J. Biosoc. Sci.

, page 1 of 15 © Cambridge University Press, 2017

doi:10.1017/S0021932017000426

D I F F E R E NC E S I N T HE P R E V A L E N C E
O F O V E R W E I G H T A N D OB E S I T Y I N 5 - T O
14-YEAR-OLD CHILDREN IN KRAKÓW,
POLAND, USING THREE NATIONAL BMI
CUT-OFFS

RENATA WOŹNIACKA*1, ANETA BAC†, MAŁGORZATA KOWAL‡ AND

STANISŁAW MATUSIK§

*Department of Anatomy, Faculty of Motor Rehabilitation, University of Physical

Education, Kraków, Poland, †Department of Clinical Forms of Occupational Therapy,
Faculty of Motor Rehabilitation, University of Physical Education, Kraków, Poland,
‡Department of Anthropology, Faculty of Physical Education, University of Physical
Education, Kraków, Poland and §Department of Statistics and Computer Science,
University of Physical Education, Kraków, Poland

Summary. The problem of overweight and obesity in children and adolescents

has been noted in many different countries. The aim of this study was to evaluate
the differences in the percentage occurrence of overweight and obesity in Polish
children depending on the criteria used, and to evaluate the usefulness of the
Polish national database. The study sample comprised 3405 children aged
5–14 years (1674 girls and 1731 boys) from the city of Kraków, Poland, in 2009–
2010. The BMI of each child was calculated and classified as overweight or obese
according to three different reference BMI cut-offs: the International Obesity
Task Force (IOTF), the Centers for Disease Control and Prevention (CDC) and
the Polish 2010 standard. To assess the statistical significance of the differences
between these three applied reference datasets, a comparison of two proportions
was performed and Cohen’s kappa coefficient calculated. The prevalences of over-
weight were 15%, 11.3% and 9.5% (IOTF, CDC, Polish 2010, respectively)
among boys and 15.5%, 11.6% and 9.9% among girls. The prevalences of obesity
were 3.3%, 6.1% and 5.5% (IOTF, CDC, Polish 2010, respectively) among boys
and 3.4%, 6.3% and 5.7% among girls. The different methods used generally
showed good agreement. Nevertheless the prevalence of overweight and obesity
differed significantly depending on the criteria used. In conclusion, the creation
and updating of national databases based on large, representative groups is
justified and provides the best reference for regional data. However, in order to
ensure the comparability of results with those from other countries, it seems advi-
sable to use cut-offs based on international data as well.

1
Corresponding author. Email: renatawozniacka@wp.pl

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 2 R. Woźniacka et al.
Introduction
Obesity is a complex disorder that is affected by many interacting genetic and non-
genetic factors. The global emergence and increase in childhood obesity represents a
serious public health problem that contributes to a higher prevalence of obesity-related
chronic diseases in adult populations (Ong et al., 2000; Ebbeling et al., 2002; Rolland-
Cachera, 2005; Han et al., 2010, Herouvi et al., 2013; Giussani et al., 2013). The problem
of overweight and obesity in children and adolescents has been noted in different
countries (Ells et al., 2015; Mladenova & Andreenko, 2015; Ogden et al., 2016; Djordjic
et al., 2016).
The city of Kraków in southern Poland has seen a considerable increase in the
prevalence of obesity of school children over the last few decades (Bac et al., 2012;
Kryst et al., 2012; Kowal et al., 2014), although in the years 1983–2010 the incidence of
overweight girls in Kraków decreased slightly, from 12.44% to 11.17% (Kowal et al.,
2014). A similar trend has been observed in other countries (Peneau et al., 2009;
Stamatakis et al., 2010; Ogden et al., 2015, 2016).
Body mass index (BMI) has limited applicability in measuring body fat in children
and adolescents (Tomaszewski et al., 2015). However, it is still a convenient way of
detecting overweight and obesity. In addition, the existing data on BMI measured in
large population groups enable the comparison of results across countries. There is now
good evidence that central obesity carries more health risks compared with total obesity,
as assessed by BMI. The predictive power of BMI as a measure of adiposity is
considered to be insufficient (Flegal & Ogden, 2011; Javed et al., 2015). Waist
circumference and waist-to-height ratio (WHtR), a proxy for central obesity, should be
measured at the same time as BMI to better predict health risk (Brammbilla et al., 2013;
Sahweel & Gibson, 2016).
In 2000, Cole et al. (2000) published a set of smoothed, sex-specific BMI values based
on six representative data sets. The International Obesity Task Force (IOTF)
recommended cut-offs based on the age- and sex-specific values of BMI extrapolated
to the adult values of 25 kg/m2 and 30 kg/m2 for defining overweight and obesity,
respectively. At the same time in the United States, the Centers for Disease Control and
Prevention (CDC) published growth charts (the CDC 2000) based on five National
Health and Nutrition Examination Surveys (NHANES) conducted in the years
1960–1994 (www.cdc.gov/nccdphp/dnpao/growthcharts/resources/sas.htm).
Many countries have created databases based on national surveys, e.g. Germany
(Kalies et al., 2002), United Kingdom (Cole et al., 1995), Spain (Martinez-Costa et al.,
2014), France (Kêkê et al., 2015), Romania (Chirita-Emandi et al., 2016), Greece
(Christoforidis et al., 2011) and others. Data from a large and representative group of
Polish children and school-aged youth (6–19 years) were published in 2011 and collected
under the OLAF Study (Kułaga et al., 2011) – a cross-sectional study on height, weight
and BMI of school-aged children in Poland using data from a current sample of
Polish children aged 6–19 years (n = 17,573). Field examinations were conducted in
416 schools in all regions of Poland between November 2007 and November 2009.
The very definition of overweight and obesity is a problem, as each country uses
different percentile-based definitions (Flegal & Ogden, 2011). In 2007 the definitions of
overweight and obesity were changed in the US and the rest of the world. Overweight
was then defined as a BMI between the 85th and 95th percentiles, while obesity was over

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 Prevalence of overweight and obesity in Poland 3
the 95th percentile (Ogden & Flegal, 2010). For greater comparability of results from
different countries, using the same definition allows the evaluation of the problem in
different populations throughout the world. Accordingly, this study used the definitions
proposed in 2007.
The overall aim of this study was to assess differences in the prevalence of overweight
and obesity in children and adolescents from Kraków (the second largest city in Poland),
in relation to various references. It was evident there were differences in these
prevalences that depended directly on the method used (O’Neill et al., 2007), and
therefore it was decided to carry out additional analysis to explore this issue further.
The present study assessed the efficiency of three standards – the IOTF reference, CDC
reference and national Polish 2010 standard – each using different cut-offs in defining
overweight and obesity in children aged 5–14 years. Finally, the study aimed to assess
the usefulness of the national database as a reference, compared to the results available
in the international literature.

Methods
Study sample
The heights and weights of children in randomly selected primary schools and high
schools in Kraków, Poland, were measured from November 2009 to March 2010.
In order to provide a representative sample, the selection of units for testing (schools and
classrooms) was determined at random, taking into account available information
sources about the study population. Analysis of the age pyramid of the population of
Kraków determined the proportion between the number of boys and girls, and the
percentages of each age group in relation to the whole sample. All types of schools were
taken into account (kindergarten, primary school, secondary school, basic vocational
school, technical school, high school), as well as their location in the city. Considering all
the above, the target sample size was established in the age groups, along with the
number of allocated research institutions and the number of classrooms in a facility in
every district. All analysed schools and kindergartens were chosen by two-stage lottery,
using the ‘urn randomization method’.

Anthropometric measurements
All measurements were performed in the morning by the authors (RW, AB, MK).
The study sample comprised 3405 children aged 5–14 years, including 1674 girls (49.2%)
and 1731 boys (50.8%). The distribution of children by sex and age group (means,
medians, standard deviations and ranges for height, weight and BMI) is presented in
Tables 1 and 2. The anthropometric measurements were made according to the
procedures in force, i.e. with the consent of the Bioethics Committee at the Regional
Medical Association in Kraków (No. 26/KBL/OIL/2007) and with the consent of the
children’s parents or legal guardians. The children were examined in light clothes
without shoes. Body height was measured with an anthropometer to the precision of
0.1 cm. Body weight was measured using a TANITA scale model TBF-300A to the
precision of 0.1 kg. All measurements were performed in the morning by the study
authors (RW, AB, MK).

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 4 R. Woźniacka et al.
Table 1. Heights, weights and BMIs of boys by age group, Kraków, Poland, 2009–2010
Height (cm) Weight (kg) BMI (kg/m2)
Age
(years) n Mean SD Range Mean Me SD Range Mean Me SD Range
5.5 23 114.9 7.9 105.0–130.4 22.3 22.2 4.1 16.4–33.5 16.8 16.5 1.4 14.4–19.7
6.5 86 121.3 5.8 103.5–133.9 24.2 24.0 4.5 15.5–40.2 16.3 16.0 2.1 12.8–23.8
7.5 230 126.9 5.9 112.8–146.0 27.1 25.9 5.4 18.0–47.4 16.7 16.2 2.4 12.9–25.1
8.5 240 133.2 6.2 117.0–152.8 31.5 30.3 6.7 19.8–60.8 17.6 17.0 2.6 12.9–26.4
9.5 224 137.8 6.6 121.7–155.7 35.0 33.6 8.1 22.0–73.1 18.3 17.5 3.2 13.0–31.9
10.5 193 142.5 6.7 128.5–168.0 37.8 34.6 10.7 24.4–108.9 18.5 17.4 3.9 13.3–41.1
11.5 187 147.8 6.5 130.4–167.6 41.6 40.1 8.7 24.1–77.6 18.9 18.4 3.2 13.1–34.3
12.5 198 154.4 8.4 132.0–178.0 47.0 45.0 11.3 26.2–106.5 19.6 18.9 3.7 13.9–38.2
13.5 227 163.1 9.1 124.0–182.4 54.8 54.0 12.6 26.3–100.5 20.4 19.7 3.6 13.8–32.9
14.5 123 168.9 8.8 142.3–192.8 61.1 58.3 16.0 35.8–111.0 21.2 19.9 4.3 14.5–35.8
Total 1731 143.6 16 103.5–192.8 39.6 36.0 14.6 15.5–111.0 18.6 17.8 3.5 12.8–41.1

Table 2. Heights, weights and BMIs of girls by age group, Kraków, Poland, 2009–2010
Height (cm) Weight (kg) BMI (kg/m2)
Age
(years) n Mean SD Range Mean Mean SD Range Mean Mean SD Range
5.5 19 112.3 6.2 103.3–124.4 21.5 21.3 3.6 16.1–29.1 17.0 16.9 2.0 13.4–20.1
6.5 98 120.5 5.5 107.2–132.7 23.7 22.8 4.3 16.3–40.0 16.2 15.7 1.9 13.3–23.6
7.5 205 125.3 5.5 108.5–140.0 25.8 24.8 5.1 16.8–47.9 16.4 15.9 2.5 11.9–26.3
8.5 221 130.8 6.4 114.4–148.5 29.1 28.0 6.0 18.7–49.3 16.9 16.3 2.5 12.9–27.3
9.5 203 136.4 7.4 119.7–157.9 32.7 31.8 7.1 19.9–58.5 17.4 17.1 2.7 12.8–26.3
10.5 208 142.2 7.1 121.0–163.0 36.6 35.6 7.6 21.1–63.7 18.0 17.4 2.8 13.4–28.8
11.5 218 149.1 7.1 131.2–170.0 41.0 40.1 8.4 25.3–73.0 18.3 18.0 2.8 13.8–29.4
12.5 183 155.0 7.3 137.4–175.8 46.8 45.4 10.2 25.7–83.0 19.3 19.0 3.2 13.1–32.0
13.5 222 159.9 5.9 140.0–173.5 52.0 50.3 10.3 31.9–88.6 20.3 19.6 3.3 14.6–32.2
14.5 97 161.7 6.1 136.0–180.0 54.5 53.5 9.7 34.1–94.5 20.8 20.1 3.3 14.3–31.4
Total 1674 142.1 15.0 103.3–180.0 37.6 35.8 12.7 16.1–94.5 18.1 17.5 3.2 11.9–32.2

Analysis
To assess the prevalence of overweight and obesity, BMI was calculated for each
child (kg/m2), and children were placed in overweight and obesity groups. The children
were put into age groups based on the method whereby a 5.5 year old group included all
children aged 5.0–5.99 on the day of the survey. The children’s BMI was calculated and
classified as normal, overweight or obese according to the International Obesity Task
Force (IOTF) (Cole et al., 2000) and Centers for Disease Control and Prevention (CDC
2000) BMI cut-offs. To assess the number of overweight and obese children, national
data references (Polish 2010) were used, as presented by Kułaga et al. (2011). Percentile
curves for height, weight and BMI were created separately for each sex using the
Lambda-Mu-Sigma (LMS) method. The LMS method summarizes the measurement
distributions with three age- and sex-specific parameters, namely: the Median (M), the

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 Prevalence of overweight and obesity in Poland 5
coefficient of variation (S) and the skewness of the distribution (L). This method was
used to take the asymmetry of the distribution into account (Scherdel et al., 2015). In the
case of BMI, in addition to the traditional set of percentiles (3rd, 10th, 25th, 50th, 75th,
90th, 97th), the 85th and 95th percentiles were included because these are the
recommended BMI cut-offs identifying children and adolescents for overweight and
obese, respectively (Ogden & Flegal, 2010). In 2013, Kułaga et al. (2013) published data
for children of preschool age. The study did not provide values for the 85th and 95th
percentiles. For this reason, in the present analysis, national data for children aged 5.5
and 6.5 were not use (see Tables 3 and 4).
Before applying statistical tests, the normality of distribution was tested separately
for each characteristic and sex using Kolmogorov–Smirnov and Shapiro–Wilk tests.
While boys’ body height had a normal distribution, their BMIs and body weights had
positively skewed distributions, so for these variables basic statistical parameters (means,
standard deviations and ranges) were determined, and in addition medians for weight
and BMI (see Fig. 1).
In order to assess the statistical significance of the differences in the proportions of
overweight or obesity between the three applied reference datasets, a comparison of two
proportions was performed using the z-test for large sample sizes, which was possible
thanks to a large number of observations in different years. This test is asymptotically
converged to a normal distribution. The concordance of classification methods was
assessed using Cohen’s kappa coefficient (Cohen, 1960). Coefficient values close to 1
indicate high compliance ratings, and those close to 0 the lack of conformity (random
distribution of ratings). Kappa coefficient values greater than 0.8 may be regarded as
indicative of near-perfect conformity, or ‘almost perfect agreement’. Values from 0.6 to
0.8 indicate a significant compliance or ‘substantial agreement’ and values from 0.4 to
0.6 indicate average compliance or ‘moderate agreement’ (Landis & Koch, 1977).
Statistical analysis was performed using STATISTICA 10 software.

Results
Tables 3 and 4 show the prevalence of overweight and obesity for boys and girls
respectively in the study sample by age group using the three different evaluation
criteria. Differences in the prevalence of overweight in both the total group of boys and
girls were statistically significantly higher (p < 0.001) using the IOTF cut-offs than using
the Polish 2010 and CDC cut-offs, and were statistically lower for obesity. Within the
age groups only a few results were statistically significantly different.
The lack of statistically significant differences when overweight and obese girls were
treated as a single group showed that the number of girls with BMI at or above the
85th percentile was similar, i.e. the cut-off points were similar for IOTF and CDC.
The differences appeared in the 95th percentile, with a nearly two times higher
percentage of obese girls as estimated by the CDC in relation to the IOTF (6.1% and
3.3%, respectively). Among the girls, the highest prevalence of overweight was observed
using the IOTF reference, and the lowest when Polish 2010 data were used (except for
the 12.5- and 14.5-years-old groups). In the case of obesity, the highest values were
observed in the youngest groups (5.5–9.5 and 12.5 years) using CDC and in the other age
groups using Polish 2010.

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 6 R. Woźniacka et al.
Table 3. Prevalence (%) of overweight and obesity in boys by age group using three
different reference datasets
Polish Polish Polish
Age group (n) IOTF CDC 2010a CDC−IOTF 2010−IOTF 2010−CDC
5.5 + 6.5 (109) OW 16.5 19.3 — 2.8 — —
OB 6.4 13.8 — 7.4 — —
OW + OB 22.9 33.1 — 10.2 — —
7.5 (230) OW 16.1 14.3 11.3 −1.8 −4.8 −3.0
OB 6.1 11.7 6.5 5.6* 0.4 −5.2
OW + OB 22.2 26.1 17.8 3.9 −4.4 −8.3**
8.5 (240) OW 23.3 20.0 15.0 −3.3 −8.3* −5.0
OB 6.7 12.5 6.7 5.8* 0.0 −5.8**
OW + OB 30.0 32.5 21.7 2.5 −8.3* −10.8**
9.5 (224) OW 23.7 15.6 18.3 −8.1* −5.4 2.7
OB 6.7 17.0 6.7 10.3*** 0.0 −10.3***
OW + OB 30.4 32.6 25.0 2.2 −5.4 −7.6
10.5 (193) OW 23.3 20.2 16.1 −3.1 −7.2 −4.1
OB 6.2 10.9 6.2 4.7 0.0 4.7
OW + OB 29.5 31.1 22.3 1.6 −7.2 −8.8
11.5 (187) OW 21.9 19.3 14.4 −2.6 −7.5 −4.9
OB 2.7 7.0 3.2 4.3 0.5 −3.8
OW + OB 24.6 26.2 17.6 1.6 −7.0 −8.6
12.5 (198) OW 21.2 17.7 16.7 −3.5 −4.7 −1.0
OB 4.5 8.1 5.1 3.6 0.6 −3.0
OW + OB 25.8 25.8 21.7 0.0 −4.0 −4.1
13.5 (227) OW 21.6 17.6 15.4 −4.0 −6.2 −2.2
OB 4.8 8.8 7.5 4.0 2.7 −1.3
OW + OB 26.4 26.4 22.9 0.0 −3.5 −3.5
14.5 (123) OW 22.0 16.3 15.4 −5.7 −6.6 −0.9
OB 8.1 13.0 13.0 4.9 4.9 0.0
OW + OB 30.1 29.3 28.5 −0.8 −1.6 −0.8
Total (1731) OW 15.0 11.3 9.5 −3.8*** −5.5*** −1.6
OB 3.3 6.1 5.5 2.8*** 2.2*** −0.6
OW + OB 18.3 17.3 15.0 −1.0 −3.3** −2.3

OW, overweight; OB, obesity.

a
Due to the lack of 85th and 95th percentile values for preschool children, the prevalence of
overweight and obesity is not presented for those age groups.
*p < 0.05; **p < 0.01; ***p < 0.001.

The prevalence of overweight in Polish children from Kraków differed significantly

accordingly to the reference used. The IOTF or CDC reference data resulted in a high
prevalence of overweight for boys and girls, while the more recent Polish 2010 reference data
indicated lower rates. The prevalence of obesity in Polish children was lowest when using the
IOTF reference, both in boys and girls, and highest when using the CDC reference.
Agreement between the three references used in the study was tested using Cohen’s
kappa coefficient (Table 5). The high values of Cohen’s kappa coefficient, ranging from
0.71 to 0.89, suggest a strong degree of compliance between the various classification

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 Prevalence of overweight and obesity in Poland 7
Table 4. Prevalence (%) of overweight and obesity for girls by age group using three
different references datasets
Polish Polish Polish
Age (n) IOTF CDC 2010a CDC–IOTF 2010–IOTF 2010−CDC
5.5 + 6.5 (117) OW 18.8 18.8 — 0 — —
OB 6.8 12.0 — 5.2 — —
OW + OB 25.6 30.8 — 5.2 — —
7.5 (205) OW 17.6 10.7 9.8 −6.9 −7.8* −0.9
OB 4.9 9.3 8.3 4.4 3.4 −1.0
OW + OB 22.4 20.0 18.0 −2.4 −4.4 −2.0
8.5 (221) OW 15.4 12.7 11.8 −2.7 −3.6 −0.9
OB 4.1 6.3 5.0 2.2 0.9 −1.3
OW + OB 19.5 19.0 17.7 −0.5 −2.8 −1.3
9.5 (203) OW 17.7 11.8 10.3 −5.9 −7.4 −1.5
OB 3.4 6.4 5.9 3.0 2.5 −0.5
OW + OB 21.2 18.2 16.3 −3.0 −4.9 −1.9
10.5 (208) OW 13.5 10.6 9.6 −2.9 −3.9 −1.0
OB 3.4 5.3 5.3 1.9 1.9 0.0
OW + OB 16.8 15.9 14.9 −0.9 −1.9 −1.0
11.5 (218) OW 14.7 11.0 9.6 −3.7 −5.1 −1.4
OB 0.9 4.1 4.6 3.2 3.7** 0.5
OW + OB 15.6 15.1 14.2 −0.5 −1.4 −0.9
12.5 (183) OW 13.7 9.8 12.6 −3.9 −1.1 2.8
OB 2.7 4.4 3.8 1.7 1.1 −0.6
OW + OB 16.4 14.2 16.4 −2.2 0.0 2.2
13.5 (222) OW 15.3 12.2 9.9 −3.1 −5.4 −2.3
OB 2.7 5.9 9.0 3.2 6.3** 3.1
OW + OB 18.0 18.0 18.9 0.0 0.9 0.9
14.5 (97) OW 13.4 8.2 12.4 −5.2 −1.0 4.2
OB 3.1 4.1 7.2 1.0 4.1 3.1
OW + OB 16.5 12.4 19.6 −4.1 3.1 7.2
Total (1674) OW 15.5 11.6 9.9 −3.9*** −5.6*** −1.7
OB 3.4 6.3 5.7 2.9*** 2.3*** −0.6
OW + OB 18.9 17.9 15.5 −1.0 −3.4** −2.4
a
Due to the lack of 85th and 95th percentile values for preschool children, the prevalence of
overweight and obesity is not presented for those age groups.
*p < 0.05; **p < 0.01; ***p < 0.001.

methods. In the girls, the compatibility between methods was higher than in boys. The
weakest level of compliance was observed between the Polish 2010 and CDC among boys.

Discussion
The problem of overweight and obesity in children and adolescents has been noted by
many authors. There has been a record increase in the prevalence of overweight and obesity
among children and adolescents in many regions of the world over the last decade (Rosati
et al., 2014; Ells et al., 2015; Mladenova & Andreenko, 2015; Djordjic et al., 2016).

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 8 R. Woźniacka et al.

Fig. 1. Histograms of abundance: body height: a) boys and b) girls; body weight:
c) boys and d), girls; BMI: e) boys and f) girls.

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 Prevalence of overweight and obesity in Poland 9
Table 5. Compliance of the classification of participants using various BMI criteria
CDC vs IOTF Polish 2010 vs IOTF Polish 2010 vs CDC
Boys (N = 1731)
Cohen’s kappa 0.80 0.83 0.71
coefficient
Consistency Substantial agreement Almost perfect Substantial agreement
agreement
Girls (N = 1674)
Cohen’s kappa 0.84 0.81 0.89
coefficient
Consistency Almost perfect Almost perfect Almost perfect
agreement agreement agreement

The present study in Polish school children found that the prevalence of overweight
and obesity varied depending on the method of evaluation. Using BMI cut-offs from a
national (Polish) database resulted in a lower percentage of overweight children for both
sexes when compared with both the CDC and IOTF cut-offs, respectively: 9.5% vs 11.3%
vs 15% for boys and 9.9% vs 11.6% vs 15.5% for girls. The highest percentage of obesity for
both sexes was observed using the CDC cut-offs (6.1% boys, 6.3% girls) and the lowest
using the IOTF (3.3% and 3.4%, respectively), while the percentage of obese children
calculated on the basis of Polish national data was 5.5% for boys and 5.7% for girls.
Similar results were obtained by Zimmermann et al. (2004) for Swiss children aged
6–12 years. Differences in the prevalence of overweight were relatively low for boys and
amounted to 16.6% (IOTF) and 20.3% (CDC) and 19.1% for girls (both BMI cut-offs).
At the same time, the percentage of obese children was nearly twice as high using the
CDC than the IOTF cut-offs; 7.36% vs 3.85% for boys, and 5.31% vs. 3.72% for girls.
The same trend was observed in 6- to 7-year-old Chilean children (Kain et al., 2002).
The percentage of overweight children was similar, regardless of the adopted method
and sex, and the percentage of obese children was twice as high when estimated with
the CDC than the IOTF cut-offs for both sexes. The results of a study on Irish school
children aged 8–12 (comparing IOTF, CDC and UK90 cut-offs) also confirmed the
finding of the present paper (O’Neill et al., 2007). Given these relationships, and the fact
that the percentage of overweight and obese children evaluated using Polish 2010 cut-
offs fell between CDC and IOTF results, it seemed appropriate to use the Polish 2010
cut-offs as reference. At the same time, it also seems adequate to present estimates based
on international BMI cut-offs when comparing Polish results with those from different
countries.
Wang and Wang (2002) compared the prevalence of overweight and obesity for three
different populations in China, Russia and the United States for two age groups: 10–18
and 6–9 years. They used the IOTF and WHO cut-offs for the 10–18 age group, and the
CDC for 6- to 9-year-olds. They obtained high agreement of results for each method
in all three populations when assessing overweight. This was shown by the Kappa
coefficient ranging from 0.88 to 0.98, with values above 0.8 indicating an excellent
agreement of results. Obesity was assessed only for Russia and the United States due to
the very low percentage of obesity in China. In the present study, the results obtained

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 10 R. Woźniacka et al.
using the IOTF and CDC cut-offs were compared. Agreement of results was not as high
as in the case of overweight. For children aged 6–9, the Kappa coefficient was 0.77 for
boys and 0.73 for girls. In the age group 10–18 all values indicated a high agreement of
results. When comparing the prevalence of obesity in 6- to 9-year-old children estimated
by IOTF and WHO for the United States, the Kappa coefficient was 0.8 regardless of
sex; for the Russian population it was only 0.58 for boys and 0.74 for girls and 0.65 for
the entire group (n = 1678). This indicates a poor agreement of obesity results in this
age group. In this study, Cohen’s kappa coefficient values ranged from 0.71 for boys to
0.89 for girls when comparing the Polish 2010 with the CDC reference.
Shields and Tremblay (2010) showed that the prevalences estimated for the OITF
(26%) and CDC (28%) cut-off points for the combined overweight and obesity category
in children and adolescents aged 2–17 years were similar. The estimates of the prevalence
of obesity were higher when based on the CDC (13%) compared with the IOTF cut-offs
(8%). In a study of Romanian children aged 6–19 years, the prevalence of overweight
(including obesity) was 23% when based on IOTF cut-offs and 23.2% when based on
CDC cut-offs (Chirita-Emandi et al., 2016). Nilsen et al. (2016) showed that, depending
on which growth reference was used (IOTF, WHO or national database), the prevalence
of overweight (including obesity) varied from 16.5% to 25.7% for boys and from 18.2%
to 25.2% for girls. They observed that there were significant gender differences
depending on the growth reference they used. Mighelli et al. (2014) observed, in a group
of 966 children aged 10–16 years, whose weight status was verified according to CDC,
IOTF and WHO criteria, that the highest level of agreement for overweight and obesity
classification was obtained with the IOTF and CDC criteria.
In this paper, agreement of results was evaluated by the comparison of two proportions.
The highest agreement was observed for the CDC and national database (Polish 2010) for
both sexes. These differences were not statistically significant. The greatest differences were
found between the IOTF and Polish 2010 results, at p < 0.001 for overweight and obesity,
and p < 0.05 for overweight included obesity. Comparing CDC and IOTF separately for
overweight and obesity, the differences were statistically significant at p <0.001, but after
combining overweight and obesity the difference was no longer statistically significant.
This resulted from the fact that, for children aged 6–12 years, the IOTF BMI cut-offs
are generally higher than those of the CDC. For boys, the difference between the CDC
and IOTF was about 0.5 units for overweight and 1.5–2 units for obesity. In girls, the
values for overweight were similar, but for obesity it was approximately 1 unit higher in
IOTF (Zimmermann et al., 2004). These differences explain an almost two times higher
prevalence of obesity identified by the CDC in both sexes.
The prevalence of overweight and obesity as defined using the Polish 2010 standard
was much lower than that estimated by Chrzanowska et al. (2002). In boys, the
difference was about 7 percentage points and in girls it was about 2 percentage points
(Kowal et al., 2013, 2014). The prevalence of overweight and obesity calculated using
IOTF data, compared with the prevalence in the population of children from Kraków
(Chrzanowska et al., 2002), determined using the same criteria, was lower for the boys
by about 5 percentage points and higher for the girls by about 1 percentage point
(22.87% and 17.34%, respectively).
Overweight determined using the Polish 2010 cut-offs was lower than when using the
CDC and IOTF cut-offs, and for obesity it was between CDC and IOTF but closer to

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 Prevalence of overweight and obesity in Poland 11
the CDC. Thus, for both sexes, the sum of overweight and obesity incidence was lower
for the Polish 2010 cut-offs than for the other BMI cut-offs specified. This trend is most
distinct for boys aged 9.5–11.5.
As clearly shown in Tables 3–4, the three procedures tended to overestimate or
underestimate the prevalence of overweight and obesity by sex and age groups when
used on the same population. This may be interpreted as a consequence of using higher
and lower cut-offs or may also depend on some other issues. Chinn and Rona (2002)
showed how IOTF curves for girls tend to overestimate overweight and obesity as a
result of a problem with the backward tracking of the BMI centiles from 18 years of age.
The differences in prevalence of overweight and obesity between different methods
may be due to the methods of data collection and/or secular trends (Flechtner-Mors
et al., 2015).
This result showed that the differences in the classification of overweight and obesity
between the presented BMI cut-offs (IOTF, CDC, Polish 2010) were not high: from
0.6% to 5.5% for boys and from 0.6% to 5.6% for girls. The overall results of the study
also suggest a strong degree of compliance between the applied classification methods
(Table 5), as confirmed by the high Cohen’s kappa coefficient, ranging from 0.71 to 0.89.
However, these differences, especially between CDC and IOTF and between Polish 2010
and IOTF, were statistically significant. This fact should be taken into account when
different criteria are used in assessing the prevalence of overweight and obesity in
children and adolescents.
In the case of populations of children from Kraków, the use of national data appears
to be the most appropriate. However, the distribution of height, weight and BMI for
school children in Poland have been found to differ from international data in the IOTF
cut-offs (Kułaga et al., 2010). These differences should be taken into account when
comparing data from different countries, and it seems to be better to rely on
international standards. A similar problem is also relevant to the comparison of
populations from different regions: Kułaga et al. (2010) clearly pointed to the fact that
there exist certain limitations to the analysis of height, weight and BMI z-scores when
Polish regional references are used. They indicated the need for the creation of a national
reference database updated every 10 years.
There is a longstanding debate in the literature about the use of an international
approach rather than national-based classification of overweight and obesity. Some
point to the weakness of the national references consisting of a small sample size,
restricted to certain age ranges or based on cross-sectional studies (Flechtner-Mors et al.,
2015). Flegal et al. (2001) observed that when IOTF and CDC methods were used to
assess US children and adolescents aged 2–19 years, the IOTF reference produced a
lower prevalence of overweight than the CDC reference. Importantly, Reilly (2002), in
his systematic review, suggested that defining paediatric obesity using national BMI
reference data was widely recommended for clinical practice, when IOTF and CDC
reference data were preferred for clinical and epidemiological applications.
Previous studies conducted in Kraków seem to confirm the relevance of regional
standards, as data on body weights, heights and BMIs of boys and girls in the Kraków
population differ from those gathered internationally. Instead, they are similar to the
data obtained in this research. It is worth noting that the choice of method does not
matter in assessing the trends of overweight and obesity changes. Studies based on

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 12 R. Woźniacka et al.
different criteria has always shown an increasing trend (Ogden et al., 2006; Chrzanowska
et al., 2007). This is a substantial piece of information indicating that the problem of
excessive weight gain is real, even if the percentages show some discrepancies.
The strength of this study was its large sample size and information on sex and age,
which allowed the evaluation of differences by age and sex groups. However, no
information was available on the socioeconomic characteristics of children. The absence
of detailed information on family economic status, living environment, dietary patterns
and physical activity at the individual level was a limitation of this study.
In conclusion, creating and updating of national databases based on large,
representative groups is justified and provides better reference for regional data than
international data (when trying to establish a situation in a country). However, in order
to ensure the comparability of results with those from other countries, it seems advisable
to use cut-offs based on international data. The Polish 2010 national reference proposed
by Kułaga et al. (2010) can be recommended as a national BMI reference for screening
and monitoring growth in children and adolescents in Poland. From the close agreement
between methods, the IOTF and CDC references can be used for international
comparisons.

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