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 ≥ 95th
percentile

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

• 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