Introduction to Pediatric
Obesity Assessment
A Case-Based Learning Tool for
First Year Medical Students
1
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
2
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.
3
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.”
4
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!
5
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
6
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 is Body Mass Index (BMI)?
7
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?
8
Obesity Criteria for 6-20 y old patients
BMI
percentiles
IOM*
CDC**
<5th
Underweight
5-84th
Reference
85-94th
Overweight
At risk of
overweight*
>95th
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
9
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
10
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
11
Try again!
BMI = weight of the patient in kilograms
divided by the height in meters squared
(kg/m2)
Try Again!
12
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 Indexfor-age percentiles”
What does ‘BMI Percentile’ mean?
13
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.
14
Alex
In what percentile is Alex’s BMI?
A) 50th
B) 90th
C) >95th
15
Not Quite.
Alex
The horizontal axis (X)
is Alex’s age (10yrs)
The vertical axis (Y) is
Alex’s BMI (29.5)
Try Again!
16
Correct!!!
Alex is > 95th
percentile
Alex
Alex
Alex would be
considered
‘overweight’ by the
CDC definition and
‘obese’ by the IOM
definition.
Review BMI Criteria.
17
Remember the criteria for 6-20 yr olds
BMI
percentiles
IOM
CDC
<5th
Underweight
5-84th
Reference
85-94th
Overweight
At risk of overweight*
>95th
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
18
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.
19
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
20
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…
21
Causes of Obesity
Endogenous
(or organic)
Anatomic
Endocrine
Syndromic
(gene mutation)
Exogenous
(or organic)
Environmental
-Psychosocial
-Lifestyle
Hereditary
22
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
23
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
24
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 midparental 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.
25
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
26
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
27
Consult an Expert
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
28
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?
29
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
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.
2Zoumas-Morse
30
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
activity levels among children aged 9-13 years – United States, 2002. MMWR 2003;52[33]:75-8.
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.
1Physical
2Burgeson
31
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. 2005;7:60-70
32
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
33
Psychological complications related
to obesity
Poor body image
Social discrimination
Low self-esteem
Depression
Eating Disorders
34
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
35
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)
36