11

Introduction to Pediatric Introduction to Pediatric Obesity AssessmentObesity Assessment

A Case-Based Learning Tool forA Case-Based Learning Tool for

First Year Medical StudentsFirst Year Medical Students

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ObjectivesObjectives

Learn the prevalence of obesity in Learn the prevalence of obesity in pediatrics and adultspediatrics and adults

Identify key risk factors for obesityIdentify key risk factors for obesity

Recognize when and how to screen for Recognize when and how to screen for obesityobesity

Identify common medical complications Identify common medical complications associated with obesityassociated with obesity

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Your PatientYour Patient

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

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AlexAlexAs Alex’s height and weight are being measured, As Alex’s height and weight are being measured,

his mother comments that he seems to have his mother comments that he seems to have gained quite a bit of weight in the past year or gained quite a bit of weight in the past year or so. She asks if this could be a problem. What so. She asks if this could be a problem. What is the most appropriate response?is the most appropriate response?

A) “It’s probably baby fat, he should outgrow this.”“It’s probably baby fat, he should outgrow this.”OROR

B) “Being overweight can be a problem. Let’s see “Being overweight can be a problem. Let’s see how his height and weight compare to other how his height and weight compare to other boys his age.”boys his age.”

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Wrong answer!Wrong answer!

The epidemic of childhood obesity is The epidemic of childhood obesity is ranked as a critical public health threat in ranked as a critical public health threat in this century.this century.-1 in 3 children is overweight in US-1 in 3 children is overweight in US

-1 in 6 children is obese in US-1 in 6 children is obese in US

It is important for all physicians to be able to It is important for all physicians to be able to screen for and recognize childhood overweight.screen for and recognize childhood overweight.

Try again!

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Correct!Correct!The epidemic of childhood obesity is ranked as The epidemic of childhood obesity is ranked as a critical public health threat in this century a critical public health threat in this century

-1 in 3 children is overweight in US-1 in 3 children is overweight in US-1 in 6 children is obese in US-1 in 6 children is obese in US

About 1/2 of school age obese children and 2/3 of About 1/2 of school age obese children and 2/3 of obese adolescents become obese adultsobese adolescents become obese adultsChildhood obesity is associated with greater risk of Childhood obesity is associated with greater risk of adult morbidity and mortality, independent of adult adult morbidity and mortality, independent of adult Body Mass Index (BMI), family history of Body Mass Index (BMI), family history of cardiovascular diseases or cancer, and smokingcardiovascular diseases or cancer, and smokingObesity is the second leading preventable cause of Obesity is the second leading preventable cause of disease and death in the United Statesdisease and death in the United States

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Defining overweight and obesityDefining overweight and obesity

Alex’s weight is 71 kg and his height is 155cm. You Alex’s weight is 71 kg and his height is 155cm. You wonder if this is appropriate for someone his age. wonder if this is appropriate for someone his age.

Overweight and obesity are both labels for ranges of Overweight and obesity are both labels for ranges of weight that are greater than what is generally considered weight that are greater than what is generally considered healthy for a given heighthealthy for a given height

At present, there is no precise clinically practical method At present, there is no precise clinically practical method to measure body fatto measure body fat

Physicians use Body Mass Index (BMI) to screen Physicians use Body Mass Index (BMI) to screen patients for overweight and obesity patients for overweight and obesity

What is Body Mass Index (BMI)?

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What is BMI?What is BMI? Body mass index (BMI) is defined as the weight of the Body mass index (BMI) is defined as the weight of the

patient in kilograms divided by the height in meters patient in kilograms divided by the height in meters squared (kg/msquared (kg/m22) )

BMI = BMI = wt/htwt/ht22

Typically used to evaluate body fat in adults; a useful Typically used to evaluate body fat in adults; a useful predictor of body fat in children and adolescentspredictor of body fat in children and adolescents

BMI is a good screening tool for body fat; but not BMI is a good screening tool for body fat; but not necessarily diagnostic of obesitynecessarily diagnostic of obesity

What’s the BMI Criteria for Overweight? What’s the BMI Criteria for Overweight?

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Obesity Criteria for 6-20 y old patients Obesity Criteria for 6-20 y old patients

BMI BMI percentilespercentiles

IOM*IOM* CDC**CDC**

<5<5thth UnderweightUnderweight

5-845-84thth ReferenceReference

85-9485-94thth OverweightOverweight At risk of At risk of overweight*overweight*

>>9595thth ObeseObese OverweightOverweight * 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

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Adult vs. ChildrenAdult vs. Children

For adults, the BMI is not age or gender For adults, the BMI is not age or gender specific, so easy- to-use specific, so easy- to-use BMI tables are are available on web sites such as the NHLBI. available on web sites such as the NHLBI.

For children, the BMI is age and gender For children, the BMI is age and gender specific. BMI for age charts have been specific. BMI for age charts have been developed:developed:

Girls BMI ChartBoys BMI Chart

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AlexAlex

Alex weighs 71kg and he is 155cm tall. Alex weighs 71kg and he is 155cm tall. What is his BMI?What is his BMI?

A) 0.003 0.003

B) 45.8 45.8

C) 29.5 29.5

D) 0.458 0.458

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Try again!Try again!

BMI = weight of the patient in kilograms BMI = weight of the patient in kilograms divided by the height in meters squared divided by the height in meters squared (kg/m(kg/m22) )

Try Again!

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Correct!Correct!

Alex’s BMI is 29.5Alex’s BMI is 29.5

You can compare Alex’s BMI with the BMI You can compare Alex’s BMI with the BMI of a other boys his age using a of a other boys his age using a CDC growth chart

This CDC chart is titled “Body Mass Index-This CDC chart is titled “Body Mass Index-for-age percentiles” for-age percentiles”

What does ‘BMI Percentile’ mean?What does ‘BMI Percentile’ mean?

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BMI PercentileBMI Percentile

The percentile for BMI is a way of ranking The percentile for BMI is a way of ranking children based on their BMI. children based on their BMI.

For example, if we examine 100 For example, if we examine 100 nationally representative children in the nationally representative children in the US and rank them according to their BMI, US and rank them according to their BMI, number 5 would be at the 5th percentile number 5 would be at the 5th percentile and number 95 would be at the 95th and number 95 would be at the 95th percentile.percentile.

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AlexAlex

In what percentile is Alex’s BMI?In what percentile is Alex’s BMI?

A) 5050thth

B) 9090th th

C) >95>95thth

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Not Quite.Not Quite.

The horizontal axis (X) The horizontal axis (X) is Alex’s age is Alex’s age (10yrs)(10yrs)

The vertical axis (Y) is The vertical axis (Y) is

Alex’s BMI (29.5)Alex’s BMI (29.5)

Try Again!

Alex

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Correct!!!Correct!!!

Alex is > 95Alex is > 95thth percentile percentile

Alex would be Alex would be considered considered ‘overweight’ by the ‘overweight’ by the CDC definition and CDC definition and ‘obese’ by the IOM ‘obese’ by the IOM definition. definition.

Review BMI Criteria.

AlexAlex

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Remember the criteria for 6-20 yr oldsRemember the criteria for 6-20 yr olds

BMI BMI percentilespercentiles

IOMIOM CDCCDC

<5<5thth UnderweightUnderweight

5-845-84thth ReferenceReference

85-9485-94thth OverweightOverweight At risk of overweight*At risk of overweight*

>>9595thth ObeseObese OverweightOverweight

* 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

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Online ToolsOnline Tools

Alex was born today ten years ago, his Alex was born today ten years ago, his weight today is 71kg and height is 155cm. weight today is 71kg and height is 155cm.

Calculate Alex’s BMI and his risk using the Calculate Alex’s BMI and his risk using the CDC Online Calculator..

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Curious?Curious?

Want to calculate your own BMI? Try the Want to calculate your own BMI? Try the BMI calculator for adults.for adults.

You will be able to analyze your food You will be able to analyze your food intake and learn more about adult related intake and learn more about adult related problems in the next modules on problems in the next modules on overweight & obesityoverweight & obesity

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Let’s get back on track…Let’s get back on track…

Summarizing Alex’s CaseSummarizing Alex’s CaseInsert Video Clip: Gita Summarizing CaseInsert Video Clip: Gita Summarizing Case

Let’s now take a history and try to figure out what Let’s now take a history and try to figure out what is causing Alex’s excessive weight gaiin.is causing Alex’s excessive weight gaiin.

Keep in mind that we usually classify obesity in the Keep in mind that we usually classify obesity in the following way…following way…

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Causes of ObesityCauses of Obesity

AnatomicEndocrine

Syndromic (gene mutation)

Environmental-Psychosocial-Lifestyle

Hereditary

Endogenous(or organic)

Exogenous(or organic)

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

BMI, BP, HRBMI, BP, HRHistory: History:

– Weight and height (and growth history) Weight and height (and growth history) – Family concerns Family concerns – Medical history Medical history – Psycho-social screeningPsycho-social screening– Family historyFamily history– Dietary and physical activity screeningDietary and physical activity screening– Cigarette, alcohol, drugs and sex historyCigarette, alcohol, drugs and sex history

Physical examination Physical examination TestsTests

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Before we interview Alex’s mother, Before we interview Alex’s mother, remember the ABCDs of Nutrition remember the ABCDs of Nutrition

AssessmentAssessment

– AAnthropometric: Weight status based on BMI nthropometric: Weight status based on BMI and Sexual maturity (tanner stage)and Sexual maturity (tanner stage)

– BBiochemical: Laboratory signs of nutritional iochemical: Laboratory signs of nutritional excess or deficiencyexcess or deficiency

– CClinical: Clinical signs of nutritional excess or linical: Clinical signs of nutritional excess or deficiencydeficiency

– DDietary: Patients’ dietary habitsietary: Patients’ dietary habits

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Alex’s HistoryAlex’s HistoryThe mother reports that they recently moved to the US from El The mother reports that they recently moved to the US from El

Salvador approximately 9 months ago. Since being in the US he has Salvador approximately 9 months ago. Since being in the US he has progressively been gaining more weight and has been less active. progressively been gaining more weight and has been less active. Per mother he was average weight and height in El Salvador. No Per mother he was average weight and height in El Salvador. No previous weight loss attempts. Height of the child is at the mid-previous weight loss attempts. Height of the child is at the mid-parental height potential.parental height potential.

Diet HistoryDiet History:: No breakfast, lunch at school, snacks heavily at home No breakfast, lunch at school, snacks heavily at home (chips, soda) and eats dinner with the family. He eats in front of the (chips, soda) and eats dinner with the family. He eats in front of the TV. Drinks between 16-24 oz of soda per day.TV. Drinks between 16-24 oz of soda per day.

ActivityActivity: Walks to and from school (20 min total/d), watches 2-3 hrs : Walks to and from school (20 min total/d), watches 2-3 hrs TV per day (“helps him learn English”)TV per day (“helps him learn English”)

Social HistorySocial History: New to US, predominantly Spanish speaking. Lives : New to US, predominantly Spanish speaking. Lives with mother, brother, aunt and cousin. Isolated neighborhood, uses with mother, brother, aunt and cousin. Isolated neighborhood, uses public transportation. Not accepted by peers in neighborhood. public transportation. Not accepted by peers in neighborhood. School 4th grade, not doing well academically.School 4th grade, not doing well academically.

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Alex’s History Alex’s History (cont.)(cont.) Past Medical History and Past Surgical HistoryPast Medical History and Past Surgical History: non- contributory: non- contributory

Family HistoryFamily History: Father died at age 30 of heart attack in El Salvador, : Father died at age 30 of heart attack in El Salvador, additionally with h/o overweight and hypertension, 3 myocardial additionally with h/o overweight and hypertension, 3 myocardial infarctions. Mother with hypertension, diet controlled no meds; infarctions. Mother with hypertension, diet controlled no meds; family denies type 2 DM, gall bladder stones, eating disorder, family denies type 2 DM, gall bladder stones, eating disorder, stroke. Brother overweight.stroke. Brother overweight.

MedicationsMedications:: none none

AllergiesAllergies: NKDA (‘No Known Drug Allergies’): NKDA (‘No Known Drug Allergies’)

Review of SystemsReview of Systems:: Shortness of breath with one flight of stairs, Shortness of breath with one flight of stairs, denies denies polyuria, , polydipsiapolydipsia, , intertrigointertrigo, , goes to sleep at 11PM & goes to sleep at 11PM & awake 6AM, no snoring or daytime sleepiness, foot hurts with awake 6AM, no snoring or daytime sleepiness, foot hurts with running, otherwise non-contributory running, otherwise non-contributory

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You Be the DoctorYou Be the DoctorWhat do you think is contributing to Alex’s What do you think is contributing to Alex’s

excessive weight gain in the past year?excessive weight gain in the past year?

Type in your answer below:Type in your answer below:

Submit Answer

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Consult an ExpertConsult an Expert

What are the key What are the key factors contributing to factors contributing to Alex’s weight gain?Alex’s weight gain?

Insert Video Clip: Carine Lenders Insert Video Clip: Carine Lenders discussing factor’s contributing to discussing factor’s contributing to

weight gainweight gain

What are the key What are the key ‘Review of Systems’ ‘Review of Systems’

questions in this questions in this interview?interview?

Insert Video Clip: Carine LendersInsert Video Clip: Carine Lenders

discussing Review of Systemsdiscussing Review of Systems

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Why is Childhood Overweight So Why is Childhood Overweight So Prevalent?Prevalent?

A variety of factors may contribute the A variety of factors may contribute the rapid rise in childhood overweight. rapid rise in childhood overweight.

Consider current Consider current trendstrends in food in food consumption and physical activity among consumption and physical activity among children in the U.S:children in the U.S:

What are these TRENDS?

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Changes in Food ConsumptionChanges in Food Consumption

The # of fast food restaurants in the United The # of fast food restaurants in the United States increased from 30,000 to 140,000 States increased from 30,000 to 140,000 between 1970 and 1980.between 1970 and 1980.11

Children consume almost twice as many Children consume almost twice as many calories in a restaurant compared to a calories in a restaurant compared to a meal at home. meal at home. 22

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.

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Decreased Physical ActivityDecreased Physical Activity

About 60% of children ages 9-13 do About 60% of children ages 9-13 do notnot participate in any kind of organized participate in any kind of organized physical activity program or sports outside physical activity program or sports outside of school.of school.11

In a national study, only 8% of elementary In a national study, only 8% of elementary schools offered daily physical education schools offered daily physical education classes for all students throughout the classes for all students throughout the whole year.whole year.22

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.

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Type of activityType of activity BMI= 20BMI= 20 BMI = 40BMI = 40 BMI = 60BMI = 60

Basketball (game)Basketball (game) 30 min30 min 15 min15 min 10 min10 min

Cross-country skiCross-country ski 4040 2020 1515

CyclingCycling   10 km/ h  10 km/ h 6565 4040 2525

Ice hockey Ice hockey Figure skatingFigure skating 2020 10-1510-15 5-105-10

RunningRunning 2525 1515 1010

SoccerSoccer 5555 2525 1515

Swimming-30 m/minSwimming-30 m/min 4040 2020 1515

    Breast strokeBreast stroke 6060 3030 2020

TennisTennis 4545 2525 1515

WalkingWalking 5050 2525 1515

How many minutes should a child be active to loose about 100 kcal?

Adapted from Riddle & Escoe. Ped Diab. 2005;7:60-70Adapted from Riddle & Escoe. Ped Diab. 2005;7:60-70

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What is the Medical Impact of Obesity?What is the Medical Impact of Obesity?

Hypertension Hypertension Dyslipidemia Dyslipidemia Type 2 DiabetesType 2 DiabetesMetabolic syndromeMetabolic syndromeCoronary heart disease Coronary heart disease Stroke Stroke GI complications GI complications Orthopedic Orthopedic Sleep apnea and respiratory problems Sleep apnea and respiratory problems Some types of CancerSome types of Cancer

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Psychological complications related to Psychological complications related to obesityobesity

Poor body image Poor body image

Social discrimination Social discrimination

Low self-esteem Low self-esteem

Depression Depression

Eating Disorders Eating Disorders

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Wrapping it upWrapping it up

After seeing Alex in clinic, you write down the After seeing Alex in clinic, you write down the Key PointsKey Points you learned today on assessing Pediatric overweight.you learned today on assessing Pediatric overweight.

Insert video clip: Gita summarizing take home ptsInsert video clip: Gita summarizing take home pts

Obesity is the most prevalent nutritional problem in the Obesity is the most prevalent nutritional problem in the primary care settingprimary care settingFew families understand the impact of obesity or Few families understand the impact of obesity or overweight on health overweight on health Overweight and obesity remains underdiagnosed and Overweight and obesity remains underdiagnosed and untreateduntreatedThe skills to identify obesity risks and its complications The skills to identify obesity risks and its complications associated with obesity are essential for physiciansassociated with obesity are essential for physicians

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AcknowledgementsAcknowledgements

Contributors: Gita RaoContributors: Gita Rao11, Carine Lenders, Carine Lenders11, Wayne LaMorte, Wayne LaMorte22, Caroline , Caroline ApovianApovian11, Adrianne Rogers, Adrianne Rogers11, Ben Siegel, Ben Siegel1,1, Joline Swonger Joline Swonger11, , Nousheen HumayanNousheen Humayan1, 1, Rob SchadtRob Schadt22

Boston University School of MedicineBoston University School of Medicine11 & & Boston University School of Public HealthBoston University School of Public Health22

Vertical Nutrition GroupVertical Nutrition Group, Boston University School of Medicine:, Boston University School of Medicine:(members…)(members…)

With Support From:With Support From:Newbalance FoundationNewbalance FoundationAmerican Society of Nutrition (ANS)American Society of Nutrition (ANS)