© Freund Publishing H o u s e Ltd., L o n d o n Journal of Pediatric E n d o c r i n o l o g y & M e t a b o l i s m .

21, 8 2 7 - 8 3 6 ( 2 0 0 8 )

Reference Body Mass Index Curves for Turkish Children

6 to 18 Years of Age
Ahmet Ozturk 1 , Mumtaz M. Mazicioglu 2 , Nihal Hatipoglu 3 , Nurten Budak 4 , Gulcan Keskin 5 , Zehra Yazlak 5 ,
Nezaket Balci 5 , Hale Yildiz 5 , Kasim Yildiz 5 , H. Basri Ustunbas 2 and Selim Kurtoglir

'Department of Biostatistics, Erciyes University Faculty of Medicine, 2 Department of Family Medicine

Erciyes University Faculty of Medicine, 3Department of Pediatric Endocrinology, Erciyes University Faculty
of Medicine, 4Specialist for Nutrition and Dietetics, Erciyes University Rectorate and 5 Institute of Health,
Kayseri, Turkey

ABSTRACT INTRODUCTION

Aim: To determine reference body mass index
(BMI) curves for Turkish children 6 to 18 years
old and to compare with BMI in other countries.
Methods: A cross-sectional study conducted in
Kayseri, Turkey. A total of 5,727 children (2,942
girls, 2,785 boys) aged between 6 and 18 years
were selected to construct a reference curve
using LMS method.
Results: BMI age reference charts of Turkish
children were constructed. The 50 th percentile
curve of Turkish girls is lower than Italian and
Turkish girls in The Netherlands but higher
than Iranian girls. The 50 th percentile curve of
Turkish boys is lower than Italian and Turkish
boys in The Netherlands and similar to Iranian
boys after 13 years of age.
Conclusion: BMI references of Turkish children
are lower than in South East Europe, UK and
North American populations, but higher than in
Central European and Scandinavian countries.
KEY W O R D S
BMI, children, adolescents, overweight, obesity
Reprint address:
Ahmet Ozturk, Ph.D.
Erciyes University, Faculty of Medicine
Department of Biostatistics
38039 Kayseri, Turkey
e-mail: ahmets67@hotmail.com
The prevalence of overweight and obesity in
children and adolescents is a principal factor in
determining the prevalence of obesity in adulthood
with its increased morbidity and mortality as
compared to the non-overweight population1"3. It
has been reported that the severity of obesity in
adulthood is related to both the degree and the age
of onset of overweight in childhood 4 . These data
underlie the necessity of early diagnosis and treat-
ment to prevent obesity-related complications in
adulthood.
Body mass index (BMI) is suggested to identify
overweight and obesity in children and adoles-
cents 5 . BMI is easily calculated from simple anthro-
pometric measures and can be used in screening for
obesity. Previous studies show a documented relation-
ship between BMI and cardiovascular disease risk
factors among children and adolescents 6 " 13 . During
childhood BMI increases with age. This study was
undertaken to emphasize the differences that can
arise when comparing BMI data of a population
using different national and international standards.
Each country must determine the prevalence of
overweight and obesity as recommended with BMI
reference values and compare these figures with
others to develop its preventive measures 14 .
The aim of this study was to develop new and
comprehensive reference values for BMI in Turkish
children and adolescents aged 6-18 years and to
compare Turkish references with other countries.
Additionally, overweight and obesity rates were
calculated from these references.

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828
CHILDREN AND METHODS
Study design
This was a cross-sectional study conducted in
primary and secondary schools of the two central
and ten outlying districts of Kayseri Province,
Turkey. Data were obtained from the study of the
Determination of Anthropometric Measurements of
Turkish Children and Adolescents (DAMTCA)
from February to April, 2005. The study protocol
was approved by the Erciyes University School of
Medicine Ethics Committee and the Kayseri
Province Education Board.
Samples and sampling
A stratified multistage probability sampling
design was employed. The first stage was the
random selection of state and private schools which
represent the city center and districts by the
stratified sampling method according to socio-
economic levels. A total of 47 (23 primary, 24
secondary) schools were selected randomly among
699 schools in Kayseri. The second stage was
random sampling of children and adolescents aged
6 to 18 years from school enrolment. A total of
6,388 primary and secondary school students
(3,286 girls, 3,102 boys) were included in the
study. Chronological age was calculated as the
decimal age by subtracting the observation date
from the birth date. To calculate the age of a child
in days, the birthday was used. Each year elapsed
from the birth date was noted as one age. Children
with known growth disorders who used any kind of
medication were excluded from the study. Parents'
written consent was obtained prior to the study, and
the procedures followed were in accordance with
those outlined by the Declaration of Helsinki.
Data collection
All measurements were performed by well
trained health technicians. Weight and height were
measured twice, and the average was recorded for
reference charts. Weight was measured to 0.1 kg
using a standard beam balance (Tefal Ultraslim,
France) in minimal (without shoes and with light
clothing) underclothes. Height was determined to
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A. OZTURK ET AL.
the nearest 1 mm with a portable stadiometer. The
portable scales and stadiometers were calibrated
daily. For each child BMI was calculated according
to the formula: weight (kg)/height (m) 2 .
Statistical analysis
There were 14 girls and 37 boys with an SD
score of height, weight or BMI of over +5 SD or
below -5 SD, considered as outliers, who were
excluded from the a n a l y s i s T h e sample size used
to calculate overweight and obese prevalence was
6,388 (3,286 girls, 3,102 boys). Children and
adolescents whose height and weight were lower
than the 3 rd percentile or higher than the 97 th
percentile were removed from the study sample, as
we did in constructing waist circumference curves
of Turkish children 16 . The final total of 5,727
primary and secondary school students (2,942 girls,
2,785 boys) were enrolled to determine percentiles
(3 rd , 5 th , 10th, 25 th , 50 th , 75 th , 85 th , 90 th , 95 th and
97 th ) to create growth curves.
Construction of the percentile curves was
performed with the LMS Chart Maker Pro version
2.3 software program (The Institute of Child
Health, London), which fits smooth percentile
curves to reference data using the LMS method.
The smoothed percentile curves for BMI were
constructed by the LMS method. This method
summarizes percentiles at each age based on the
power of age-specific Box-Cox power transforma-
tions that are used to normalize data 17 . These three
quantities depend on age. The final curves of
percentiles are produced by three smooth curves
representing L (lambda; skewness), Μ (mu;
median) and S (sigma; coefficient of variation). The
LMS transformation equation is:
X = M(\ + LSz)"· L* 0
or
Χ ~ Μ exp(Sz) 1 = 0
where X is the physical measurement and ζ is the z-
score that corresponds to the percentile 15 . The key
task of the transformation was to estimate para-
meters L, M, and S. With estimates of L, M, and S,
values of X are connected to the values of ζ through
the above equation. The percentile is obtained from
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 BMI REFERENCES OF TURKISH CHILDREN 829

a normal distribution table in which the z-score
corresponds to the percentile of interest. In boys,
the effective degrees of freedom (edf) for BMI were
equal to 3 (M curve), 4 (S curve) and 3 (L curve),
respectively. In girls, edf for BMI were equal to 3, 4
and 3, respectively. Percentile values were mea-
sured by the LMS Chart Maker Pro version 2.3
software program, and percentile curves (3 rd , 5 th ,
10th, 25 th , 50 th , 75 th , 85 th , 90 th , 95 th and 97 th ) were
constructed by Microsoft Office Excel® version
2003. Descriptive statistics for each whole year
(e.g., 15.00-15.99 yr, etc.) within each sex were
calculated by SPSS version 13.0 (Chicago, IL,
USA). The prevalence of overweight and obesity in
Turkish children was calculated according to
references recommended by the International
Obesity Task Force (IOTF) 1 8 .
RESULTS
Table 1 presents the LMS curves for BMI by
age and sex. Smoothed 3 rd , 5 th , 10 th , 25 th , 50 th , 75 th ,
85 th , 90 th , 95 th and 97 th percentiles are shown in
Tables 2 and 3. Figures 1 and 2 show the smoothed
percentile curves for boys and girls. Table 4 shows
the mean and median BMI for Turkish children
aged 6-18 years.
Figures 3 and 4 show the median curves for
BMI in four different data sets by sex from 6 to 18
years. The medians for BMI of a neighboring
country, Iran, a Mediterranean country, Italy, and
Turkish children living in a European country, The
Netherlands, were compared 1 ^' 19 " 20 .
, The cut-off points of overweight and obesity of
the IOTF 1 8 were used to calculate overweight and
obesity prevalence of Turkish children (Table 5).

TABLE 1

LMS values of body mass index by age and sex

Age Boys Girls

(yr) η L Μ S η L Μ S

6 118 -1.733 16.301 0.097 117 -1.022 15.964 0.104

7 187 -1.761 16.616 0.103 159 -1.032 16.235 0.111
8 183 -1.783 16.946 0.109 194 -1.044 16.549 0.117
9 206 -1.789 17.298 0.115 181 -1.064 16.960 0.122
10 203 -1.772 17.680 0.119 209 -1.113 17.494 0.126
11 164 -1.732 18.111 0.123 180 -1.181 18.13 0.128
12 214 -1.668 18.587 0.125 206 -1.245 18.826 0.128
13 218 -1.591 19.107 0.126 222 -1.297 19.529 0.127
14 279 -1.517 19.668 0.126 359 -1.329 20.178 0.125
15 413 -1.450 20.221 0.125 435 -1.328 20.697 0.121
16 303 -1.382 20.734 0.124 385 -1.292 21.063 0.118
17 214 -1.318 21.233 0.123 225 -1.234 21.327 0.1 14
18 83 -1.260 21.733 0.121 70 -1.167 21.550 0.11 1

A g e indicates w h o l e age g r o u p , e.g., 6 . 0 - 6 . 9 9 yr, etc.

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TABLE 2
Smoothed age specific body mass index percentiles for Turkish boys aged 6-18 years

Age Percentiles
(yr) 3 rd
5 ,h
10 ,h
25 ,h
50th 75 ,h 85th 90 ,h 95th 97th
6 13.911 14.159 14.565 15.321 16.301 17.473 18.204 18.750 19.648 20.297
7 14.065 14.326 14.756 15.562 16.616 17.894 18.702 19.309 20.319 21.058
8 14.230 14.505 14.960 15.815 16.946 18.335 19.224 19.898 21.031 21.870
9 14.417 14.706 15.184 16.091 17.298 18.797 19.767 20.508 21.765 22.705
10 14.639 14.942 15.445 16.400 17.680 19.283 20.326 21.128 22.497 23.529
11 14.913 15.231 15.758 16.762 18.111 19.805 20.911 21.764 23.221 24.323
12 15.242 15.574 16.126 17.177 18.587 20.357 21.510 22.398 23.914 25.057
13 15.624 15.971 16.547 17.642 19.107 20.936 22.123 23.033 24.578 25.737
14 16.059 16.421 17.020 18.155 19.668 21.544 22.754 23.677 25.235 26.396
15 16.506 16.881 17.500 18.670 20.221 22.133 23.356 24.285 25.843 26.995
16 16.931 17.317 17.953 19.153 20.734 22.667 23.896 24.823 26.367 27.501
17 17.353 17.749 18.402 19.626 21.233 23.180 24.409 25.331 26.858 27.970
18 17.782 18.188 18.855 20.104 21.733 23.694 24.923 25.841 27.352 28.446

Age indicates whole age group, e.g., 6.0-6.99 yr, etc.

TABLE 3

Smoothed age specific body mass index percentiles for Turkish girls aged 6-18 years

Age Percentiles
rd th ,h <h
(yr) 3 5 10 25 50 ,h 75,h 85,h 90th 95 ,h 97th
6 13.356 13.635 14.088 14.918 15.964 17.171 17.897 18.426 19.270 19.861
7 13.446 13.741 14.223 15.109 16.235 17.546 18.342 18.925 19.861 20.521
8 13.579 13.891 14.400 15.342 16.549 17.968 18.837 19.476 20.509 21.242
9 13.809 14.137 14.674 15.672 16.960 18.487 19.430 20.127 21.261 22.071
10 14.176 14.518 15.080 16.130 17.494 19.127 20.144 20.901 22.140 23.032
11 14.667 15.021 15.604 16.698 18.130 19.859 20.946 21.759 23.099 24.071
12 15.242 15.607 16.208 17.339 18.826 20.632 21.774 22.632 24.054 25.091
13 15.857 16.230 16.845 18.004 19.529 21.387 22.564 23.451 24.923 26.000
14 16.453 16.832 17.457 18.632 20.178 22.060 23.251 24.147 25.635 26.722
15 16.954 17.336 17.967 19.149 20.697 22.573 23.754 24.640 26.106 27.173
16 17.328 17.713 18.345 19.526 21.063 22.908 24.062 24.923 26.337 27.360
17 17.621 18.006 18.637 19.811 21.327 23.128 24.244 25.071 26.420 27.388
18 17.885 18.270 18.898 20.061 21.550 23.302 24.376 25.167 26.447 27.358

Age indicates whole age group, e.g., 6.0-6.99 yr, etc.

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Boys

6 7 8 9 10 11 12 13 14 15 16 17 18
Age (years)

Fig. I: Smoothed L M S curves for the 3 rd , 5 lh , I0 lh , 25 th , 50 th , 7 5 ' \ 85 ,h , 90 l h , 95 th , and 97 th percentiles of body mass index for
Turkish boys aged 6-18 years.

Girls

Age (years)

Fig. 2: Smoothed L M S curves for the 3 r d , 5 ' \ 1D'\ 2 5 ' \ 50 th , 7 5 ' \ 85 l h , 90 , h , 9 5 ' \ and 97 , h percentiles of body mass index for
Turkish girls aged 6-18 years.

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TABLE 4

Mean (SD) and median ( m i n i m u m - m a x i m u m ) of body mass index for Turkish children aged 6-18 years

Age Boys Girls

(yr)
η Mean (SD) Median η Mean (SD) Median
(min-max) (min-max)*

6 118 16.61 (1.73) 16.42 117 16.27 (1.57) 16.13

(12.59-23.16) (13.15-20.83)

7 187 16.72(1.66) 16.51 159 16.47 (1.78) 16.29

(13.02-23.08) (12.01-22.44)

8 183 17.24 (2.05) 16.93 194 16.68(2.10) 16.26

(13.30-26.40) (13.21-24.80)

9 206 17.84 (2.40) 17.44 181 17.00 (2.25) 16.93

(13.67-25.33) (12.13-26.34)

10 203 17.86(2.31) 17.55 209 17.84 (2.46) 17.49

(13.59-27.13) (13.59-27.14)

11 164 18.80 (2.99) 18.18 180 18.47 (2.64) 17.85

(13.70-33.92) (14.14-25.80)

12 214 19.11 (2.71) 18.59 206 19.30(2.84) 18.78

(14.44-30.08) (13.38-29.08)

13 218 19.17(2.70) 18.57 222 19.69 (2.66) 19.17

(13.67-30.33) (14.48-28.41)

14 279 20.13 (2.68) 19.69 359 20.82 (2.78) 20.45

(14.68-29.02) (15.16-29.46)
15 413 20.97(2.85) 20.48 435 21.32 (2.68) 20.82
(15.41-30.38) (15.99-30.70)
16 303 21.02 (3.57) 20.63 385 21.40 (2.63) 20.96
(15.52-32.00) (15.59-30.32)
17 214 21.37 (2.54) 21.04 225 21.50(2.67) 21.08
(16.79-29.76) (15.97-32.89)
18 83 22.36 (3.62) 21.77 70 21.14(2.03) 21.04
(16.11-39.68) (17.26-26.23)
Age indicates whole age group, e.g., 6.0-6.99 yr, etc.

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Girls
Boys

Age (years) Age (years)

Fig. 3: Medians of body mass index by age in boys for four Fig. 4: Medians of body mass index by age in girls for four
countries. (The missing data [age 16-18 years] in countries. (The missing data [age 16-18 years] in
the Iranian study could not be shown in the figure.) the Iranian study could not be shown in the figure.)

TABLES

Prevalence of overweight and obesity in Turkish children (6-18 years) according to references
recommended by the International Obesity Task Force (IOTF) 1 8

Age Girls Boys

(yr) Overweight Obese η Overweight Obesity
η
percent ( 9 5 % CI) percent ( 9 5 % CI) percent ( 9 5 % CI) percent ( 9 5 % CI)

6 131 20.6(14.0-28.6) 4.6(1.7-9.7) 128 20.3 (13.7-28.3) 7.8(3.8-13.9)

7 175 16.6(11.4-22.9) 6.3 (3.2-10.9) 215 16.3 (11.6-21.9) 6.0(3.3-10.1)

8 215 12.6(8.4-17.7) 6.5 (3.6-10.7) 204 19.1 (13.9-25.2) 5.9 (3.1-10.0)

9 198 15.2(10.4-20.9) 2.5 (0.8-5.8) 229 18.8(13.9-24.4) 7.0(4.0-11.1)

10 236 17.4(12.8-22.8) 4.2 (2.0-7.6) 224 12.1 (8.1-17.1) 4.9(2.5-8.6)

11 201 18.4(13.3-24.5) 2.5 (0.8-5.7) 182 17.6(12.3-23.9) 6.0(3.0-10.6)

12 233 18.5(13.7-24.0) 3.9(1.7-7.2) 237 14.8(10.5-19.9) 5.1 (2.6-8.7)

13 242 14.9(10.6-19.9) 2.5 (0.9-5.3) 240 12.9 (8.9-17.8) 3.3 (1.4-6.5)

14 412 16.3 (12.8-20.2) 2.9(1.5-5.0) 311 15.1 (1 1.3-19.6) 3.5 (1.8-6.2)

15 488 15.4(12.3-18.9) 2.3 (1.1-4.0) 459 16.1 (12.9-19.8) 4.8(3.0-7.2)

16 430 15.6(12.3-19.4) 1.6(0.7-3.3) 341 12.9(9.5-16.9) 3.8(2.0-6.4)

17 249 9.6(6.3-14.0) 2.8(1.1-5.7) 240 1 1.3 (7.5-15.9) 2.5 (0.9-5.3)

18 76 7.9 (2.9-16.4) - 92 14.1 (7.7-22.9) 4.3 (1.2-10.7)

Overall 3,286 15.5 (14.3-16.8) 3.1 (2.6-3.8) 3102 15.2 (14.0-16.6) 4.8(4.1-5.6)

Age indicates whole age group, e.g.. 6.0-6.99 yr. etc.

CI = confidence interval.

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 834
The prevalence of overweight was 15.5% in boys
and 15.2% in girls. The prevalence of obesity was
4.8% in boys and 3.1% in girls. The overall
prevalence of overweight and obesity was 15.4%
(95% confidence interval [CI] =14.5%, 16.3%) and
3.9% (95% CI=3.5%, 4.5%), respectively.
DISCUSSION
This study provides an update on BMI referen-
ces for Turkish children. There are few studies on
BMI in Turkish children. The most comprehensive
and detailed study, conducted in Istanbul, repre-
sents a high socio-economic group 14 . The present
study with its larger sample size is more compre-
hensive, and the children recruited in this study
represent all socio-economic levels. Therefore our
data can be considered updated and inclusive of all
socio-economic levels.
Overweight and obesity have serious health
consequences 21 . Preventive actions are needed to
identify overweight and obese children in early
life 1 . Increased morbidity and mortality associated
with being overweight or obese, and secondary
chronic degenerative diseases, are often initiated
from the first year of life in these children 22 .
The definition of obesity is based on BMI, but
organizations such as the World Health Organiza-
tion (WHO) and the National Centre for Health
Statistics (NCHS), and groups such as IOTF, use
different definitions 15 ' 22 " 24 .
According to the WHO reference for adults,
BMI >25 kg/m 2 is referred to as overweight, while
BMI >30 kg/m 2 indicates obesity 21 . In the United
States, the 85 th and 95 th percentiles (85-95 th :
overweight, >95 th obese) of BMI for age and sex
based on nationally representative survey data have
been recommended as cut-off points to identify
overweight and obesity 25 . On the other hand, the
IOTF recommended a new definition of overweight
and obesity in childhood, based on pooled inter-
national data for BMI constructed by using results
from studies across six countries of different conti-
nents.
The study conducted in Istanbul 14 revealed that
the prevalence of overweight was 25.0% and
obesity 4.0% in boys, and overweight was 15.0-
20.0% and obesity 1.0-2.0% in girls. Compared
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A. OZTURK ET AL.
with the study conducted by Bundak et al.14, the
prevalence of obesity in our study was similar,
while the prevalence of overweight was lower in
boys. The prevalence of overweight in girls was
lower than in the previous study, while obesity in
our study was significantly high. The sample selec-
tion criteria of these two studies may be responsible
for these differences. The socio-economic level,
diet, physical activity, geographical region, and the
size of the sample may also have led to these
differences.
We also compared our 50th percentiles with
those from Iran, Italy and Turkish children living in
The Netherlands. Median BMI percentiles of
Turkish boys in Kayceri were similar to Turkish
boys in The Netherlands and higher than Italian
boys at 6-9 years of age 15 ' 19 ' 20 . At older ages, BMI
percentiles of Turkish boys gradually increased. It
should be noted that Turkish children who were
born and brought up in The Netherlands had
slightly higher 50 th percentile BMI values, but
Italian boys had markedly increased values when
compared with Turkish children. The 50th percen-
tile values of Iranian boys were lower than our
study group at 6-13 years and were similar to our
50th percentile values at puberty.
The 50 th percentile curves of Italian girls and
Turkish girls who were born and brought up in The
Netherlands were higher than those of Turkish girls
in Kayceri. The Iranian 50 th percentile curve for
girls is significantly lower but increases up to the
level of the Turkish 50 th percentile curve at 13-15
years. The 50 th percentile curve for Turkish boys
was found to be lower than Italian boys and similar
to Turkish children who were born and brought up
in The Netherlands at 6-9 years of age. Considering
the apparent difference of curves for Turkish
children living in Turkey and in The Netherlands,
environmental factors may be an important cause of
this difference.
The prevalence of overweight and obesity calcu-
lated from BMI references puts Turkish adolescents
within the top 10 countries in Europe 25 . The highest
prevalence for overweight and obesity in adoles-
cents was found to be in South Western Europe and
the UK 25 . The prevalence of overweight and
obesity in Turkish children is higher than 15%,
similar to North American countries (Canada,
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 BMI REFERENCES OF TURKISH CHILDREN
USA), the UK and South-West Europe (Greece,
Italy, Malta, Portugal, and Spain). The prevalence
of overweight in Turkish children is similar to that
in Scandinavia, Central European countries (Austria,
Belgium, France, Germany, The Netherlands, and
Switzerland) where the prevalence is 10-15%. We
consider that the geographical location of a country
is not the primary determinant for overweight and
obesity in children and adolescents, thus the socio-
economic level and population characteristics must
be taken into account for preventive measures.
In conclusion, it is important to determine BMI
references for each country and compare these
references with other countries to prevent over-
weight and obesity in children and adolescents. On
the other hand, standardized references must be
used for comparison of Figures for different
countries. Health authorities need both international
comparison of the prevalence and incidence data
for overweight and obesity to set up preventive
strategies.
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835
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