1. 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

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

3. What growth charts are available?

4. 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

5. Disjunction: Smoothed in New Charts 40 50 60 70 80 90 100 110 120 061218243036 42 48 5460 Age in month Length/height in cm 40 50 60 70 80 90 100 110 120 0 6 121824303642485460 Age in month Length/height in cm 1977 2000

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

7. Reference Data Sets: Birth to 36 Months

8. Reference Data Sets: 2 to 20 Years

9. Exclusions from the Reference Data 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 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

10. 1 >95 th percentile BMI-for-age 2 http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm 1 >95 th percentile BMI-for-age 2 http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm Age-Adjusted Prevalence of Overweight 1 From NHANES I to III 2 Sex and Age Group Percent

11. 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

12. 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): 111-116

13. Breast-Fed vs. Formula-Fed Infants Mode of infant feeding can influence growth 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 Mode of infant feeding can influence growth 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

14. 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

15. 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

16. 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

17. 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

18. What Is BMI? Body mass index (BMI) = weight (kg)/height (m) 2 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 Body mass index (BMI) = weight (kg)/height (m) 2 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

19. Advantages of BMI-for-Age  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  Tracks childhood overweight into adulthood  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  Tracks childhood overweight into adulthood

20. 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;337:869-873

21. Advantages of BMI-for-Age  BMI-for-age relates to health risks  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 relates to health risks  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

22. Weight-for-stature measurements 1 Measures of body fat BMI-for-Age Compares Well with Mei et al., Am J Clin Nutr 2002;75:978-85.

23. Why Use BMI-for-Age? Recommended by expert committees to evaluate overweight  Guidelines for Overweight in Adolescent Preventive Services (Am J Clin Nutr 1994;59:307-316)  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)

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

25. Example: 95th Percentile Tracking Age BMI 2 yrs 19.3 4 yrs 17.8 9 yrs 21.0 13 yrs 25.1 For Children, BMI Changes with Age Boys: 2 to 20 years BMI

26. Shape of BMI-for- Age Growth Curve: “Adiposity” Rebound (AR) Example: Early AR Age (mos) BMI 26 18.2 32 17.4 38 18.5 41 18.7 Boys: 2 to 20 years BMI

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

28. 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. 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. Performance of BMI-for-Age as a Screening Tool

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

30. Calculating BMI with the English System Formula: weight (lb)/[height (in)] 2 x 703 Calculation: [ weight (lb)/height (in)/height (in)] x 703 Formula: weight (lb)/[height (in)] 2 x 703 Calculation: [ weight (lb)/height (in)/height (in)] x 703 Example: A child’s 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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: 42.25 BMI=16.3 BMI-for-age=75 th %tile Accurate Measurements are Critical Boys: 2 to 20 years BMI

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

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

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

43. Sam’s BMI Plotted on Boy’s BMI-for-Age Chart Interpretation: Sam’s 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 Sam’s. Boys: 2 to 20 years BMI

44. 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

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

46. For additional training materials related to the growth charts For tools related to the growth charts To download the growth charts Please visit: http://www.cdc.gov/growthcharts/

47. www.cdc.gov/growthcharts