Introduction to Pediatric Obesity Assessment

1
Introduction to Pediatric Obesity Assessment

• A Case-Based Learning Tool for
• First Year Medical Students

2
Objectives

• Learn the prevalence of obesity in pediatrics and
  adults
• Identify key risk factors for obesity
• Recognize when and how to screen for obesity
• Identify common medical complications associated
  with obesity

3
Your Patient

• Alex is a 10 year old boy who presents to your
  office for a sports physical accompanied by his
  mother. He saw you 2 months ago for
  immunizations, which are up to date. At that
  time, his history and physical exam were
  unremarkable.

4
Alex

• As Alexs height and weight are being measured,
  his mother comments that he seems to have gained
  quite a bit of weight in the past year or so.
  She asks if this could be a problem. What is the
  most appropriate response?
• A) Its probably baby fat, he should outgrow
  this.
• OR
• B) Being overweight can be a problem. Lets see
  how his height and weight compare to other boys
  his age.

5
Wrong answer!

• The epidemic of childhood obesity is ranked as a
  critical public health threat in this century.
• -1 in 3 children is overweight in US
• -1 in 6 children is obese in US
• It is important for all physicians to be able to
  screen for and recognize childhood overweight.

Try again!
6
Correct!

• The epidemic of childhood obesity is ranked as a
  critical public health threat in this century
• -1 in 3 children is overweight in US
• -1 in 6 children is obese in US
• About 1/2 of school age obese children and 2/3 of
  obese adolescents become obese adults
• Childhood obesity is associated with greater risk
  of adult morbidity and mortality, independent of
  adult Body Mass Index (BMI), family history of
  cardiovascular diseases or cancer, and smoking
• Obesity is the second leading preventable cause
  of disease and death in the United States

7
Defining overweight and obesity

• Alexs weight is 71 kg and his height is 155cm.
  You wonder if this is appropriate for someone his
  age.
• Overweight and obesity are both labels for ranges
  of weight that are greater than what is generally
  considered healthy for a given height
• At present, there is no precise clinically
  practical method to measure body fat
• Physicians use Body Mass Index (BMI) to screen
  patients for overweight and obesity
• What is Body Mass Index (BMI)?

8
What is BMI?

• Body mass index (BMI) is defined as the weight of
  the patient in kilograms divided by the height in
  meters squared (kg/m2)
• BMI wt/ht2
• Typically used to evaluate body fat in adults a
  useful predictor of body fat in children and
  adolescents
• BMI is a good screening tool for body fat but
  not necessarily diagnostic of obesity
• Whats the BMI Criteria for Overweight?

9
Obesity Criteria for 6-20 y old patients
BMI percentiles IOM CDC
lt5th Underweight
5-84th Reference
85-94th Overweight At risk of overweight
gt95th Obese Overweight
Institute of Medicine (IOM) based on
severity of current epidemic of excess body
fat Center for Disease Control (CDC) based
on risk for obesity in adulthood
10
Adult vs. Children

• For adults, the BMI is not age or gender
  specific, so easy- to-use BMI tables are
  available on web sites such as the NHLBI.
• For children, the BMI is age and gender specific.
  BMI for age charts have been developed
• Girls BMI Chart
• Boys BMI Chart

11
Alex

• Alex weighs 71kg and he is 155cm tall. What is
  his BMI?
• A) 0.003
• B) 45.8
• C) 29.5
• D) 0.458

12
Try again!

• BMI weight of the patient in kilograms divided
  by the height in meters squared (kg/m2)

Try Again!
13
Correct!

• Alexs BMI is 29.5
• You can compare Alexs BMI with the BMI of a
  other boys his age using a CDC growth chart
• This CDC chart is titled Body Mass Index-for-age
  percentiles
• What does BMI Percentile mean?

14
BMI Percentile

• The percentile for BMI is a way of ranking
  children based on their BMI.
• For example, if we examine 100 nationally
  representative children in the US and rank them
  according to their BMI, number 5 would be at the
  5th percentile and number 95 would be at the 95th
  percentile.

15
Alex

• In what percentile is Alexs BMI?
• A) 50th
• B) 90th
• C) gt95th

16
Not Quite.

• The horizontal axis (X) is Alexs age (10yrs)
• The vertical axis (Y) is Alexs BMI (29.5)

Alex
Try Again!
17
Correct!!!
Alex
Alex

• Alex is gt 95th percentile
• Alex would be considered overweight by the CDC
  definition and obese by the IOM definition.
• Review BMI Criteria.

18
Remember the criteria for 6-20 yr olds
BMI percentiles IOM CDC
lt5th Underweight
5-84th Reference
85-94th Overweight At risk of overweight
gt95th Obese Overweight
Institute of Medicine (IOM) based on
severity of current epidemic of excess body
fat Center for Disease Control (CDC) based
on risk for obesity in adulthood see slide 7
19
Online Tools

• Alex was born today ten years ago, his weight
  today is 71kg and height is 155cm.
• Calculate Alexs BMI and his risk using the CDC
  Online Calculator.

20
Curious?

• Want to calculate your own BMI? Try the BMI
  calculator for adults.
• You will be able to analyze your food intake and
  learn more about adult related problems in the
  next modules on overweight obesity

21
Lets get back on track

• Summarizing Alexs Case
• Insert Video Clip Gita Summarizing Case
• Lets now take a history and try to figure out
  what is causing Alexs excessive weight gaiin.
• Keep in mind that we usually classify obesity in
  the following way

22
Causes of Obesity
Exogenous (or organic)
Endogenous (or organic)

• Anatomic
• Endocrine
• Syndromic
• (gene mutation)

• Environmental
• -Psychosocial-Lifestyle
• Hereditary

23
What components do you need to make your medical
assessment?

• BMI, BP, HR
• History
• Weight and height (and growth history)
• Family concerns
• Medical history
• Psycho-social screening
• Family history
• Dietary and physical activity screening
• Cigarette, alcohol, drugs and sex history
• Physical examination
• Tests

24
Before we interview Alexs mother, remember the
ABCDs of Nutrition Assessment

• Anthropometric Weight status based on BMI and
  Sexual maturity (tanner stage)
• Biochemical Laboratory signs of nutritional
  excess or deficiency
• Clinical Clinical signs of nutritional excess or
  deficiency
• Dietary Patients dietary habits

25
Alexs History

• The mother reports that they recently moved to
  the US from El Salvador approximately 9 months
  ago. Since being in the US he has progressively
  been gaining more weight and has been less
  active. Per mother he was average weight and
  height in El Salvador. No previous weight loss
  attempts. Height of the child is at the
  mid-parental height potential.
• Diet History No breakfast, lunch at school,
  snacks heavily at home (chips, soda) and eats
  dinner with the family. He eats in front of the
  TV. Drinks between 16-24 oz of soda per day.
• Activity Walks to and from school (20 min
  total/d), watches 2-3 hrs TV per day (helps him
  learn English)
• Social History New to US, predominantly Spanish
  speaking. Lives with mother, brother, aunt and
  cousin. Isolated neighborhood, uses public
  transportation. Not accepted by peers in
  neighborhood. School 4th grade, not doing well
  academically.

26
Alexs History (cont.)

• Past Medical History and Past Surgical History
  non- contributory
• Family History Father died at age 30 of heart
  attack in El Salvador, additionally with h/o
  overweight and hypertension, 3 myocardial
  infarctions. Mother with hypertension, diet
  controlled no meds family denies type 2 DM, gall
  bladder stones, eating disorder, stroke. Brother
  overweight.
• Medications none
• Allergies NKDA (No Known Drug Allergies)
• Review of Systems Shortness of breath with one
  flight of stairs, denies polyuria, polydipsia,
  intertrigo, goes to sleep at 11PM awake 6AM, no
  snoring or daytime sleepiness, foot hurts with
  running, otherwise non-contributory

27
You Be the Doctor

• What do you think is contributing to Alexs
  excessive weight gain in the past year?
• Type in your answer below

Submit Answer
28
Consult an Expert

• What are the key factors contributing to
  Alexs weight gain?
• Insert Video Clip Carine Lenders discussing
  factors contributing to weight gain

• What are the key Review of Systems questions in
  this interview?
• Insert Video Clip Carine Lenders
• discussing Review of Systems

29
Why is Childhood Overweight So Prevalent?

• A variety of factors may contribute the rapid
  rise in childhood overweight.
• Consider current trends in food consumption and
  physical activity among children in the U.S

What are these TRENDS?
30
Changes in Food Consumption

• The of fast food restaurants in the United
  States increased from 30,000 to 140,000 between
  1970 and 1980.1
• Children consume almost twice as many calories in
  a restaurant compared to a meal at home. 2

1Paeratakul S, Ferdinand D, Champagne C, Ryan D,
Bray G. Fast-food consumption among US adults and
children. J Am Diet Assoc 2003(103)1332-8 2Zouma
s-Morse C, Rock CL, Sobo EJ, Neuhouser ML.
Childrens patterns of macronutrient intake and
associations with restaurant and home eating. J
Am Diet Assoc 2001(101)923-5.
31
Decreased Physical Activity

• About 60 of children ages 9-13 do not
  participate in any kind of organized physical
  activity program or sports outside of school.1
• In a national study, only 8 of elementary
  schools offered daily physical education classes
  for all students throughout the whole year.2

1Physical activity levels among children aged
9-13 years United States, 2002. MMWR
2003523375-8. 2Burgeson CR, Wechsler H,
Brener ND, Young JC, Spain CG. Physical Education
and activity Results from the School Health
Policies and Programs Study 2000. Journal of
School Health 2001717 279-293.
32
How many minutes should a child be active to
loose about 100 kcal?
Type of activity BMI 20 BMI 40 BMI 60
Basketball (game) 30 min 15 min 10 min
Cross-country ski 40 20 15
Cycling   10 km/ h 65 40 25
Ice hockey Figure skating 20 10-15 5-10
Running 25 15 10
Soccer 55 25 15
Swimming-30 m/min 40 20 15
  Breast stroke 60 30 20
Tennis 45 25 15
Walking 50 25 15
Adapted from Riddle Escoe. Ped Diab.
2005760-70
33
What is the Medical Impact of Obesity?

• Hypertension
• Dyslipidemia
• Type 2 Diabetes
• Metabolic syndrome
• Coronary heart disease
• Stroke
• GI complications
• Orthopedic
• Sleep apnea and respiratory problems
• Some types of Cancer

34
Psychological complications related to obesity

• Poor body image
• Social discrimination
• Low self-esteem
• Depression
• Eating Disorders

35
Wrapping it up

• After seeing Alex in clinic, you write down the
  Key Points you learned today on assessing
  Pediatric overweight.
• Insert video clip Gita summarizing take home pts
• Obesity is the most prevalent nutritional problem
  in the primary care setting
• Few families understand the impact of obesity or
  overweight on health
• Overweight and obesity remains underdiagnosed and
  untreated
• The skills to identify obesity risks and its
  complications associated with obesity are
  essential for physicians

36
Acknowledgements

• Contributors Gita Rao1, Carine Lenders1, Wayne
  LaMorte2, Caroline Apovian1, Adrianne Rogers1,
  Ben Siegel1, Joline Swonger1, Nousheen Humayan1,
  Rob Schadt2
• Boston University School of Medicine1
• Boston University School of Public Health2
• Vertical Nutrition Group, Boston University
  School of Medicine
• (members)
• With Support From
• Newbalance Foundation
• American Society of Nutrition (ANS)