Severely underweight 12-year-old Hispanic girl with underweight parents who has been bullied in school just recently
Most nurses are aware of the body mass index (BMI) assessment tool, either through their practice or through personal experience. It is a tool deeply engrained into American culture and the collective consciousness of the American public. Home scales are set up to calculate it, most annual and sports physicals include it, and its reduction is the focus of most weight loss programs. But what is BMI and what does it truly tell us about overall health particularly in adolescents? The following paper will attempt to answer these inquiries as well as explore other factors involved in this patient’s condition.
BMI and Growth Charts
An individual’s BMI is calculated as their “weight in kilograms divided by height in meters squared” (Fryar, Carroll, & Ogden, 2016). In pediatrics, particularly in the early ages, growth charts often play a larger role than BMI calculations. There are two major growth charts that are utilized, one created by the Center for Disease Control (CDC) and another created by the World Health Organization (WHO). The growth chart established by the WHO is not applicable in this scenario because it only pertains to children under five years of age. The CDC growth chart, on the other hand, measures growth “from birth to 20 years of age” (Rosario, Schienkiewitz, & Neuhauser, 2010). Therefore, it is the growth chart that will be referenced in the remainder of this paper as it pertains to this patient. BMI calculations are done strictly based on height and weight, while growth charts take age, sex, and BMI into consideration. Using the most complete tool available is ideal when making clinical decisions.
Validity of the Tools
BMI is widely used because it is inexpensive and noninvasive to perform and calculate. These calculations estimate body fat based off height and weight, and there are many studies that draw correlations between BMI and the development of conditions such as hypertension, diabetes, and cardiovascular disease. This illustrates the overall utility of the tool. But basing the calculation on only two values present limitations because people have different body types even in childhood and adolescence. This is not grounds to dismiss the use of BMI altogether but rather to encourage its use in combination with other measurements such as waist circumference. Another problem with BMI is the fact that it doesn’t take into account the placement of adipose tissue. The accumulation of adipose tissue is a natural part of sexual maturation for females just as the accumulation of muscle mass is a natural part of sexual maturation in males. BMI calculations don’t take these factors into account. A study by Gläßer, Zellner, & Kromeyer-Hauschild, suggested that measuring both “BMI and waist circumference performed well in detecting excess fat mass in children and adolescents” (2010). This article also mentions using skinfold thickness as a determinant of adiposity, but it did not directly measure this strategy. Much of the available research focuses primarily on childhood obesity. This makes sense considering the higher prevalence of childhood obesity compared to children who are underweight. As of 2014, “17% of children were obese while only 3.5% were underweight” (Fryar, Carroll, & Ogden, 2016). Although this is the case, further research should be conducted to analyze the circumstances surrounding low weight in childhood and adolescence.
Discussion of the Patient Case
There is a lot to dissect from the scenario and a lot of questions that the provider would need to ask in order to best ascertain the best course of treatment for this patient. The first piece of information is the fact that the patient is underweight which means she has a “BMI less than 18.5 and her weight falls in the lowest 5th percentile for her age and gender” (Ball et al, 2019). A knee jerk reaction when faced with an underweight teenaged female is to consider the possibility of anorexia or bulimia. One key detail presented in the scenario that could cause the provider to consider another mode of thinking is the fact that the parents are also underweight. This could lead the practitioner to infer that the child’s weight could have either a genetic or environmental component. It is important, therefore, to consider the role the parents play in the child’s condition. Children in most cases are reliant upon their parents for sustenance. According to Williams et al, “family can influence children’s dietary behavior in at least five areas: availability and accessibility of foods, meal structure, adult food modeling, food socialization practices, and food-related parenting style” (2017). This same study also displayed that authoritative parenting styles were more likely to result in children with low BMIs.
The Assessment and Treatment Process
Performing a thorough health history would be integral to treating this patient. Even before a physical assessment is performed on the patient, the provider can zone in on possible problem areas by simply conducting a joint interview between the parents and the child. Since the parents would be in attendance, important factors such as family history, the patients past medical history, socioeconomics, and cultural practices could all be discussed. Some example questions could be; does your family eat a well-balanced diet, do you all have the available resources to eat three meals a day, is exercise strongly encouraged in your household, and is the patient’s current weight a sudden weight loss or consistent with your daughter’s baseline. The presence of bullying might also warrant investigation of the patient’s psychosocial health. Through this process the underlying problem could become more evident. The patient’s low weight could be due to poor appetite or a high metabolism, but only investigation will truly tell. One useful tool that could be used during this process is the 24-hour diet recall. This tool asks the patient to “list all the food, beverages, and snacks eaten during the past 24 hours” (Ball et al, 2019). This could give the practitioner a snapshot into the patient’s normal dietary intake. In terms of treatment the provider should encourage the parents to not only monitor their child’s diet and exercise regimen but also encourage body positivity. She may be predisposed to having a lean frame, so understanding this and collectively working towards developing a positive self-image will be key to maintaining both physical and mental well-being. Weight, BMI, and other measure can predict the development of certain conditions, but they are not a fool-proof indicator of health. The patient and her family could be perfectly healthy with their current lifestyle. If the low weight was due to lack of resources and poor nutrition, the provider could provide the family with contact information for resources designed to assist in such cases.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Fryar, C. D., Carroll, M. D., & Ogden, C. L. (2016). Aged 2–19 Years: United States, 1963–1965 Through 2013– 2014. Retrieved from https://www.cdc.gov/nchs/data/hestat/underweight_child_13_14/underweight_child_13_14.pdf
Gläßer, N., Zellner, K., & Kromeyer-Hauschild, K. (2010). Validity of body mass index and waist circumference to detect excess fat mass in children aged 7–14 years. European Journal of Clinical Nutrition, 65(2), 151–159. doi: 10.1038/ejcn.2010.245
Rosario, A. S., Schienkiewitz, A., & Neuhauser, H. (2010). German height references for children aged 0 to under 18 years compared to WHO and CDC growth charts. Annals of Human Biology, 38(2), 121–130. doi: 10.3109/03014460.2010.521193
Williams, J., Helsel, B., Griffin, S., & Liang, J. (2017). Associations Between Parental BMI and the Family Nutrition and Physical Activity Environment in a Community Sample. Journal of Community Health, 42(6), 1233–1239. https://doi-org.ezp.waldenulibrary.org/10.1007/s10900-017-0375-y