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Nutrition and growth challenges in children with cystic fibrosis (CF) are well-documented. However, in the past decade, a dramatic shift in CF care with more people with CF (pwCF) eligible for highly effective CF transmembrane conductance regulator (CFTR) modulators. Reviewing the Cystic Fibrosis Foundation Patient Registry (CFFPR) in 2021, it was clearly indicated that more than forty percent of adults with CF (awCF) met criteria for overweight or obese based on the Center for Disease Control and Prevention (CDC) definitions for adult overweight/obesity. The percentage of overweight/obese awCF has tripled in the past two decades. In general pediatrics, overweight and obese children are more likely to stay obese into adulthood. Since obesity affects one in five children and adolescents in the United States, the CF team at Children’s Mercy recognized the need to change our approach.


The goal of this quality improvement (QI) initiative was to create a standard process to ensure information provided to families on growth and nutrition was consistent among all CF care team members across all nutrition statuses, malnutrition or overweight and obese.


Our CF nutrition committee created a nutrition risk algorithm and interventions for color coded groups in October 2018. The groups defined as red, yellow, and green zones for BMI for age < 25%ile, between 25-50%ile, and greater than 50%ile accordingly. In September 2020, we implemented purple zone with BMI for age > 85%ile aligned with CDC categories for pediatric overweight/obesity. During each pre-clinic huddle, yellow, red as well as purple zones patients were identified and followed closely by the dietitians according to the algorithm.


Fifty two percent patients met the goal of BMI > 50%ile in 2022. The percentage of patients in overweight/obese category, purple zone, has declined from 20% in 2020 down to 13% in 2022. Care givers and patients have better understanding of their nutrition status in colorful ways.


Implementing the nutrition risk algorithm has strengthened our team’s efforts to improve patient nutrition status. The addition of purple zone brought awareness of being overweight or obese for pwCF. Standard nutrition language used by all CF team members has fostered more consistent communications to patients and families.

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Purple zone: a preventative initiation to address elevated BMI for age in people with cystic fibrosis. A pediatric care center practice