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\levelstartat1}{\lfolevel\listoverridestartat\levelstartat1}{\lfolevel\listoverridestartat\levelstartat1}{\lfolevel\listoverridestartat\levelstartat1}{\lfolevel\listoverridestartat\levelstartat1}{\lfolevel\listoverridestartat\levelstartat1}{\lfolevel \listoverridestartat\levelstartat1}{\lfolevel\listoverridestartat\levelstartat1}{\lfolevel\listoverridestartat\levelstartat1}\ls5}{\listoverride\listid1706446356\listoverridecount0\ls6}{\listoverride\listid148644607\listoverridecount0\ls7}}{\info {\title Adolescent Physical Development: Uses and Limitations of Growth Charts}{\author Richard Kreipe}{\operator ISD}{\creatim\yr2001\mo10\dy2\hr11\min1}{\revtim\yr2001\mo10\dy2\hr11\min1}{\printim\yr2001\mo2\dy21\hr13\min56}{\version2}{\edmins1} {\nofpages10}{\nofwords4361}{\nofchars24860}{\*\company }{\nofcharsws30529}{\vern113}}\margl1440\margr1440 \widowctrl\ftnbj\aenddoc\formshade\viewkind4\viewscale92\pgbrdrhead\pgbrdrfoot \fet0\sectd \linex0\sectdefaultcl {\*\pnseclvl1 \pnucrm\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang{\pntxta )}}{\*\pnseclvl5 \pndec\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}\pard\plain \s15\widctlpar\adjustright \fs28\cgrid {\f1 Adolescent Physical Development: Uses and Limitations of Growth Charts \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 \par }\pard\plain \s16\widctlpar\adjustright \b\fs22\cgrid {\f1 Introduction \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 \par The second decade of life, from 10 to 20 years of age, coincides with the process of }{\f1\cf2 adolescence}{\f1 and is marked by numerous physical changes. Growth and development that occurs during }{\f1\cf2 puberty}{\f1 affects all body }{\f1\cf2 organs and systems}{\f1 . \ldblquote Growing\rdblquote in both weight and height (stature) is a characteristic feature of this stage of life, and the pubertal \ldblquote growth spurt\rdblquote is the only post-natal period in which there is normally an acceleration in the increase of both height and weight. The growth spurt in height (\ldblquote peak height velocity\rdblquote ) has an onset and duration that is highly variable from individual to individual, and is affected by genetic, gender and nutritional influences. It is followed by a rapid decrease in the rate at which stature increases as the final }{\f1\cf2 adult height}{\f1 is approached. The growth spurt in weight is dependent on the balance between energy (caloric) intake and output. If energy intake is significantly less than output , underweight results; if energy intake significantly exceeds output, overweight or obesity can result. This module addresses practical uses and limitations of the new CDC growth charts applied to adolescents. Three cases are presented to illustrate key points. \par \par \par }\pard\plain \s1\keepn\widctlpar\outlinelevel0\adjustright \b\f1\fs22\cgrid {Objectives \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 \par Upon completion of this module, you will be able to: \par }{\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 Describe three features of normal growth curves during adolescent development \par \par }{\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 List two differences between \ldblquote early\rdblquote and \ldblquote late\rdblquote developers in puberty \par \par }{\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 Apply data from growth charts to appropriately screen, assess and monitor adolescents \par \par \par }\pard\plain \s1\keepn\widctlpar\outlinelevel0\adjustright \b\f1\fs22\cgrid {Estimated Time Needed to Complete This Module \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 \par To read through text: 40 minutes \par \par To read through text and complete exercises: 60 minutes \par }\pard\plain \s1\keepn\widctlpar\outlinelevel0\adjustright \b\f1\fs22\cgrid {\page Normal Pubertal Development \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 The application of growth c harts to adolescents requires an understanding of normal growth and development during puberty. More than 40 years ago, James Tanner and associates began describing the normal physical changes that occur during puberty. Tanner has noted that \ldblquote the only thing that is constant about puberty is change\rdblquote . Besides the obvious differences of the genitalia and secondary sex characteristics between males and females, there are also differences between individuals who develop early compared to those who develop lat er in their teenage years. This context of change must be appreciated when using growth charts in adolescents. \par \par Tanner and colleagues serially measured and photographed a large number of normal British males and females to determine the physical changes t hat adolescents experience as they grow from boys to men and from girls to women. Five recognizable stages of pubertal changes (called Tanner Stages, or Sexual Maturity Ratings--SMR), have been described for males and for females. For }{\f1\cf2 boys}{ \f1 , the three physical elements of sexual maturity rating are the size of the testes, the length of the penis, and the development of pubic hair. The two physical elements of sexual maturity rating for }{\f1\cf2 girls}{\f1 are breast and pubic hair development. \par \par In addition to the changes genitalia and pubic hair, adolescents experience a sequence of events during puberty. For girls, a rapid increase in the velocity at which their stature increases during the pubertal \ldblquote growth spurt\rdblquote (peak height velocity) occurs about a year after the onset of breast development, generally around age 12. This phase is represented in the girls stature-for-age curve as a slight upward inflection point at about 10 years of age, followed by a more rapid increase in stature until about 12 years of age, w h en the slope of the stature curve reaches its maximum. Another inflection point can be seen around 13 years of age, when the slope of the stature curve noticeably falls downward and the curve eventually flattens out entirely as the final adult height is reached. \par \par }{\f1\cf5 Show each of these points in a graphic on the 50}{\f1\cf5\super th}{\f1\cf5 %tile line: inflection upward at 10 years old, peak height velocity at 12 years of age, inflection downward at 13 years of age, final adult height by 20 years of age. This would require five con secutive views of the same stature-for-age chart for girls, but would not require the learner to click on anything. The effect would be like added successive overlays on a transparency, each \ldblquote new\rdblquote chart adding a new element to the previous chart: 1) stature-for-age curve with 50}{\f1\cf5\super th}{\f1\cf5 %tile highlighted, 2) add arrow at upward inflection point, at 10 years of age, 3) add arrow at peak height velocity, at 12 years of age, 4) add arrow at downward inflection, at 13 years of age, 5) final adult height, around 18 ye ars of age. I would suggest this being one whole screen, not something people scroll down to get to. Alternatively, you may want to have the screen split in two, with the text on the left and the chart on the right that follows the text. \par }{\f1 \par Breast development begins (thelarche) around 11 years of age, and menses generally begin (\ldblquote menarche\rdblquote ) about two years after the onset of breast development, at an average age of about 12.5 to 13 years of age. Recent data suggests that girls may be experiencing thelarche earlier than previously thought, on average around 10 years of age for white girls and 9 years of age for black girls. However, a number of pediatric endocrinologists have called the validity of these studies into question and these studies have not dem onstrated a dramatic decrease in the age of menarche. }{\f1\cf5 [Add the word \ldblquote thelarche\rdblquote between 10.5 and 11 years of age, and the word \ldblquote menses\rdblquote between 12.5 and13 year age span on the chart above].}{\f1 Although not demonstrated on the charts, it is known that earlier pubertal development is associated with more rapid increase in stature and weight than average, while later pubertal development is associated with a less rapid increase in stature and weight. \par \par Similar to girls, boys demonstrate an upward inflection in the slope of stature at the beginning of their growth spurt, followed by a more rapid increase in stature, but the peak height velocity occur about 2 years later than for girls, around 14 years of age. Unlike females, males can continue to grow to the en d of the stature curves at age 20, although the increment in height after age 18 is usually not more than 1 cm. The increase in height in males is due to androgens produced by the testes, so the growth spurt in stature is preceded by an increase in the si ze of the testes. These same androgens also cause the penis to lengthen and widen. \par \par }{\f1\cf5 Show a graphic similar to the one above for girls with the 2 to 20 year old boys stature-for-age chart: 1) stature-for-age curve with 50}{\f1\cf5\super th}{\f1\cf5 %tile highlighted, 2) add arrow a t peak height velocity, at 14 years of age, 3) add arrow at final adult height, around 20 years of age. Then add the word \ldblquote testes enlarge\rdblquote around 11.5 years of age and penis lengthens and widens around 13 years of age. \par }{\f1 \par During puberty, there is not a distinct spurt in weight gain as there is in stature, and the variability of weight is greater than for stature, leading to a widening \ldblquote spread\rdblquote over time in weight between the higher and lower percentiles between 10 and 20 years of age. In addition, during puberty the composition of the tissues that make up body weight changes over time in different ways for females and males. \par \par Early in puberty, females slow their accumulation of total body fat, but during their peak height velocity they accelerate their ac cumulation of fat and lean body tissue, leading to an increase in weight that peaks just prior to menarche. After that time, the rate at which weight is added slows, with an inflection point around 13 years of age. There is a large difference between th e rate at which weight is gained at the extremes of percentiles. Between the age of 12 and 13, girls at the 5}{\f1\super th}{\f1 %tile gain less than 8 lbs, while those at the 95}{\f1\super th}{\f1 %tile gain more than 13 lbs. \par \par }{\f1\cf5 Show the weight-for-age 50}{\f1\cf5\super th}{\f1\cf5 %tile curve for 2 to 20 year old girls with the above points highlighted with an arrow: 1) 50}{\f1\cf5\super th}{\f1\cf5 %tile highlighted, 2) add arrow at weight peak around 12.5 years, 3) add arrow at weight downward inflection 13 years, 4) add bracket at 5}{\f1\cf5\super th}{\f1\cf5 %tile between 12-13 years with caption \ldblquote <8 lbs.\rdblquote 5) add bracket at 95 }{\f1\cf5\super th}{\f1\cf5 %tile between 12-13 years with caption \ldblquote >13 lbs.\rdblquote \par }{\f1 \par Boys, on the other hand, lose body fat early in puberty until their growth spurt. With the growth spurt, boys begin to accumulate fat, but not as great as that noted in girls at a similar st age of development. Likewise, boys accumulate muscle mass and overall body weight at an accelerated rate until they reach their peak height velocity. After the peak height velocity, lean body mass continues to be added, but at a slower pace than during the growth spurt. Thus, for boys there is an inflection point on the weight curve around 14 years of age, after which weight continues to accrue, but more slowly. \par \par }{\f1\cf5 Show the weight-for-age 50}{\f1\cf5\super th}{\f1\cf5 %tile curve for 2 to 20 year old boys with the above points highlighted with an arrow: 1) 50}{\f1\cf5\super th}{\f1\cf5 %tile highlighted, 2) inflection point at 14 years of age. \par }{\f1 \par \par \par \par \par }\pard\plain \s1\keepn\widctlpar\outlinelevel0\adjustright \b\f1\fs22\cgrid {Clinical Pearls: Pubertal Growth and Development \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 \tab }{\b\f1 Breast development}{\f1 . True breast development in both females (thelarche) and males (}{\f1\cf2 gynecomastia}{\f1 ) is due to gr owth of glandular tissue, not fat. For adolescents who are appear to be developing breast tissue, it is important to differentiate between glandular tissue (firmer and somewhat tender tissue immediately under the areola) and fat (increase in fat in the b r east tissue, along with fat in other sites of the body). Some overweight adolescents may not be developing sexually, but merely increasing the amount of fat in their breast tissue. If a pre-pubertal girl or boy is already overweight, she/he can be expect ed to gain weight even more rapidly when s/he eventually does go through puberty. \par \par \par \tab }{\b\f1 Weight}{\f1 . Between 8 and 14 years of age, girls tend to gain weight more rapidly than boys, but the 50}{\f1\super th}{\f1 %tile BMI measures for girls and boys are nearly identical. A girl at the 50}{\f1\super th}{\f1 %tile gains four times as much weight between 10 and 14 years of age as she does between 16 and 20 years of age (40 compared to 10 pounds). After 14 years of age, weight continues to increase, but at a decreased rate. Because boys have thei r growth spurt about two years later than girls, the maximum rate of weight gain for boys is between 12 and 16 years of age. A boy at the 50}{\f1\super th}{\f1 %tile in weight gains about 45 pounds over those four years, while he gains an additional 20 pounds between 16 and 20 years of age. \par \par }\pard \fi720\widctlpar\adjustright {\b\f1 Height}{\f1 . Until 10 years of age, boys and girls grow in stature at nearly identical rates. Around 10 years of age, girls at the 50}{\f1\super th}{\f1 %tile begin to grow taller more rapidly than boys. The growth rate for girls continues to be greater than boys between 10 and 13 years of age. After 13 years of age, the height spurt of girls generally is completed and the boys height spurt is in its early phase. Therefore, by 14 years of age boys are taller than girls, on average. Girls generally ga in no more than 2 inches in height after the onset of menstrual periods. However, males can continue to grow in height in their early 20s. By the time that adult height is reached, the 50}{\f1\super th}{\f1 %tile for height is about 6 inches higher for males than for females. Thus, the average adult male is about 70 inches and the average adult female is about 64 inches tall. \par }\pard \widctlpar\adjustright {\f1 \par \par }{\b\f1 Normal Changes in Body Mass Index (BMI) During Adolescence \par }{\f1 \par }\pard\plain \s1\keepn\widctlpar\outlinelevel0\adjustright \b\f1\fs22\cgrid {Tracking of BMI \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 BMI decreases during early childhood, reaches a nadir (the so-called }{\i\f1 rebound}{\f1 point) between 4 and 7 years of age, and then increases to 20 years of age. These changes in BMI reference values with advancing age reflect normal changes in body composition during puberty. Fat-free body mass increases in both sexes, but its acc umulation is more marked in boys than in girls after 13 years of age. Body fat continually increases in girls during most of the second decade, while boys tend to decrease fat after age 14. The sum total of changes in fat-free and fat body mass result i n the numerator (weight), while the sum total of the changes in stature result in the denominator (height)}{\f1\super 2}{\f1 in the equation for BMI. These normal changes must be considered when interpreting data for individual adolescents, as well as for groups of adolescents. \par \par The increase in BMI is nearly linear in boys during the second decade of life in all but the highest percentiles (in which the line becomes slightly convex upward) The BMI percentiles for adolescent girls, on the other hand, are all slightly conve x upward. Just as weight and height tend to follow a percentile \ldblquote channel\rdblquote , so does BMI. This \ldblquote tracking\rdblquote of BMI can be used to identify changes in growth that may indicate an underlying problem or call for some kind of intervention. \par \par \par }{\b\f1 Lower Ranges of BMI \par }{\f1 In the lower ranges, BMI tends to increase more slowly in both adolescent boys and girls. At the 5}{\f1\super th}{\f1 %tile, BMI increases at the rate of about 0.5 unit/year during most of the second decade. \par }{\b\f1 \par Higher Ranges of BMI}{ \par }{\f1 In the higher ranges, BMI tends to increase more rapidly in both boys and girls. At the 97}{\f1\super th}{\f1 %tile, for example, BMI can increase more than 1 unit/year. An increase in BMI of >1 unit/year puts an adolescent at-risk of overweight and obesity. The new BMI charts are useful in monitoring adolesce nts for an excessive rate of weight gain relative to increase in stature. \par \par }\pard\plain \s1\keepn\widctlpar\outlinelevel0\adjustright \b\f1\fs22\cgrid {Gender Differences \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 At any given age between 10 and 14 years old, girls at the 50}{\f1\super th}{\f1 %itle have a slightly higher BMI than do boys. Below the 50}{\f1\super th}{\f1 %tile, girls have a lower absolute BM I value than boys at any given %tile. Above the 50}{\f1\super th}{\f1 %tile, girls have a higher absolute BMI value than boys at any given %tile. \par For example, at 14 years of age, the 5}{\f1\super th}{\f1 %tile BMI for girls and boys is 15.8 and 16.0, respectively, while the 95}{\f1\super th}{\f1 %tile BMI for girls and boys is 27.2 and 26.0, respectively. \par \par }{\f1\cf5 Show the BMI charts for 2-20 year olds, and graphically illustrate the above points, with boys and girls charts side by side. Boys: 1) Rebound point between 4 and 7 years of age, 2) linear increase in BMI at 50}{\f1\cf5\super th}{\f1\cf5 %tile, 3) convex curve at highest %tiles, with >1 unit/year increase in BMI, 4) at 5}{\f1\cf5\super th}{\f1\cf5 %tile, slope of BMI averages about 0.5 unit/year. Girls: 1) Rebound point between 4 and 7 years of age, 2) all curves slightly convex upward, 3) at 5}{\f1\cf5\super th}{\f1\cf5 %tile, girls have a lower BMI than boys at any given age, 4) at 95}{ \f1\cf5\super th}{\f1\cf5 %tile, girls have a higher BMI than boys at any given age. \par }{\f1 \par \page }{\b\f1 Case #1: Use of growth charts for assessing pre-pubertal growth during adolescence \par }{\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 Mandy is a 12 year old female who has been a ballet dancer since age 6. At her health supervision visit, she weighs 66 lbs (3}{\f1\super rd%}{\f1 tile) and is 58 inches tall (25}{\f1\super th}{\f1 %tile). Her BMI is 13.8 (<3}{\f1\super rd}{\f1 %tile for age). She has no evidence of breast or pubic hair development, and expresses no interest in \ldblquote growing up\rdblquote because she does not want to \ldblquote get fat\rdblquote . She has heard her dance teachers make comments about other students in her dance class gaining weight too quickly. She eats a low-fat diet because her mother was found to have a high cholesterol and Type II di abetes associated with moderate obesity, weighing 175 pounds at 64 inches tall. Father is a 70 inch tall competitive runner, who is a self-described \ldblquote fitness fanatic\rdblquote . \par \par }{\f1\cf5 Her growth curves are shown, side by side, stature on left and weight on right. She was at the 50}{\f1\cf5\super th}{\f1\cf5 %tile for stature and 25}{\f1\cf5\super th}{\f1\cf5 %tile for weight till age 10: average height, but thin. Then, the slope of her weight curve began to decrease more than her stature curve. I would add points for her yearly check-ups, so that the learner sees the curve on the chart, with all points being on or near the 50}{\f1\cf5\super th}{\f1\cf5 %tile for stature and 25}{\f1\cf5\super th}{\f1\cf5 %tile for weight. Her BMI chart could be shown below the stature and weight charts. Since there were no BMI charts available until this year, she will only have one point on it, from this visit, at 13.8. \par }{\f1 \par }{\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 Discussion. Mandy\rquote s case illustrates three key points in the application of growth charts to pre-pubertal adolescents. \par \par 1) Mandy has not yet reached her adult height, because she has not yet begun puberty and has not gone through her growth spurt. Final adult height can be affected by many factors, including nutrition and illness, but her }{\i\f1 genetic potential}{\f1 with respect to height, can be estimated from her }{\i\f1 mid-parental height formula}{\f1 : (Father\rquote s height + Mother\rquote s height \endash 5) }{\f1 {\field{\*\fldinst SYMBOL 184 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 2. In Mandy \rquote s case, that would be (70+64-5)}{\f1 {\field{\*\fldinst SYMBOL 184 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 2=64.5 inches for her expected adult height. If she were to continue to grow along the 25}{\f1\super th}{\f1 %tile, her final adult height would be 62.5 inches, 2 inches less than otherwise expected. Although this ma y not be important to Mandy at this time, it may become important to her later. When pointed out to adolescents, such reduction of growth potential may be a motivating factor for adolescents to improve their nutrition. The data from the CDC growth charts are an important element of her }{\f1\cf2 health supervision}{\f1 assessment, but could also be used to motivate changing her eating behavior to allow an adolescent to reach her/his expected stature. Improving nutrition would not necessarily result in increased stature, \par \par 2) Mandy\rquote s fall in weight and height indicate that her growth has slowed more than expected, similar to what is called \ldblquote failure to thrive\rdblquote in younger children }{\f1\cf2 (link with Peter\rquote s module on this topic)}{\f1 . This could possibly due to inadequate caloric intake relative to increased energy needs during puberty. It definitely deserves attention, since it is not part of healthy growth and development at this age. \par \par Her interest in ballet and in \ldblquote not growing up\rdblquote , may have led to her limiting her food intake throu gh dieting. Also, it is clear that she is hearing messages from her dance teacher about not gaining weight too quickly. This may have started as early as 10 years of age, since her growth curves began to fall off around that time. From a clinical persp ective, that be a time when her peers may have begun pubertal development and \ldblquote growing up\rdblquote , which could include gaining more than 10 pounds of weight annually. The CDC growth charts can thus be used to identify the effects of subtle changes in the diet that may not be apparent in day-to-day living, especially in busy households. \par \par 3) Her family history of a mother who is overweight and has diet-related medical complications, and a father who is a \ldblquote fitness fanatic\rdblquote , are additional risk factors for Mandy pos sibly developing dysfunctional eating habits, possibly even an eating disorder. }{\i\f1\cf2 Bright Futures in Practice: Nutrition}{\f1\cf2 }{\f1 emphasizes a family-oriented approach to nutrition that is especially important when eating problems arise. An adolescent\rquote s growth and development always needs to be assessed in the context of her family and her environment. \par \par \par \par }\pard\plain \s1\keepn\widctlpar\outlinelevel0\adjustright \b\f1\fs22\cgrid {Case #2: Use of growth charts to screen for excessive weight gain during adolescence \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 Jose is a 15 year old male who has asthma and a decreased level of activity because of exercise-induced wheezing. His favorite activity is playing videogames on the computer. His has had episodic health care, generally related to asthma attacks. When he enrolls in his high school health clinic, his weight is 160 lbs (90}{ \f1\super th}{\f1 %tile) and his height is 67 inches tall (50}{\f1\super th}{\f1 %tile). His BMI is 25.2 (90-95}{\f1\super th}{\f1 %tile). The only other stature and weight measurement available in his record is from 13 years of age, when his stature, weight and BMI were all at the 50}{\f1\super th}{\f1 %tile, (61.5 inches, 100 l bs, and 18.5, respectively). *****make weight be 85-90 BMI**** \par \par }\pard\plain \s17\widctlpar\adjustright \f1\fs22\cf5\cgrid {Show stature and weight charts, side-by-side, as above for Mandy, but using charts for males, 2-20 years old. Only two data points at 13 and 15 years of age, as listed above would be available . These would be plotted on each of the three charts. \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 \par }{\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 Discussion. Jose\rquote s case illustrates three key points in the application of growth charts to adolescents who are gaining weight rapidly. \par \par 1) Jose\rquote s growth charts demonstrates a steep slope in weigh t gain, with no increase in stature over two years. The rate of weight gain is concerning because if it continues at this rate, he will be at increased risk for various health related problems associated with obesity. His failure to gain any height over the past two years could be due to three factors: a) the height or weight recorded at 13 years of age could have been wrong, b) he may have already reached his adult height due to early pubertal development, and/or c) medications related to the treatment of his asthma could have stunted his growth in stature. Now that he is in a }{\f1\cf2 school-based health clinic}{\f1 , there is an opportunity to monitor his growth in weight and stature, using the CDC charts, and to interpret these findings in ways that might motivate him to change some of his lifestyle habits. \par \par 2) Assuming that all of the measurements on the growth charts were accurate, Jose has had a rapid increase in BMI over the past two years. The new CDC growth charts allow plotting of BMI, similar to plotting th e curves for stature and weight. BMI values are positively correlated with total }{\f1\cf2 body fat}{\f1 , fat as a proportion of body weight (% body fat), as well as the total of all lean tissue (}{\f1\cf2 fat-free body mass}{\f1 ). When BMI is used to identify adolescents who have an excess amount of body fat (obese), there are more false negatives (individuals who are truly obese, but not identified as such by BMI) than false positives (individuals who are not obese, but who are identified as such by BMI). There are other means of d etermining body fat, such as triceps skinfold thickness, but this is prone to large errors, depending on the skill and experience of the individual performing the measure. BMI is preferable as a clinical tool, since height and weight are easy to measure reliably and the CDC growth charts now plot population reference standards. \par \par }{\i\f1 Bright Futures}{\f1 recommends using the 85}{\f1\super th}{\f1 %tile of BMI as the cutoff for \ldblquote at risk of overweight\rdblquote and the 95}{\f1\super th}{\f1 %tile as the cutoff for \ldblquote overweight\rdblquote . Adolescents who are at risk of ov erweight should be screened for family history, blood pressure, total cholesterol, large change in BMI over time and concerns about weight. If any of these factors are positive, an in-depth medical assessment in indicated. An in-depth medical assessment is also indicated for adolescents whose BMI is }{\f1 {\field{\*\fldinst SYMBOL 179 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 95}{\f1\super th}{\f1 %tile. There are substantial data to support these recommendations High BMI values in children and adolescents are related to high blood pressure, cholesterol and low-density lipoprotein cholesterol and triglycerides (}{\f1\cf2 Freedman DS et al. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics 103:1175-1182, 1999}{\f1 .) In addition, high BMI values in childhood are related to increased morb idity and mortality rates in adulthood}{\f1\cf2 . (Must A et al Long-term morbidity and mortality of overweight adolescents: A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 327:1350-1355, 1992}{\f1 ). Thus, having a healthy BMI is a health issue, not merely a cosmetic one. \par \par Since Jose\rquote s BMI has increased at least three-times the normal rate (from 18.5 to 25 over 2 years), he deserves a more in-depth medical assessment. In addition to the screening factors noted above, this should include evaluatio n of exogenous causes of obesity, the complications of obesity, as well as a diet and activity history. \par \par 3) Medications used to treat asthma, especially corticosteroids, may increase appetite and retard growth in stature. In addition, breathing difficult ies associated with asthma may make exercising difficult. Thus, Jose may be experiencing a troublesome combination of increased energy intake and reduced physical activity, similar to that reported in the general population of adolescents over the last 2 0 years. If at all possible, medications that might increase his appetite or decrease his growth in stature should be avoided, and every effort should be made to improve his exercise-induced symptoms, with the goal of facilitating increased physical activi ty. \par \page }{\b\f1 Case #3: Use of growth charts to monitor weight fluctuation during adolescence \par }{\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 Don is an 18 year old male wants to lose weight to make his college lightweight freshman crew team, since he does not think he is good enough to make the heavyweight tea m. He underwent early puberty and gained a large amount of weight between 11 and 13 years of age, which he maintained throughout high school. During those two years, his stature increased by 10 inches, from 56 to 66 inches tall. He has been \ldblquote getting in shape for the season\rdblquote by eating a balanced, low-fat diet, and exercising regularly (aerobic and resistance training), and has dropped his weight from 200 to 180 lbs. However, he wants to decrease his weight to 155lbs, at a height of 71 inches, so that he can try out as a lightweight. \par \par }\pard\plain \s17\widctlpar\adjustright \f1\fs22\cf5\cgrid {Show his stature and weight charts like in cases 1 and 2, and BMI chart below, with early pubertal growth spurts and fall-off in weight over past eight months \par }\pard\plain \widctlpar\adjustright \fs22\cgrid {\f1 \par }{\f1 {\field{\*\fldinst SYMBOL 183 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 Discussion. Don\rquote s case illustrates three key points in the application of growth charts to adolescents whose weight fluctuates during adolescence. \par \par 1) Don\rquote s goal of goal of weighing 155 lbs at 71 inches would result in a BMI of 21.6. This would be a \ldblquote healthier\rdblquote BMI than he had at 13 years of age (170 lbs and 66 inc hes, BMI 27.5). However, the way in which an obese individual reduces his/her high BMI must be examined closely, and every effort should be made to maintain the lower BMI once it is attained. There is evidence in adults that having a BMI fluctuate bet ween high and lower values (\ldblquote yo-yo\rdblquote ) may be associated with greater morbidity and mortality than maintaining a moderately elevated BMI. It appears as if Don is approaching \ldblquote getting in shape\rdblquote using healthy means of reducing energy intake and increasing activity. However, attempting to reach an artificial goal established by a competitive sport could be a problem, if his athletic performance becomes compromised by a too-low weight. \par \par 2) Because the formula for BMI (wt in kg }{\f1 {\field{\*\fldinst SYMBOL 184 \\f "Symbol" \\s 11}{\fldrslt\f3\fs22}}}{\f1 [ht in m]}{\f1\super 2}{\f1 ) does not consider bod y composition, athletes who have a higher than average amount of lean body mass (muscle) may have a higher than expected BMI, but not be obese. This could result in a \ldblquote false positive\rdblquote label of obesity, using BMI cutoffs. However, it is usually possible to identify on physical examination adolescents whose high BMI is due to extreme muscularity rather than excessive fat tissue. The use of triceps skinfold thickness in this situation can help confirm the clinical impression of normal body fat stores (}{ \f1\cf2 Himes, et al. Validity of anthropometry in classifying youths as obese. Int J Obes 13:183-193, 1989}{\f1 ). This underscores the importance of applying the CDC growth charts to individuals in the context of their history and physical examination. It is even possible for adolescent athletes to have a }{\i\f1 high}{\f1 BMI and a }{\i\f1 low}{\f1 body fat, especially if they are using anabolic steroids. \par \par 3) Previous growth charts ended at 18 years of age. The inclusion of population standards up to age 20, including BMI charts, is a major adv antage of the new CDC charts. It is important to keep in mind, however, that the charts are population-based and at times it is inappropriate to apply them to an individual. For example, between 18 and 20 years of age, there is a range of more than 55 lbs between the 10}{\f1\super th}{\f1 %tile and the 90}{\f1\super th}{\f1 %tile in weight. This amount of variability is normal within a group of adolescents, but is not normal for an individual adolescent over a brief period of time. Thus, in Don \rquote s case, the primary value of the CDC growth charts is to plot his trend toward improved health based on his decreased BMI. If his BMI were to continue to drop, however, the issue of excessive weight loss would need to be addressed with him. Since he appears to have completed his growth in statur e, one would not expect any further increase in height. Some adolescent males who experience a late growth spurt, however, can continue to grow into their early 20\rquote s. \par \page \par }\pard\plain \s1\qc\keepn\widctlpar\outlinelevel0\adjustright \b\f1\fs22\cgrid {References \par }\pard\plain \qc\widctlpar\adjustright \fs22\cgrid {\f1 \par }\pard \widctlpar\adjustright {\f1 Barlow SE, Dietz WH. Obesity Evaluation and Treatment: Expert Committee Recommendations. Pediatrics 1998;102 (3):e29- \par \par Forbes GB. Human Body Composition. New York, Springer-Verlag, 1987 \par \par Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics 103:1175-1182, 1999 \par \par Guo SS. Roche AF. Chumlea WC. Gardner JD. Siervogel RM. The predictive value of childhood body mass index values for overweight at age 35 y. American Journal of Clinical Nutrition. 59(4):810-9, 1994 \par \par Guo SS. Chumlea WC. Tracking of body mass index in children in relation to overweight in adulthood. American Journal of Clinical Nutrition. 70(1):145S-8S, 1999 \par \par Himes JH. Dietz WH. Guidelines for overweight in adolescent preventive services: Recommenda tions from an expert committee. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services. American Journal of Clinical Nutrition. 59(2):307-16, 1994 \par \par Himes JH. Bouchard C. Validity of anthropometry in classifying youths as obese. International Journal of Obesity. 13(2):183-93, 1989 \par \par Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL. CDC Growth Charts: Unites States. Advance Data 314:1-28, 2000. \par \par Must A, Jacques PF, Dallal E, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents: A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 327:1350-1355, 1992 \par \par Siervogel RM. Roche AF. Guo SM. Mukherjee D. Chumlea WC. Patterns of change in weight/stature2 from 2 to 18 years: findings from long-term serial data for children in the Fels longitudinal growth study. International Journal of Obesity. 15(7):479-85, 1991 \par \par Troiano RP. Flegal KM. Kuczmarski RJ. Campbell SM. Johnson CL. Overweight prevalence \par and trends for children and adolescents. The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics & Adolescent Medicine. 149(10):1085-91, 1995 \par }}