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CDC Growth Charts 2000 Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Division of Nutrition and Physical Activity Maternal and Child Nutrition Branch Revised June 2002

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Training Objectives Science behind development of growth charts Science behind development of growth charts Rationale for including BMI-for-age Rationale for including BMI-for-age Using BMI-for-age as a screening tool Using BMI-for-age as a screening tool

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What growth charts are available?

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BMI-for-age charts (2-20 years) 85th percentile (at risk of overweight) 3rd and 97th percentiles available Lower limits of length (45 vs. 49 cm) and height (77 vs. 90 cm) extended Smoothed percentile curves and z- scores agree Correction in the disjunction BMI-for-age charts (2-20 years) 85th percentile (at risk of overweight) 3rd and 97th percentiles available Lower limits of length (45 vs. 49 cm) and height (77 vs. 90 cm) extended Smoothed percentile curves and z- scores agree Correction in the disjunction New Features of the Growth Charts

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Disjunction: Smoothed in New Charts Age in month Length/height in cm Age in month Length/height in cm

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Racially and ethnically diverse Racially and ethnically diverse Infants: Birth to 36 months Infants: Birth to 36 months Children and Adolescents: 2 to 20 years Children and Adolescents: 2 to 20 years Breast- and formula-fed infants Breast- and formula-fed infants Racially and ethnically diverse Racially and ethnically diverse Infants: Birth to 36 months Infants: Birth to 36 months Children and Adolescents: 2 to 20 years Children and Adolescents: 2 to 20 years Breast- and formula-fed infants Breast- and formula-fed infants Reference Population for CDC Growth Charts

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Reference Data Sets: Birth to 36 Months

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Reference Data Sets: 2 to 20 Years

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Exclusions from the Reference Data Very low birth weight (VLBW) infants (<1500 g) were excluded because they have different growth patterns Very low birth weight (VLBW) infants (<1500 g) were excluded because they have different growth patterns NHANES III weight data for 6+ year olds were excluded to avoid an upward shift in weight-for-age and BMI-for-age curves NHANES III weight data for 6+ year olds were excluded to avoid an upward shift in weight-for-age and BMI-for-age curves

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1 >95 th percentile BMI-for-age 2 9.htm 1 >95 th percentile BMI-for-age 2 9.htm Age-Adjusted Prevalence of Overweight 1 From NHANES I to III 2 Sex and Age Group Percent

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CDC Growth Charts Are for All Racial and Ethnic Groups Combined Environmental influences appear to contribute to variations in growth more than genetic influences Inadequate sample data for racial- and ethnic- specific charts The effect of race and ethnicity on BMI- for-age is unclear

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Age Adjusted Prevalence of Low Height- for-Age by Ethnic Groups, Children Aged 0 to 5 Years 1 Year of Visit Percentage 1 Mei, Yip and Trowbridge, Asia Pacific J Clin Nutr 1998; 7(2):

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Breast-Fed vs. Formula-Fed Infants Mode of infant feeding can influence growth Mode of infant feeding can influence growth New charts represent the combined growth patterns of breast-fed and formula-fed infants New charts represent the combined growth patterns of breast-fed and formula-fed infants Working group of the World Health Organization (WHO) is developing growth charts for infants and children through age 5 using data collected on infants following WHO feeding recommendations Working group of the World Health Organization (WHO) is developing growth charts for infants and children through age 5 using data collected on infants following WHO feeding recommendations

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Indicators of Nutritional Status <5 th percentile Stunting/shortness length or stature-for-age Head circumference-for- age <5 th percentile >95 th percentile Underweight weight-for-length BMI-for-age

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Indicators of Nutritional Status Overweight Weight-for-length BMI-for-age >95 th percentile Risk of overweight BMI-for-age 85 th to 95 th percentile

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Prevalence of Nutritional Status Indicators New Reference Curves Compared with Old Curves* < 2 Years Old Nutrition Indicator Change in Prevalence Stunting/shortness length-for-age <5 th 1% to 2% lower Underweight weight-for-length <5 th * NHANES III Overweight weight-for-length >95 th 2% lower for females 2% higher for males 1% to 2% higher

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Prevalence of Nutritional Status Indicators New Reference Curves Compared with Old Curves* Children 2 to 5 years of age Nutrition Indicator Change in Prevalence Stunting/shortness stature-for-age <5 th 1% lower Underweight** <5 th 3% to 4% higher * NHANES III **BMI-for-age, weight-for-stature Overweight** 95 th No change for females 1% higher for males

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What Is BMI? Body mass index (BMI) = Body mass index (BMI) = weight (kg)/height (m) 2 BMI is an effective screening tool; it is not a diagnostic tool BMI is an effective screening tool; it is not a diagnostic tool For children, BMI is age and gender specific, so BMI-for-age is the measure used For children, BMI is age and gender specific, so BMI-for-age is the measure used Body mass index (BMI) = Body mass index (BMI) = weight (kg)/height (m) 2 BMI is an effective screening tool; it is not a diagnostic tool BMI is an effective screening tool; it is not a diagnostic tool For children, BMI is age and gender specific, so BMI-for-age is the measure used For children, BMI is age and gender specific, so BMI-for-age is the measure used

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Advantages of BMI-for-Age Provides a reference for adolescents that was not previously available Provides a reference for adolescents that was not previously available Consistent with adult index so it can be used continuously from2 years of age to adulthood Consistent with adult index so it can be used continuously from2 years of age to adulthood Tracks childhood overweight into adulthood Tracks childhood overweight into adulthood Provides a reference for adolescents that was not previously available Provides a reference for adolescents that was not previously available Consistent with adult index so it can be used continuously from2 years of age to adulthood Consistent with adult index so it can be used continuously from2 years of age to adulthood Tracks childhood overweight into adulthood Tracks childhood overweight into adulthood

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Tracking BMI-for-Age from Birth to 18 Years with Percent of Overweight Children who Are Obese at Age 25 1 Whitaker et al. NEJM: 1997;337:

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Advantages of BMI-for-Age BMI-for-age relates to health risks BMI-for-age relates to health risks Correlates with clinical risk factors for cardiovascular disease including hyperlipidemia, elevated insulin, and high blood pressure Correlates with clinical risk factors for cardiovascular disease including hyperlipidemia, elevated insulin, and high blood pressure BMI-for-age during pubescence is related to lipid levels and high blood pressure in middle age BMI-for-age during pubescence is related to lipid levels and high blood pressure in middle age BMI-for-age relates to health risks BMI-for-age relates to health risks Correlates with clinical risk factors for cardiovascular disease including hyperlipidemia, elevated insulin, and high blood pressure Correlates with clinical risk factors for cardiovascular disease including hyperlipidemia, elevated insulin, and high blood pressure BMI-for-age during pubescence is related to lipid levels and high blood pressure in middle age BMI-for-age during pubescence is related to lipid levels and high blood pressure in middle age

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Weight-for-stature measurements 1 Measures of body fat BMI-for-Age Compares Well with Mei et al., Am J Clin Nutr 2002;75:

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Why Use BMI-for-Age? Recommended by expert committees to evaluate overweight Recommended by expert committees to evaluate overweight Guidelines for Overweight in Adolescent Preventive Services (Am J Clin Nutr 1994;59: ) Obesity Evaluation and Treatment: Expert Committee Recommendations (Pediatrics 1998 Sept;(102)3:e 29) Assessment of Childhood and Adolescent Obesity: International Obesity Task Force (Am J Clin Nutr 1999, 70,suppl)

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Shape of Weight-for-Stature Curve versus BMI-for-Age Curve 95 th 50 th 5 th 95 th 50 th 5 th

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Example: 95th Percentile Tracking Age BMI 2 yrs yrs yrs yrs 25.1 For Children, BMI Changes with Age Boys: 2 to 20 years BMI

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Shape of BMI-for- Age Growth Curve: Adiposity Rebound (AR) Example: Early AR Age (mos) BMI Boys: 2 to 20 years BMI

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BMI-for-Age Cutoffs > 95 th percentile Overweight 85 th to < 95 th Risk of overweight percentile < 5 th percentile Underweight

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Using the 85 th and 95 th percentiles as cut points, few children are incorrectly identified as over-fat but some over-fat children will be missed. Using the 85 th and 95 th percentiles as cut points, few children are incorrectly identified as over-fat but some over-fat children will be missed. It is desirable to correctly identify those children not at risk of overweight or overweight. It is desirable to correctly identify those children not at risk of overweight or overweight. Performance of BMI- for-Age as a Screening Tool

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Formula: weight (kg)/[height (m)] 2 Formula: weight (kg)/[height (m)] 2 Calculation: [ weight (kg)/ height (cm)/ Calculation: [ weight (kg)/ height (cm)/ height (cm)] x 10,000 height (cm)] x 10,000 Formula: weight (kg)/[height (m)] 2 Formula: weight (kg)/[height (m)] 2 Calculation: [ weight (kg)/ height (cm)/ Calculation: [ weight (kg)/ height (cm)/ height (cm)] x 10,000 height (cm)] x 10,000 Calculating BMI with the Metric System Example: A childs weight=16.9 kg and height=105.4 cm BMI = [16.9 kg / cm / cm] x 10,000 = 15.2

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Calculating BMI with the English System Formula: weight (lb)/[height (in)] 2 x 703 Formula: weight (lb)/[height (in)] 2 x 703 Calculation: [ weight (lb)/height (in)/height (in)] x 703 Calculation: [ weight (lb)/height (in)/height (in)] x 703 Formula: weight (lb)/[height (in)] 2 x 703 Formula: weight (lb)/[height (in)] 2 x 703 Calculation: [ weight (lb)/height (in)/height (in)] x 703 Calculation: [ weight (lb)/height (in)/height (in)] x 703 Example: A childs weight = 37 pounds, 4 ounces and height = 41 1/2 inches (convert fractions to decimal value) BMI = [37.25 lb / 41.5 in / 41.5 in] x 703 = 15.2

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Can you see risk? This boy is 3 years, 3 weeks old. Is his BMI-for-age - >85 th to <95 th percentile: at risk for overweight? Photo from UC Berkeley Longitudinal Study, 1973

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Measurements: Age=3 y 3 wks Height=100.8 cm (39.7 in) Weight=18.6 kg (41 lb) BMI=18.3 BMI-for-age= >95 th percentile overweight Plotted BMI-for-Age Boys: 2 to 20 years BMI

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Can you see risk? This girl is 4 years, 4 weeks old. Is her BMI-for-age - >85 th to <95 th percentile: at risk for overweight? Photo from UC Berkeley Longitudinal Study, 1974

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Measurements : Plotted BMI-for-Age Girls: 2 to 20 years Age= 4 y 4 wks Height=106.4 cm (41.9 in) Weight=15.7 kg (34.5 lb) BMI=13.9 BMI-for-age= 10 th percentile Normal BMI

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Can you see risk? This girl is 4 years old. Is her BMI-for-age - >85 th to <95 th percentile: at risk for overweight? Photo from UC Berkeley Longitudinal Study, 1973

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Measurements: Age=4 y Height=99.2 cm (39.2 in) Weight=17.55 kg (38.6 lb) BMI=17.8 BMI-for-age= between 90 th –95 th percentile At risk for overweight Plotted BMI-for-Age Girls: 2 to 20 years BMI

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5 1/2 year old boy Weight: 41.5 lb Height: 43 in BMI= 15.8 BMI-for-age=50 th %tile Inaccurate height measurement: BMI=16.3 BMI-for-age=75 th %tile Accurate Measurements are Critical Boys: 2 to 20 years BMI

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Interpreting the BMI-for-Age Cutoffs > 95 th percentile Overweight 85 th to < 95 th Risk of overweight percentile < 5 th percentile Underweight

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Interpreting the BMI-for-Age Chart BMI-for-age indicates a childs weight in relation to his/her height for a specific age and gender BMI-for-age indicates a childs weight in relation to his/her height for a specific age and gender Need a series of BMI plots to determine the growth trend Need a series of BMI plots to determine the growth trend If indices deviate from normal growth patterns, further assessment may be needed If indices deviate from normal growth patterns, further assessment may be needed

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Example: Sam Example: Sam Name: Sam Name: Sam Weight: 37 lb 4 oz (16.9 kg) Weight: 37 lb 4 oz (16.9 kg) Height: 41.5 inches (105 cm) Height: 41.5 inches (105 cm) Age: 3.5 years Age: 3.5 years BMI: 15.2 BMI: 15.2

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Sam s BMI Plotted on Boy s BMI-for-Age Chart Sam s BMI Plotted on Boy s BMI-for-Age Chart Interpretation: Sams BMI-for-age is slightly below the 25th %tileso it falls within the normal range. Of 100 boys who are the same age, fewer than 25 have a BMI- for-age lower than Sams. Boys: 2 to 20 years BMI

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Summary of Using BMI-for-Age BMI-for-age is the recommended method for screening overweight and underweight For children, BMI is age and gender specific; for adults there are fixed cut points Accurate and periodic measurements are important elements of any anthropometric screening

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Steps to Plot BMI-for-Age Obtain accurate weight and height measurements Obtain accurate weight and height measurements Select the appropriate growth chart Select the appropriate growth chart Record the data Record the data Calculate BMI Calculate BMI Plot measurements Plot measurements Interpret plotted measurements Interpret plotted measurements

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For additional training materials related to the growth charts For tools related to the growth charts To download the growth charts Please visit: rts/

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