estimates
were made, covering 98·7% of the world’s population
in 2019 (appendix p 94–95), and at least two data sources
for 177 countries, covering 98·0% of the world’s
population. Of these 2181 data sources, 1289 (59·1%)
were sampled from national populations, 360 (16·5%)
covered one or more subnational regions, and the
remaining 532 (24·4%) were from one or a small num­
ber of communities. Regionally, data availability ranged
from approximately three data sources per country in
Oceania to approxi­mately 46 sources per country in the
high-income Asia-Pacific region.
In 2019, the 19-year-olds who were on average the tallest
in the world lived in northwestern and central European
countries: the Netherlands (mean height 183·8 cm,
95% credible interval [CrI] 181·5–186·2), followed by
Montenegro, Estonia, and Bosnia and Herzegovina for
boys; and the Netherlands (170·4 cm, 168·3–172·4),
followed by Montenegro, Denmark, and Iceland for girls
(figure 1A). The 19-year-olds who were on average the
shortest in 2019 lived in south and southeast Asia,
Latin America, and east Africa: Timor-Leste (160·1 cm,
158·0–162·2), followed by Laos, Solomon Islands, and
Papua New Guinea for boys; and Guatemala (150·9 cm;
149·4–152·4), followed by Bangladesh, Nepal, and Timor-
Leste for girls. The 20 cm or higher dif­ference between
countries with the tallest and shortest mean height
represents approximately 8 years of growth gap for girls
and approximately 6 years for boys. For example, 19-year-
old girls in four countries (Guatemala, Bangladesh,
Nepal, and Timor-Leste) had the same mean height as
that of 11-year-old Dutch girls, and those in another
53 countries—such as Burundi, India, Indonesia, Laos,
Pakistan, Peru, the Philippines, and Yemen—had the
same mean height as that of 12-year-old Dutch girls
(figure 2). Similarly, 19-year-old boys in 11 countries
throughout Asia, Latin America, and sub-Saharan Africa
had the same mean height as that of Dutch boys
aged 13 years.
Although northwestern European children and For the model code, estimates,
adolescents were on average the tallest in the world in and visualisations see
http://www.ncdrisc.org/
2019, much of this advantage was achieved before the
late 20th century, and many of these countries had below
median height change from 1985 to 2019 (figure 1B,
appendix pp 96–296). By contrast, central European
countries such as Montenegro and Poland achieved a
substantial part of their height advantage since 1985,
 Articles

A Girls Boys

Caribbean Caribbean
American Samoa Fiji Montenegro Seychelles American Samoa Fiji Montenegro Seychelles
Bahrain French Polynesia Nauru Solomon Islands Bahrain French Polynesia Nauru Solomon Islands
Bermuda Kiribati Niue Tokelau Bermuda Kiribati Niue Tokelau
Brunei Maldives Palau Tonga Brunei Maldives Palau Tonga
Cape Verde Marshall Islands Samoa Tuvalu Cape Verde Marshall Islands Samoa Tuvalu
Comoros Mauritius São Tomé and Príncipe Comoros Mauritius São Tomé and Príncipe
Cook Islands Federated States of Micronesia Vanuatu Cook Islands Federated States of Micronesia Vanuatu
Height (cm) Height (cm)

150 155 160 166 171 160 166 172 178 184

Caribbean Caribbean

American Samoa Fiji Montenegro Seychelles American Samoa Fiji Montenegro Seychelles
Bahrain French Polynesia Nauru Solomon Islands Bahrain French Polynesia Nauru Solomon Islands
Bermuda Kiribati Niue Tokelau Bermuda Kiribati Niue Tokelau
Brunei Maldives Palau Tonga Brunei Maldives Palau Tonga
Cape Verde Marshall Islands Samoa Tuvalu Cape Verde Marshall Islands Samoa Tuvalu
Comoros Mauritius São Tomé and Príncipe Comoros Mauritius São Tomé and Príncipe
Cook Islands Federated States of Micronesia Vanuatu Cook Islands Federated States of Micronesia Vanuatu
Height change (cm) Height change (cm)

–1 0 2 4 5 7 −3 0 2 4 7 9

Figure 1: Height and height change by country and territory

(A) Mean height of 19-year-olds in 2019. (B) Change in mean height of 19-year-olds from 1985 to 2019.

Dutch-equivalent age (years)

11 12 13 14 15 16 17 18 19
Girls Boys

Caribbean Caribbean
American Samoa Fiji Montenegro Seychelles American Samoa Fiji Montenegro Seychelles
Bahrain French Polynesia Nauru Solomon Islands Bahrain French Polynesia Nauru Solomon Islands
Bermuda Kiribati Niue Tokelau Bermuda Kiribati Niue Tokelau
Brunei Maldives Palau Tonga Brunei Maldives Palau Tonga
Cape Verde Marshall Islands Samoa Tuvalu Cape Verde Marshall Islands Samoa Tuvalu
Comoros Mauritius São Tomé and Príncipe Comoros Mauritius São Tomé and Príncipe
Cook Islands Federated States of Micronesia Vanuatu Cook Islands Federated States of Micronesia Vanuatu

Figure 2: Growth gap for 19-year-olds in 2019 by country and territory

The growth gap is the difference between 19 years and the age at which a Dutch girl or boy, who had the highest height in the world, achieved the height of 19-year-
olds in different countries.

1514 www.thelancet.com Vol 396 November 7, 2020

 Articles

especially in boys. However, the largest gains in height
over the past 3·5 decades were those in some emerging
economies, including China (largest gain for boys and
third largest for girls) and South Korea (third largest for
boys and second largest for girls), and through parts
of southeast Asia, the Middle East and north Africa,
and Latin America and the Caribbean. Nonetheless, how
much mean height changed from 1985 to 2019 varied
substantially, even within this group of countries. For
example, gains in mean height at age 19 years in China
were larger than in India by 3·5 cm (95% CrI 1·8–5·1)
for boys and 2·3 cm (0·9–3·7) for girls. By contrast
with emerging economies, the height of children and
adolescents, especially boys, has on average stagnated or
become shorter since 1985 in many countries in sub-
Saharan Africa.10
Pacific island countries in Oceania had the highest
mean BMI in the world in 2019, surpassing 28 kg/m²
for 19-year-olds in many of these nations (figure 3A).
Late-adolescence BMI was also high for boys and girls in
Middle Eastern and north African countries such as
Kuwait and Bahrain; in Caribbean islands such as the
Bahamas; in Chile, the USA, and New Zealand; and, for
girls, in South Africa. The mean BMI of 19-year-old boys
and girls was lowest (approximately 21 kg/m² or lower)
in countries in south Asia (eg, India and Bangladesh),
southeast Asia (eg, Timor-Leste), and east and central
Africa (eg, Ethiopia and Chad), as was it for 19-year-old
girls in Japan and some central European countries (eg,
Romania and Bosnia and Herzegovina). The highest and
lowest worldwide BMIs were approximately 9–10 kg/m²
apart, equivalent to about 25 kg of weight.
Change in late-adolescence BMI from 1985 to 2019
ranged from small changes (less than 0·5 kg/m²) in both
sexes in Japan and some European countries (eg, Italy,
Russia, and Denmark) and, for girls, in some central
Asian (eg, Armenia) and sub-Saharan African countries,
to increases higher than 3 kg/m² in Malaysia and some

A Girls Boys

Caribbean Caribbean
American Samoa Fiji Montenegro Seychelles American Samoa Fiji Montenegro Seychelles
Bahrain French Polynesia Nauru Solomon Islands Bahrain French Polynesia Nauru Solomon Islands
Bermuda Kiribati Niue Tokelau Bermuda Kiribati Niue Tokelau
Brunei Maldives Palau Tonga Brunei Maldives Palau Tonga
Cape Verde Marshall Islands Samoa Tuvalu Cape Verde Marshall Islands Samoa Tuvalu
Comoros Mauritius São Tomé and Príncipe Comoros Mauritius São Tomé and Príncipe
Cook Islands Federated States of Micronesia Vanuatu Cook Islands Federated States of Micronesia Vanuatu
BMI (kg/m2)

19 22 24 27 30

Caribbean Caribbean

American Samoa Fiji Montenegro Seychelles American Samoa Fiji Montenegro Seychelles
Bahrain French Polynesia Nauru Solomon Islands Bahrain French Polynesia Nauru Solomon Islands
Bermuda Kiribati Niue Tokelau Bermuda Kiribati Niue Tokelau
Brunei Maldives Palau Tonga Brunei Maldives Palau Tonga
Cape Verde Marshall Islands Samoa Tuvalu Cape Verde Marshall Islands Samoa Tuvalu
Comoros Mauritius São Tomé and Príncipe Comoros Mauritius São Tomé and Príncipe
Cook Islands Federated States of Micronesia Vanuatu Cook Islands Federated States of Micronesia Vanuatu
BMI change (kg/m2)

–1 0 1 2 3 4

Figure 3: BMI and BMI change by country and territory

(A) Mean BMI of 19-year-olds in 2019. (B) Change in mean BMI of 19-year-olds from 1985 to 2019. BMI=body-mass index.

www.thelancet.com Vol 396 November 7, 2020 1515

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Central and eastern Europe East and southeast Asia High-income western countries* Oceania Sub-Saharan Africa
Central Asia, the Middle East, and north Africa High-income Asia-Pacific Latin America and the Caribbean South Asia
Girls
30

28
Mean BMI (kg/m2)

26

24

22

20

18
145 150 155 160 165 170 175 145 150 155 160 165 170 175 145 150 155 160 165 170 175

Boys
30

28
Mean BMI (kg/m2)

26

24

22

20

18
155 160 165 170 175 180 185 155 160 165 170 175 180 185 155 160 165 170 175 180 185
Mean height (cm) Mean height (cm) Mean height (cm)

Figure 4: Combined change from 1985 to 2019 in mean height and mean BMI of 19-year-olds
Each arrow shows one country. For each country, the arrow begins at mean height and BMI values in 1985 and ends in mean height and BMI values in 2019. Each arrow
colour refers to countries in one region. BMI=body-mass index. *Countries in northwestern Europe, southwestern Europe, and English-speaking high-income countries
(Australia, Canada, Ireland, New Zealand, the UK and the USA).

countries in Oceania for both sexes, in China for boys,
and in Mexico for girls (figure 3B).
From 1985 to 2019, 19-year-old girls in some countries
in central Asia (eg, Armenia and Azerbaijan) and 19-year-
old boys in some European countries (eg, Portugal,
Denmark, Poland, and Montenegro) had moderate-to-
large gains in height alongside small or no increases in
BMI (figure 4). Meanwhile, children grew much taller
in some countries (eg, girls in South Korea, Turkey,
Vietnam, and Saudi Arabia), while their BMI increased
about the same as the global median. Both these trends
were healthier than those of boys and girls in much of
sub-Saharan Africa and in New Zealand and the USA,
boys in Malaysia and some countries in Oceania, and
girls in Mexico, where little or no height gain occurred,
much larger weight was gained, or both, relative to other
countries.
Boys born in 2000 (ie, who were aged 19 years
in 2019) gained from 53·4 cm to 71·3 cm of height
from their 5th to 19th birthday in different countries
(appendix pp 96–296); for girls born in the same year,
height gain from their 5th to 19th birthday ranged
from 43·8 cm to 55·5 cm in different countries. We
compared the mean height and mean BMI of children
born in 2000 in each country with the median of the
respective WHO growth reference12 at each age
from 5 to 19 years (figure 5A). This comparison showed
that, in many countries, mean height through­out late
childhood and adolescence was lower than the median
of the WHO growth reference (figure 5A, appendix
pp 297–98). Exceptions to this pattern were much of
Europe and a few countries in the Caribbean and
Polynesia (eg, Dominica for boys and girls and French
Polynesia for girls), where mean height throughout
late child­hood and adolescence was higher than the
median of the WHO reference by about 3 cm or more.
Elsewhere, either height advantage (ie, having mean
height higher than the WHO reference median) at
5 years was diminished or reversed as children grew
older, or height disadvantage (ie, having mean height
lower than the WHO reference median) increased.
This progres­sive falling behind as children grew older
was especially noticeable in middle-income countries
in Latin America and the Caribbean (eg, Chile and
Uruguay), the Middle East and north Africa (eg, United
Arab Emirates), and sub-Saharan Africa (eg, Mauritius
and South Africa), where children had optimal height
at age 5 years, but by the time they reached age 19 years,
their height was shorter than the median of the WHO
reference, by about 2 cm or more. A small number of

1516 www.thelancet.com Vol 396 November 7, 2020

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(Figure 5 continues on next page)

www.thelancet.com Vol 396 November 7, 2020 1517

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Central and eastern Europe Central Asia, the Middle East, and north Africa East and southeast Asia High-income Asia-Pacific High-income western countries*
Latin America and the Caribbean Oceania South Asia Sub-Saharan Africa

1518 www.thelancet.com Vol 396 November 7, 2020


countries (eg, Russia for boys and girls and Iran for
boys) slightly reduced the gap to the WHO reference
median during late childhood and adolescence.
For BMI, the deficit relative to the WHO reference
median at age 5 years, which was seen mainly in sub-
Saharan Africa and south and southeast Asia, generally
became smaller or disappeared as children grew to
adolescence and reached age 19 years (figure 5A). For
girls in South Africa and girls and boys in Canada, China,
and some countries in Oceania, the Middle East and
north Africa, and Latin America and the Caribbean,
mean BMI was similar to the WHO reference median for
5-year-old children, but exceeded the WHO reference
median as the children became older.
Comparing height and BMI in each country with the
median of all countries (figure 5B) showed that children
and adolescents in some countries had a consistent
height advantage or disadvantage relative to those in
other countries at every age. This was especially the case
for countries at the top (eg, the Netherlands, Denmark,
Montenegro, Estonia, and Iceland) and the bottom
(eg, Timor-Leste, Laos, Nepal, Yemen, and Guatemala) of
the global ranks at age 19 years. For other countries,
children’s height caught up with or fell behind their
comparators during school ages. For example, children in
some European countries (eg, girls in Belgium and boys
in Austria) and Latin America and the Caribbean (eg, girls
in Puerto Rico and boys in Barbados) had about the same
height as Dutch children at age 5 years, but progressively
fell behind such that, by the time they were 19 years old,
they were more than 5 cm shorter than Dutch adolescents.
By contrast, the height of children and adolescents in
Latvia, Czech Republic, Morocco, and Iran progressively
improved relative to others as they approached age
19 years.
When age-specific mean BMI was compared with the
global median (figure 5B), whether a country had low
(eg, countries in south and southeast Asia) or high
(eg, the USA, Chile, and countries in Oceania) mean
BMI relative to others, persisted more than was the case
for height. Nonetheless, some differences in age trajec­
tories of BMI occurred across countries. For example,
girls and boys in some European countries (eg, Italy,
Figure 5: Age trajectory of height and BMI for 19-year-olds in 2019
Mean height and BMI of 19-year-olds in 2019 (ie, those born in 2000) at each age
from 5 to 19 years compared with the median of the WHO growth reference12 (A)
and the world median (B). Each cell represents the difference between the height
or BMI of children and adolescents in one country and the median value for a
given age of the WHO growth reference (A) and all countries (B). Countries are
ordered by decreasing height or increasing BMI in adolescents at age 19 years in
2019. The median of the WHO growth reference and world median are presented
in the appendix (pp 90–93). Results reported as Z scores of the WHO growth
reference are presented in the appendix (pp 297–98). A comparison of height and
BMI gap between boys and girls is presented in the appendix (pp 299–300).
BMI=body-mass index. SAR=Special Administrative Region. *Countries in
northwestern Europe, southwestern Europe, and English-speaking high-income
countries (Australia, Canada, Ireland, New Zealand, the UK and the USA).
www.thelancet.com Vol 396 November 7, 2020 1519
Articles
France, and Croatia), Japan, and Seychelles progressively
moved towards healthier BMIs relative to other countries,
and the difference between their BMI and the global
median changed from positive to negative. By contrast,
girls and boys in countries such as Kuwait, Bahrain,
Fiji, Jamaica, and Mexico; and girls in South Africa and
New Zealand had a progressively higher BMI relative to
the global median as they became older.
Discussion
We identified highly variable age trajectories and trends
over time in the height and BMI of school-aged children
and adolescents across countries and territories. These
cross-country differences show that childhood and adoles­
cence are crucial periods in differentiating countries in
terms of how they shape these determinants of lifelong
health.
Our results are consistent with findings from both
studies of adolescents in individual countries and global
studies of adult height, which show substantial variation
in how much height has changed throughout the
world.14 One study,15 assessing cross-sectional height in
53 community-based samples, found substantial cross-
population variation in height differences from ages
10–17 years, which is consistent with our findings on
age trajectories. Our results are also consistent with
previous global analyses11 in terms of regions and
countries with the highest and lowest BMI, but previous
studies had not considered age trajectories.
Our study has strengths in scope, data, and methods:
we presented novel estimates of height in school-aged
children and adolescents for all countries in the world,
and we did so alongside estimates of BMI. We used
an unprecedented scale of population-based data from
193 countries and territories covering approximately
99% of the world’s population, while maintaining a high
standard of data representativeness and quality. Data
were analysed according to a consistent protocol, and
the characteristics and quality of data from each country
were rigorously verified through repeated checks by
NCD-RisC members. We used a statistical model that
accounted for non-linear changes in height and BMI
throughout childhood and adolescence, and we used all
available data while giving more weight to national data
than to subnational and community sources.
As with all global analyses, our study has some
limitations. Despite our extensive efforts to identify
and access worldwide population-based data, some
countries, espe­cially those in the Caribbean, Polynesia
and Micronesia, Melanesia, and sub-Saharan Africa, had
fewer data sources than in other regions. The scarcity of
data is reflected in the larger uncertainty of our estimates
for these countries and regions compared with those for
other countries. Of the studies used, less than half
had data for children aged 5–9 years compared with
nearly 90% with data for children aged 10–19 years,
which increases the uncertainty of findings for the
 Articles
younger age groups. BMI is an imperfect measure of the
extent and distribution of fat in the body, but it has the
major advantage of having consistent and comparable
data in many population-based surveys, especially com­
pared with measures such as body fat measured by dual-
energy x-ray absorptiometry (DEXA), which is complex
and costly and cannot be used in surveys. A systematic
review reported that BMI and DEXA-measured body
fat were highly correlated.16 We compared height and
BMI in each country with the median of the WHO
growth reference.12 Although the reference is the current
international comparison tool,17 unlike that of children
younger than 5 years, it is not based on a multicountry
sample of predominantly healthy and well-nourished
children.12 Consequently, the reference might be affected
by slower growth as the sample children grew older.18
Future studies should also evaluate the socio­economic
and geographical patterns of height and BMI in these
ages, as has been done for children younger than 5 years
and adults.19,20
Several factors that interact throughout childhood and
adolescence, and possibly across generations, might
be responsible for the heterogeneous worldwide age
trajectories and trends of height and BMI.21 First, there
is an important genetic component to height22,23 and, to
a lesser extent, to BMI24 within populations. However,
genetics explains a small part of the variation across
countries or the changes over time, especially for
BMI.25–28 That genetics has a small role in height and
BMI at the population level relative to nutrition and
environment is also supported by the finding that the
height of migrant descendents typically converges to the
height of their new country within a few generations.29–31
Second, some of the observed differences in height and
BMI might be intergenerational or due to exposures
and experiences during pregnancy, mediated through
birth length and weight.21 Third, the age of puberty
onset, which is influenced by diet, physical activity,
and weight gain during childhood, might affect height
gain during the adolescent growth spurt and in late
adolescence.32 Although some studies have found a
negative association between age of pubertal onset and
final height,33 others have found that age of pubertal
onset does not affect final height, because an earlier
puberty onset might be compensated by a more intense
or longer period of peak height velocity.34 No comparable
global data exist on age at menarche and timing of
pubertal growth, but national data indicate substantial
changes in some countries. Finally, all of these pathways
are influenced by food and nutrition,28,35,36 including
energy balance, and adequacy and quality of nutrients,
especially proteins, fats, and micronutrients.18,21,37 There
is also an important effect from the occurrence and
treatment of infections, which itself is influenced by
water and sanitation, and whether episodes of infections
are effectively treated in a timely manner. Similarly,
physical activity at home and school can influence BMI.
1520 www.thelancet.com Vol 396 November 7, 2020
Fully establishing the drivers of the observed height
and BMI trajectories and trends requires data on these
determinants and their distributions in different
countries.
Our findings on the heterogeneous age trajectories
and time trends of height and BMI in late childhood and
adolescence raise the need to rethink and revise two
common features of global health and nutrition pro­
grammes. First, we need to overcome the disconnect in
research and practice between reducing undernutrition,
particularly short stature, and preventing and managing
overweight and obesity.11,19,21 Second, the finding that
children in some countries grow healthily to age 5 years
but do not continue to do so during school years shows
an imbalance between investment in improving nutrition
and growth before age 5 years and doing so in school-
aged children and adolescents.38 Therefore, our findings
should motivate policies and interventions at home, at
school, in the community, and through the health system
to support healthy growth during the entire period
from birth to adolescence through enhanced nutritional
quality, healthier living environment, and provision of
high-quality preventive and curative care. These mea­
sures include agricultural and food system policies39 that
increase the availability and reduce the cost of nutritious
foods that help children grow taller without gaining
excessive weight for their height; (conditional) cash
transfers and food vouchers towards nutritious foods
for low-income families; free healthy school meal
programmes; fiscal and regulatory policies that restrict
the consumption of unhealthy foods, especially pro­
cessed carbohydrates; the provision of affordable healthy
housing, clean water, and sanitation; and the provision of
facilities for play and sports in the community and at
school. Taking these actions would enable children to
grow taller without gaining excessive weight, with
lifelong benefits for their health and wellbeing.
Contributors
ARM, ZB, RB, and ME designed the study. Members of the Country and
Regional Data Group collected and re-analysed data and checked pooled
data for accuracy of information about their study and other studies in
their country. ARM, BZ, and MS led the data collection. ARM led the
statistical analysis with input from BZ, JB, JEB, CJP, and ME and
prepared results. Members of the Pooled Analysis and Writing Group
contributed to study design, collated data, and checked all data sources
in consultation with the Country and Regional Data Group. ARM and
ME wrote the first draft of the report with input from other members of
the Pooled Analysis and Writing Group. Members of the Country and
Regional Data Group commented on the draft report. ME oversaw
research. The authors alone are responsible for the views expressed in
this Article and they do not necessarily represent the views, decisions,
or policies of the institutions with which they are affiliated.
NCD Risk Factor Collaboration (NCD-RisC) pooled analysis and writing
Andrea Rodriguez-Martinez, Bin Zhou, Marisa K Sophiea,
James Bentham, Prof Christopher J Paciorek, Maria LC Iurilli,
Rodrigo M Carrillo-Larco, James E Bennett, Mariachiara Di Cesare,
Cristina Taddei, Honor Bixby, Gretchen A Stevens, Leanne M Riley,
Melanie J Cowan, Stefan Savin, Goodarz Danaei, Adela Chirita-Emandi,
Prof Andre P Kengne, Prof Young-Ho Khang, Prof Avula Laxmaiah,
Prof Reza Malekzadeh, Prof J Jaime Miranda, Prof Jin Soo Moon,
Stevo R Popovic, Prof Thorkild IA Sørensen, Maroje Sorić, Gregor Starc,
 Articles

Ahmad A Zainuddin, Prof Edward W Gregg, Prof Zulfiqar A Bhutta, Alexandra M Cucu*, Liufu Cui*, Felipe V Cureau*, Graziella D’Arrigo*,
Prof Robert Black, Prof Majid Ezzati. Eleonora d’Orsi*, Liliana Dacica*, María Ángeles Dal Re Saavedra*,
Jean Dallongeville*, Albertino Damasceno*, Camilla T Damsgaard*,
NCD Risk Factor Collaboration (NCD-RisC) country and regional data, listed
Goodarz Danaei*, Rachel Dankner*, Thomas M Dantoft*,
alphabetically
Parasmani Dasgupta*, Saeed Dastgiri*, Luc Dauchet*, Kairat Davletov*,
Leandra Abarca-Gómez*, Ziad A Abdeen*, Shynar Abdrakhmanova*,
Guy De Backer*, Dirk De Bacquer*, Giovanni de Gaetano*,
Suhaila Abdul Ghaffar*, Hanan F Abdul Rahim*,
Stefaan De Henauw*, Paula Duarte de Oliveira*, David De Ridder*,
Niveen M Abu-Rmeileh*, Jamila Abubakar Garba*,
Karin De Ridder*, Susanne R de Rooij*, Delphine De Smedt*,
Benjamin Acosta-Cazares*, Robert J Adams*, Wichai Aekplakorn*,
Mohan Deepa*, Alexander D Deev*, Vincent Jr DeGennaro*,
Kaosar Afsana*, Shoaib Afzal*, Imelda A Agdeppa*,
Abbas Dehghan*, Hélène Delisle*, Francis Delpeuch*,
Javad Aghazadeh-Attari*, Carlos A Aguilar-Salinas*,
Stefaan Demarest*, Elaine Dennison*, Katarzyna Dereń*,
Charles Agyemang*, Mohamad Hasnan Ahmad*, Noor Ani Ahmad*,
Valérie Deschamps*, Klodian Dhana*, Meghnath Dhimal*,
Ali Ahmadi*, Naser Ahmadi*, Soheir H Ahmed*, Wolfgang Ahrens*,
Augusto F Di Castelnuovo*, Juvenal Soares Dias-da-Costa*,
Gulmira Aitmurzaeva*, Kamel Ajlouni*, Hazzaa M Al-Hazzaa*,
María Elena Díaz-Sánchez*, Alejandro Diaz*, Zivka Dika*,
Amani Rashed Al-Othman*, Rajaa Al-Raddadi*, Monira Alarouj*,
Shirin Djalalinia*, Visnja Djordjic*, Ha TP Do*, Annette J Dobson*,
Fadia AlBuhairan*, Shahla AlDhukair*, Mohamed M Ali*,
Maria Benedetta Donati*, Chiara Donfrancesco*, Silvana P Donoso*,
Abdullah Alkandari*, Ala’a Alkerwi*, Kristine Allin*,
Angela Döring*, Maria Dorobantu*, Ahmad Reza Dorosty*,
Mar Alvarez-Pedrerol*, Eman Aly*, Deepak N Amarapurkar*,
Kouamelan Doua*, Wojciech Drygas*, Jia Li Duan*,
Parisa Amiri*, Norbert Amougou*, Philippe Amouyel*,
Charmaine A Duante*, Priscilla Duboz*, Rosemary B Duda*,
Lars Bo Andersen*, Sigmund A Anderssen*, Lars Ängquist*,
Vesselka Duleva*, Virginija Dulskiene*, Samuel C Dumith*,
Ranjit Mohan Anjana*, Alireza Ansari-Moghaddam*,
Anar Dushpanova*, Vilnis Dzerve*, Elzbieta Dziankowska-Zaborszczyk*,
Hajer Aounallah-Skhiri*, Joana Araújo*, Inger Ariansen*, Tahir Aris*,
Ricky Eddie*, Ebrahim Eftekhar*, Eruke E Egbagbe*, Robert Eggertsen*,
Raphael E Arku*, Nimmathota Arlappa*, Krishna K Aryal*,
Sareh Eghtesad*, Gabriele Eiben*, Ulf Ekelund*,
Thor Aspelund*, Felix K Assah*, Maria Cecília F Assunção*,
Mohammad El-Khateeb*, Jalila El Ati*, Denise Eldemire-Shearer*,
May Soe Aung*, Juha Auvinen*, Mária Avdicová*, Ana Azevedo*,
Marie Eliasen*, Paul Elliott*, Reina Engle-Stone*, Macia Enguerran*,
Mohsen Azimi-Nezhad*, Fereidoun Azizi*, Mehrdad Azmin*,
Rajiv T Erasmus*, Raimund Erbel*, Cihangir Erem*, Louise Eriksen*,
Bontha V Babu*, Maja Bæksgaard Jørgensen*, Azli Baharudin*,
Johan G Eriksson*, Jorge Escobedo-de la Peña*, Saeid Eslami*,
Suhad Bahijri*, Jennifer L Baker*, Nagalla Balakrishna*,
Ali Esmaeili*, Alun Evans*, David Faeh*, Albina A Fakhretdinova*,
Mohamed Bamoshmoosh*, Maciej Banach*, Piotr Bandosz*,
Caroline H Fall*, Elnaz Faramarzi*, Mojtaba Farjam*,
José R Banegas*, Joanna Baran*, Carlo M Barbagallo*, Alberto Barceló*,
Victoria Farrugia Sant’Angelo*, Farshad Farzadfar*,
Amina Barkat*, Aluisio JD Barros*, Mauro Virgílio Gomes Barros*,
Mohammad Reza Fattahi*, Asher Fawwad*, Francisco J Felix-Redondo*,
Abdul Basit*, Joao Luiz D Bastos*, Iqbal Bata*, Anwar M Batieha*,
Trevor S Ferguson*, Romulo A Fernandes*, Daniel Fernández-Bergés*,
Rosangela L Batista*, Zhamilya Battakova*, Assembekov Batyrbek*,
Daniel Ferrante*, Thomas Ferrao*, Marika Ferrari*, Marco M Ferrario*,
Louise A Baur*, Robert Beaglehole*, Silvia Bel-Serrat*,
Catterina Ferreccio*, Eldridge Ferrer*, Jean Ferrieres*,
Antonisamy Belavendra*, Habiba Ben Romdhane*, Judith Benedics*,
Thamara Hubler Figueiró*, Anna Fijalkowska*, Günther Fink*,
Mikhail Benet*, James E Bennett*, Salim Berkinbayev*,
Krista Fischer*, Bernhard Föger*, Leng Huat Foo*, Maria Forsner*,
Antonio Bernabe-Ortiz*, Gailute Bernotiene*, Heloísa Bettiol*,
Heba M Fouad*, Damian K Francis*, Maria do Carmo Franco*,
Jorge Bezerra*, Aroor Bhagyalaxmi*, Sumit Bharadwaj*,
Oscar H Franco*, Ruth Frikke-Schmidt*, Guillermo Frontera*,
Santosh K Bhargava*, Zulfiqar A Bhutta*, Hongsheng Bi*, Yufang Bi*,
Flavio D Fuchs*, Sandra C Fuchs*, Isti I Fujiati*, Yuki Fujita*,
Daniel Bia*, Elysée Claude Bika Lele*, Mukharram M Bikbov*,
Matsuda Fumihiko*, Takuro Furusawa*, Zbigniew Gaciong*,
Bihungum Bista*, Dusko J Bjelica*, Peter Bjerregaard*,
Mihai Gafencu*, Andrzej Galbarczyk*, Henrike Galenkamp*,
Espen Bjertness*, Marius B Bjertness*, Cecilia Björkelund*,
Daniela Galeone*, Myriam Galfo*, Fabio Galvano*, Jingli Gao*,
Katia V Bloch*, Anneke Blokstra*, Simona Bo*, Martin Bobak*,
Manoli Garcia-de-la-Hera*, Marta García-Solano*, Dickman Gareta*,
Lynne M Boddy*, Bernhard O Boehm*, Heiner Boeing*,
Sarah P Garnett*, Jean-Michel Gaspoz*, Magda Gasull*,
Jose G Boggia*, Elena Bogova*, Carlos P Boissonnet*, Stig E Bojesen*,
Adroaldo Cesar Araujo Gaya*, Anelise Reis Gaya*, Andrea Gazzinelli*,
Marialaura Bonaccio*, Vanina Bongard*, Alice Bonilla-Vargas*,
Ulrike Gehring*, Harald Geiger*, Johanna M Geleijnse*, Ali Ghanbari*,
Matthias Bopp*, Herman Borghs*, Pascal Bovet*, Lien Braeckevelt*,
Erfan Ghasemi*, Oana-Florentina Gheorghe-Fronea*,
Lutgart Braeckman*, Marjolijn CE Bragt*, Imperia Brajkovich*,
Simona Giampaoli*, Francesco Gianfagna*, Tiffany K Gill*,
Francesco Branca*, Juergen Breckenkamp*, João Breda*,
Jonathan Giovannelli*, Glen Gironella*, Aleksander Giwercman*,
Hermann Brenner*, Lizzy M Brewster*, Garry R Brian*,
Konstantinos Gkiouras*, Justyna Godos*, Sibel Gogen*,
Lacramioara Brinduse*, Sinead Brophy*, Graziella Bruno*,
Rebecca A Goldsmith*, David Goltzman*, Santiago F Gómez*,
H Bas Bueno-de-Mesquita*, Anna Bugge*, Marta Buoncristiano*,
Aleksandra Gomula*, Bruna Goncalves Cordeiro da Silva*,
Genc Burazeri*, Con Burns*, Antonio Cabrera de León*,
Helen Gonçalves*, David A Gonzalez-Chica*, Marcela Gonzalez-Gross*,
Joseph Cacciottolo*, Hui Cai*, Tilema Cama*, Christine Cameron*,
Margot González-Leon*, Juan P González-Rivas*,
José Camolas*, Günay Can*, Ana Paula C Cândido*, Felicia Cañete*,
Clicerio González-Villalpando*, María-Elena González-Villalpando*,
Mario V Capanzana*, Nadežda Capková*, Eduardo Capuano*,
Angel R Gonzalez*, Frederic Gottrand*, Antonio Pedro Graça*,
Vincenzo Capuano*, Marloes Cardol*, Viviane C Cardoso*,
Sidsel Graff-Iversen*, Dušan Grafnetter*, Aneta Grajda*,
Axel C Carlsson*, Esteban Carmuega*, Joana Carvalho*,
Maria G Grammatikopoulou*, Ronald D Gregor*, Tomasz Grodzicki*,
José A Casajús*, Felipe F Casanueva*, Ertugrul Celikcan*, Laura Censi*,
Else Karin Grøholt*, Anders Grøntved*, Giuseppe Grosso*,
Marvin Cervantes-Loaiza*, Juraci A Cesar*, Snehalatha Chamukuttan*,
Gabriella Gruden*, Dongfeng Gu*, Emanuela Gualdi-Russo*,
Angelique W Chan*, Queenie Chan*, Himanshu K Chaturvedi*,
Pilar Guallar-Castillón*, Andrea Gualtieri*, Elias F Gudmundsson*,
Nish Chaturvedi*, Norsyamlina Che Abdul Rahim*, Chien-Jen Chen*,
Vilmundur Gudnason*, Ramiro Guerrero*, Idris Guessous*,
Fangfang Chen*, Huashuai Chen*, Shuohua Chen*, Zhengming
Andre L Guimaraes*, Martin C Gulliford*, Johanna Gunnlaugsdottir*,
Chen*, Ching-Yu Cheng*, Bahman Cheraghian*, Angela Chetrit*,
Marc J Gunter*, Xiu-Hua Guo*, Yin Guo*, Prakash C Gupta*,
Ekaterina Chikova-Iscener*, Arnaud Chiolero*, Shu-Ti Chiou*,
Rajeev Gupta*, Oye Gureje*, Beata Gurzkowska*,
Adela Chirita-Emandi*, María-Dolores Chirlaque*, Belong Cho*,
Enrique Gutiérrez-González*, Laura Gutierrez*, Felix Gutzwiller*,
Kaare Christensen*, Diego G Christofaro*, Jerzy Chudek*,
Seongjun Ha*, Farzad Hadaegh*, Charalambos A Hadjigeorgiou*,
Renata Cifkova*, Michelle Cilia*, Eliza Cinteza*, Frank Claessens*,
Rosa Haghshenas*, Hamid Hakimi*, Jytte Halkjær*, Ian R Hambleton*,
Janine Clarke*, Els Clays*, Emmanuel Cohen*, Hans Concin*,
Behrooz Hamzeh*, Dominique Hange*, Abu AM Hanif*,
Susana C Confortin*, Cyrus Cooper*, Tara C Coppinger*,
Sari Hantunen*, Rachakulla Hari Kumar*,
Eva Corpeleijn*, Simona Costanzo*, Dominique Cottel*, Chris Cowell*,
Seyed Mohammad Hashemi-Shahri*, Maria Hassapidou*, Jun Hata*,
Cora L Craig*, Amelia C Crampin*, Ana B Crujeiras*, Semánová Csilla*,

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 Articles
Teresa Haugsgjerd*, Alison J Hayes*, Jiang He*, Yuan He*, Yuna He*,
Regina Heidinger-Felso*, Mirjam Heinen*, Tatjana Hejgaard*,
Marleen Elisabeth Hendriks*, Rafael dos Santos Henrique*,
Ana Henriques*, Leticia Hernandez Cadena*, Sauli Herrala*,
Victor M Herrera*, Isabelle Herter-Aeberli*, Ramin Heshmat*,
Allan G Hill*, Sai Yin Ho*, Suzanne C Ho*, Michael Hobbs*,
Albert Hofman*, Ingunn Holden Bergh*, Michelle Holdsworth*,
Reza Homayounfar*, Clara Homs*, Wilma M Hopman*,
Andrea RVR Horimoto*, Claudia M Hormiga*, Bernardo L Horta*,
Leila Houti*, Christina Howitt*, Thein Thein Htay*, Aung Soe Htet*,
Maung Maung Than Htike*, Yonghua Hu*, José María Huerta*,
Ilpo Tapani Huhtaniemi*, Constanta Huidumac Petrescu*,
Abdullatif Husseini*, Chinh Nguyen Huu*, Inge Huybrechts*,
Nahla Hwalla*, Jolanda Hyska*, Licia Iacoviello*, Jesús M Ibarluzea*,
Mohsen M Ibrahim*, Norazizah Ibrahim Wong*, Nayu Ikeda*,
M Arfan Ikram*, Violeta Iotova*, Vilma E Irazola*, Takafumi Ishida*,
Muhammad Islam*, Sheikh Mohammed Shariful Islam*,
Masanori Iwasaki*, Rod T Jackson*, Jeremy M Jacobs*,
Hashem Y Jaddou*, Tazeen Jafar*, Kenneth James*, Kazi M Jamil*,
Konrad Jamrozik*, Imre Janszky*, Edward Janus*, Juel Jarani*,
Marjo-Riitta Jarvelin*, Grazyna Jasienska*, Ana Jelakovic*,
Bojan Jelakovic*, Garry Jennings*, Anjani Kumar Jha*,
Chao Qiang Jiang*, Ramon O Jimenez*, Karl-Heinz Jöckel*,
Michel Joffres*, Mattias Johansson*, Jari J Jokelainen*, Jost B Jonas*,
Torben Jørgensen*, Pradeep Joshi*, Farahnaz Joukar*, Dragana P Jovic*,
Jacek J Jóźwiak*, Anne Juolevi*, Gregor Jurak*, Iulia Jurca Simina*,
Vesna Juresa*, Rudolf Kaaks*, Felix O Kaducu*, Anthony Kafatos*,
Eero O Kajantie*, Zhanna Kalmatayeva*, Ofra Kalter-Leibovici*,
Yves Kameli*, Kodanda R Kanala*, Srinivasan Kannan*,
Efthymios Kapantais*, Khem B Karki*, Marzieh Katibeh*, Joanne Katz*,
Peter T Katzmarzyk*, Jussi Kauhanen*, Prabhdeep Kaur*,
Maryam Kavousi*, Gyulli M Kazakbaeva*, Ulrich Keil*,
Lital Keinan Boker*, Sirkka Keinänen-Kiukaanniemi*, Roya Kelishadi*,
Cecily Kelleher*, Han CG Kemper*, Andre P Kengne*,
Maryam Keramati*, Alina Kerimkulova*, Mathilde Kersting*,
Timothy Key*, Yousef Saleh Khader*, Davood Khalili*,
Young-Ho Khang*, Kay-Tee Khaw*, Bahareh Kheiri*,
Motahareh Kheradmand*, Alireza Khosravi*, Ilse MSL Khouw*,
Ursula Kiechl-Kohlendorfer*, Stefan Kiechl*, Japhet Killewo*,
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George S Stergiou*, Jochanan Stessman*, Ranko Stevanovic*,
Jutta Stieber*, Doris Stöckl*, Tanja Stocks*, Jakub Stokwiszewski*,
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Tania Tello*, KR Thankappan*, Holger Theobald*,
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Betina H Thuesen*, Lubica Tichá*, Erik J Timmermans*,
Anne Tjonneland*, Hanna K Tolonen*, Janne S Tolstrup*,
Murat Topbas*, Roman Topór-Madry*, Liv Elin Torheim*,
María José Tormo*, Michael J Tornaritis*, Maties Torrent*,
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Shoichiro Tsugane*, Azaliia M Tuliakova*, Marshall K Tulloch-Reid*,
Fikru Tullu*, Tomi-Pekka Tuomainen*, Jaakko Tuomilehto*,
Maria L Turley*, Per Tynelius*, Themistoklis Tzotzas*,
Christophe Tzourio*, Peter Ueda*, Eunice Ugel*, Flora AM Ukoli*,
Hanno Ulmer*, Belgin Unal*, Zhamyila Usupova*,
Hannu MT Uusitalo*, Nalan Uysal*, Justina Vaitkeviciute*,
Gonzalo Valdivia*, Susana Vale*, Damaskini Valvi*, Rob M van Dam*,
Johan Van der Heyden*, Yvonne T van der Schouw*, Koen Van Herck*,
Hoang Van Minh*, Irene GM van Valkengoed*, Dirk Vanderschueren*,
Diego Vanuzzo*, Anette Varbo*, Gregorio Varela-Moreiras*,
Patricia Varona-Pérez*, Senthil K Vasan*, Tomas Vega*,
Toomas Veidebaum*, Gustavo Velasquez-Melendez*, Biruta Velika*,
Giovanni Veronesi*, WM Monique Verschuren*, Cesar G Victora*,
Giovanni Viegi*, Lucie Viet*, Salvador Villalpando*, Paolo Vineis*,
Jesus Vioque*, Jyrki K Virtanen*, Marjolein Visser*,
Sophie Visvikis-Siest*, Bharathi Viswanathan*, Mihaela Vladulescu*,
Tiina Vlasoff*, Dorja Vocanec*, Henry Völzke*, Ari Voutilainen*,
Sari Voutilainen*, Martine Vrijheid*, Tanja GM Vrijkotte*,
Alisha N Wade*, Aline Wagner*, Thomas Waldhör*, Janette Walton*,
Elvis OA Wambiya*, Wan Mohamad Wan Bebakar*,
Wan Nazaimoon Wan Mohamud*, Rildo de Souza Wanderley Júnior*,
Ming-Dong Wang*, Ningli Wang*, Qian Wang*, Xiangjun Wang*,
Ya Xing Wang*, Ying-Wei Wang*, S Goya Wannamethee*,
Nicholas Wareham*, Adelheid Weber*, Niels Wedderkopp*,
Deepa Weerasekera*, Daniel Weghuber*, Wenbin Wei*, Aneta Weres*,
Bo Werner*, Peter H Whincup*, Kurt Widhalm*,
Indah S Widyahening*, Andrzej Wiecek*, Rainford J Wilks*,
Johann Willeit*, Peter Willeit*, Julianne Williams*, Tom Wilsgaard*,
Bogdan Wojtyniak*, Roy A Wong-McClure*, Andrew Wong*,
Jyh Eiin Wong*, Tien Yin Wong*, Jean Woo*, Mark Woodward*,
Frederick C Wu*, Jianfeng Wu*, Li Juan Wu*, Shouling Wu*,
Haiquan Xu*, Liang Xu*, Nor Azwany Yaacob*, Uruwan Yamborisut*,
Weili Yan*, Ling Yang*, Xiaoguang Yang*, Yang Yang*, Nazan Yardim*,
Mehdi Yaseri*, Tabara Yasuharu*, Xingwang Ye*,
Panayiotis K Yiallouros*, Moein Yoosefi*, Akihiro Yoshihara*,
Qi Sheng You*, San-Lin You*, Novie O Younger-Coleman*,
Safiah Md Yusof*, Ahmad Faudzi Yusoff*, Luciana Zaccagni*,
Vassilis Zafiropulos*, Ahmad A Zainuddin*, Seyed Rasoul Zakavi*,
Farhad Zamani*, Sabina Zambon*, Antonis Zampelas*,
Hana Zamrazilová*, Maria Elisa Zapata*, Abdul Hamid Zargar*,
Ko Ko Zaw*, Tomasz Zdrojewski*, Tajana Zeljkovic Vrkic*, Yi Zeng*,
Luxia Zhang*, Zhen-Yu Zhang*, Dong Zhao*, Ming-Hui Zhao*,
Wenhua Zhao*, Shiqi Zhen*, Wei Zheng*, Yingfeng Zheng*,
Bekbolat Zholdin*, Maigeng Zhou*, Dan Zhu*, Yanina Zocalo*,
Julio Zuñiga Cisneros*, Monika Zuziak*.
*Contributed equally.
Declaration of interests
ME reports a charitable grant from the AstraZeneca Young Health
Programme, and personal fees from Prudential and Scor, outside the
 Articles
submitted work. MS reports grants from the EU Horizon 2020 research
and innovation programme under Grant Agreement number 774548,
during the conduct of the study. All other authors declare no competing
interests.
Acknowledgments
The NCD-RisC database was supported by a Biomedical Resource and
Multi-user Equipment Grant from the Wellcome Trust (101506/Z/13/Z) and
was expanded to include children and adolescents with partial support by a
charitable grant from AstraZeneca Young Health Programme. The analysis
in this paper was partly supported by the STOP project which received
funding from EU Horizon 2020 research and innovation programme
under Grant Agreement 774548. The content of this publication reflects
only the views of the authors, and the European Commission is not liable
for any use that may be made of the information it contains.
Editorial note: the Lancet Group takes a neutral position with respect to
territorial claims in published maps and institutional affiliations.
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