Jen Bass, MD
Sandy Hassink , MD
Robert Karp, MD
and the members of the Nutrition and Obesity Special Interest Groups of the Academic Pediatrics Association.
Childhood Obesity Knowledge Assessment
Q1. Use of Body Mass Index (BMI) to assess obesity growth is limited by: all of the facts listed below EXCEPT (annotated answer)
A. BMI percentiles have only been published for children 2 years of age and up
B. patterns of growth in infancy are too variable to use BMI
C. One can not be certain whether it is fat or muscle that contributes to elevations
D. All are limitations.
Q2. In children and adolescents, a body mass index (BMI) at the 85th percentile for age and gender is termed (CDC): (annotated answer)
A. "overweight"
B. "at risk of overweight"
C. "obese"
D. "within normal range"
Q3. In early childhood, the following are predictors of future risk of obesity EXCEPT? (annotated answer)
A. the child past six months of age being underweight or failing to thrive
B. one or both parents being overweight or obese
C. the family having a sedentary lifestyle
D. All are predictors of obesity later in life
Q4. During a health supervision visit you assess that a 3 year-old overweight patient is watching more than 3 hours of TV a day, of the following the MOST APPROPRIATE ADVICE is: (annotated answer)
A. Three hours of television viewing a day is not too much.
B. Limit the child's television viewing to no more than 2 hours per day.
C. Discontinue all television viewing as children 3 and under should not watch television at all.
D. Allow children to watch about as much television as the parents watch themselves.
E. Parents do not need to monitor the amount of television viewing as long as children get plenty of exercise. They should only concern themselves with the content.
Q5 . True or false: The age for Adiposity Rebound is similar for children at the lower percentiles for BMI as it is for those children at higher percentiles. (annotated answer)
Q6. Which of the following is most likely to be associated with the development of obesity later in life? (annotated answer)
A. Not having access to low cost, nutritional foods
A. Breastfeeding
B. Television viewing less than 2 hours per day
C. Having ready access to a public playground
A. for a longer duration is associated with a decrease in risk of overweight in
later life
B. makes babies hungrier and more prone to abnormal weight gain
C. means there can be no monitoring of intake so babies can easily over-consume breast milk causing obesity later in life
D. usually causes slow weight gain in infancy, so that when babies are introduced to solid foods, they tend to overeat.
Q8. The following parental feeding practices provoke excessive weight gain in childhood EXCEPT: (annotated answer)
A. Parental monitoring childhood eating
B. Giving large portion sizes at meals and snacks
C. Increased frequency of fast food meals
D. All of the above contribute to excess gain.
Q9. True or False: Children who have a rising BMI begin to rise before 5 years of age may be at increased risk of adult obesity. (annotated answer)
Q10. By the end of the 2nd year of life, somatic and brain growth slows, with corresponding changes in nutritional requirements. Therefore, at the 2 year health supervision visit, you should make the following recommendation: (annotated answer)
A. decrease the daily protein intake
B. cut the child's feedings from 6 per day to 3 per day
C. change from whole milk to low fat dairy products.. (skim or 1% milk).
D. children can self-regulate food intake so they don't have to be served regular meals
Q11. True or False: During the early school years, normally growing children will gain 5 pounds for every inch in height. (annotated answer)
Q12. True or False: To become overweight or obese, children must consume too many calories for their level of activity. (annotated answer)
Q13. Insulin resistance is associated with which of the following chemical findings: (annotated answer)
A. elevated insulin to fasting plasma glucose ratio
B. reduced insulin to fasting plasma glucose ratio
C. elevated fasting plasma glucose
D. elevated two hour glucose in a glucose tolerance test
Q14. Melanie is a 14 year old AA female with a family history of type 2 diabetes who comes into your clinic for evaluation of overweight. After taking a detailed history, you calculate her BMI to be 38.2. On physical exam, you note a dark, creased ring around her neck. Labs were drawn and you are evaluating the results. Which of the following make the diagnosis of pre-diabetes in Melanie? (annotated answer)
A. acanthosis nigricans
B. increased fasting plasma glucose level between 106 and 126 mg/dl
C. elevated HgbA1C level
D. elevated triglyceride level
Q15. Melanie has experienced polyuria and polydipsia, but she does drink about six regular caffeinated sodas per day. Which of the following abnormal laboratory values would be the BEST help in making a diagnosis for the pediatric onset of Type 2 diabetes? (annotated answer)
A. a random plasma glucose >200
B. an elevated HgbA1C
C. a 2 hour plasma glucose (from an oral glucose tolerance test) of 138 mg/L.
D. all of the above
Q16. Nationally, non-alcoholic fatty liver disease is present in what percentage of obese children? (annotated answer)
A. 5%
B. 10%
C. 15%
D. 20%
E. Uncertain
Q17. True or False Non-alcoholic fatty liver disease is usually asymptomatic in children. (annotated answer)
Q18. True or False: Cirrhosis of the liver occurs more often in children with non-alcoholic fatty liver disease than in adults with the same disorder. (annotated answer)
Q19. Non-alcoholic fatty liver disease in childhood is often associated with: (annotated answer)
A. Insulin resistance
B. hypothyroidism
C. Both A and B
D. Neither A nor B
Q20. True or False; Non-alcoholic fatty liver disease usually responds to weight reduction. (annotated answer)
Q21. The most accurate way to diagnose non-alcoholic fatty liver disease and NASH is: (annotated answer)
A. elevated transaminases
B. liver biopsy
C. splenomegaly
D. abdominal ultrasound
Q22. All of the following factors are used in the diagnosis of metabolic syndrome EXCEPT: (annotated answer)
A. high blood pressure
B. increased waist circumference
C. elevated fasting glucose
D. high LDL cholesterol
E. elevated triglycerides
Q23. All of the following are symptoms associated with obstructive sleep apnea EXCEPT: (annotated answer)
A. intermittent periorbital edema
B. recurrent early morning sore throat
C. persistent snoring
D. daytime somnolence
E. poor school performance
Q24. An eight year old boy has had rapid weight gain since his parents divorced 2 years ago and now has a BMI of 33. He has been snoring loudly for the past 6 months. His brother has noticed he occasionally stops breathings at night. His grades have declined this year. The most likely cause of this child's problem is: (annotated answer)
A. seasonal allergic rhinitis
B. obstructive sleep apnea
C. deviated nasal septum
D. attention deficit disorder
E. binge eating disorder
Q25. All of the following are conditions associated with obstructive sleep apnea (OSA) EXCEPT: (annotated answer)
A. obesity
B. Down syndrome
C. craniofacial anomalies
D. failure to thrive (FTT)
E. sinusitis
Q26. The underlying pathophysiology of Polycystic Ovary (PCO) disease includes: (annotated answer)
A. insulin resistance
B. dysfunction secretion of gonadotropin-releasing hormone (GnRH)
C. increased production of androgens from the ovary
D. all of the above
Q27. In addition to weight loss interventions, the first line treatment for polycystic ovary disease is: (annotated answer)
A. androgen blockade with spironolactone
B. metformin
C. combination oral contraceptive therapy
D. estrogen replacement therapy
Q28. RJ is a 16-year-old African American female, with a BMI of 41 and a history of a left leg pain for 6 weeks and an intermittent limp for 1 month. She does not recall any preceding trauma but states she has had some intermittent leg pain in the last year. Your working diagnosis is: (annotated answer)
A. Blount disease
B. osteopenia stress fracture
C. slipped capital femoral epiphysis (SCFE)
D. Osgood Schlatter disease
Q29. After a thorough physical examination of RJ, you decide to order the following: (annotated answer)
A. Anterior-posterior, frog-leg, and lateral views of the left hip
B. CT scan of both hips
C. Anterior-posterior and lateral views of the left knee
D. Erythrocyte sedimentation rate
E. A and C
A. A typical 15 year old female needs about 800 more calories a day than a 15 year old male
B. a typical 3 year old needs about 1300 calories a day
C. a typical 10 year old needs about 200 more calories a day than a 6 year old
D. a typical 6 year old boy about needs 1800 calories a day
A. 1 carbohydrate exchange is 10 grams of carbs (40 calories)
B. 1 carbohydrate exchange is 30 calories (120 calories
C. 1 carbohydrate exchange is 15 grams of carbs (60 calories)
D. 1 carbohydrate exchange is 40 calories (160 calories)
Q32. Which of the following factors is it ESSENTIAL to be assessed when evaluating a family's readiness and ability to make behavioral change? (annotated answer)
A. proximity to a health care facility
B. family history of mental health problems and obesity
C. child/parent are motivated to make dietary and lifestyle changes
D. skipping meals and eating large snacks
E. family can financially afford to buy healthy foods and enroll in a physical activity program
Q33. Which of the following are important components of effective obesity management? (annotated answer)
A. Family engagement
B. individualized goal-setting
C. Maintaining a growth chart
D. All of the above
Q34. Which of the following laboratory tests should be ordered when a child is identified as overweight? (annotated answer)
A. fasting glucose
B. fasting lipid panel
C. TSH
D. all of the above
Q35. Which of the following co-morbid conditions can be related to morbid obesity in childhood? (annotated answer)
A. pseudotumor cerebri
B. esotropia
C. chronic lymphadenopathy
D. leg length discrepancy
E. mesenteric adenitis
F. . All are increased with obesity
Q36. Which food habit or behavior is MOST likely to be associated wiith childhood obesity? (annotated answer)
A. eating breakfast 7 days per week
B. eating 3 meals and 2 snacks daily
C. binge eating and purging
D. limiting simple sugars and fiber free cereals.
Q37. Which of the following approaches would be best to introduce a concern for excess weight gain? (annotated answer)
A. tell the parent of your concern for their child's growth or size and ask if they have been concerned themselves
B. tell the parent that their child eats too much and they need to lose weight
C. show them the growth chart and explain it to them
D. A and C
Q38. The use of motivational interviewing in childhood obesity means that: (annotated answer)
A. the clinician, child and family work together to identify problems and choose goals
B. the clinician increases the child's motivation by telling them what to do in a very positive way
C. group education is used to motivate the child and family
D. the clinician recommends a series of nonfood rewards to engage the child and increase motivation
Q39. The American Academy of Pediatrics recommends the following strategies for the prevention of childhood obesity: (annotated answer)
A. promote breastfeeding
B. calculate and plot BMI once a year
C. track the change in BMI to catch abnormal weight gain early
D. recommend less than 2 hours of television viewing for children over 2 years old
E. all of the above
Q40. True or False. A glass of whole milk has the same nutrient content as 5 strips of bacon. (annotated answer)
Q41. An overweight 13 year old girl says that she wants to slim down, but she doesn't know how to get started. She doesn't want diabetes like her grandmother and she is tired of the kids at school making fun of her. When you ask her if she can set a start date, she makes excuses and says it will have to wait until school is out, which is 3 months away. At what stage of change is this girl in the Readiness to Change model? (annotated answer)
A. pre-contemplation
B. contemplation
C. preparation
D. action
E. maintenance
Q42. Which of the following are appropriate goals for a 9 year old overweight child who is ready to change? (annotated answer)
A. limit TV and video games to 2 hours per day
B. self-monitor by keeping food and activity records
C. eat a combination of 5 fruits and vegetables daily
D. get at least 60 minutes of active play daily
E. all of the above
Q43. A six year old girl has gained weight rapidly since moving to a new house in a new school district. Which of the following could be the likely cause of this abnormal weight gain? (annotated answer)
A. depression due to loss of her old friends
B. anxiety about being in a new school
C. decreased opportunities for play
D. increasing eating in fast food restaurants
E. all of the above
Q44. A mother brings her overweight 11 year old boy into your clinic, very frustrated and wants you to help him slim down to normal size. The young man is sullen and says he is fine just the way he is now. You calculate his BMI at 42. What do you do? (annotated answer)
A. Because he is at high risk for co-morbidities, you schedule him for fasting blood work next week.
B. You tell the young man that he is extremely overweight and he must face his problem.
C. You tell the mother that you will work with her for now is to achieve a healthy home environment and work on their relationship. You use motivational interviewing techniques when you see the boy.
D. A and C
E. all of the above
TELL US ABOUT YOURSELF
Q45. What best describes you?
A. Medical Student
B. Pediatric Resident
C. Family Practice Resident
D. Other
Q46. If you are a resident, what year of training are you in?
A. PL-1
B. PL-2
C. PL-3
D. PL-4
E. Doesn't apply
Q47. What is your gender?
A. Male
B. Female
Q48. What is your age?
A. Under 25
B. 26-34
C. 35-44
D.45 or more
Q49. What year did you graduate from medical school?
Write in the year: __ __ __ __
Annotated Answers:
1. The answer is B. (That is B is an incorrect statement.) Patterns of growth are fairly consistent for well-nourished children though norms have not been established for children before two years of age. We do not know, however, whether fat or muscle contribute to an increased BMI
2. B is correct. Children with a BMI between 85th and 95th percentiles adjusted for age and gender are considered "at-risk." This is more than "political correctness." The health hazards associated with obesity may not be found at this level of overweight, but, to use Jelliffes' terminology, a child is "at risk for malnutrition in the "…presence of (a) biologic or environmental factors that predispose to disease.... and (b) easily recognizable early warning signs that malnutrition is impending" (from Jelliffe and Jelliffe The "at-risk" concept and young child nutrition programs (practices and principles). Journal of Tropical Pediatrics. 1970; 18:199-201.) The term "at-risk" then does apply.
3. A is correct. Having an obese parent gives a 40 to 60% probability of obesity. A sedentary lifestyle is a known predictor. Barker provides data showing that in-utero undernutrition increases risk for obesity, as does rapid weight gain in the first six months of life. Postnatal Failure To Thrive, however, is not a predictor of later obesity. Prenatal undernutrition may be.
4. B is correct. T.V. watching associated with obesity has been a consistent finding though multiple studies with different designs. The two-hour maximum is our best estimate of an upper limit. As for a "no TV" rule, some cultures do not permit television watching. If parents make such a rule they had better stick by it themselves with no exception for the World Series, Super Bowl, and old Seinfeld reruns or whatever super special is on PBS.
5. This is False. The curves show a distinct discipline in deviation from the mean for the lower percentiles -- those below 50%. Above mean levels splay out widely so as to produce a non-Gaussian distribution for the population as a whole. Children with lower BMIs will have a later adiposity rebound.
6. A is correct. As food costs rise, selection narrows to those items providing most energy at lowest cost. This phenomenon is a precursor to both obesity and micronutrient deficiencies. The other factors are all known to limit the prevalence of obesity in a population.
7. A is correct. Multiple studies with different designs in various populations show that breast fed infants tend to grow on a somewhat lower curve than bottle-fed ones. Data are available from the WHO at http://www.who.int/childgrowth/standards/en/.
NCHS curves predict that an infant will double birth weight at 4 months of age = 120 days.
WHO curves predict that the same infant will double birth weight at 5 months of age = 180 days
Consider an infant with a birth weight of 3,500 gms..
NCHS gains 3,500 gms In 120 days A gain of 29 gms/day
WHO gains 3,500 gms In 150 days A gain of 23 gms/day
8. A is correct. (that is monitoring does not lead to obesity) Overfeeding fatty foods is obvious as is too much fats food. Excessive restriction has been reported to prevent self-regulation and is associated with excess weight gain, too.
9. The answer is True. The phenomenon of Adiposity Rebound (AR) or BMI Rebound is the 2nd of three phases of fat deposition in a child's life. The earlier the AR, the more likely the child will become an obese adult.
10. C is correct. We are exceedingly aware of the danger of early restriction in fat content. Fat containing food also contains essential nutrients and sufficient energy for growth. A child can adapt to a "Heart Smart" diet including low fat dairy products at two years of age.
11. This is True. This is a nice rule of thumb (5lbs gain for each inch from about 4 years of age to puberty) in that children "at-risk" for obesity and even obese children can continue to grow with a gain of 1 or 2 pounds for every inch with remarkable reeducations in BMI. Needlman in the 17th edition of the Nelson textbook of pediatrics, notes that from about age 6 to preadolescence (age 10 for girls and 12 for boys), normally growing children gain 2.5 inches per year (6cm) and 7 lbs (3-3.5 kg). During the preschool years (3-5), weight gain is 2 kg/year and 6-8 cm/year. [See page 51 of the 17th edition.)
12 The answer is "True" no matter how many false prophets of nutrition tell us that the First law of Thermodynamics can be repealed. That is, within any closed system energy entering the system minus energy used will lead to either storage or reduction in energy stores.
13. A is correct. The first step of the Metabolic Syndrome is for the circulating insulin to increase to keep blood glucose levels at normal levels. Insulin as 14 % of the Fasting Blood Glucose levels in absolute numbers is an upper limit for normality.
14. B is correct. Acanthosis nigricans will vary in expression. HgbA1C and Triglyceride levels rise in time, but they are not the first true sign of T2DM
15. A is the answer. This is a greatly elevated fasting Glucose level. The Hgb A1C would be elevated in both type 1 and Type 2 DM. A 2-hour Blood Glucose level is a borderline measure for a GTT following a 75 gm glucose load.
16. E is correct. The problem is that there is no denominator. Clinics can provide data on their prevalence, but this is a selection bias.
17. The answer is True. NAFL is asymptomatic, and, by definition, there are no alterations in hepatic enzyme measures. NAFLD is associated with abnormalities in liver function associated with the fatty liver. It too, however is asymptomatic in childhood.
18. The answer is False. The hepatic disease associated with fat storage requires more time to develop than the inflammatory hepatic diseases associated with toxic ingestions and infectious disease,
19. A is correct. Fat storage is a characteristic of elevated insulin levels. An entity "Mauriac syndrome" where poor insulin control permits fat entry into the liver but prevents exit. Hypothyroidism is not associated with endogenous obesity.
20. The answer is True. Most of the syndromes associated with childhood obesity will regress if reduction is done prior to cellular injury.
21. B is correct. While Non Alcoholic Fatty liver reflects an accumulation of fatty tissue, the disease state, often called Non Alcoholic Steato hepatitis requires a biopsy to show the inflammatory changes.
22. D is correct. There are now several different working models for assaying the metabolic derangements associated with chronic insulin resistance and truncal obesity. While dyslipidemia is a feature, the recognized abnormalities are a decrease in HDL-Cholesterol and hypertriglyceridemia. Hypertension is on some criteria but not others. See module on hypercholesterolemia in the Teacher's Guide.
23. The answer is A. Obstructive sleep apnea can lead to daytime drowsiness, poor school performance due to inability to concentrate. Individuals may snore loudly with gasping episodes and have a sore throat in the morning due to mouth breathing. They do not have periorbital edema.
24. The answer is B. Although allergic rhinitis can lead to loud breathing, it shouldn't be associated with pauses during sleep. Although ADHD may be associated with a decline in grades, it doesn't have sleep disturbances. Binge eating disorder is also not associated with sleep issues. Snoring with occasional pauses associated with inadequate sleep and poor school performance can be OSA.
25. The answer is D. OSA occurs with any disorder that affects the anatomy or function of the upper airway. All others do just that, but FTT does not.
26. The answer is D. PCO is one of the associated co-morbidities of obesity. There is an inherent insulin resistance. The origins of the disorder are not actually known, but it is characterized by dysfunction in the hypothalamic pituitary axis with end organ hormone production disturbances.
27. The answer is C. Teens with PCO respond well to regulation of their menstrual cycle. Affected individuals may have chemical diabetes associated with obesity. This will respond to some extent to the hormone therapy. Androgen blockade would be inappropriate. Excess estrogen is a characteristic of the disease. Combination therapy mimics the normal physiologic pattern and permits the regular cycling of the endometrium. Metformin is used on occasion, but only for individuals that have more serious issues with insulin resistance that have not responded to weight loss interventions.
28. The answer is C. There are two somatotypes associated with SCFE. These are the rapidly growing bean pole, often a boy. The other is an overweight adolescent of either gender usually in early adolescence. The disease occurs because ossification proceeds at a much lower rate than growth in these high-risk teens. Blount disease is associated with genu varus (bow legs) without limp or pain. Osgood Schlatter's disease is a point specific pain over the tibial tuberosity. There is no reason for an overweight teen-ager to have osteopenia. Think bulimia and anorexia for that one.
29. The answer is E. Hip pain is often referred to the knee, but sometimes the source of pain is the knee. A "C-T" would not be necessary when the history does not point to either infection or rheumatoid disease.
30. The answer is A. There are various formulations for estimating weights at different ages. One is to double birth weight from 4 to 5 months of age and triple it to about 10 kg at a year of age. That 10 kg weight is doubled to 20 kg at 4 to 5 years of age, tripled to 30 kg at 9 to 10, and hits 40 prepubertaly at about 12 years of age. Calorie intake is roughly 100 cal/kg for the first 10 kg. Add 50 cal/kg for the next 10 kg. The curve then becomes linear with 20 cal/kg for each kg of body mass. A teen-age girl will not be increasing caloric intake to such an extreme even if she does go through puberty earlier than a similarly aged boy.
31. The answer is C. Exchange units have not been used in pediatrics as commonly as in adult medicine. They are, however, relevant as we are seeing more diabetes in the obese population. Residents should be familiar with these concepts as they care for these children on the wards and in clinic. The rule of thumb for an exchange unit is 60 to 70 calories of carbohydrate.
32. C is correct. Some of the others count, too including accessibility, affordability, a modest restriction on fatty and fast food and more. Without a motivated family, however, all will fail. The first question is always, "Do you want to do this? An negative answer would predict failure. An equivocal answer requires a patient approach. See Prohaska system.
33. D is an obviously correct answer. Every family member has to be committed to the program. Is it possible to convince an immigrant grandparent that a baby can be too fat? Is it "OK" to provide a child who asks for food what you think it's right to give? The answer is "Yes" to both questions. The actual goals however, have to come from the family and child in negotiation. They should be reasonable so that success is possible and comes fairly soon. The maintaining of growth curves is important. A growing child will lower weight and increase height having a profound effect on BMI. Pre teens like that.
34. D is correct. The medical consequences of obesity are likely to affect glucose and lipid metabolism. While, most obese children are not hypothyroid, SOME ARE!
35. A is correct. Pseudotumor is a syndrome that arises in several circumstances that may be associated with obesity such as an increase in Vitamin A or with tension. The other conditions may occur in obese children, but they do not do so in greater frequency than among the lean.
36. C is correct. Eating breakfast inhibits that late hunger triggering a crescendo of eating so common in obesity. The 3 plus five is a mainstay of diabetes treatment in pregnancy and it works for children, too. Increasing fiber intake and limiting the consumption of sugar beverages and fiber free cereal grains in a "low glycemic index" meal pattern have all part of an effective eating pattern. Binging and purging to keep weight off ids a part of the bulimia syndrome.
37. A is correct. Always begin introduction of behavior change with a message of personal concern and a request for parents' feelings. Do not direct parent unless they want to be directed. The growth curve is only important after the connection has been made. Engage first with Empathy. Follow with Enlistment and Education.
38. A is correct. The motivational interview is non judgmental and bi-directional. "Tell me about X?" " What do you think of Y?" "Here's what I think." All of this is conducted with a balance of respect for the child's choices and thoughts while incorporating child's thought and behaviors where possible. It is not a matter of telling the teen or family what to do. The four "E's" of motivational interviewing are "Engagement, Empathy, Enlistment, and Education."
39. A is correct. These are the "cut up vegetables" of obesity prevention. Keep it really simple! Also, check waist circumference when the BMI is elevated, but the child just doesn't look obese. See assessing nutritional status module.
40. The answer is False. The saturated fat content is the same, which is why whole milk is recommended before 2 years of age. ,The other nutrients in milk are essential. Two to three cups will suffice. At two, the AAP recommends use of low fat (1%) or non-fat milk. Reduced fat milk is not recommended though some families will only reduce to 2%. One can mix 2% and 1% for a while and slowly develop a palate for low fat milk. Other low fat dairy products are usually well accepted.
41. B is correct. This is not the place for a discussion of the Prohaska system for approaching behavior change. Simply ask, "do you want to make the change?" A clear "no" is an invitation to step back (it's "precontemplative"). A yes with fear is "contemplative." Make suggestions and an appointment for a follow-up appointment as soon as the patient is willing.
42. E is correct. All are necessary; none are sufficient. See Part III Section 8 on Successful losing."
43. E is correct. Again, the child "at-risk' for obesity will become obese unless he or she has an effective plan that can withstand the rigors of everyday life.
44. D is correct. Answer A recognizes the medical risks. It is essential to determine the level of danger the child is experiencing. But C is important, too. Appreciating the difference between telling people what they should do and eliciting cooperation is essential. The former always makes for failure. The later makes success possible.
