Challenges in Clinician-Parent
Communication: Pediatric BMI
Daniel L. Marks, MD, PhD
Associate Professor of Pediatric Endocrinology
Oregon Health & Science University
Doernbecher Children's Hospital
Portland, Oregon
Eliana M. Perrin, MD, MPH
Associate Professor
Division of General Pediatrics and Adolescent Medicine
Department of Pediatrics
School of Medicine
University of North Carolina at Chapel Hill
What Is BMI?
• Formula: weight (pounds) / [height
(inches)]2 x 703
• Can be calculated with a wheel,
computer program, or paper and pencil
• Not a perfect screening tool, but it is
objective
BMI = body mass index
Plotting BMI
• Plot BMI on standardized Centers for
Disease Control and Prevention (CDC)
BMI for Age Charts (for boys and girls)
• These charts translate the BMI number
into a percentile and take into account
that BMI is both age- and sex-specific
for children and teens
Weaknesses of BMI
• BMI may overestimate the degree of
adiposity in some children (eg, those
with high muscle mass)
• BMI may underestimate the degree of
adiposity in some children (eg, those
with central adiposity)
• Remember — BMI is not a diagnostic
tool
American Academy of Pediatrics
Recommendation
• Beginning at age 2, BMI should be
calculated and plotted for every child
on a yearly basis
• 2007 expert committee
recommendations outlined new BMI
percentile weight categories[a]
a. Barlow SE and the Expert Committee. Pediatrics. 2007;120:S254-S288.
BMI for Age Chart
Underweight
< 5th
percentile
Healthy weight
5th to < 85th
percentiles
Overweight
85th to 94th
percentiles
Obese
CDC. Available at
http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.
≥ 95th
percentile
Color-Coded BMI Charts
• Oettinger MD, Finkle JP, Esserman D, et al. Colorcoding improves parental understanding of body
mass index charting. Acad Pediatr. 2009;9:330-338.
Parents Don't Recognize Overweight
in Their Children
• Parry LL, Netuveli G, Parry J, Saxena S. A
systematic review of parental perception of
overweight status in children. J Ambul Care
Manage. 2008;31:253-268.
• Huang JS, Becerra K, Oda T, et al. Parental
ability to discriminate the weight status of
children: results of a survey. Pediatrics.
2007;120:e112-119.
Parents Don't Recognize Overweight
in Their Children (cont)
• Baughcum AE, Chamberlin LA, Deeks CM,
Powers SW, Whitaker RC. Maternal
perceptions of overweight preschool
children. Pediatrics. 2000;106:1380-1386.
• Jain A, Sherman SN, Chamberlin LA, et al.
Why don't low-income mothers worry about
their preschoolers being overweight?
Pediatrics. 2001;107:1138-1146.
Parents Don't Recognize Overweight
in Their Children (cont)
• Maynard LM, Galuska DA, Blanck HM,
Serdula MK. Maternal perceptions of weight
status of children. Pediatrics.
2003;111:1226-1231.
• Jeffery AN, Voss LD, Metcalf BS, Alba S,
Wilkin TJ. Parents' awareness of overweight
in themselves and their children: cross
sectional study within a cohort (EarlyBird21).
BMJ. 2005;330:23-24.
Do Providers Recognize Overweight
in Their Patients?
• Providers don't do a good job recognizing
overweight by visual impression
• In a study, BMI charting prompted greater
recognition of weight problems than did
height and weight charting[a]
• Regular use of BMI charts can help
providers:
– Recognize overweight and obesity
– Document overweight and obesity
– Counsel patients and parents about overweight
and obesity
a. Perrin EM, et al. J Pediatr. 2004;144:455-460.
A Tough Conversation
• Perrin EM, Vann JC, Lazorick S, et al.
Bolstering confidence in obesity prevention
and treatment counseling for resident and
community physicians. Patient Educ Couns.
2008;73:179-185.
• Perrin EM, Flower KB, Ammerman AS.
Pediatricians' own weight: self perception,
misclassification, and ease of counseling.
Obes Res. 2005;13:326-332.
Parents Want to Have Sensitive,
Health-Focused Conversations
• Borra ST, Kelly L, Shirreffs MB, et al.
Developing health messages: qualitative
studies with children, parents, and teachers
help identify communications opportunities
for healthful lifestyles and the prevention of
obesity. J Am Diet Assoc. 2003; 721-728.
• Rhee KE, De Lago CW, Arscott-Mills T, et
al. Factors associated with parental
readiness to make changes for overweight
children. Pediatrics. 2005; 116:e94-e101.
Our Obesogenic World
• Focus on making healthy choices in the
household
–
–
–
–
–
–
–
Portion size
Whole grains
Lean meats
Cooking styles
Fruits and vegetables
Screen time
Active time
• Be sensitive to family income when making
recommendations
Perrin EM, et al. Acad Pediatr. 2010;10:274-281.
Results
• First study to show that a simple toolkit can
change parents' perceptions of their
children's weight
• The study interventions improved
consumption of fruits and vegetables,
sugary drinks, unhealthy snacks, restaurant
food, and lower-fat milk
• Screen time was reduced
Other Findings
• Parents reported more frequent
conversations about weight status with
providers
• Residents felt more effective
• Color-coded charts helped close parents'
numeracy and literacy gaps
Summary
• Providers: Establish a partnership with
parents/caregivers and try to have more
frequent conversations about weight
• These conversations should be:
–
–
–
–
Remembered
Sensitive
Motivating
Focused on healthy changes, not on weight