CDC Growth Charts 2000

Centers for Disease Control and Prevention

National Center for Chronic Disease Prevention and Health Promotion
Division of Nutrition and Physical Activity
Maternal and Child Nutrition Branch
Revised June 2002
Training Objectives
Science behind development of growth
charts

Rationale for including BMI-for-age

Using BMI-for-age as a screening tool


What growth charts are available?
BMI-for-age charts (2-20 years)

85th percentile (at risk of overweight)

3rd and 97th percentiles available

Lower limits of length (45 vs. 49 cm) and
height (77 vs. 90 cm) extended

Smoothed percentile curves and z-scores
agree

Correction in the disjunction

New Features of the Growth Charts
Disjunction: Smoothed in New Charts
40
50
60
70
80
90
100
110
120
0 6 12 18 24 30 36 42 48
54 60
Age in month
L
e
n
g
t
h
/
h
e
i
g
h
t

i
n

c
m

40
50
60
70
80
90
100
110
120
0 6 12 18 24 30 36 42 48 54 60
Age in month
L
e
n
g
t
h
/
h
e
i
g
h
t

i
n

c
m

1977
2000
Racially and ethnically diverse

Infants: Birth to 36 months

Children and Adolescents: 2 to 20
years

Breast- and formula-fed infants


Reference Population for
CDC Growth Charts
Reference Data Sets: Birth to 36 Months
Weight-for-Length
Weight
Length
Head Circum
MO/WI Natality National Natality PedNSS
Fels NHANES III ('88-'94) NHANES II ('76-'80)
NHANES I ('71-'74)
B 3 6 9 12 15 18 21 24 27 30 33 36
Age in Months
Reference Data Sets: 2 to 20 Years
Weight/BMI
Stature
NHANES III ('88-'94) NHANES II ('76-'80) NHES II ('63-65)
NHES III ('66-'70) NHES II ('63-'65)
2 4 6 8 10 12 14 16 18 20
Age in Years
Exclusions from the Reference Data
Very low birth weight (VLBW) infants
(<1500 g) were excluded because they
have different growth patterns

NHANES III weight data for 6+ year olds
were excluded to avoid an upward shift
in weight-for-age and BMI-for-age curves


1
>95
th
percentile BMI-for-age
2
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm

Age-Adjusted Prevalence of
Overweight
1
From NHANES I to III
2

0
5
10
15
20
Boys 6-11 y Boys 12-17 y Girls 6-11 y Girls 12-17 y
NHANES I II III
Sex and Age Group
CDC Growth Charts Are for All
Racial and Ethnic Groups Combined
Environmental influences appear to contribute
to variations in growth more than genetic
influences
Inadequate sample data for racial- and ethnic-
specific charts
The effect of race and ethnicity on BMI-for-
age is unclear

Age Adjusted Prevalence of Low Height-for-Age
by Ethnic Groups, Children Aged 0 to 5 Years
1

0
5
10
15
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93
White
Asian
Year of Visit
1
Mei, Yip and Trowbridge, Asia Pacific J Clin Nutr 1998; 7(2):
111-116
Breast-Fed vs. Formula-Fed Infants
Mode of infant feeding can influence growth

New charts represent the combined growth
patterns of breast-fed and formula-fed infants

Working group of the World Health Organization
(WHO) is developing growth charts for infants and
children through age 5 using data collected on
infants following WHO feeding recommendations
Indicators of Nutritional Status
<5
th
percentile
Stunting/shortness
length or stature-for-age
Head circumference-for-age

<5
th
percentile
<5
th
percentile
>95
th
percentile
Underweight
weight-for-length
BMI-for-age
Indicators of Nutritional Status
Overweight
Weight-for-length
BMI-for-age
>95
th
percentile
Risk of overweight
BMI-for-age
85
th
to 95
th
percentile
Prevalence of Nutritional Status Indicators
New Reference Curves Compared with Old Curves*

< 2 Years Old
Nutrition Indicator
Change in Prevalence
Stunting/shortness
length-for-age <5
th

1% to 2% lower
Underweight
weight-for-length <5
th

* NHANES III
Overweight
weight-for-length >95
th

2% lower for females
2% higher for males
1% to 2% higher
Prevalence of Nutritional Status Indicators
New Reference Curves Compared with Old Curves*

Children 2 to 5 years of age
Nutrition Indicator Change in Prevalence
Stunting/shortness
stature-for-age <5
th

1% lower
Underweight** <5
th

3% to 4% higher
* NHANES III
**BMI-for-age, weight-for-stature
Overweight** 95
th

No change for females
1% higher for males
What Is BMI?




Body mass index (BMI) =
weight (kg)/height (m)
2

BMI is an effective screening tool; it is not a
diagnostic tool

For children, BMI is age and gender specific,
so BMI-for-age is the measure used


Advantages of BMI-for-Age

Provides a reference for adolescents that
was not previously available

Consistent with adult index so it can be
used continuously from 2 years of age to
adulthood

Tracks childhood overweight into
adulthood


Tracking BMI-for-Age from Birth to 18 Years with
Percent of Overweight Children who Are Obese at Age 25
1

16
15
12
11
10
9
17
19
55
75
67
26
52
69
83
77
36
0
20
40
60
80
100
Birth 1 to 3 3 to 6 6 to 10 10 to 15 15 to 18
Age of child (years)
%

o
b
e
s
e

a
s

a
d
u
l
t
s
BMI < 85th BMI >=85th BMI >=95th
Whitaker et al. NEJM: 1997;337:869-873
Advantages of BMI-for-Age

BMI-for-age relates to health risks

Correlates with clinical risk factors for
cardiovascular disease including hyperlipidemia,
elevated insulin, and high blood pressure

BMI-for-age during pubescence is related to
lipid levels and high blood pressure in middle
age

Weight-for-stature measurements
1

Measures of body fat


BMI-for-Age Compares Well with
Mei et al., Am J Clin Nutr 2002;75:978-85.
Why Use BMI-for-Age?




Recommended by expert committees to
evaluate overweight
Guidelines for Overweight in Adolescent Preventive
Services (Am J Clin Nutr 1994;59:307-316)
Obesity Evaluation and Treatment: Expert Committee
Recommendations (Pediatrics 1998 Sept;(102)3:e 29)
Assessment of Childhood and Adolescent Obesity:
International Obesity Task Force (Am J Clin Nutr 1999,
70,suppl)
Shape of Weight-for-Stature Curve
versus BMI-for-Age Curve
10
15
20
25
30
35
24 72 120 168 216
Age (months)
B
M
I

0
5
10
15
20
25
30
35
80 90 100 110 120 130
Stature (cm)
W
e
i
g
h
t

(
k
g
)

95
th

50
th

5
th

95
th

50
th

5
th

Example: 95th
Percentile Tracking

Age BMI

2 yrs 19.3
4 yrs 17.8
9 yrs 21.0
13 yrs 25.1
For Children, BMI Changes with Age
Boys: 2 to 20 years
BMI
BMI
BMI
BMI
Shape of BMI-for-
Age Growth Curve:
Adiposity Rebound
(AR)

Example: Early AR

Age (mos) BMI
26 18.2
32 17.4
38 18.5
41 18.7
Boys: 2 to 20 years
BMI BMI
BMI
BMI
BMI
BMI-for-Age Cutoffs
> 95
th
percentile Overweight

85
th
to < 95
th
Risk of overweight

percentile

< 5
th
percentile Underweight


Using the 85
th
and 95
th
percentiles as cut points,
few children are incorrectly identified as over-fat
but some over-fat children will be missed.

It is desirable to correctly identify those children
not at risk of overweight or overweight.
Performance of BMI-for-Age
as a Screening Tool




Formula: weight (kg)/[height (m)]
2

Calculation: [weight (kg)/ height (cm)/
height (cm)] x 10,000

Calculating BMI with the Metric System
Example: A childs weight=16.9 kg and height=105.4 cm

BMI = [16.9 kg / 105.4 cm / 105.4 cm] x 10,000 = 15.2
Calculating BMI with the English System




Formula: weight (lb)/[height (in)]
2
x 703


Calculation: [weight (lb)/height (in)/height (in)] x 703
Example: A childs weight = 37 pounds, 4 ounces and
height = 41 1/2 inches
(convert fractions to decimal value)

BMI = [37.25 lb / 41.5 in / 41.5 in] x 703 = 15.2
Can you see risk?
This boy is 3 years, 3 weeks old.
Is his BMI-for-age

- >85
th
to <95
th
percentile:
at risk for overweight?


Photo from UC Berkeley Longitudinal Study, 1973
Measurements:
Age=3 y 3 wks
Height=100.8 cm
(39.7 in)
Weight=18.6 kg
(41 lb)
BMI=18.3
BMI-for-age=
>95
th
percentile
overweight
Plotted BMI-for-Age
Boys: 2 to 20 years
BMI
BMI
BMI
BMI
Can you see risk?
This girl is 4 years, 4 weeks old.
Is her BMI-for-age

- >85
th
to <95
th
percentile:
at risk for overweight?

Photo from UC Berkeley Longitudinal Study, 1974
Measurements:
Plotted BMI-for-Age
Girls: 2 to 20 years Age= 4 y 4 wks
Height=106.4 cm
(41.9 in)
Weight=15.7 kg
(34.5 lb)
BMI=13.9
BMI-for-age=
10
th
percentile
Normal
BMI BMI
BMI
BMI
Can you see risk?
This girl is 4 years old.
Is her BMI-for-age

- >85
th
to <95
th
percentile:
at risk for overweight?
Photo from UC Berkeley Longitudinal Study, 1973
Measurements:
Age=4 y
Height=99.2 cm
(39.2 in)
Weight=17.55 kg
(38.6 lb)
BMI=17.8
BMI-for-age= between
90
th
95
th
percentile

At risk for overweight
Plotted BMI-for-Age
Girls: 2 to 20 years
BMI
BMI BMI
BMI
5 1/2 year old boy
Weight: 41.5 lb
Height: 43 in
BMI= 15.8
BMI-for-age=50
th
%tile
Inaccurate height
measurement: 42.25
BMI=16.3
BMI-for-age=75
th
%tile
Accurate Measurements are Critical
Boys: 2 to 20 years
BMI
BMI
BMI
BMI
Interpreting the BMI-for-Age Cutoffs
> 95
th
percentile Overweight

85
th
to < 95
th
Risk of overweight
percentile

< 5
th
percentile Underweight

Interpreting the BMI-for-Age Chart
BMI-for-age indicates a childs weight in
relation to his/her height for a specific age
and gender

Need a series of BMI plots to determine
the growth trend

If indices deviate from normal growth
patterns, further assessment may be
needed

Example: Sam
Name: Sam
Weight: 37 lb 4 oz (16.9 kg)
Height: 41.5 inches (105 cm)
Age: 3.5 years
BMI: 15.2

Sams BMI Plotted on Boys BMI-for-Age Chart

Interpretation:
Sams BMI-for-age is
slightly below the 25th
%tile so it falls within
the normal range.
Of 100 boys who are
the same age, fewer than
25 have a BMI-for-age
lower than Sams.
Boys: 2 to 20 years
BMI
BMI
BMI
BMI
Summary of Using BMI-for-Age
BMI-for-age is the recommended method
for screening overweight and underweight
For children, BMI is age and gender
specific; for adults there are fixed cut
points
Accurate and periodic measurements are
important elements of any anthropometric
screening

Steps to Plot BMI-for-Age
Obtain accurate weight and height
measurements
Select the appropriate growth chart
Record the data
Calculate BMI
Plot measurements
Interpret plotted measurements
For additional training materials
related to the growth charts
For tools related to the growth charts
To download the growth charts
Please visit:
http://www.cdc.gov/growthcharts/
www.cdc.gov/growthcharts