{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T17:42:11Z","timestamp":1792172531984,"version":"4.4.0"},"reference-count":30,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T00:00:00Z","timestamp":1778198400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100008120","name":"Regionale forskningsfond Oslofjordfondet","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100008120","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100031564","name":"Kristiania University College","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100031564","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Horten Municipality"},{"name":"the Norwegian Order of Odd Fellow Research Fund,"},{"DOI":"10.13039\/501100009729","name":"Norwegian Fund for Post-Graduate Training in Physiotherapy","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100009729","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Body mass index (BMI) and waist-to-height ratio (WHtR) are widely used markers of adiposity in children, but their relative associations with cardiometabolic and functional health measures remain debated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We analyzed data from children aged 6\u201312 years (n\u2009=\u20092297) in the Health Oriented Pedagogical Project (HOPP) with annual assessments from 2015\u20132020. Associations between BMI or WHtR and outcomes (body composition, blood lipids, blood pressure, physical activity, and cardiorespiratory fitness\/endurance) were examined using linear mixed-effects models with repeated measures (random intercept for child; study year as the repeated factor). BMI and WHtR were evaluated in separate models.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Both BMI and WHtR were consistently associated with less favorable profiles across outcomes, including higher adiposity, lower fitness\/endurance and MVPA, higher blood pressure, and a more adverse lipid profile (lower HDL and higher non-HDL cholesterol). Across most outcomes, differences between BMI- and WHtR-based models were modest; however, WHtR generally showed slightly stronger associations for lipid measures and fitness-related outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>BMI and WHtR demonstrate largely comparable associations with cardiometabolic and functional health measures in children aged 6\u201312 years. WHtR may provide complementary information on central adiposity and can be considered alongside BMI in pediatric screening and surveillance.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0347538","type":"journal-article","created":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T23:09:40Z","timestamp":1778281780000},"page":"e0347538","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Comparative associations of body mass index and waist-to-height ratio with cardiometabolic and functional health risk markers in children aged 6\u201312 years - the Health Oriented Pedagogical Project (HOPP)"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7450-2925","authenticated-orcid":true,"given":"Per Morten","family":"Fredriksen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Morten","family":"Lindberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nandu","family":"Goswami","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asgeir","family":"Mamen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,5,8]]},"reference":[{"key":"pone.0347538.ref001","author":"WHO","year":"2016"},{"key":"pone.0347538.ref002","unstructured":"WHO. The top 10 causes of death [Internett]. 2024 [sitert 19. desember 2024]. Tilgjengelig p\u00e5: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/the-top-10-causes-of-death"},{"key":"pone.0347538.ref003","unstructured":"WHO. Obesity and overweight. https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/obesity-and-overweight. 2025. Accessed 2025 June 26."},{"issue":"1","key":"pone.0347538.ref004","doi-asserted-by":"crossref","first-page":"1549","DOI":"10.1186\/s12889-023-16418-9","article-title":"Waist-to-height ratio associated cardiometabolic risk phenotype in children with overweight\/obesity","volume":"23","author":"TE Ukegbu","year":"2023","journal-title":"BMC Public Health"},{"key":"pone.0347538.ref005","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1186\/s12916-014-0207-1","article-title":"A proposal for a primary screening tool: \u201cKeep your waist circumference to less than half your height\u201d","volume":"12","author":"M Ashwell","year":"2014","journal-title":"BMC Med"},{"issue":"7244","key":"pone.0347538.ref006","doi-asserted-by":"crossref","first-page":"1240","DOI":"10.1136\/bmj.320.7244.1240","article-title":"Establishing a standard definition for child overweight and obesity worldwide: international survey","volume":"320","author":"TJ Cole","year":"2000","journal-title":"BMJ"},{"issue":"3","key":"pone.0347538.ref007","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2015-010159","article-title":"Waist-to-height ratio as an indicator of \u201cearly health risk\u201d: simpler and more predictive than using a \u201cmatrix\u201d based on BMI and waist circumference","volume":"6","author":"M Ashwell","year":"2016","journal-title":"BMJ Open"},{"key":"pone.0347538.ref008","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/j.1758-8111.2012.00037.x","article-title":"Plea for simplicity: use of waist-to-height ratio as a primary screening tool to assess cardiometabolic risk","volume":"2","author":"M Ashwell","year":"2012","journal-title":"Clin Obes"},{"issue":"3","key":"pone.0347538.ref009","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1111\/j.1467-789X.2011.00952.x","article-title":"Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis","volume":"13","author":"M Ashwell","year":"2012","journal-title":"Obes Rev"},{"issue":"2","key":"pone.0347538.ref010","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1159\/000203363","article-title":"Waist to height ratio is a simple and effective obesity screening tool for cardiovascular risk factors: Analysis of data from the British National Diet And Nutrition Survey of adults aged 19-64 years","volume":"2","author":"M Ashwell","year":"2009","journal-title":"Obes Facts"},{"issue":"2","key":"pone.0347538.ref011","doi-asserted-by":"crossref","DOI":"10.1111\/obr.13375","article-title":"Accuracy of different cutoffs of the waist-to-height ratio as a screening tool for cardiometabolic risk in children and adolescents: A systematic review and meta-analysis of diagnostic test accuracy studies","volume":"23","author":"Y Ezzatvar","year":"2022","journal-title":"Obes Rev"},{"key":"pone.0347538.ref012","unstructured":"NICE. NICE website: The National Institute for Health and Care Excellence. https:\/\/www.nice.org.uk\/news\/articles\/keep-the-size-of-your-waist-to-less-than-half-of-your-height-nice--recommends. 2022. Accessed 2025 June 26."},{"issue":"12","key":"pone.0347538.ref013","doi-asserted-by":"crossref","first-page":"1258","DOI":"10.1111\/obr.12456","article-title":"Waist-to-height ratio, body mass index and waist circumference for screening paediatric cardio-metabolic risk factors: a meta-analysis","volume":"17","author":"K Lo","year":"2016","journal-title":"Obes Rev"},{"issue":"1","key":"pone.0347538.ref014","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1186\/s12916-023-03169-y","article-title":"Establishing international optimal cut-offs of waist-to-height ratio for predicting cardiometabolic risk in children and adolescents aged 6\u201318 years","volume":"21","author":"X Zong","year":"15","journal-title":"BMC Med"},{"issue":"5","key":"pone.0347538.ref015","doi-asserted-by":"crossref","first-page":"103042","DOI":"10.1016\/j.dsx.2024.103042","article-title":"Utility of waist-to-height ratio, waist circumference and body mass index in predicting clustered cardiometabolic risk factors and subclinical vascular phenotypes in children and adolescents: A pooled analysis of individual data from 14 countries","volume":"18","author":"X Zong","year":"2024","journal-title":"Diabetes Metab Syndr"},{"issue":"2","key":"pone.0347538.ref016","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0149351","article-title":"A comparison between BMI, waist circumference, and waist-to-height ratio for identifying cardio-metabolic risk in children and adolescents","volume":"11","author":"LB Sardinha","year":"2016","journal-title":"PLoS One"},{"issue":"2","key":"pone.0347538.ref017","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1016\/j.clnu.2013.05.010","article-title":"Waist-to-height ratio, waist circumference and BMI as indicators of percentage fat mass and cardiometabolic risk factors in children aged 3-7 years","volume":"33","author":"A Sijtsma","year":"2014","journal-title":"Clin Nutr"},{"issue":"3","key":"pone.0347538.ref018","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1123\/pes.2016-0016","article-title":"Waist-to-Height Ratio, Aerobic Fitness, and Cardiometabolic Risk in Hispanic Children From Low-Income U.S. Schools","volume":"28","author":"RD Burns","year":"2016","journal-title":"Pediatr Exerc Sci"},{"issue":"5","key":"pone.0347538.ref019","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1016\/j.orcp.2017.01.001","article-title":"Utility of Body Mass Index, Waist-to-Height-Ratio and cardiorespiratory fitness thresholds for identifying cardiometabolic risk in 10.4-17.6-year-old children","volume":"11","author":"DS Buchan","year":"2017","journal-title":"Obes Res Clin Pract"},{"issue":"3","key":"pone.0347538.ref020","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1111\/j.2047-6310.2011.00028.x","article-title":"Physical activity vs. sedentary time: independent associations with adiposity in children","volume":"7","author":"JP Chaput","year":"2012","journal-title":"Pediatr Obes"},{"issue":"1","key":"pone.0347538.ref021","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1186\/s12889-017-4282-z","article-title":"The health Oriented pedagogical project (HOPP) - a controlled longitudinal school-based physical activity intervention program","volume":"17","author":"PM Fredriksen","year":"2017","journal-title":"BMC Public Health"},{"issue":"4","key":"pone.0347538.ref022","first-page":"434","article-title":"An intermittent running test to estimate maximal oxygen uptake: the Andersen test","volume":"48","author":"LB Andersen","year":"2008","journal-title":"J Sports Med Phys Fitness"},{"issue":"4","key":"pone.0347538.ref023","doi-asserted-by":"crossref","first-page":"687","DOI":"10.1111\/j.1651-2227.2008.01181.x","article-title":"Cardiorespiratory fitness and body mass index values in 9-year-old rural Norwegian children","volume":"98","author":"GK Resaland","year":"2009","journal-title":"Acta Paediatr"},{"issue":"1","key":"pone.0347538.ref024","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1249\/mss.0b013e31815a51b3","article-title":"Physical activity in the United States measured by accelerometer","volume":"40","author":"RP Troiano","year":"2008","journal-title":"Med Sci Sports Exerc"},{"key":"pone.0347538.ref025","unstructured":"NOKLUS. The Norwegian Organization for Quality Improvement of Laboratory Examinations. https:\/\/www.noklus.no\/. 2021."},{"issue":"5","key":"pone.0347538.ref026","doi-asserted-by":"crossref","first-page":"1369","DOI":"10.1038\/s41390-024-03112-8","article-title":"Waist-circumference-to-height-ratio had better longitudinal agreement with DEXA-measured fat mass than BMI in 7237 children","volume":"96","author":"AO Agbaje","year":"2024","journal-title":"Pediatr Res"},{"issue":"1","key":"pone.0347538.ref027","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1186\/s13098-021-00688-7","article-title":"Performance of waist-to-height ratio as a screening tool for identifying cardiometabolic risk in children: a meta-analysis","volume":"13","author":"Y Jiang","year":"2021","journal-title":"Diabetol Metab Syndr"},{"issue":"11","key":"pone.0347538.ref028","doi-asserted-by":"crossref","first-page":"425","DOI":"10.3345\/kjp.2016.59.11.425","article-title":"Waist-to-height ratio as a screening tool for obesity and cardiometabolic risk","volume":"59","author":"E-G Yoo","year":"2016","journal-title":"Korean J Pediatr"},{"key":"pone.0347538.ref029","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1177\/1403494818769852","article-title":"Development of weight and height in Norwegian children: The Health Oriented Pedagogical Project (HOPP)","volume":"46","author":"A Sk\u00e5r","year":"2018","journal-title":"Scand J Public Health"},{"key":"pone.0347538.ref030","unstructured":"WHO. Growth reference 5-19 years - BMI-for-age (5-19 years). https:\/\/www.who.int\/tools\/growth-reference-data-for-5to19-years\/indicators\/bmi-for-age. 2025. Accessed 2025 June 27."}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0347538","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T23:09:46Z","timestamp":1778281786000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0347538"}},"subtitle":[],"editor":[{"given":"Hansani Madushika","family":"Abeywickrama","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,5,8]]},"references-count":30,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5,8]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0347538","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,8]]}}}