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**Assessing Child Growth Using Body Mass Index (BMI)-for-Age Growth Charts**

Speaker Tips are listed in italics throughout the speaker notes pages. Preparation: Customize slides, slide titles, charts, and speaker notes for your individual county prior to giving presentation. Look for items listed in red font. Talking Points: Pediatric growth charts have been used by doctors, nurses, and parents to track the growth of infants, children, and adolescents in the United States since 1977. In 2000, the CDC standardized growth charts were updated using a more representative sample of children. The new charts included the Body Mass Index (BMI)-for-age charts for children and adolescents from ages 2 through 20. Background Information: The CDC Growth Charts, released in May 2000, consist of revised versions of the growth charts developed by the National Center for Health Statistics (NCHS) in and the addition of the Body Mass Index (BMI)-for-age charts. The development of the growth charts was a collaborative effort between the Division of Health Examination Statistics in the National Center for Health Statistics (NCHS) and the Division of Nutrition and Physical Activity (DNPA) in the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) at the Centers for Disease Control and Prevention (CDC). 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

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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 Speaker Tips: Describe contents of training packet and flow of presentation and practice. Refer to handout: Presentation handout. Talking Points: By the end of this training session, 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

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**Obesity Trends in Children and Teens Receiving CHDP Exams**

Ages 5 to < 20 Speaker Tips/Customizing this slide: The county data shown in this slide are for Ventura County. Access the current PedNSS data for your county by visiting: or > County Surveillance Data > Pediatric Nutrition Surveillance System (PedNSS) Select Table 16B: Growth Indicators by Race/Ethnicity and Age for the groups that you would like to feature. Enter the most current data in the chart data sheet to display on the prevalence of overweight and obesity in your county. You may show data trends over time or illustrate prevalence by age group and/or ethnicity. See the User Guide for more tips on editing charts in this presentation. This slide provides an example illustrating trend data. The following two slides provide examples of the annual data sorted by age group and ethnicity. You may arrange your data in any format that works for you. Talking Points: The primary focus of using the Body Mass Index in children and teens is screening for overweight and obesity. You are seeing many obese children in your practice. Survey data on pediatric BMI of children receiving CHDP exams in our county shows that what you are observing is supported by the data. Over the last [N] years reported, [20-25] % of [Your County] children receiving CHDP exams have had BMI- for-age percentiles above the 95th percentile. Compare [Your County] data to the trends for the state of California. Customize chart with PedNSS data from your county. See User Guide. CDC Pediatric Nutrition Surveillance System (PedNSS) Data, Accessed online at (accessed 9/30/10).

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**CDC Pediatric Nutrition Surveillance System (PedNSS) Data, 2009.**

Childhood Overweight and Obesity by Age Group [Insert Your County Name] 2009 Speaker Tips/Customizing this slide: The county data shown in this slide are for Ventura County. Access the current PedNSS data for your county by visiting: or > County Surveillance Data > Pediatric Nutrition Surveillance System (PedNSS) Select Table 16B: Growth Indicators by Race/Ethnicity and Age for the groups that you would like to feature. Enter the most current data in the chart data sheet to display on the prevalence of overweight and obesity in your county. See the User Guide for more tips on editing charts in this presentation. Talking Points: This slide features PedNSS data for Your County sorted by age group. In which age group is overweight and obesity most prevalent? What is the combined rate of overweight and obesity in this critical age group? Customize chart with PedNSS data from your county. See User Guide. CDC Pediatric Nutrition Surveillance System (PedNSS) Data, 2009. Accessed online at (accessed 9/30/10).

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**Childhood Overweight and Obesity by Ethnicity California 2009 [Insert Your County Name]**

Children Aged 5 to < 20 years Speaker Tips/Customizing this slide: The data shown in this slide are for the state of California. Access the current PedNSS data for your county by visiting: or > County Surveillance Data > Pediatric Nutrition Surveillance System (PedNSS) Select Table 16B: Growth Indicators by Race/Ethnicity and Age for the age group that you would like to feature. Enter the most current data in the chart data sheet to display on the prevalence of overweight and obesity in your county. See the User Guide for more tips on editing charts in this presentation. Talking Points: In the 2009 PedNSS, the highest obesity rates were among children in the Pacific Islander, American Indian/Alaska Native, and Hispanic groups. The lowest rates were among Asian, Filipino, white, and black children. Customize chart with PedNSS data from your county. See User Guide. CDC Pediatric Nutrition Surveillance System (PedNSS) Data, 2009. Accessed online at (accessed 9/30/10).

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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 Talking Points: BMI is a mathematical relationship of a person’s weight to height. It is the recommended tool for assessing growth and overweight in children starting at 2 years of age. Body Mass Index (BMI) is defined as body weight in kilograms divided by height in meters squared. Like weight-for-height, BMI is a screening tool used to identify individuals who are underweight or overweight. BMI alone is not a diagnostic tool. For example, a child who is relatively muscular may have a high BMI for his or her age without being overfat or obese. Background Information: The accuracy of the Body Mass Index percentile as an indicator of adiposity varies greatly according to the degree of body fatness. In children with BMIs ≥ 85th percentile, the BMI is a good indicator of excess fat. However, the differences in the BMIs of relatively thin children (that is, BMI for age < 85th percentile) can be largely due to differences in fat-free mass. The cut points for weight categories based on BMI percentiles were selected to provide ranges at which BMI-for-age is fairly accurate for identifying children with excess body fatness and increasing risk for other associated health problems. As compared with thinner children, overweight children (85th - 94th percentiles) are more likely to have multiple risk factors and to become obese adults; their risks, however, are lower than those of obese (and severely obese) children. Reference: Freedman S and Sherry B. The Validity of BMI as an Indicator of Body Fatness and Risk Among Children. Pediatrics 2009;124:S23–S34

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**Why Use BMI-for-Age? 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 Talking Points: There are several advantages to using BMI-for-age as a tool to assess growth. BMI-for-age provides a reference for adolescents that was not previously available. Also BMI-for-age is the measure that is consistent with the adult index so BMI can be used continuously from 2 years of age to adulthood. Normal levels of fatness change with child growth. By including all three variables, BMI can account for those natural changes. It is a clinical screening of health and nutrition status consistent with CHDP program goals of early detection and referral for early intervention/treatment High BMI-for-age is related with clinical risk factors for chronic disease including hyperlipidemia, elevated insulin, and high blood pressure. Data from the Bogalusa Heart Study found that approximately 60% of 5 to 10 year-old children who were over the 95th percentile had at least one biochemical or clinical risk factor for cardiovascular disease such as those just mentioned, and 20% had two or more risk factors. Reference: Freedman et al., The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Pediatrics 1999;103: Background Information: When the 1977 NCHS growth charts were developed, weight-for-height percentiles were provided only for prepubescent girls up to 10 years and for boys up to 11.5 years. BMI- for-age is the only indicator that allows us to plot a measure of weight and height with age on the same chart. Age and stage of sexual maturation are highly related to body fatness. BMI-for-age was not available in the 1977 charts.

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**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 Talking points: Determining Body Mass Index-for-age for pediatric clients, interpreting the results, follow-up , and making appropriate referrals is recommended by several public health agencies and professional organizations including The Centers for Disease Control; The American Academy of Pediatrics; The Expert Committee convened by the American Medical Association with representatives from 15 organizations; and More recently, the US Preventive Services Task Force and the White House Task Force on Childhood Obesity Determining Body Mass Index-for-age values and percentiles is a required component of the CHDP exam for children and teens from age two through The National Committee for Quality Assurance (NCQA) has also proposed the Body Mass Index as a HEDIS* requirement for reporting by commercial and Medicaid plans for children years of age. Background Information: *The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Reference: National Committee for Quality Assurance. HEDIS & Quality Measurement Accessed 07/09/10.

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**Body Mass Index Cutoff Values for Adults**

Standard weight categories Same for all ages Same for men and women Weight Status BMI Obese 30.0 and above Overweight Normal Underweight Below 18.5 Talking Points: You may be familiar with the adult BMI cut-off values. For adults, there are categories for underweight, ‘normal’ weight, overweight, and obesity. The BMI cutoffs for adults are: Obese and above Overweight Normal weight Underweight Below 18.5 Background Information: Body Mass Index (BMI) is a number calculated from a person's weight and height. BMI is a fairly reliable indicator of body fatness for most people. BMI does not measure body fat directly, but research has shown that BMI correlates to direct measures of body fat, such as underwater weighing and dual energy x-ray absorptionometry (DXA). BMI can be considered an alternative for direct measures of body fat. Additionally, BMI is an inexpensive and easy-to-perform method of screening for weight categories that may lead to health problems.

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**For Children, BMI Changes with Age Example: Child’s growth tracking along 95th percentile**

Talking Points: Arbitrary cutoff values cannot be given for children because the BMI changes with age. Let’s follow this child who is growing consistently along the 95th percentile BMI-for-age. Notice how BMI changes with age, even though the percentile is the same. You see that after 2 years of age, BMI-for-age begins to decline and continues falling during the preschool years until it reaches a minimum around 4 to 6 years of age. The BMI (the number value) begins rising again through the teen years, yet when plotted, BMI-for-age tracks consistently on the 95th percentile. Therefore, in children we need to determine BMI-for-age percentile. The BMI value alone is impossible to interpret unless it is plotted. Age 2 4 9 13 BMI Value 19.3 17.8 21.0 25.1

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**BMI for Children and Teens**

Age- and sex-specific Plot BMI on growth chart to find percentile Weight status determined by percentile Weight Status Category Percentile Range Obese ≥ 95th percentile Overweight 85th to < 95th percentile Normal 5th to < 85th percentile Underweight < 5th percentile Talking Points: BMI for children and teens is age- and sex-specific. For children and teens up to age 20, you need to plot BMI on the growth chart to find the percentile. The child’s weight status is determined by the child’s BMI-for-age percentile. The next few slides will explain this further. The weight status categories and percentile ranges for children are: Obese Greater than or equal to the 95th percentile Overweight 85th to below the 95th percentile Normal 5th to below the 85th percentile Underweight Below the 5th percentile

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

Talking Points: Let’s take a look at what a percentile is. Weight and height in a normal population of children follows a bell-shaped curve. The shape of each growth chart is based on this curve. The bell-shaped curve in this photo represents the distribution of different body sizes of 100 healthy girls of the same age . You’ll see that most of them are of a size that puts them near the 50th percentile. There are fewer children at either extreme of the bell curve. In fact, in a normally distributed population, only 5% of children should be under the 5th percentile, or over the 95th percentile. Likewise, you would expect 15 out of 100 children (15%) to be over the 85th percentile and be experiencing normal growth. However, what we are seeing today, is that many more children are at or above the 95th percentile than just 5%. In our county, we are seeing about [Insert your county data] percent of low income school aged children at or above the 95th percentile. Although some of these children may be athletic and lean, most of these children are overly fat. Using percentiles based on a normal or bell curve to define overweight is very useful when considering large populations of children. But using cutoff percentiles to define overweight is not necessarily appropriate to evaluate an individual child because at every percentile you need to expect to see normal, healthy children. The growth charts are not intended to be used as the only diagnostic tool. Instead, plotting the growth chart over time can help form an overall clinical impression for the child being measured. Major Percentile Divisions

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**CDC Growth Charts Tip: Download and print from**

Formula to calculate BMI Percentile lines 5th - 10th - 25th - 50th 75th - 85th - 90th - 95th Talking Points: This is the 2 to 20 years: Boys BMI chart. The vertical line represents the BMI number (or value). The horizontal line represents age, so that you are plotting the BMI value relative to the child’s age. The formulas to calculate the BMI value in metric or English measurements are listed below the data entry table. The 5th, 50th, 85th, and 95th percentiles are displayed in bold. Charts with the 5th and 95th percentiles are recommended for CHDP exams and other routine clinical assessments. Charts with the 3rd to the 97th percentile are available for use with children with special health care needs. Children who are growing well generally track along a percentile line or in a percentile channel. Parents may think that the 50th percentile is “normal” or “ideal”. The 50th percentile simply represents the middle of the normal range. The new charts were released in Check the fine print on the bottom left margin of the growth chart to make sure you are using a chart with the text “Published May 30, 2000” and a modification date between in parentheses. Published May 30, 2000 (modified )

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**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 Talking Points: When assessing physical growth, it is desirable to have a series of accurate measurements to establish an observed growth pattern. Having a series of measurements takes into consideration short- and longer-term conditions. If the percentiles fall outside the normal range, that is, below the 5th percentile, between the 84th and 94th, and the 95th percentile or greater, recheck measurements, plots, and calculations. If measurements are correct, further evaluation may be needed to determine the cause.

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Adiposity Rebound The increase in BMI that occurs after it reaches its lowest point, usually between ages 4 to 6 Normal growth pattern Talking Points: Here you see a section of the BMI-for-age chart for boys enlarged to show the shape of the curve in more detail. Normally, a child’s Body Mass Index decreases after age 2 until it reaches its lowest point, on average, at 5 or 6 years old. Kindergarteners are normally skinny! After the early elementary years, BMI begins a gradual increase through adolescence until the child reaches adult weight and height. The increase in BMI that occurs after it reaches its lowest point is referred to as "adiposity rebound”. The age at which a child’s BMI reaches its lowest point varies with the individual child. This growth chart shows a boy following along the 50th percentile curve. His Body Mass Index reached its lowest point at age 6. After this age, his BMI increases gradually while still maintaining a curve (or following a channel) near the same percentile range. This is a normal pattern of growth that occurs in all children. Reference: Dietz WH. Periods of risk in childhood for the development of adult obesity — what do we need to learn? J Nutr 1997;127:1884S-6S. Accessed 12/23/10. ↑BMI AGE →

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**Adiposity Rebound Child following 10th percentile curve**

At what age does the BMI reach its lowest point? Talking Points: Let’s look at how adiposity rebound occurs in other children. Here’s another growth chart of a young boy whose growth is following close to the 10th percentile curve. His Body Mass Index reached its lowest point between ages 6 and 7 before rebounding. This is also a normal growth pattern. ↑BMI AGE →

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**Adiposity Rebound Child following 85th percentile curve**

At what age does the BMI reach its lowest point? Talking Points: Now let’s review the growth chart of a young boy whose BMI is following the 85th percentile curve. His Body Mass Index reached its lowest point at age 5 before rebounding. Again, this is also a normal growth pattern. Consistency of the growth pattern is more important than what line or channel the child is following. The CDC uses percentile cut-offs to define obesity, overweight or underweight. When evaluating the individual child, look at how the child’s growth tracks over time. A growth pattern that tracks consistently along a percentile channel or line indicates that the child is probably growing normally. If the growth pattern moves upward or downward (crossing percentile lines), the child may not be experiencing normal growth and further assessment is needed. We’ll discuss this in the next few slides. ↑BMI AGE →

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**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 Talking Points: This chart shows a growth chart for a child whose BMI initially followed the 75th percentile curve. At age 4, instead of continuing the expected downward trend, the Body Mass Index value shows a gradual increase. This pattern is called early adiposity rebound. The earlier the age at which the minimum BMI value occurs, the more likely a child is to be overweight or obese as an adult. Adiposity rebound that occurs before age 5 can be considered early. This early increase in Body Mass Index percentiles is a red flag or warning sign, and an indicator that a more thorough nutrition assessment is needed. This child may need intervention to prevent excess weight gain and crossing percentile lines into the overweight or obese ranges. Make a note of the Body Mass Index value (16.8) and Body Mass Index percentile (just under the 85th percentile) at age 4. References: Dorosty AR, Emmett PM, Cowin S, Reilly JJ. Factors associated with early adiposity rebound: ALSPAC Study Team. Pediatrics. 2000;105: Accessed 12/23/10. Whitaker RC, Pepe MS, Wright, JA, Seidel KD, Dietz W. Early adiposity rebound and the risk of adult obesity. Pediatrics 1998;101(3):E Accessed 12/23/10. ↑BMI AGE →

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**Early Adiposity Rebound**

Without Intervention With Intervention Talking Points: View 1 Without Intervention Without intervention, the pattern of excess weight gain is likely to continue resulting in rapidly increasing Body Mass Index values and Body Mass Index percentiles. This child’s BMI is at the 90th percentile at age 5. In which weight category does this place him? Answer: Overweight By ages 6, 7, and 8, the child’s BMI is tracking along the 95th percentile. Which weight category does the child fall in now? Answer: Obese At age 9, the child’s BMI is over the 95th percentile. View 2 With Intervention By initiating intervention at the 4 year check, this upward trend may be prevented. The intervention may be as simple as the health provider spending 5 minutes to give “brief focused advice” at each visit. This is a topic for another training “Counseling the Overweight Child”. Speaker Tip: Give training date, if available. For example, the provider learns at the 4 year old visit that the preschooler drinks 3 8-oz glasses of juice between meals. The parents agree to eliminate juice and stick to this plan at home. At each following visit, the provider focuses on a single strategy for change. The gradual shift in the boy’s eating and activity patterns results in a slowing of the weight gain while he grows taller. Over time, the BMI value levels off bringing the child back into the healthy range and onto his original 75th percentile curve. Speaker Tip: share an individual success story here. Some children will benefit from referral to a more formal pediatric weight management program. We will give you more information about this at the end of today’s presentation. ↑BMI ↑BMI AGE → AGE →

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**Excessive Adiposity Rebound**

Excessive adiposity rebound is related to higher BMI in adulthood Increasing BMI percentiles crossing major percentile lines are red flags Talking Points: This chart shows a boy whose BMI is tracking along the 50th percentile. However, when he begins his adiposity rebound he gains weight rapidly resulting in abnormal increases in BMI and BMI percentile. Excessive adiposity rebound is related to higher BMI in adulthood. Increasing BMI percentiles crossing major percentile lines is a red flag that warrants further assessment, intervention, and/or referral Reference: Esposito L, Fisher JO, Mennella JA, Hoelscher DM, Huang TT. Developmental perspectives on nutrition and obesity from gestation to adolescence. Prev Chronic Dis 2009;6(3). Accessed 12/23/10. ↑BMI AGE →

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**Steps to Plot BMI-for-age**

Select appropriate growth chart Measure standing height accurately Measure weight accurately Determine BMI value Determine BMI-for-age percentile Record BMI percentile on PM 160 Determine weight category Speaker Tip: Refer to handout: Body Mass Index (BMI)-for-Age Percentile Job Aid (PIN No ) Obtaining and Recording Body Mass Index-for-Age Percentile on the Confidential Screening/Billing Report Talking Points: What are the steps you need to take in order to plot the BMI? Select appropriate growth chart Measure standing height accurately following standard procedure Measure weight accurately following standard procedure Determine BMI value Determine BMI-for-age percentile Record BMI percentile on PM 160 Determine weight category Who does each of these steps in your clinic? Trained staff may do steps 1-6. The certified CHDP health care provider (MD, NP, or PA) needs to determine the weight category

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**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 BMI-for-age Speaker Tip: Refer to worksheets: CDC Growth Chart 2 to 20 Years: Boys and Practice PM 160 for Carlos. Talking Points: Let’s walk through our first example together. For this demonstration, you’ll need the practice growth charts and the practice PM 160s from your packet. For Step 1, select the appropriate growth chart based on the age and gender of the child being weighed and measured. At 2 years of age, the CDC recommends that you begin using the years BMI-for-age chart. You no longer need to use the weight-for-length chart. Carlos, pictured here, appeared for his 6 year CHDP exam. Which growth chart is appropriate for Carlos? That’s right. CDC 2 to 20 Years: Boys. Find the growth chart in your packet with Carlos’ name at the top. His measurements and BMI values for his 3 and 4 year exams are plotted. Background Information: In nutritional screening, the word “stature” is used to describe a child’s height. Children ages two years and older should be measured while standing. Measurements should be plotted on the BMI-for-age growth chart. Children up to age three, who cannot stand without help due to special circumstances, can be measured lying down. In this case, the weight-for-length chart continues to be used up to age 36 months.

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**Chart Carlos Correctly Step 2: Measure Standing Height Record on growth chart and PM 160**

Date Age Weight Stature BMI* 3 32 # 38 ½ ” 15.2 4 36 # 41 ” 15.0 6 45 ¾ ” Step 2: Measure Standing Height Record on growth chart and PM 160 Carlos’ height is measured at 45 ¾ inches. Record this in the Stature column on the growth chart in the box that corresponds to Carlos’ age (6). Find the Practice PM 160 for Carlos. The units on the PM 160 are inches and quarter inches. Enter 4 5 inches and 3 fourths in the height box. 4 5 3

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**Chart Carlos Correctly Step 3: Measure Weight Record on growth chart and PM 160**

Date Age Weight Stature BMI* 3 32 # 38 ½ ” 15.2 4 36 # 41 ” 15.0 6 43 ½ # 45 ¾ ” Step 3: Measure Weight Record on growth chart and PM 160 Carlos’ weight is measured at 43 ½ pounds. Enter this in the Weight column on the growth chart in the box that corresponds to Carlos’ age (6). The units on the PM 160 are pounds and ounces. In the weight box, enter 4 3 pounds, a leading zero (0) and 8 ounces.

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**Chart Carlos Correctly Step 4A: Determine BMI Value**

Method 1: Using a calculator 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 Step 4A: Determine BMI Value Using a Calculator Now, let’s get to work. To calculate the BMI, enter the weight and height measurements in the calculator using the appropriate formula. With practice, this will only take about 15 seconds. There are special calculators that include a built-in BMI calculation. An online BMI calculator, Excel spreadsheet, or PDA/phone software program can also be used. Next we’ll learn about a shortcut using the BMI calculation wheel.

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**Chart Carlos Correctly Step 4A: Determine BMI Value**

Method 2: Using a BMI calculation wheel 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! Step 4A: Determine BMI Value Many practitioners find a BMI calculation wheel easy to use. The device fits easily in your pocket and doesn’t require batteries. One provider office hangs the BMI wheel on a cord attached to the blood pressure/temperature machine. The readings from a BMI wheel may not be as accurate as those obtained by calculation but they are adequate for most CHDP exams. If you question your reading, double-check using a calculator, especially if the child plots in the underweight, overweight or obese range. Find height on inner wheel TIP: Mark with your thumb and index finger Line up with weight on outer wheel Read BMI value in the window on the inner wheel TIP: Read decimal points from right to left!

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**Chart Carlos Correctly Step 4B: Determine BMI Value Record on growth chart**

Date Age Weight Stature BMI* 3 32 # 38 ½ ” 15.2 4 36 # 41 ” 15.0 6 43 ½ # 45 ¾ ” 14.6 Step 4B: Determine BMI Value Once you’ve determined the BMI value, record it on the growth chart

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**Chart Carlos Correctly Step 5: Determine BMI-for-Age %ile**

TIP: Use a transparent growth chart plotting aid Find age on horizontal axis Find BMI value on vertical axis Mark point of intersection Estimate BMI percentile Speaker Tip: Demonstrate use of clinical tool: Growth Chart Plotting Aid. Step 5: Determine BMI-for-Age Percentile Find age on horizontal axis. Find BMI value on vertical axis. Mark point of intersection. Estimate BMI percentile by looking at the percentile line on which the point falls. If the point falls between lines, look at the percentile lines above and below the point. Follow the lines to the right to find the percentile range in which the point plots (such as 5-10%, 10-25%, 25-50%, etc.). On the PM 160, you will record a single number not a range. If the point falls above the 95th percentile line, estimate a whole number between 95 and 99 that best represents the percentile point. If the point falls above the 99th percentile (determined using a 99th percentile cutoff chart or software application), use 99. If the point falls below the 5th percentile line, estimate a whole number between 4 and 1 that best represents the percentile point. The following slides and practice case studies will demonstrate recording percentiles.

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**Chart Carlos Correctly 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 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 In this case, Carlos’ BMI-for-age plots on the 25th percentile. Enter Carlos’ BMI-for-age percentile 2 5. 2 5

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**Chart Carlos Correctly Step 7A: Determine Weight Category**

Weight Status Category Percentile Range Obese ≥ 95th percentile Overweight 85th to < 95th percentile Normal 5th to < 85th percentile Underweight < 5th percentile Step 7: Determine Weight Category The certified CHDP health care provider (MD, NP, or PA) determines the weight category using the CDC guidelines listed again here. However, remember that these percentile ranges are indicators of risk. A BMI-for-age above the 85th percentile is a reason for further assessment to look at secondary conditions and lifestyle habits that may be contributing to overweight. In a population of normal, healthy children 10% will be normal weight in the 85th - 94th percentile range. Growth divergence and a careful assessment are your keys to action. A BMI greater than or equal to the 99th percentile is correlated with increased risk of medical problems. About 4% of children nationwide have a BMI in this range. For our CHDP children, more than 10% of children fall at or above the 99th percentile.

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**Chart Carlos Correctly Step 7B: Record Abnormal Results**

On PM 160, enter follow up code in appropriate column under “PROBLEM SUSPECTED” Enter diagnosis under “COMMENTS/PROBLEMS” Underweight Overweight Obese Talking points: Enter the “FOLLOW UP CODES” in appropriate column. For example, for a child with known obesity that you refer to a pediatric weight management program, enter “5. REFERRED TO ANOTHER EXAMINER FOR DX/TX” in the “KNOWN” (D) column for row 03 “NUTRITIONAL ASSESSMENT” Record abnormal results only (Underweight, overweight, obese) for the weight category in the “COMMENTS” box. If the BMI-for-age falls within the normal range, do not enter anything. Another situation that may arise is that a child’s BMI-for-age percentile plots in the 85th to less than 95th percentile range or even at the 95th percentile or greater, but the MD, NP, or PA determines the child is not “overweight” or “obese” based on their physical exam and clinical judgment. The provider can check “NO PROBLEM SUSPECTED” (A) column for row 03 “NUTRITIONAL ASSESSMENT” but they also need to provide justification as to why the child is not “overweight” or “obese”. Include a note such as “Athlete – high lean muscle mass” in the “COMMENTS/PROBLEMS” box.

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**Accurate Measurements Are Critical**

BMI for 5 year old boy Weight: 43.5 lb Height: in BMI= 16.5 BMI-for-age = th percentile Normal range If height is inaccurate: Weight: 43.5 lb Height: in BMI = 17.0 Talking Points: Measurements must be obtained and recorded accurately if they are to be used as an effective screening tool. Use recommended procedures for measuring stature and weight. To illustrate the importance of accurate data, we use the case of a 5 year old boy, whose height was inaccurately measured as shorter than he actually is. Notice that when the BMI is calculated and plotted, the measurement error of 0.5 inch in height results in a movement upward on the growth curve. This child, who is truly between the 75th - 84th percentile, and should be classified as ‘normal weight’, will be plotted on the 85th - 94th percentile, and classified as ‘overweight’. You can see here how errors in measurement can cause errors in interpretation. You can see from this example that it is desirable to have a series of accurate measurements to monitor growth trends. Having a series of measurements takes into consideration short- and longer-term conditions. A sudden change in the consistency of the growth pattern may alert you to errors in obtaining, recording or plotting measurements. If a child’s growth deviates from an expected pattern, is below the 5th percentile, between the 84th and 94th, and at or above the 95th percentile, recheck your work even if it means repeating the weight and height measurement, calculations and plotting. When you’ve confirmed your work, then you can make an accurate determination of the weight category and provide appropriate follow up and referrals. BMI-for-age = th percentile Overweight range

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**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 In today’s session you have learned how to: Use 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 The next two slides show some additional resources that may help you use BMI for the CHDP exam.

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**Color-coded BMI Charts**

5210 Let’s Go! Eat Smart, Move More North Carolina National Initiative for Children’s Healthcare Quality > Childhood Obesity Speaker Tip: Optional: You may include a color-coded BMI chart in the training packet . See Growth Assessment Resources handout for list of internet addresses. Talking Points: Color-coded BMI charts may make it easier for health care staff to read the BMI percentile. This slide lists a few resources for accessing and downloading printable color-coded charts. Color-coded BMI charts may also be used to help parents understand the BMI percentile and the individual risks it presents for their child or teen.

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**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 Software applications Speaker Tip: Refer to Handout: Growth Assessment Resources. Talking Points: The essential tools for calculating BMI and using the BMI-for-Age growth charts for determining percentiles are included in the training packet. The handout Growth Assessment Resources in your packet includes these and other resources that your office may need for future training and information, ordering or downloading growth charts, plotting aids, calculators, or software. You may demonstrate an online BMI calculator such as BMI Calculator for Child and Teen found on the CDC website Children’s Hospital of Philadelphia website Shape Up America! Website (Mention nutrition and activity programs available in your area.) This concludes today’s training. The skills you practiced today will help you use the Body Mass Index to evaluate child growth at the CHDP exam. CHDP will be offering trainings on related topics in the future, such as: How to Weigh and Measure Children Accurately for the CHDP Well Child Exam Counseling the Overweight Child Glucose and Cholesterol Screening for Pediatric Obesity (Share information about training dates and registration information, if known.)

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References American Academy of Pediatrics Policy Statement: Prevention of Pediatric Overweight and Obesity. Pediatrics. 112: , Assessment of Child and Adolescent Overweight and Obesity. Pediatrics 120: S193-S228, Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics 120 : S164-S192, Recommendations for Prevention of Childhood Obesity. Pediatrics 120 : S229-S253, The Validity of BMI as an Indicator of Body Fatness and Risk Among Children. Pediatrics 124: S23-S34, Talking Points: Here is a list of references used in the development of this presentation.

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