1. Childhood Obesity Screening and Surveillance Barbara J. Moore, PhD* Rachel Pahut, RN‡ and Mary McCourt, BSW £ * Montana Nutrition and Physical Activity Program ‡Marias Medical Center, Shelby, MT £ Missoula City-County Health Department February 11, 2010 9:00 – 10:30 AM barbara.moore@att.net

2. Topics Planning, Safety and Confidentiality Engaging parents and health care professionals in the community What to consider and how to proceed Measurement protocols Calculating BMI and plotting age- and sex-specific BMI percentile

3. Montana’s Health Ranking Since 1990, Montana’s health ranking has steadily declined Source: The Future Costs of Obesity (by Thorpe); United Health Foundation, APHA and Partnership for Prevention

4. Montana’s Health Ranking A major factor contributing to our declining overall ranking is Montana’s increase in obesity prevalence

5. Trends in Obesity Prevalence in U.S. Children % DATA SOURCE: Ogden JAMA 2002 and Ogden JAMA 2006

6. Growing % of Pediatric Diabetes is now Type 2 (Obesity-related) < 1990 2000

7. Mortality in lean children (BMI quartile 1) vs. heaviest children (BMI quartile 4) Source: Franks et al. NEJM 362(6) Feb. 11, 2010

8. E. Frongillo, Cornell University and B. J. Moore, Shape Up America!

9. Adult Obesity is typically defined by BMI BMI is “Body Mass Index” BMI = weight (kg)/height (m) 2 BMI = [weight (lbs)/height (in) 2 ] X 703 Overweight  BMI 25.0 – 29.9 Obesity  BMI 30.0 or higher

10. Pediatric Assessment – BMI Percentile History BMI = weight (kg)/height (m) 2 Requires measured height and weight Plot age-specific and sex-specific BMI Percentile on CDC growth chart (2000) ≥85 th - <95 th percentile = “overweight” ≥95 th percentile = “obese”

11. Reference Population of 5 year old females 95 th 5 th 50 th Percentile 85th

12. CDC Growth Charts - BMI 95 th 85 th 50 th 5 th 95 th 85 th 50 th 5 th

13. Reference Population of 5 year old females 95 th 5 th 50 th Percentile 85th

14. BMI declines until age 3 – 5; then BMI increases thereafter Age BMI 2 yrs 19.3 4 yrs 17.8 9 yrs 21.0 13 yrs 25.1 For Children, BMI Differs by Age and Sex Boys: 2 to 20 years BMI 95 th 85 th 50 th 5 th

15. 85th 75th For this 10 year old girl with a BMI of 19.3, her BMI Percentile falls between the 75 th and 85 th percentile lines (normal weight)

16. 85 th 75 th But 2 ½ years later, her BMI Percentile is above the 90 th percentile so she is now categorized as “overweight” AND Her BMI trajectory is clearly upward (i.e. NOT tracking close to the 75th percentile) 90 th 95 th

17. Example: 95th Percentile Tracking Age BMI 2 yrs 19.3 4 yrs 17.8 9 yrs 21.0 13 yrs 25.1 Is this boy obese? Boys: 2 to 20 years BMI

18. Growth Charts “Children's Growth Charts Don't Measure Up With Parents” Many don't understand how to read or interpret them, survey shows You can help!

19. In a normal population of 300 children … How many would you expect to meet the definition of “obese”?

20. 5% 15 children Obesity is defined by the 95 th percentile so only 5% would be expected to be obese.

21. Childhood Obesity in Preschoolers, by Ethnicity Anderson & Whitaker Arch Pediatr Adolesc Med 2009;163(4):344-348 %

22. Costs of Childhood Obesity – $15 billion (2004) “ Children treated for obesity are roughly three times more expensive for the health system than the average insured child ” Much higher rates of comorbidities >3X higher hospitalization rates 2X physician visit rates

23. Risk of Childhood Obesity Increases if One or Both Parents Obese

24. Vicious Cycle More obese children are growing up to be obese adults and obese parents. Their children are more likely to be obese What can be done to break the cycle ?

25. Preventing Childhood Obesity: Health in the Balance Institute of Medicine 2005

26. School-based BMI programs Screening programs measure children to identify those at risk Send confidential letters home to parents on BMI status of child Encourage referral to local professionals if appropriate for more thorough evaluation Expensive but good for prevention

27. U.S. Preventive Services Task Force (USPSTF) January 2010 Recommendation Statement on Screening for Obesity in Children and Adolescents The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. Grade: B recommendation. See also: Pediatrics in January 2010 (Pediatrics 2010;125:361-367. http://www.pediatrics.org).

28. School-based BMI programs Surveillance programs measure children and calculate percentages of overweight and obesity at each grade level (and by sex) to assess health, inform policy and track progress Can be limited to a single grade level or to two or more grade levels Provide a “snapshot” on health status

29. Planning Funding for equipment and staff School Nurse(s) Orientation and Training of Staff Wellness Committee Parents involved/supportive Local Health Care Professionals alerted Data handling and storage

30. Safety Respect for students (↓trauma ↓stigma) Accurate data Clean, private setting for measurements Discourage comparing numbers Be alert to anxiety (heaviest girls and boys small-for-age) Permit opt-out (?) –Parent –Student

31. Confidentiality Think of how you will use and analyze the data, store it and maintain it in a safe place Store for years if screening; matching Disclose only to parent(s) or legal guardian(s) Special circumstances (teen) ?

32. What to consider? Screening vs. Surveillance What do you want the data for? Budget constraints Alerting parents they may opt out –Passive vs. Active Alerting and engaging local health providers (prepare for referrals)

33. School Wellness Committee Can help garner support for screening and/or surveillance of children Committee members: school nurse, food service personnel, administrators, teachers, parents, students and local health care professionals

34. How to Proceed Train staff Choose and calibrate equipment Adopt protocols for height and weight measures (test and re-test) Agree on dates, place and time(s) Establish process for data collection, analysis and storage Prepare reports and communicate results

35. Height Protocol

36. Errors in height measures are squared Consult the CDC website and training resources Research various stadiometers and select the best equipment your budget permits If student body is large, this is essential

37. Height Protocol Think about straight lines and right angles Use ONLY a clinical quality stadiometer to measure height (QuickMedical.com; model 31-420)

38. Height Protocol Measure to nearest 0.1 cm (or 1/8 inch) and record value Repeat measurement, having the child line up again, and record appropriate value immediately on data form. Repeat measurements should agree within ½ cm or ¼ inch, if they do not, repeat measurement a third time.

39. Weight Protocol Consult the CDC website and training resources Research various scales and select the best equipment your budget permits Select scale that is durable Detachable readout is recommended Measure in metric units (confidentiality)

40. Weight Protocol (Tanita.com)

41. Recording Data Do you need a recorder? Date of birth? Record sex/gender Screening data year to year ? Matching up student’s data next year? ID numbers for students? Record directly into Excel?

42. Calculations Use the CDC Excel Spreadsheet Checks for error messages/bad data Calculates data AND summarizes the data automatically Graphs your data by grade level if you use a separate spreadsheet for each grade

43. The Link to the CDC Spreadsheets (English and Metric) http://www.cdc.gov/healthyweight/ assessing/bmi/childrens_BMI/tool _for_schools.html

44. Measurements (Metric vs. English)

45. Measurements

46. Group Summary

48. Resources – Missoula www.co.missoula.mt.us/measures/PDF/BMIReport08.pdf Contact Mary McCourt at McCourtM@ho.missoula.mt.us

49. Resources - Massachusetts Includes guidelines for measuring non- ambulatory students To be revised in 2010

50. Resources - Arkansas www.ACHI.net Arkansas measured all children in the state (now alternate grades) Procedures well established

51. Resources - Arkansas

52. Resources – Ohio (www.odh.ohio.gov/ASSETS/.../bmiguidlines_0607.pdf)

53. Resources - Wisconsin http://dhs.wisconsin.gov/health/physicalactivity/Sites/School/To_Weigh_Measure.pdf

54. Background Reading http://www.cdc.gov/mmwr/preview/mmwrhtml /mm5817a3.htm?s_cid=mm5817a3_e Florida: Assessment of Body Mass Index Screening of Elementary School Children --- Florida, 2007—2008 MMWR May 8, 2009 / 58(17);460-463

55. Background Reading Nihiser AJ, Lee SM, Wechsler H, McKenna M, Odom E, Reinold C, Thompson D, Grummer-Strawn L. Body mass index measurement in schools. J Sch Health. 2007; 77: 651-671. (see CDC website to download a copy)

56. QUESTIONS?