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 Alex’s 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)“It’s probably baby fat, he should outgrow this.” OR B)“Being overweight can be a problem. Let’s 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 Alex’s 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 isBody 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 What’s the BMI Criteria for Overweight?

9. Obesity Criteria for 6-20 y old patients * 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 tablesare 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! Alex’s BMI is 29.5 You can compare Alex’s 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 Alex’s BMI? A) 50th B) 90th C) >95th

16. Not Quite. Alex The horizontal axis (X) is Alex’s age (10yrs) The vertical axis (Y) is Alex’s BMI (29.5) Try Again!

17. Correct!!! Alex Alex • Alex is > 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 * 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 Alex’s BMI and his risk using the CDC Online Calculator.

20. Curious? • Want to calculate your own BMI? Try the BMI calculatorfor 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. Let’s get back on track… Summarizing Alex’s Case Insert Video Clip: Gita Summarizing Case Let’s now take a history and try to figure out what is causing Alex’s 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 Alex’s 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. Alex’s 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. Alex’s 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 Alex’s excessive weight gain in the past year? Type in your answer below: Submit Answer

28. What are the key factors contributing to Alex’s weight gain? Insert Video Clip: Carine Lenders discussing factor’s contributing to weight gain What are the key ‘Review of Systems’ questions in this interview? Insert Video Clip: Carine Lenders discussing Review of Systems Consult an Expert

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: WhataretheseTRENDS?

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 2Zoumas-Morse C, Rock CL, Sobo EJ, Neuhouser ML. Children’s 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 2003;52[33]:75-8. 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 2001;71[7]: 279-293.

32. How many minutes should a child be active to loose about 100 kcal? Adapted from Riddle & Escoe. Ped Diab. 2005;7:60-70

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)