title: Validity of the WHO cutoffs for biologically implausible values of weight, height, and BMI in children and adolescents in NHANES from 1999 through 2012.
abstract: BACKGROUND
  The WHO cutoffs to classify biologically implausible values (BIVs) for weight, height, and weight-for-height in children and adolescents are widely used in data cleaning.
  
  
  OBJECTIVE
  We assess 1) the prevalence of these BIVs, 2) whether they were consistent with information on waist circumference, arm circumference, and leg lengths, and 3) the effect of their exclusion on the estimated prevalence of obesity in 2- to 19-y-olds in the NHANES, which is a study in which extreme values were verified when recorded.
  
  
  METHODS
  We conducted cross-sectional analyses in 26,480 children and adolescents in the NHANES from 1999-2000 through 2011-2012.
  
  
  RESULTS
  The overall prevalence for a BIV for any body-size measure was 0.9% (n = 277), and almost all BIVs were due to extremely high, rather than low, values. Of 186 subjects who had a high BIV for weight or body mass index (BMI), all but one subject had both arm and waist circumferences that were greater than the sex- and age-specific 95th percentiles; 75% of subjects had circumferences greater than the 99th percentile. Of 63 subjects with a high height BIV, 75% of them had a leg length that was greater than the 95th percentile. The exclusion of children and adolescents with a BIV reduced the overall prevalence of obesity by ∼0.5 percentage points and by 1.7% in non-Hispanic blacks.
  
  
  CONCLUSIONS
  Most of the extremely high values of weight, height, and BMI flagged as BIVs in the NHANES are very likely correct. The increase of z score cutoffs or the use of an alternative method to detect possible errors could improve the balance between removing incorrect values and retaining extremely high, but accurate, values in other data sets.
authors.affiliation: Division of Nutrition, Physical Activity and Obesity, CDC, Atlanta, GA; dxf1@cdc.gov.
authors.forename: David S
authors.initials: DS
authors.lastname: Freedman
authors.affiliation: National Center for Health Statistics, CDC, Hyattsville, MD;
authors.forename: Hannah G
authors.initials: HG
authors.lastname: Lawman
authors.affiliation: Department of Health Policy and Management, School of Public Health, University of North Carolina, Chapel Hill, NC; and.
authors.forename: Asheley C
authors.initials: AC
authors.lastname: Skinner
authors.affiliation: Division of Nutrition, Physical Activity and Obesity, CDC, Atlanta, GA;
authors.forename: Lisa C
authors.initials: LC
authors.lastname: McGuire
authors.affiliation: Nutrition Obesity Research Center, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: David B
authors.initials: DB
authors.lastname: Allison
authors.affiliation: National Center for Health Statistics, CDC, Hyattsville, MD;
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Ogden
mesh_terms: D000293:Adolescent; D017195:Adolescent Nutritional Physiological Phenomena; D000328:Adult; D001827:Body Height; D015992:Body Mass Index; D001835:Body Weight; D002648:Child; D002664:Child Nutritional Physiological Phenomena; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008954:Models, Biological; D009749:Nutrition Surveys; D063766:Pediatric Obesity / Q000175:diagnosis / Q000453:epidemiology*; D015995:Prevalence; D012016:Reference Values; D013223:Statistics as Topic; D014481:United States / Q000453:epidemiology; D014944:World Health Organization; D055815:Young Adult
keywords: BIV; BMI; NHANES; body size; children; outliers