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Assessing Child Growth Using the Body Mass Index (BMI)-for-age Growth Charts: A Training for Health Care Providers Adapted by the CHDP Bay Area Nutrition Subcommittee (BANS) from 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 March 2006

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BMI-for-age Growth Chart is: considered standard practice by the American Academy of Pediatrics. now required as part of the well-child exam for children ages 2 through 19 by the Child Health and Disability Prevention (CHDP) Program.

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Training Objectives Understand BMI and how it is useful to screen for normal growth Understand BMI and how it is useful to screen for normal growth Learn how to plot BMI on the BMI-for-age growth charts Learn how to plot BMI on the BMI-for-age growth charts Learn how to assess a child’s growth using BMI-for-age growth charts for early identification of childhood overweight Learn how to assess a child’s growth using BMI-for-age growth charts for early identification of childhood overweight

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1985 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1986 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1987 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1988 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1989 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1990 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1991 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1992 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1993 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1994 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1995 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1996 No Data <10% 10%–14% 15%–19% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1997 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1998 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 1999 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2000 No Data <10% 10%–14% 15%–19% ≥20 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity Trends* Among U.S. Adults BRFSS, 2001 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

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Source: Behavioral Risk Factor Surveillance System, CDC. (*BMI 30, or ~ 30 lbs overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002

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Source: Behavioral Risk Factor Surveillance System, CDC. Obesity* Trends Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

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All Races 17.90% not enough data Pediatric Nutrition Surveillance System (PedNSS) Growth Statistics for City and County of San Francisco 2004 BMI for age > 95% for Children 2-4 Years

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All Races 19.20% White 17.90% Pediatric Nutrition Surveillance System (PedNSS) Growth Statistics for City and County of San Francisco 2004 BMI for age > 95% for Children 5-19 Years

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A number that compares a child’s weight to her height A number that compares a child’s weight to her height Body Mass Index (BMI) = Body Mass Index (BMI) = Weight (kg) / Height (m)² BMI is an effective tool; alone it is not a diagnostic tool BMI is an effective SCREENING tool; alone it is not a diagnostic tool What is BMI?

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BMI is Not the Same for Adults and Children Adult BMI is evaluated by use of cut-off numbers; for example BMI >30 is indicative of adult obesity Adult BMI is evaluated by use of cut-off numbers; for example BMI >30 is indicative of adult obesity There are no BMI cut-off numbers for children. The BMI number must be plotted on the BMI-for-age growth chart There are no BMI cut-off numbers for children. The BMI number must be plotted on the BMI-for-age growth chart The BMI for children is useful only when it is plotted on the “BMI-for-age Growth Chart” The BMI for children is useful only when it is plotted on the “BMI-for-age Growth Chart”

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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

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Tracking tool for body size starting at age 2 years through adulthood Tracking tool for body size starting at age 2 years through adulthood Only indicator that examines weight, stature AND age for a child on a single growth chart Only indicator that examines weight, stature AND age for a child on a single growth chart Correlates with clinical risk factors for chronic disease including hyperlipidemia, elevated insulin, and high blood pressure Correlates with clinical risk factors for chronic disease including hyperlipidemia, elevated insulin, and high blood pressure Importance of Using BMI-for-age

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BMI is Only an Indirect Measure of Body Fat

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> 95 th percentileOverweight 85 th to < 95 th Risk of percentileoverweight < 5 th percentileUnderweight Using BMI-for-age Percentiles to Assess Risk

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What is a Percentile? 95 th 5 th 50 th Percentile 85 th

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CDC Standardized Growth Chart Formula to calculate BMI Published May 30, 2000 Percentiles (5 th,10 th,25 th, 50 th, 75 th,85 th,90 th,95 th )

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> 95 th percentileOverweight? 85 th to < 95 th Risk of percentile overweight? < 5 th percentileUnderweight? Growth acceleration or deceleration across 2 percentile lines Using BMI-for-age Percentiles to Assess Risk

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What is “Adiposity” Rebound (AR)? BMI A rebound or increase in BMI that occurs after it reaches its lowest point, usually between ages 4 to 6. Normal pattern of growth An early "adiposity" rebound, occurring before ages 4 to 6, is associated with obesity in adulthood.

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Normal “Adiposity” Rebound BMI Early “Adiposity” Rebound

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Steps to Plot BMI-for-age 1. Obtain accurate weight and height measurements 2. Select the appropriate growth chart 3. Record the data 4. Calculate BMI 5. Plot measurements 6. Interpret plotted measurements

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5 year old boy Weight: 43.5 lb Height: 43 in BMI= 16.5 BMI-for-age = 75-84 th %tile Inaccurate height measurement: 42.5 in BMI=17 BMI-for-age = 85-94 th %tile 1. Obtain Accurate Weight and Height Measurements Accurate Measurements are Critical Boys: 2 to 20 years BMI

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2. Select the Appropriate Growth Chart For ages birth to 36 months old: For ages birth to 36 months old: “Length-for-age,” and “Weight-for-age” “Length-for-age,” and “Weight-for-age” “Weight-for-length,” and “Head Circumference-for-age” “Weight-for-length,” and “Head Circumference-for-age” For ages 2 to 20 years: For ages 2 to 20 years: “Weight-for-age,” and “Stature-for-age” “Weight-for-age,” and “Stature-for-age” Body Mass Index “BMI-for-age” Body Mass Index “BMI-for-age”

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3. Record Data

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4. Calculate BMI English: Wt (lbs.) ÷Ht (in.) ÷ Ht (in.) x 703 Metric: Wt (kg.) ÷Ht (cm.) ÷ Ht (cm.) x 10,000

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4. Calculate BMI Use a Pediatric BMI Wheel Use a Pediatric BMI Wheel

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5. Plot Measurements Age BMI 50 th 75 th 85 th 5 th 95 th

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6. Interpret the BMI-for-age Chart Need a series of BMI plots to determine the growth trend Need a series of BMI plots to determine the growth trend If growth deviates from expected growth pattern, further assessment may be needed If growth deviates from expected growth pattern, further assessment may be needed

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Practice using “BMI-for-age” Growth Chart Liz (4 y)Pete (3 y)Gabriella (4 y) Photos from UC Berkeley Longitudinal Study, 1973

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Please Plot Pete Perfectly Photo from UC Berkeley Longitudinal Study, 1973 Measurements for Pete: Age= 3 y 3 wks Weight= 41 lbs (18.6 kg) Height= 39.7 in (100.8 cm) Find BMI, plot, & interpret growth trend BMI= Wt ( lbs) ÷ Ht (in) ÷ Ht (in) x 703

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BMI=18.3 Boys: 2 to 20 years BMI Interpretation: BMI-for-age = >95 th percentile Overweight Of 100 boys the same age, more than 95 have a lower BMI-for-age Answers: Pete’s “BMI-for-age”

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Let’s Look at Liz Liz

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Liz’s - BMI Liz 17.7

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2-3-02

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Graph Gabriella’s Growth

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Gabriella’s BMI

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Please Identify Overweight Children on PM160 Put comments here ex: overweight, > 95 th % BMI

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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) Centers for Disease Control and Prevention Website (www.cdc.gov/growthcharts)www.cdc.gov/growthcharts American Academy of Pediatrics Policy Statement: Prevention of Pediatric Overweight and Obesity (Pediatrics 2003 Aug (112)2; 424-430) References

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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: www.cdc.gov/growthcharts/

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