Waist-Circumference-to-Height-Ratio Had Better Longitudinal Agreement with DEXA-Measured Fat Mass Than BMI in 7,237 Children

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The absolute agreement of surrogate measures of adiposity with dual-energy X-ray absorptiometry (DEXA)-measured body composition was examined.


Over a 15-year follow-up, 7237 (3667 females) nine-year-old children from the Avon Longitudinal Study of Parents and Children (ALSPAC) UK birth cohort were included. Total fat mass (FM) and trunk FM were serially measured with DEXA at ages 9, 11, 15, 17, and 24 years. BMI and waist circumference-to-height ratio (WHtR) were computed. Pearson’s correlations, intraclass correlations (ICC), and area under curve (AUC) analyses were conducted.


Over 15 years, BMI, total FM, and trunk FM, increased but WHtR was relatively stable. WHtR provided a better longitudinal absolute agreement [males ICC 0.84 (95% CI 0.84–0.85); females 0.81 (0.80–0.82)] than BMI [(males (0.65 (0.64–0.66); females 0.72 (0.71–0.73)] with total FM as well as trunk FM from ages 9–24 years. WHtR cut-point for predicting excess total FM (75th–95th percentile) was 0.50–0.53 in males [AUC 0.86–0.94, sensitivity 0.51–0.79 and specificity 0.93–0.95]. WHtR cut-point for predicting excess total FM (75th–95th percentile) was 0.52–0.54 in females [AUC 0.83–0.95, sensitivity 0.38–0.68 and specificity 0.92–0.95]. Results were similar with trunk FM.


WHtR is an inexpensive alternative to BMI for predicting FM in pediatrics.


  • Waist circumference-to-height ratio (WHtR) is a better adiposity surrogate measure than body mass index (BMI) in predicting fat mass and discriminating lean mass from childhood through young adulthood.

  • BMI has been used as an inexpensive surrogate measure of adiposity in children for several decades. However, emerging findings suggest that BMI fails to discriminate between fat mass adiposity and lean mass.

  • This is the first-ever longitudinal study in over 7000 children followed up for 15 years that identified WHtR as an inexpensive accurate measure that discriminates fat mass from lean mass that could replace BMI measure of obesity in pediatrics.

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