Recently, in my continuity clinic on the South side of Chicago, I evaluated a robust 36-month-old girl who weighed 16 kg and was 95 cm long. Our clinic is transitioning to the 2000 Centers for Disease Control and Prevention's growth charts, from the 1979 National Center for Health Statistics' pink and blue charts that most residents can remember from their own pediatrician visits. I flipped the new chart open so the child's mother could see her child was between the 75th and 90th percentiles for weight and between the 50th and 75th percentiles for height. These percentiles are not alarming.
"I thought her weight was off the chart last visit," her mother asked quickly. Indeed, the old chart had shown her to be higher than the 95th percentile for weight. Because children are increasingly heavier, the growth charts have shifted such that this child's weight fits into a lower percentile curve than it did on the older charts.
I then plotted the girl's body mass index (BMI). Her BMI of 18 is between the 90th and 95th percentiles, and puts her at risk for becoming overweight and for developing related health problems as an adult. In this case, the height and weight data alone were slightly misleading. Tools such as the BMI help clinicians recognize overweight that might otherwise be overlooked.
Pediatric residents learn to synthesize different types of information in quick visits with typically well patients in the outpatient setting. We develop a system that helps us cover important topics while completing required tasks such as the physical exam or reviewing immunization information. The related issues of overweight and physical activity must become a routine part of this system.
At the population, community, and individual levels, two of the most concerning trends are toward overweight and inactivity.1 Sedentary behavior is a habit that contributes to childhood overweight. Despite recommendations that people older than 2 participate in at least 20 minutes of endurance-type physical activity of moderate intensity on most, if not all, days of the week, most people fail to meet this standard.2
Children are surprisingly inactive. Although available data on children are limited to those ages 12 to 21, they tell an ominous tale. For example, in 1999, only 27% of students in grades 9 through 12 engaged in moderate physical activity for at least 30 minutes on 5 or more of the previous 7 days.2
Community and family structures are preventing children from being active. Seventy percent of children ride in the back seat of a car to make their daily trips. Less than 1% of transportation spending funds pedestrian projects in the United States.4 Most children ages 12 to 18 are not receiving daily physical education in school; only 20% to 25% of children ages 12 to 13 have physical education each week in school.35
As future pediatricians, residents need a strategy for recognizing overweight and inactivity and - as for other medical diagnoses - should develop a plan for approaching these problems. This requires knowledge of local resources; a list of sources for dietary counseling and one of food stores that carry inexpensive produce are helpful. Program information from the park district or local community centers can help families include their children in physical activity. Advice for limiting television and video game use can help families structure time at home. Diagnosis and referral for overweight-related problems, such as orthopedic problems or diabetes, are crucial.
Most clinicians know patient information should be easy to understand and recommendations should be easy to implement. Having diet and activity handouts, the same way that there are safety sheets, poison-control phone numbers, and back-to-sleep brochures, can be helpful. Asking families to work on just one or two goals makes change more manageable.
For a clinician who is going to partner with many overweight or inactive children, it is helpful to relate to others who work on overweight issues and physical-activity promotion. A multidisciplinary approach fosters a variety of linked initiatives.
Currently, overweight is almost as common as asthma in children, but the overweight or inactive child is much more likely to be unrecognized. Indeed, we have welcomed many of the societal changes that have led to these problems. Because whole families are affected by overweight and inactivity, the practitioner needs to help patients implement family-wide changes.
1. Troiano RP. Flegal KM, Kuczmarski RJ, Campbell SM. Johnson CL. Overweight prevalence and trends for children and adolescents: the National Health and Nutrition Examination Surveys, 1963 to 1991. Arcft Pediatr Adolesc Med. 1995:149(10):1085-1091.
2. US Department of Health and Human Services. Physical Activity and Fitness. In: Healthy People 2010 - Conference Edition. Available at: http://www.healuiypeople.gov.
3. US Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Boston, Ma: Jones and Bartlett Publishers; 1998.
4. Ernst M, McCann B. Mean Streets 2002: A Publication of the Surface Transportation Policy Project. http://www.transact.org/PDFs/ms2O02/meanstreets2OO2. pdf.
5. Gordon-Larsen P, McMurray RG, Popkin BM. Determinants of adolescent physical activity and inactivity patterns. Pediatrics. 2000;105(6):e83.