1. What is the family physician’s role?
Child Obesity
What is the family physician’s role?
Sheryl Rosenberg Thouin, MPH, RD, CDE

2. Health Consequences of Childhood Obesity
Hypertension
Hypercholesterolemia
Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes.
Sleep apnea
Asthma
Joint problems and musculoskeletal discomfort
Fatty liver disease, gallstones, and GERD
Obese children and adolescents have a greater risk of social and psychological problems, such as discrimination and poor self-esteem, which can continue into adulthood
Becoming obese Adults

4. 2007 Rates of Overweight and Obese Children

5. BMI = weight (kg)/height (m)2 BMI is an effective screening tool
= weight (lb)/[height (in)]2 x 703
BMI is an effective screening tool
For children, BMI is age and gender specific
Body Mass Index (BMI) is an anthropometric index of weight and height (stature) that is defined as body weight in kilograms divided by height in meters squared. BMI is the commonly accepted index for classifying adiposity in adults and it is recommended for use with children and adolescents.
Like weight-for-height, BMI is a screening tool used to identify individuals who are underweight or overweight. BMI is not a diagnostic tool. For example, a child who is relatively heavy may have a high BMI for his or her age or high weight-for-stature. To determine whether the child has excess fat, further assessment needed might include triceps skinfold measurements. To determine a counseling strategy, assessments of diet, health, and physical activity are needed.
BMI is gender specific and age specific for children. BMI-for-age is the measure used for ages 2 to 20 years since BMI changes substantially as children get older. Whereas for adults, BMI is neither age nor gender specific and nutritional status is defined by fixed cut points.

6. Indicators of Pediatric Overweight Plotting BMI-for-age
Obese
>95th percentile
Overweight
85th to 95th percentile
“Overweight” rather than obesity is the term preferred for describing infants or children greater than or equal to the 95th percentile of weight-for-length or BMI-for-age. The 85th percentile is included on the BMI-for-age and the weight-for-stature charts. Expert committees have indicated that children and adolescents aged 2 to 20 years between the 85th and 95th percentiles are at risk of overweight.
Evaluating a child’s pattern of growth over time is more important than a single measure of size. The pattern of growth is based on periodic measurements which are tracked on a percentile line as a child grows.

7. For Children, BMI Changes with Age
Example: 95th Percentile Tracking
Age BMI
2 yrs
4 yrs
9 yrs
13 yrs
Boys: 2 to 20 years
BMI changes substantially with age. After about 1 year of age, BMI-for-age begins to decline and it continues falling during the preschool years until it reaches a minimum around 4 to 6 years of age. Here you see BMI-for-age tracking on the 95th percentile.
BMI
BMI

8. Example: “Sam” Name: Sam Weight: 35 lbs 4 oz Height: 35 inches
Age: 4 years old
BMI: 20
Is this child normal weight?
Here is an example of interpretation of BMI-for-age:
Sam weighs 37 pounds and 4 ounces and is 41.5 inches tall. He is 3 1/2 years old and his calculated BMI is 15.2.

9. Sam’s BMI Plotted on Boy’s BMI-for-Age Chart
Boys: 2 to 20 years
BMI
Interpretation:
Sam’s BMI-for-age is significantly above the 95th %tile
On the BMI-for-age chart, find Sam’s age on the horizontal axis and visually draw a vertical line up from that point, then find his BMI on the vertical axis and visually draw a horizontal line across from that point. The point where the two intersect represents Sam’s BMI-for-age.
When plotted on the growth chart, Sam’s BMI-for-age falls just below the 25th percentile curve. Percentile indicates the rank of a measure in a group of This means that of 100 children the same sex and age as Sam, fewer than 25 children will have a BMI lower than his.
Sam is neither overweight, underweight nor at risk of overweight. When a child’s plotted measurement falls between the 5th and 95th percentiles it is considered to be in the normal range. Sam’s BMI-for-age is in the normal range. When a child’s percentile rank falls outside the normal range (i.e., outside the 5th or 95th percentiles), further evaluation is needed.

10. If Sam were 11.5 years old... Interpretation:
Boys: 2 to 20 years
BMI
Interpretation:
Sam’s BMI-for-age is just below the 85th %tile
On the BMI-for-age chart, find Sam’s age on the horizontal axis and visually draw a vertical line up from that point, then find his BMI on the vertical axis and visually draw a horizontal line across from that point. The point where the two intersect represents Sam’s BMI-for-age.
When plotted on the growth chart, Sam’s BMI-for-age falls just below the 25th percentile curve. Percentile indicates the rank of a measure in a group of This means that of 100 children the same sex and age as Sam, fewer than 25 children will have a BMI lower than his.
Sam is neither overweight, underweight nor at risk of overweight. When a child’s plotted measurement falls between the 5th and 95th percentiles it is considered to be in the normal range. Sam’s BMI-for-age is in the normal range. When a child’s percentile rank falls outside the normal range (i.e., outside the 5th or 95th percentiles), further evaluation is needed.

11. If Sam were 18 years old... Interpretation:
Boys: 2 to 20 years
BMI
Interpretation:
Sam’s BMI-for-age is just above the 10th %tile
On the BMI-for-age chart, find Sam’s age on the horizontal axis and visually draw a vertical line up from that point, then find his BMI on the vertical axis and visually draw a horizontal line across from that point. The point where the two intersect represents Sam’s BMI-for-age.
When plotted on the growth chart, Sam’s BMI-for-age falls just below the 25th percentile curve. Percentile indicates the rank of a measure in a group of This means that of 100 children the same sex and age as Sam, fewer than 25 children will have a BMI lower than his.
Sam is neither overweight, underweight nor at risk of overweight. When a child’s plotted measurement falls between the 5th and 95th percentiles it is considered to be in the normal range. Sam’s BMI-for-age is in the normal range. When a child’s percentile rank falls outside the normal range (i.e., outside the 5th or 95th percentiles), further evaluation is needed.

12. Looking for the Cause Genetics
Biological factors: hormonal and neurochemical mechanisms
Growth hormone
Leptin
Ghrelin
Neuropeptide Y
melanocortin
Psychological factors
Socio-cultural factors
Environmental factors
Interaction between these factors clearly are evident in childhood obesity.
LIFESTYLE:
21 hours television/week
Barriers to physical activity: (0 in school/after school safety issues)
middle and upper income parents can buy their way out of the problems: league sports/club teams/lessons
Lower income: highest obesity rates.

13. Looking for the Cause Genetics
Biological factors: hormonal and neurochemical mechanisms
Growth hormone
Leptin
Ghrelin
Neuropeptide Y
melanocortin
Psychological factors
Socio-cultural factors
Environmental factors
Interaction between these factors clearly are evident in childhood obesity.
LIFESTYLE:
21 hours television/week
Barriers to physical activity: (0 in school/after school safety issues)
middle and upper income parents can buy their way out of the problems: league sports/club teams/lessons
Lower income: highest obesity rates.

14. Data Description Data Sources Table 1: Categorization of Children
Comparisons are made among four groups of 9- to 11-year-old children using federal poverty level and CalFresh participation (Table 1). Only statistically significant differences are reported (p<.05).
Data Sources
1 California Department of Public Health, Network for a Healthy
Table 1: Categorization of Children
California, California
Children’s Healthy Eating and Exercise Practices Survey (CalCHEEPS). Background and Documentation: 2009 CalCHEEPS. Documentation2009.pdf. Accessed April 7, 2011.
2 California Department of Education. DataQuest: Free or Reduced Price Meals Data. Accessed April 7, 2011.
This material was produced by the California Department of Public Health’s Network for a Healthy California with funding from USDA SNAP, known in California as CalFresh (formerly Food Stamps). These institutions are equal opportunity providers and employers. CalFresh provides assistance to low-income households and can help buy nutritious foods for better health. For CalFresh information, call For important nutrition information, visit

15. Low-income children are more likely to be overweight.1
fact
Nearly two out of five children in California are overweight or obese. The rate is over 60 percent higher among children from very low-income homes compared to those from average and higher income households. Over half of these children are overweight and of those, up to two-thirds are already obese.

17. Children do not get the recommended amount of physical activity.2
fact
Fewer than half (48%) of the 9- to 11-year-old children in California meet the guideline to engage in at least 60 minutes of moderate and vigorous physical activity daily. Only two out of five (40%) children who reside in very low-income CalFresh households meet this guideline.

18. Children eat too few fruits and vegetables.3
fact
Fewer than one out of three (31%) California children meet the fruit recommendation for good health and only one in ten (9%) eat the recommended cups of vegetables.

19. Low-income children get more screen time.4
fact
Children from lower income households spend up to 30 minutes more daily watching television and playing video or computer games compared to children from average and higher income homes. They are up to 50 percent more likely to have a television in their bedroom. California children with televisions in their bedrooms average 30 minutes more screen time and are 20 percent less likely to meet the recommended two or fewer hours a day of screen time, when compared to children without a television in their bedroom.

22. More parents can be role models for a healthy lifestyle.5
fact
Almost two-thirds of children who reside in CalFresh households agree that their parents eat high calorie, low nutrient foods compared to about two-fifths of the children from other groups. California children who agree with this statement report more daily servings of high-fat snacks (0.9 vs. 0.7 servings) and high calorie, low nutrient foods (3.8 vs. 3.3 servings), compared to those who disagree. Parents and other adults can support healthy eating by being role models.

24. Few low-income children participate in organized sports to support an active lifestyle.6
fact
Low-income children are up to 50 percent less likely to participate in organized sports. California children who participate in organized sports are 34 percent more likely to meet the physical activity recommendation on a typical day. Organized sports, offered outside of the school day, support physically active lifestyles among low-income children.

26. Many students get high calorie, low nutrient foods as rewards in the classroom.7
fact
Just under half of California children report that their teachers reward students by giving out high calorie, low nutrient rewards like candy, cookies, chips, or soda.

28. Higher participation in the school breakfast program may help increase fruit and vegetable intake.8
fact
Children participating in school breakfast average 0.6 to 1.3 servings more fruits and vegetables in every survey year from 1999 through 2009.

30. Low-income children have less access to nutrition lessons.9
fact
Children from average and higher income households are up to 27 percent more likely to report access to nutrition lessons at school compared to children from lower income homes.

32. School nutrition lessons empower children to make healthy food choices.1
fact
Participating in nutrition lessons at school is positively related to fruit and vegetable consumption in most survey years.

35. The physician’s role: AAFP Prevention of Pediatric Overweight and Obesity
Calculate and plot BMI once a year in all children and adolescents.
Encourage parents and caregivers to promote healthy eating patterns
Encourage children’s autonomy in self-regulation of food intake and setting appropriate limits on choices;
Encourage modeling of healthy food choices.
Routinely promote physical activity, including unstructured play at home and in school;
Recommend limitation of television and video time to a maximum of 2 hours per day.
Recognize and monitor changes in obesity-associated risk factors for adult chronic disease, such as hypertension, dyslipidemia, hyperinsulinemia, impaired glucose tolerance, and symptoms of obstructive sleep apnea syndrome.

36. How Can I Possibly Do This?

37. The Division of Responsibility adapted from Ellen Satter, MSW, RD
Parental Responsibilities
What is accessible
What food is available
When kitchen is open/closed
When food is available
TV/computer/cell phone time
Where food is consumed
What beverages are allowed
Physical activity/play time
Being a nutrition role model
All adults on ‘same page’
Child Responsibilities
How much is eaten
How their body turns out
“Overweight” rather than obesity is the term preferred for describing infants or children greater than or equal to the 95th percentile of weight-for-length or BMI-for-age. The 85th percentile is included on the BMI-for-age and the weight-for-stature charts. Expert committees have indicated that children and adolescents aged 2 to 20 years between the 85th and 95th percentiles are at risk of overweight.
Evaluating a child’s pattern of growth over time is more important than a single measure of size. The pattern of growth is based on periodic measurements which are tracked on a percentile line as a child grows.

38. Parental Feeding Responsibilities:
Establish predictable eating schedules.
Determine when kitchen is open/closed.
Plan the same menu for all family members.
Involve the child in meal planning/preparation/label reading
Model positive eating behaviors.
Enthusiastic about new foods
Focused eating
Slow-paced
Make exercise part of daily life.
Limit media viewing/video games.
Provide non-food rewards.
Parents ARE NOT responsible for:
How much the child decides to eat
Child’s eventual body size
Predictable eating schedules help to regulate appetite.
Focused eating with little distractions.
Limiting premeal snacking--
Everyone sits together at table.
“DO as I say, not as do” never works!

39. Helpful Assessment Questions
When did the excessive weight gain
Any major events/changes in the child’s life at that time?
What is the child eating?
Beverages?
Where does eating take place?
Does the child eat with the family?
At a table?
When does eating take place?
Who is in charge of food decisions?
Is the television on during meals? Snacks?
Who is in charge of TV/computer/video game time?
Are weekends different?
Where:
67% of school-age children consume food/drink away from home.
Outside food = 35% total calories
1:3 school-age children consume >40% of total calories from outside foods.
Children’s food preferences are learned through repeated exposure to foods.
minimum 8-10 exposures to a food– increased preference for that food

40. Recommended Resources