1. Adapted by the State of California CHDP Nutrition Subcommittee from materials developed by California Department of Health Care Services  Children’s Medical Services Branch Centers for Disease Control and Prevention Maternal and Child Health Bureau May 2011 Assessing Child Growth Using Body Mass Index (BMI)-for-Age Growth Charts

2. Training Objectives By the end of this presentation, you will be able to: describe the use of Body Mass Index (BMI) as a screening tool for overweight and obesity calculate or determine BMI value from measured weight and height plot BMI value on the growth chart determine BMI-for-age percentile interpret weight category record results on PM 160

3. Obesity Trends in Children and Teens Receiving CHDP Exams CDC Pediatric Nutrition Surveillance System (PedNSS) Data, 2000-2009. Accessed online at www.dhcs.ca.gov/services/chdp/Pages/PedNSS2009.aspx (accessed 9/30/10).www.dhcs.ca.gov/services/chdp/Pages/PedNSS2009.aspx Ages 5 to < 20 Customize chart with PedNSS data from your county. See User Guide.

4. Childhood Overweight and Obesity by Age Group [ Insert Your County Name] 2009 CDC Pediatric Nutrition Surveillance System (PedNSS) Data, 2009. Accessed online at www.dhcs.ca.gov/services/chdp/Pages/PedNSS2009.aspx (accessed 9/30/10).www.dhcs.ca.gov/services/chdp/Pages/PedNSS2009.aspx Customize chart with PedNSS data from your county. See User Guide.

5. Childhood Overweight and Obesity by Ethnicity California 2009 [Insert Your County Name] CDC Pediatric Nutrition Surveillance System (PedNSS) Data, 2009. Accessed online at www.dhcs.ca.gov/services/chdp/Pages/PedNSS2009.aspx (accessed 9/30/10).www.dhcs.ca.gov/services/chdp/Pages/PedNSS2009.aspx Children Aged 5 to < 20 years Customize chart with PedNSS data from your county. See User Guide.

6. What Is Body Mass Index? A number that compares an individual’s weight to height Body Mass Index (BMI) = Weight (kg) / Height (m)² As an indirect measure, a screening test for body fatness

7. Lifetime tracking tool –Age 2 years through adulthood Examines weight, stature and age Screening for health and nutrition status Early indicator of other health risk factors –Hyperlipidemia –Elevated insulin –High blood pressure Why Use BMI-for-Age?

8. Body Mass Index-for-Age for Children and Teens Recommended by –Centers for Disease Control –American Academy of Pediatrics –Expert Committee –USPSTF –White House Task Force Required by – CHDP – Health Plans

9. Body Mass Index Cutoff Values for Adults Standard weight categories Same for all ages Same for men and women Weight StatusBMI Obese30.0 and above Overweight25.0 - 29.9 Normal18.5 - 24.9 UnderweightBelow 18.5

10. Age24913 BMI Value19.317.821.025.1 For Children, BMI Changes with Age Example: Child’s growth tracking along 95 th percentile

11. BMI for Children and Teens Age- and sex-specific Plot BMI on growth chart to find percentile Weight status determined by percentile Weight Status CategoryPercentile Range Obese ≥ 95 th percentile Overweight85 th to < 95 th percentile Normal5 th to < 85th percentile Underweight< 5 th percentile

12. What is a Percentile? 95 th 5 th Major Percentile Divisions 85 th 50 th

13. Tip: Download and print from www.cdc.gov/growthcharts/ Formula to calculate BMI Published May 30, 2000 (modified 2000-2001) Percentile lines 5 th - 10 th - 25 th - 50 th 75 th - 85 th - 90 th - 95 th CDC Growth Charts

14. How to Read and Interpret the Growth Chart A single point on the curve indicates current status A series of BMI plots are needed to determine the growth trend If growth deviates from the expected growth pattern, further assessment may be needed

15. Adiposity Rebound The increase in BMI that occurs after it reaches its lowest point, usually between ages 4 to 6 Normal growth pattern ↑BMI AGE →

16. Adiposity Rebound Child following 10 th percentile curve At what age does the BMI reach its lowest point? ↑BMI AGE →

17. Adiposity Rebound Child following 85 th percentile curve At what age does the BMI reach its lowest point? ↑BMI AGE →

18. Early Adiposity Rebound Early adiposity rebound (before age 5) is related to higher BMI in adulthood An increase in BMI percentile < 5 years is a red flag ↑BMI AGE →

19. Early Adiposity Rebound Without InterventionWith Intervention ↑BMI AGE →

20. Excessive Adiposity Rebound Excessive adiposity rebound is related to higher BMI in adulthood Increasing BMI percentiles crossing major percentile lines are red flags ↑BMI AGE →

21. Steps to Plot BMI-for-age 1.Select appropriate growth chart 2.Measure standing height accurately 3.Measure weight accurately 4.Determine BMI value 5.Determine BMI-for-age percentile 6.Record BMI percentile on PM 160 7.Determine weight category

22. Chart Carlos Correctly Step 1: Select Appropriate Growth Chart Birth to 36 months: Boys or Girls –Length-for-age –Weight-for-age –Head circumference –Weight-for-length 2 to 20 years: Boys or Girls –Stature-for-age –Weight-for-age –BMI-for-age

23. 4 5 3 DateAgeWeightStatureBMI* 332 #38 ½ ”15.2 436 #41 ”15.0 645 ¾ ” Chart Carlos Correctly Step 2: Measure Standing Height Record on growth chart and PM 160

24. Chart Carlos Correctly Step 3: Measure Weight Record on growth chart and PM 160 4 5 3 0 4 3 0 8 DateAgeWeightStatureBMI* 332 #38 ½ ”15.2 436 #41 ”15.0 643 ½ #45 ¾ ”

25. English measurements Wt (pounds) ÷ Ht (inches) ÷ Ht (inches) x 703 Metric measurements Wt (kg) ÷ Ht (cm) ÷ Ht (cm) x 10,000 TIP: Formulas are listed on the BMI-for-age chart Method 1: Using a calculator Chart Carlos Correctly Step 4A: Determine BMI Value

26. Find height on inner wheel TIP: Mark with your thumb and index finger Line up the height with weight on outer wheel Read BMI value in the window on the inner wheel TIP: Read decimal points from right to left! Method 2: Using a BMI calculation wheel Chart Carlos Correctly Step 4A: Determine BMI Value

27. DateAgeWeightStatureBMI* 332 #38 ½ ”15.2 436 #41 ”15.0 643 ½ #45 ¾ ”14.6 Chart Carlos Correctly Step 4B: Determine BMI Value Record on growth chart

28. Find age on horizontal axis Find BMI value on vertical axis Mark point of intersection Estimate BMI percentile TIP: Use a transparent growth chart plotting aid Chart Carlos Correctly Step 5: Determine BMI-for-Age %ile

29. Estimate a whole number between 1 and 99 that best represents the percentile point plotted on the growth chart 4 5 3 0 4 3 0 8 2 5 Chart Carlos Correctly Step 6: Record BMI Percentile on PM 160

30. Weight Status CategoryPercentile Range Obese ≥ 95 th percentile Overweight85 th to < 95 th percentile Normal5 th to < 85th percentile Underweight< 5 th percentile Chart Carlos Correctly Step 7A: Determine Weight Category

31. On PM 160, enter follow up code in appropriate column under “PROBLEM SUSPECTED” Enter diagnosis under “COMMENTS/PROBLEMS” –Underweight –Overweight –Obese Chart Carlos Correctly Step 7B: Record Abnormal Results

32. BMI for 5 year old boy Weight: 43.5 lb Height: 43.0 in BMI= 16.5 BMI-for-age = 75-84 th percentile Normal range If height is inaccurate: Weight: 43.5 lb Height: 42.5 in BMI = 17.0 BMI-for-age = 85-94 th percentile Overweight range Accurate Measurements Are Critical

33. Practice Using BMI-for-Age Growth Charts Liz - 4 yrs Pete - 4 yrs Gabriela - 4 yrs Photos from UC Berkeley Longitudinal Study, 1973

34. Plot Pete Perfectly FIRST STEPS 1.Select appropriate growth chart 2.Measure standing height 3.Measure weight DateAgeWeightStatureBMI* 230 #34 ½ ”17.7 336 ½ #38 ”17.8 443 #41 ”

35. Plot Pete Perfectly DateAgeWeightStatureBMI* 230 #34 ½ ”17.7 336 ½ #38 ”17.8 443 #41 ”18.0 NEXT STEP 4.Determine BMI Value

36. Plot Pete Perfectly NEXT STEP 5.Determine BMI-for-age percentile

37. NEXT STEP 6.Record BMI Percentile on PM 160 –Estimate a whole number between 1 and 99 that best represents the percentile point plotted on the growth chart 4 1 0 0 4 3 0 0 9 6 Plot Pete Perfectly

38. FINAL STEP 7.Determine category and record on PM 160 if needed –Enter follow up code in appropriate column under “PROBLEM SUSPECTED” –Enter diagnosis under “COMMENTS/PROBLEMS” Underweight Overweight Obese (03) Obese Plot Pete Perfectly

39. Let’s Look at Liz DateAgeWeightStatureBMI* 228 ¾ #33 ½ ”18.2 333 #36 ½ ”17.4 437 #39 ¼ ” FIRST STEPS 1.Select appropriate growth chart 2.Measure standing height 3.Measure weight

40. Let’s Look at Liz NEXT STEP 4.Determine BMI Value DateAgeWeightStatureBMI* 228 ¾ #33 ½ ”18.2 333 #36 ½ ”17.4 437 #39 ¼ ”16.9

41. NEXT STEP 5.Determine BMI-for-age percentile Let’s Look at Liz

42. 3 9 1 0 3 7 0 0 8 7 Let’s Look at Liz NEXT STEP 6.Record BMI Percentile on PM 160 –Estimate a whole number between 1 and 99 that best represents the percentile point plotted on the growth chart

43. FINAL STEP 7.Determine category and record on PM 160 if needed –Enter follow up code in appropriate column under “PROBLEM SUSPECTED” –Enter diagnosis under “COMMENTS/PROBLEMS” Underweight Overweight Obese (03) Overweight Let’s Look at Liz

44. Graph Gabriela’s Growth DateAgeWeightStatureBMI* 225 #34 ½ ”14.8 329 ½ #38 ½ ”14.0 432 ¼ #41 ” FIRST STEPS 1.Select appropriate growth chart 2.Measure standing height 3.Measure weight

45. Graph Gabriela’s Growth NEXT STEP 4.Determine BMI Value DateAgeWeightStatureBMI* 225 #34 ½ ”14.8 329 ½ #38 ½ “14.0 432 ¼ #41 ”13.5

46. Graph Gabriela’s Growth NEXT STEP 5.Determine BMI-for-age percentile

47. 4 1 0 0 3 2 0 4 0 3 Graph Gabriela’s Growth NEXT STEP 6.Record BMI Percentile on PM 160 –Estimate a whole number between 1 and 99 that best represents the percentile point plotted on the growth chart

48. FINAL STEP 7.Determine category and record on PM 160 if needed –Enter follow up code in appropriate column under “PROBLEM SUSPECTED” –Enter diagnosis under “COMMENTS/PROBLEMS” Underweight Overweight Obese (03) Underweight Graph Gabriela’s Growth

49. Summary You are now able to: describe the use of BMI as a screening tool determine BMI value plot BMI value on the growth chart determine BMI-for-age percentile interpret weight category record results on PM 160

50. Color-coded BMI Charts 5210 Let’s Go! www.letsgo.org/ www.letsgo.org/ Eat Smart, Move More North Carolina www.eatsmartmovemorenc.com/ www.eatsmartmovemorenc.com/ National Initiative for Children’s Healthcare Quality www.nichq.org/ > Childhood Obesity www.nichq.org/

51. Growth Assessment Resources Essential clinical tools in training packet Resource handout lists sources for –Online tutorials –Online resources –Growth charts –Plotting aids –BMI calculators and wheels CDC BMI Percentile Calculator for Child and Teen CHOP Body Mass Index and Z-Score Calculation in Children Shape Up America! Childhood Obesity Assessment Calculator CDC BMI Percentile Calculator for Child and Teen CHOP Body Mass Index and Z-Score Calculation in Children Shape Up America! Childhood Obesity Assessment Calculator –Software applications

52. References American Academy of Pediatrics Policy Statement: Prevention of Pediatric Overweight and Obesity. Pediatrics. 112: 424-430, 2003. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424 http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424 Assessment of Child and Adolescent Overweight and Obesity. Pediatrics 120: S193-S228, 2007. http://pediatrics.aappublications.org/cgi/content/full/120/Supplement_4/S193 http://pediatrics.aappublications.org/cgi/content/full/120/Supplement_4/S193 Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics 120 : S164-S192, 2007. http://pediatrics.aappublications.org/cgi/content/abstract/120/Supplement_4/S164 http://pediatrics.aappublications.org/cgi/content/abstract/120/Supplement_4/S164 Recommendations for Prevention of Childhood Obesity. Pediatrics 120 : S229-S253, 2007. http://pediatrics.aappublications.org/cgi/content/abstract/120/Supplement_4/S229 http://pediatrics.aappublications.org/cgi/content/abstract/120/Supplement_4/S229 The Validity of BMI as an Indicator of Body Fatness and Risk Among Children. Pediatrics 124: S23-S34, 2009. http://pediatrics.aappublications.org/cgi/content/abstract/124/Supplement_1/S23 http://pediatrics.aappublications.org/cgi/content/abstract/124/Supplement_1/S23