Towards Healthy Growth and Development: Issues of overweight ...

2001
Queensland Government
Queensland Health
Health Information Centre
information
C I R C U L A R
Towards Healthy Growth and Development: Issues of overweight, obesity and under-
nutrition among children in Queensland
l In Australia and in Queensland obesity is
increasing among children as well as adults, and
I N S I D E is directly linked to several major national and
State health priority areas - cardiovascular
disease, hypertension, diabetes and certain
KEY MESSAGES
1
cancers.
Introduction
2
l 19% to 24% of school age children in Australia
Overweight and Obesity in Children
2
are overweight or obese* and these rates are
Childhood Obesity Predicts Adult Weight
among the highest in the world.
and Chronic Diseases
4
l Overweight and obesity are also occurring
Cost of Overweight and Obesity
5
among Indigenous children, particularly in
urban centres but in rural communities as well.
Indigenous Children - Over- and
Under-nutrition
6
l Poor intrauterine growth coupled with
Effects of Under-nutrition
7
suboptimal childhood growth patterns may be
predictive of chronic diseases in adulthood -
Growth Assessment and Action
7
coronary heart disease, hypertension, diabetes
Effectiveness of Growth Monitoring
8
and even renal disease.
Growth and Health Outcomes
8
l Under-nutrition, as expressed by low weight
Recommendations for Growth Assessment
for age, low height for age or low weight for
height has been reported in several Indigenous
and Action in Queensland
9
communities in Queensland, and is directly
References
11
related to increased rates of hospitalisation for
infectious diseases in early life and chronic
diseases in adult life.
l Child Growth Assessment and Action programs
in the Northern Territory have reported
Monitoring early childhood growth and
significant decreases in the numbers of
development should be the ‘gold standard’
undernourished Indigenous children since the
for measuring the success of human
programs were established.
development efforts. (Kul Gautam, UNICEF Deputy
Executive Director, address to the United Nations meeting
l Childhood overweight and obesity and under-
on Nutrition, 13 April 20001)
nutrition are crises facing Australian and
Queensland children today. Action must be
taken now to prevent and manage both
KEY MESSAGES
overweight and poor growth among the children
of the State and the country.
l Growth is the most important determinant of
health status of a child and is an indirect
reflection of the well being of the entire l The cost savings of instituting growth
assessment and action programs in Queensland
community.
are potentially enormous - in the short term in
reducing hospitalisation of undernourished
* See Definitions for Overweight and Obesity (a) on page 10
1
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August 2001

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Indigenous children, and in the long term in nutritional, medical or social interventions are
reducing the burden of disease among children instituted. The service of growth assessment and
who will become obese adults.
action, while common in many health care
settings, may not be reaching all children,
l There is a critical need for a regular systematic
especially those most in need. The importance
program to assess growth among children in placed on including growth assessment and action
Queensland. The above issues cannot be as part of child health services also varies from
addressed until we establish routine growth one health service to the next.
statistics and provide action programs aimed at
prevention and management of abnormal growth In Queensland, there is currently no regular
patterns.
systematic program to address the issues of over-
and under-nutrition or to monitor changes in these
l Efforts to both prevent and manage over- and
conditions. Without regular routine statistics on
under-nutrition must involve appropriate and growth parameters of children it is impossible to
culturally sensitive intervention programs, determine the scope of the problem or to institute
education and research.
appropriate strategies to address these concerns.
Introduction
There is an urgent need to take action to both
Australia and Queensland face two major issues prevent and manage childhood obesity and under-
related to child growth. Firstly, as in many nutrition. Such action needs to include
industrialised countries of the world today, intervention, education, and research.
childhood obesity /overweight is emerging as a Intervention programs need to be culturally
critical public health problem. Secondly, as in most sensitive and have an emphasis on training
developing countries of the world, under-nutrition community-based health workers, and be designed
is having a major impact on the health of with community input. Educational efforts should
Indigenous children and other children in be directed towards policy makers, health
disadvantaged circumstances.
professionals, community leaders and parents.
Research needs to address psychological,
There is abundant evidence in Australia that social behavioural, environmental, financial and health
inequity has a profound effect on health. Data implications of obesity and under-nutrition.
show that children from lower socio-economic
(SES) backgrounds are more likely to be shorter, Overweight and Obesity in Children
have higher Body Mass Index (BMI*) and higher The increasing prevalence of childhood obesity is
skinfold thickness than those of higher SES considered a major epidemic in many of the
backgrounds.2 Children from low SES backgrounds
have also been shown to have lower dietary intakes industrialised countries of the world today.
Recent reports from the United Kingdom,3 Canada,4
of vitamins A, C, folate and thiamine, lower intakes the United States5 and Europe6 identify childhood
of iron, calcium and fibre and higher intakes of obesity as a growing and significant public health
sugar, fat and energy than children from higher SES concern. While it is difficult to compare rates in
groups.2
various countries due to different age groupings and
criteria used to determine overweight, the
Assessing the growth of individual children has prevalence of childhood obesity in Australia may
been the cornerstone of child health care services be one of the highest in the world.
in some areas of Queensland for decades. Simple
measures of weight, height and age have been
considered the most appropriate parameters to Figures 1 and 2 compare rates of overweight and
define the health and nutritional status of a child. obesity for Australian children7 with rates from
Ideally, when abnormal growth is detected, the United States8 and five other countries9 using
* BMI-weight in kilograms divided by height in metres squared - kg/m2
2
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the same criteria for assessing overweight and children selected at random from large
obesity.*
populations. Each study included over 3000
children, but age ranges differed between the
Figure 1: Prevalence of overweight and obesity among surveys.
female children in Australia* compared with the United
States† and five other countries‡
The data show that 19% to 24% of Australian
school-age children are either overweight or
30
obese. The researchers noted that overweight/
Overweight
Obese
obesity was 3.6% higher in urban than in rural
25
areas for boys, but there was no difference for
20
girls.
15
Per cent
Magarey and Daniels13 also applied the recently
10
developed obesity criteria9 to the 1995 NNS data.11
5
This analysis found that among 2 - 18 year olds,
16% of girls and 15% of boys were overweight, and
0
a further 4.9% and 4.5% of girls and boys,
Australia
respectively, were obese. The highest prevalence
Data Source: * Booth, 20017
Data Source: † Popkin and Udry, 19988
of overweight /obesity among the girls was in the 8
Data Source: ‡ Cole, 20009
- 11 year age group (25%), and for boys was in the
12 - 15 year age group (26.1%). The prevalence of
overweight at 18 years among Australian youths
Figure 2: Prevalence of overweight and obesity among was considerably higher than in any of the six
male children in Australia* compared with the United international reference populations from which
States† and five other countries‡
these criteria were derived.
Using criteria based on US National Health and
30
Overweight
Obese
Nutrition Examination Survey I (NHANES I) survey
25
data, the 1995 NNS11 reported that 21.2% and
20
23.3% of girls and boys, respectively, were at risk
of overweight or were overweight† across 3 age
15
Per cent
categories 9 to18 years.
10
Concerns about childhood obesity have also been
5
raised in other industrialised countries. Reports
0
from the UK3 suggest that 13 to 16% of girls and
Australia
9 to 10% of boys are overweight/obese. Canadian
Data Source: * Booth, 20017
reports4 indicate that as many as 24% of girls and
Data Source: † Popkin and Udry, 19988
Data Source: ‡ Cole, 20009
29% of boys are overweight/obese (data not
shown). Childhood overweight/obesity rates from
the Unites States range widely from 11 to 24%,
Data from large population-based surveys in these depending on the definitions used.5 Yet it appears
six countries were used to develop these criteria. that, using data from several sources and using
For the Australian children, Booth7 analysed data different criteria, Australian children may rank
from three independent surveys: the 1997 NSW among the heaviest in the world. These findings
Schools Fitness and Physical Activity Survey,10 the should not be surprising given the well
1995 National Nutrition Survey (NNS)11 and the documented rates of obesity among Australian
1997 Health of Young Victorians Study.12 All adults.
three surveys measured weight and height of
* See Definitions for Assessing Overweight and Obesity (a) on page 10
† See Definition of Overweight (b) on page 10
3
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As in other western countries, there is considerable Study12 (N= 2277) compared with the 1985
evidence that overweight among Australian Australian Health and Fitness14 survey (N=1421).
children is increasing dramatically. Figure 3 This increase was found for most age/gender
shows the striking increase in overweight* among groups, and reflected an increase in BMI of 1.03
school age children, especially among boys, in and 1.04 for boys and girls, respectively. The
one decade from 1985 to 1995. These data are increases were most marked in the heavier end of
taken from the Australian Health and Fitness the distribution. This study did not report a
Survey 1985 conducted by the Australian Council prevalence of overweight or obesity among the
for Health, Physical Education and Recreation14 children.
and the 1995 NNS.11 Harvey et al15 showed that
among 8000 children 7 - 15 years of age, A similar study was conducted among school
approximately 9% were considered overweight children in southeastern Sydney.16 Height and
in 1985. That rate increased to approximately weight were measured in 3645 children aged 5 -
12% in the 1995 NNS as shown in Figure 3.
12 years during 1994-97, and compared with the
1985 ACHPER survey. This study showed an
Figure 3: Increasing prevalence of overweight among overall increase in BMI of 3.9% among boys and
Australian children - 1985 - 1995
1.2% in girls during this time period.
30
Childhood obesity appears to be an emerging
1985 ACHPER*
1995 NNS†
concern in Indigenous communities as well. Data
25
from the first National Aboriginal and Torres Strait
20
Islander Survey17 found that children 5 - 9 years of
age were, on average, shorter and heavier than
15
Per cent
international reference values. Approximately
10
28% of children 7 - 15 years were at risk of
5
overweight or were overweight compared with
Australian growth references. In general,
0
underweight and short stature were more common
in rural areas, and overweight was more prevalent
in urban centres, yet even in rural areas overweight
GIRLS
BOYS
was greater than expected and in cities
Data Source: * Harvey et al., 199315 ; † 1995 National Nutrition Survey11
underweight was more than expected.17
Harvey15 also compared the 12 – 14 year age Community health screenings conducted in 11
group, using slightly different cut-off levels of Indigenous communities in central Queensland18
overweight.† According to these criteria, 11.7% reported more obesity than underweight among
of the boys and 8.7 % of the girls were classified 534 children screened. More than 6% of children
as overweight in 1985, but that increased were estimated to be overweight or obese while
dramatically in 1995 (especially among boys to 3% were considered underweight. The report did
over 25%).
not provide the age ranges of the children included
in the screening.
Other recent surveys have also shown dramatic
increases in BMI among Australian school Childhood Obesity Predicts Adult Weight and
children. In Victoria, height and weight data from Chronic Diseases
two cross-sectional population-based surveys of
primary school children revealed a significantly Obesity and overweight in childhood are important
higher BMI in the 1997 Health of Young Victorians predictors of adult adiposity.19,20 A recent follow-
up study21 of a cohort of 2548 women and 2814
men born in England in 1946, found that adults
* See Definition of Overweight and Obesity (c) on page 10
4 † See Definition of Overweight (d) on page 10
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who were overweight* as children (at 14 years of Few studies have examined the contribution of
age) had higher BMIs at all ages of follow up (20, childhood obesity to adult disease. A 57-year
26, 36 and 43 years) compared with adults who follow-up, the Boyd Orr cohort study,22 was based
were not overweight as children (Figure 4). BMIs on British females (n =1234) and males (n=1165)
increased with age and were higher for women who were between 2 and 14 years of age in
than men.
prewar Britain (1937-1939). The study reported a
hazard ratio for all-cause mortality of 1.5 (CI 1.1,
Figure 4: Mean body mass index of British women and 2.2) and for ischaemic heart disease of 2.0 (CI
men at four ages between 20 and 43 by weight at 14 1.0, 3.9) when those whose BMI as children had
years of age
been > 75th centile were compared with children
classified as the reference group with BMI 25th to
49th centile.† This study lends strong support to
32
* * * Women overweight at 14 years
+ + + Men not overweight at 14 years
x x x Men overweight at 14 years
* * * Women not overweight at 14 years
the view that overweight in childhood is
*
30
associated with increased mortality in later life.
)2
*
x
28
x
Cost of Overweight and Obesity
*
*
26
It is well documented that among adults
x
x
+
overweight and obesity are major risk factors
24
+
*
associated with cardiovascular disease, type 2
Body Mass Index (kg/m
+
diabetes, hypertension and certain types of
*
22
+
cancers. The cost of obesity in terms of death
*
*
and disability in most western countries is
20
20
26
36
43
enormous. It is estimated that the direct medical
Age (years)
costs of obesity could amount to 4 to 5% of total
Data Source: Hardy et al., 200021
health care costs.23 A conservative estimate of the
health costs of obesity in Australia is $810 million
At all ages in this British study, those from a per year, with a further $500 million spent on weight
manual social class had a greater proportion control programs.24 Mathers25 estimates that in
classified as overweight and obese compared with Australia the proportion of the burden of disease
those from non-manual social classes. Overall, attributable to obesity is 4%. This proportion is
of those adults who were overweight as children, greater than that attributable to high blood
twice as many were overweight or obese at age cholesterol, illicit drugs or unsafe sex.
43 and four times as many were obese compared
with adults who were not overweight at 14 years The savings in health care costs in terms of
(Table 1).
preventing infant and child hospitalisation and
adult diseases such as diabetes and renal disease
Table 1. Prevalence of overweight and obesity among could pay for relatively inexpensive growth
British adults at age 43 years by overweight status at assessment and action programs. In the Northern
14 years of age.
Territory, an evaluation of one nutrition program
reported a decrease of 70% in the number of
Percent Overweight or
Percent Obese
Obese as adults
as adults
children hospitalised for gastrointestinal disease
Overweight at
and nutritional problems.26 This report estimated
age 14
80
36
that the effect of the nutrition program resulted in
Not overweight
at age 14
43
8
an estimated cost saving to the health system of
$59,322 - which was just under the cost of the
Source: Hardy et al, 200021
nutrition program ($69,766). Preventing just one
child from becoming obese, developing diabetes
and acquiring renal disease could save a minimum
of $70,000 per year in the cost of dialysis alone.
* See Definition of Overweight (e) on page 10
† See Definition of Overweight (f) on page 10
5
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Indigenous Children – Over- and Under- Cox32 also reported growth characteristics of over
nutrition
500 Indigenous children born in the 1970s in five
government or mission-organised communities in
Clinically evident malnutrition, such as Queensland. This survey used weight for age and
kwashiorkor is uncommon among Aboriginal and head circumference data recorded by nursing sisters
Torres Strait Islander children today. Yet under- in the Royal Flying Doctor Service. The analyses
nutrition, defined as weight for age (WAZ), height of these records showed that mean birth weights
for age (HAZ) and weight for height (WHZ) more for males (3.2 kg) and females (3.1 kg) corresponded
than 2 standard deviations (or z scores) below the to the 25th percentile of British references.34 Mean
median of accepted references27 may be weights of both girls and boys increased steadily
common.28 Children who live in Aboriginal during the early months of life, and by three months
communities in Western Australia have been of age were at the British 50th percentile. After three
reported to be shorter and lighter than non- to four months of age, however, growth slowed so
Aboriginal Australian children.29 The prevalence that by 18 months mean weights compared with
of under-nutrition was estimated to be 20% in the 10th percentile of the British reference. Growth
children less than 2 years of age in the Top End of in head circumference showed a similar pattern to
the Northern Territory. The rate for stunting was weight. Thus by five years of age, Indigenous
10% (HAZ <-2.0) and that for wasting was 36% children were considerably lighter and had a smaller
(WHZ <-2.0) - rates that are considerably higher head circumference as compared with British
than in many developing countries. These children. This pattern of growth is commonly
estimates were derived from weight and height reported in Indigenous communities today.35
measurements of children admitted to Royal
Darwin Hospital in 1990-91 and therefore may
not be representative of the Top End population.30
In some remote and rural areas, a substantial
proportion of preschool children over six
Few reports of nutritional status of Indigenous
months have an unacceptable level of
children in Queensland have attempted to assess
malnutrition.
growth. Those few that have been reported used
(National Health and Medical Research Council, Nutrition
only weight for age in several communities,31, 32 or
in Aboriginal and Torres Strait Islander Peoples: An
measured only small numbers of children in one
Information Paper, 200035)
community.33
Dugdale31 investigated patterns of growth of Another small study in one central Queensland
Aboriginal children from the 1950s through the community assessed growth among 127 school
1990s in several communities in central and age Aboriginal children in 1992 and again in
northern Queensland. The data for these studies 1997.33 Weight and height measurements revealed
were weight measurements obtained from child that z-scores for weight for age (WAZ) and height
health centre records. The general trend over this for age (HAZ) for females were not significantly
time period showed an improved pattern of different from NCHS/WHO reference36 at either time
growth in weight for age in most of the period. The boys, however, had significantly lower
communities in central Queensland and those WAZ and HAZ than the NCHS/WHO reference
near Cairns. Mean weight for age increased over both in 1992 and in 1997. WHZ was not
this time period in one of the more accessible significantly different from the NCHS/WHO
communities but decreased in a remote reference. Only small numbers of children had z-
community. It appeared that the further north scores less than -2.0 for WAZ, HAZ, or WHZ (the
the community, the less likely was an standard criteria for under-nutrition), and small
improvement in growth. Remoteness of the numbers had BMIs greater than the 95th percentile
community was considered a major factor in (4.4% in 1997). These data indicate that for this
growth retardation in these communities.
accessible Aboriginal community, growth among
girls compares closely with reference values, but
6
that growth for boys may be lagging.
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The above studies are among the few attempts to interest in environmental exploration. Severe
assess growth patterns of Indigenous children in malnutrition in the first few years of life, if coupled
Queensland. They highlight the paucity of with social deprivation, can have a detrimental
information regarding growth parameters among effect on mental development throughout
these children and the need to accurately and childhood.35
systematically ascertain the nutritional status of
Indigenous children, not only in remote Growth Assessment and Action
communities but in urban centres as well.
Growth assessment is the single
Both under-nutrition and over-nutrition may point
measurement that best defines the health and
to broader issues such as access and capacity, as
nutritional status of children, because
well as availability of food storage and preparation
disturbances in health and nutrition,
facilities and not just carer/parent lack of knowledge.
regardless of their etiology, invariably affect
child growth. (de Onis, Rome, 199241)
Effects of Under-nutrition
The synergism between under-nutrition and Growth assessment, also referred to as growth
infectious disease has been recognised for monitoring, is defined as:
decades.37 Under-nutrition affects defence
mechanisms which results in increased
the regular measurement, recording and
interpretation of a child’s growth in order to
susceptibility to infectious diseases. These
counsel, act and follow-up results.42
illnesses, in turn, cause further deterioration of
nutritional status through reduced food intake,
malabsorption of nutrients, increased mobilisation It is clear that measuring a child is not an
of body stores, and increased nutrient losses.
intervention in itself but is a strategy or a process
37
used to generate action. The most common
A recent World Health Organization bulletin
purposes of growth assessment and action are as:
38
reviewed studies related to malnutrition and (1) an educational and promotional tool, (2) an
mortality. The authors concluded that the integrating strategy and (3) a source of
strongest and most consistent relationship was information. As an educational tool, through the
between under-nutrition and increased death from use of growth charts, assessment can make health
diarrhoeal disease and acute respiratory promotion action-oriented, timely, relevant and
infections. They estimated that up to 50% of all specific, and thus more effective. As a
childhood mortality is associated with promotional tool or motivational tool, growth
malnutrition. Worldwide it is estimated that assessment can create an awareness of the
malnutrition among 0 – 4 year olds is responsible importance of growth problems and a demand
for 16% of the total global burden of disease.
for their solution. As an integrating strategy,
39
growth assessment has the capacity to improve
Analysis of hospital separation data for Aboriginal child growth and health by reducing morbidity
and Torres Strait Islander children in northern through a more efficient and effective delivery of
Queensland reveals extremely high rates of health services and with the potential to integrate a
hospitalisation for gastrointestinal disorders, variety of health and nutrition interventions. As
respiratory diseases, skin diseases, and nutritional a source of data, growth assessment can be used
conditions. Hospital separation rates for Indigenous to evaluate the health status of the individual child
children in the northern zone are four to six times and direct appropriate actions. At the community,
higher than for non-Indigenous children.
state or national level data can be used for decision-
40
making and resource allocation, as well as for
Under-nutrition has also been linked with reduced monitoring and evaluating the health care delivery
intellectual capacity. Malnourished children have system and the success of targeted programs or
lower levels of activity, which reduces their projects.
7
Information circular 58

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Effectiveness of Growth Monitoring
l
identification of chronic disorders,
The benefits of monitoring the growth of children l provision of assurances to parents,
in developing countries have been well described. l monitoring the health of the nation’s children,
Pinstrup-Anderson
and
43 and Jelliffe44 advise that
assessing growth, providing feedback to caregivers l support of future research.
and referring at risk children for specialised These experts suggested that a major justification
intervention is one of the most effective strategies for systematic growth monitoring is to identify
in reducing or preventing malnutrition among children with growth hormone deficiency and
children in developing countries.
Turner’s syndrome46.
Co-ordinated, systematic growth assessment and Growth and Health Outcomes
action programs (GAA) have been established in Over the past decade, several large observational
remote Aboriginal communities in the Alice studies have shown a strong association between
Springs area since 1996. A recent evaluation birth weight and adult chronic diseases including
(Figure 5) revealed that under-nutrition (as coronary heart disease (CHD),47 hypertension48 and
assessed by WAZ, HAZ or WHZ (z-score <-2.0) diabetes.49 Reports from countries such as the
decreased in several communities from 26% in United Kingdom,50 Sweden51 and the United States52
April 1997 to 13% in April 2000 among children have shown an association among both males and
under 5 years.45 These programs demonstrate that females between the development of CHD and low
early identification of poor growth or “failure to birth weight in relation to length of gestation.
thrive” allows for early and appropriate
interventions. The GAA programs also provide Forsen and colleagues53 in Finland described men
feedback on growth assessment to parents, born between 1924 and 1933 and death rates from
caregivers, communities and health policy-makers. coronary heart disease. Low birth weight was
strongly associated with CHD, but a stronger
Figure 5: Percentage of children <5 years in Alice association was found with thinness at birth (birth
Springs Remote District with poor growth - 1997 and weight/length3).
2000
We found the highest death rates from
coronary heart disease occurred in boys who
30
April - 1997
April - 2000
were thin at birth but whose weight caught
25
up so that they had an above average body
20
mass from the age of 7 years. (Eriksson, 199954)
15
Per cent
10
5
Some investigators suggest that the associations
0
between low birth weight and CHD, blood
pressure and diabetes may be more influenced by
the change in relative body size between birth and
adulthood rather than birth weight alone. Lucas55
suggests that it is the change in relative weight in
childhood or adulthood, or centile crossing that
Data Source: Territory Health Services, 200045
must also be considered.
Although the effectiveness of growth monitoring Lucas55 reported that insulin concentration at 9 to12
in industrialised countries has not been well years of age was unrelated to birth weight in pre-
defined, a multi-professional group met in term babies. However, when he adjusted for weight
Coventry, England in 199846 and concluded that at 9 - 12 years there was a significant negative effect
the potential benefits of growth monitoring in the
UK included:
8
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of birth weight on insulin concentration. This about the importance of growth and development
suggests that change in relative weight between among Indigenous children. The National
birth and 9 - 12 years may have been influential.
Aboriginal and Torres Strait Islander Nutrition
Strategy and Action Plan59 emphasises the
Other researchers56 suggest stunting (low height for importance of childhood growth and recommends
age) early in life plays a significant role in the that measures be taken to:
development of obesity. Studies in Brazil57
compared metabolic rates and fat oxidation rates
…… Identify and facilitate local and State/
among stunted children (height for age z-scores <
Territory activities designed to achieve
1.5) and normal height children. Although the
outcomes of: healthy birth weight, promotion
stunted children had normal resting metabolic
of breastfeeding, healthy childhood growth,
rates, they had significantly lower fat oxidation
healthy lifestyles and the treatment and
rates. Impaired fat oxidation rates have been
management of diet related diseases affecting
shown to be associated with excess weight gain -
Indigenous people. (NATSINSAP, 200059)
because fat that is not oxidised must be stored.
These findings may help to explain increases in Measures to improve Aboriginal and Torres Strait
body fatness and prevalence of obesity in stunted Islander children’s health and well-being must
adults and in developing countries. These data address those factors that may prevent families
highlight the importance of monitoring not only and communities from meeting the broader health
birth weight and birth length in the total and nutritional needs of their children.
population, but of systematically monitoring
growth throughout childhood.
Factors which are embedded in social and
structural inequities impact significantly on families’
Recommendations for Growth Assessment and and communities’ capacity to fully address the
Action in Queensland
health and nutritional needs of their children. These
In order to address the concerns of childhood factors include dispossession, unemployment,
obesity and subsequent adult lifestyle diseases, income level and financial security, education,
Australian experts in paediatrics, nutrition and housing tenure (adequate storage and food
sports medicine have published preparation areas and cooking facilities) and access
recommendations58 for nutrition and physical issues (supply and availability of fresh food in remote
activity for Australian children. For the management communities, choice and range of food at an
of healthy body weight, two major affordable cost).
recommendations are:
In Queensland, a nutritional surveillance working
l
body mass index (weight/height2), based
party in 1999 recommended strategies to:
on accurately measured height and
weight, is the most convenient way to
l
Establish systems to access growth
assess a child’s degree of fatness; (O’Connor
monitoring data for children under five
and Eden, 200058) and
and from school screenings. (Nutrition
l
growth measures, such as height and
Surveillance Working Party, 199960)
weight, should be monitored for early
detection of overweight or obesity,
It is clear from reports from Queensland, Australia
especially within families with a high risk
and around the world, that combating the
of type 2 diabetes or early atherosclerosis.
increasing rates of childhood overweight and
obesity and the continuing occurrence of under-
(O’Connor and Eden, 200058)
nutrition in Queensland will require programs of
Also, because of the critical issues related to growth; growth assessment and action. A regular systematic
obesity, infectious disease and intellectual potential, program needs to be a high priority for Queensland
Aboriginal and Torres Strait Islander health and and should ensure that:
nutrition advisory groups have voiced concerns
9
Information circular 58

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$
l
timely and accurate assessment of the
nutritional status of individual children is
Definitions for Assessing Overweight and
undertaken at regular intervals in childhood;
Obesity Used in Surveys
l
appropriate and timely action is taken when
assessment indicates that growth is outside
A variety of indices and cut-points have been
designated parameters;
used in international and Australian studies and
l
feedback on the growth and nutritional status
surveys to assess overweight and obesity in
of children is provided to parents, caregivers
children. The indicators and cut-points used in
and communities so that they can make
the surveys reviewed in this paper are
decisions about family and community level
summarized below:
responses to the problem and lobby for
resources to develop programs;
a) BMI - relates a child’s age-adjusted BMI z-
score to a BMI of 25 (overweight) or 30
l
standard practice training is provided to
community-based health workers, community
(obesity) at age 18 years.9
and child health nurses, and general
b) BMI - at risk of overweight and overweight
practitioners; and
based on the 85th and 95th percentiles,
respectively, derived from US NHANES I
l
data on the prevalence of over- and under-
survey data.62
nutrition are available to policy makers, health
c) BMI - overweight defined as BMI 85th
service providers and planners in health centres,
percentile of NHANES II 1976-8063 BMI for
districts and zones in Queensland to inform
girls $23.4 and for boys³ $23.0 (obesity not
decisions about resource allocation and to
defined).
ensure communities have access to the programs
d) BMI - overweight defined as BMI$ 85th
needed to improve the health of children.
percentile US NHANES II 1976-1980 weighed
and smoothed by Harlan64 (BMI for girls $23.5
The second recommendation in the National
and for boys $22.5) (obesity not defined).
Health and Medical Research Council’s Dietary
e) Overweight at 14 years defined as 20% above
Guidelines for Children and Adolescents61 reads:
standard weight for height of British reference
values.
Children need appropriate food and physical
f) Centiles based on 1990 British reference
activity to grow and develop normally. Growth
values for BMI.65
should be checked regularly. (NHMRC,199561)
A consistent policy response and resources to This paper was prepared by Terry Coyne,
ensure effective implementation of growth Nutritional Epidemiologist, Epidemiology Services
assessment and action strategies are urgently Unit, in collaboration with Public Health Services
required for Queensland.
Nutritionists; Ros Gabriel, Anita Groos, Amanda
Lee, Dympna Leonard, Simone Lowson and Helen
Valentini.
10
Information circular 58

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