Challenges in Clinician-Parent Communication: Pediatric BMI 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 ProfessorDivision of General Pediatrics and Adolescent Medicine Department of Pediatrics School of Medicine University of North Carolina at Chapel Hill

What Is BMI? 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 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 BMIWeaknesses 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 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 BMI for Age Chart

Underweight < 5th

percentile

Healthy weight 5th to < 85th percentiles

Overweight 85th to 94th percentiles

Obese ≥ 95th percentile

CDC. Available at http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.

Color-Coded BMI Charts Color-Coded BMI Charts

• Oettinger MD, Finkle JP, Esserman D, et al. Color-coding improves parental understanding of body mass index charting. Acad Pediatr. 2009;9:330-338.

Parents Don't Recognize Overweight in Their Children 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)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) 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? 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 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 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 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.

ResultsResults

• 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 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

SummarySummary

• 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