In hopes of reversing the alarming trend of childhood obesity, 25 states currently have instituted BMI (Body Mass Index) surveillance and screening programs in schools-and 9 of those states require BMI “report cards” be sent home to parents.
Childhood obesity is a serious and growing problem in the United States and according to the Centers for Disease Control and Prevention (CDC), childhood obesity has more than doubled in children and tripled in adolescents over the last 30 years. In hopes of reversing this alarming trend, 25 states currently have instituted BMI (Body Mass Index) surveillance and screening programs in schools-and 9 of those states require BMI “report cards” be sent home to parents. This move has been met with varying degrees of acceptance among parents, as many worry that this approach may ultimately prove to do more harm than good in their children.
“Our research has shown that school-based BMI screening programs might not be effective at preventing or reducing obesity. In our review of past studies1, the evidence demonstrates that these programs are good at increasing parent and child awareness of the child’s weight status and improving their ability to accurately identify the child’s weight status,” states Allison J. Nihiser, M.P.H., health scientist at the Centers for Disease Control and Prevention, Division of Population Health, Atlanta, GA. “However, there is not any evidence that these school-based programs result in reducing overweight and obesity.”
A little over a decade ago, Arkansas was the first state to implement mandatory BMI surveillance and screening programs in schools. Since then, 24 other states have followed suit. Although legislation for BMI surveillance and screening programs has passed in 25 states to date, with another 4 states having this legislation pending or proposed, debates continue regarding confidentiality and privacy, school to parent communication, and students’ safety and self-esteem issues.
For school districts and schools that choose to initiate a BMI screening program, the CDC identified parameters for schools to implement intended to ensure respect for student privacy and confidentiality, protect students from potential harm, and increase the likelihood that the program will have a positive impact on promoting a healthy weight. According to Ms. Nihiser, these safeguards are intended to address the main concerns surrounding the programs.
In a recent study2 that looked at the impact of BMI screening programs performed in schools, researchers found that despite the ongoing controversies associated with school-based BMI screening programs, such programs could prove to be valuable for students in terms of obesity prevention and promoting healthy lifestyles in this population.
Dominique G. Ruggieri, Ph.D., CEO, BonVie Health and Nutrition Consulting, Faculty Fellow, University of Pennsylvania's Center for Public Health Initiatives (CPHI), Philadelphia, PA, the main author of the study, says that while there are debates regarding the use of these programs in schools, they can potentially be very useful in helping to stem the current childhood obesity epidemic, and can be instrumental in the development of obesity prevention programs and in the promotion of healthy lifestyles in students.
“Clearly, we have a pediatric obesity crisis in the United States, and BMI programs can be very helpful here,” states Dr. Ruggieri, “However, one of the controversies with school-based BMI programs is that there are a lot of parents who believe that schools should not be involved in the first place and that this is a private matter for parents and their children to discuss with their pediatrician or family doctor.”
In the years since their inception however, some research has pointed to a shift in some parental attitudes towards school-based BMI programs. Numerous studies have been conducted in which parents were surveyed and interviewed about their feelings regarding BMI report cards. Most of the research indicates that the majority of parents are now generally supportive of the idea that schools get more involved in their children’s health and most respond positively to BMI screening programs in their children’s schools-if such programs meet specific criteria.
“A study included in our review shows that parents would support programs if they received advanced notice about BMI measurement programs, had the opportunity to decline permission for their children to participate, received assurance that the measurements would be collected in a private and respectful manner that minimizes weight-related teasing, and received the results in a letter mailed to all parents that used a neutral tone and did not assign blame,” Ms. Nihiser reports.
Confidentiality is a major area of concern in terms of how the BMI report cards are created, how the information is gathered, and how the BMI report cards are issued. Ideally, the BMI data collection should be done privately and not in the presence of other students in order to help prevent “fat shaming” or stigmatization, which could ultimately work against such programs.
While there are many schools with the resources for a school nurse and a private area in which children can be measured, many school districts simply lack such resources. In addition, many parents have voiced concerns about the confidentiality of their child’s BMI data and who would have access to it. Although many states attempt to ensure that the students’ BMI data are kept confidential, and make recommendations that are sent directly home to the parents via email or other electronic means, most schools still rely on the students themselves as the information conduit to parents. As such, parents may never receive their children’s BMI report. Moreover, children may share results with each other, opening the door for potential bullying from fellow classmates.
To help reduce the risk of stigmatizing students, Ms. Nihiser recommends that BMI reports should be sent to all parents, regardless of their child’s weight status. To avoid giving the impression that a clinical diagnosis has been made, the letters to parents about students who need further evaluation (i.e., those classified as underweight, overweight, or obese) should avoid definitive statements about the student’s weight category. According to Ms. Nihiser, there are a number of ways to approach this:
• Letters might state that the student’s BMI result ‘‘suggests’’ that he/she ‘‘might be’’ overweight.
• Letters might simply identify the student’s height, weight, and BMI-for-age percentile and include a table defining BMI-for-age percentile categories.
• Letters might state that the student’s weight was found to be low/normal/high for his/her height and age.
In any case, Ms. Nihiser says that all letters should strongly encourage parents to consult a health care provider to determine if the student’s weight presents a health risk.
Another concern raised by parents regarding in-school BMI screening programs is how the BMI results might impact their children in terms of self-esteem and if they may increase the likelihood of children developing an eating disorder and/or bullying from fellow students.
“Obese children are at an increased risk of being teased, bullied, or socially isolated and having low self-esteem or depression,” says Ms. Nihiser. “A common concern expressed about school-based BMI screening programs is that the programs might stigmatize students and lead to harmful behaviors. The concern is that BMI measurement programs might intensify this stigma, dissatisfaction with body image, and pressure to engage in harmful behaviors that might result in eating disorders.”
However, according to Dr. Ruggieri, the many outcome and evaluation studies conducted in Arkansas indicate that incidents of weight-related bullying and teasing-as well as eating disorders-have actually declined in schools since the implementation of in-school BMI programs.
“This is a very positive effect we’ve seen from in-school BMI screening programs,” says Dr. Ruggieri. “Typically, when you are in a school that has adopted a BMI screening program, you are also in a school that is showing a new commitment to help deal with the pediatric obesity crisis. These schools are really making an effort to promote sensitivity related to weight among students.”
Eating disorders are increasingly being seen in younger-aged children, and are seen more frequently in females. According to Dr. Ruggieri, this, in part, is due to the fact that parents are unaware that their child might be in an underweight unhealthy category or in an overweight unhealthy category, as there are eating disorders on both ends of the spectrum. There are hundreds of research studies indicating that parents overwhelmingly misperceive their child’s weight category Dr. Ruggieri observes, not recognizing if their child is underweight, normal weight, overweight, or obese. In addition, studies have also shown that African American, Hispanic, and Native American populations tend to significantly underestimate their children’s weight. In-school BMI programs could help to alert parents about their child’s weight and help them catch an eating disorder or at least be mindful of this ever-growing issue.
“The good news is that, despite the fact that concerns are raised over and over again about BMI report cards and that they are going to lead to bullying and eating disorders, the research actually shows that this is not the case,” states Dr. Ruggieri.
Another concern regarding school-based BMI screening programs is that they may result in parents putting their children on diets that are not supervised by a health care provider. When parents receive the results of their child’s BMI screening, Ms. Nihiser says that they should first meet with their child’s health care provider for further examination to determine if the individual actually has excess body fat or other health risks related to obesity. The health care provider will then counsel the family on the results and determine if the child needs a weight maintenance plan (i.e. maintain the youth’s current weight to prevent additional weight gain) or a healthy and developmentally appropriate weight loss plan supervised by a health care provider.
“Alternatively, a concern is that parents may not agree with the BMI screening results and families may not pursue follow-up actions with a health care provider to determine if their child is overweight or obese,” says Ms. Nihiser.
“Further, if parents disagree with the results, they might not make healthy changes to their families’ lifestyle. Therefore, the screening program might waste valuable resources if families do not respond to the BMI screening results.”
Although there is an increasing favorable consensus regarding in-school BMI programs among some parents, critics often point out that such programs are not very successful given that the overall BMI scores of students do not show significant improvements. According to Dr. Ruggieri however, this could be interpreted as a very myopic view of success.
“I think that we need to expand our view on what success really means,” suggests Dr. Ruggieri. “If you look at the BMI scores, until these were regularly measured in schools, Arkansas-like all other states-showed a steady increase in the rates of pediatric obesity every year, and while we haven’t seen a decrease, we did see stabilization or a leveling off of BMI scores. That, in and of itself, if you are only looking at BMI scores, is a marker for success.”
Raising awareness among parents is key, and a comprehensive approach is needed to optimally address this issue. According to Dr. Ruggieri, the evaluation and outcome studies in Arkansas and other states that have BMI programs in place have shown that vending machine purchases and soft drink consumption have declined, and children are reporting that they are spending more time being physically active outside of school than they did before. In addition, parents’ perception of their child’s weight is more accurate, reflecting a better understanding of their child’s benchmark. Moreover, BMI screenings and report cards can be particularly important in rural areas and inner city schools in which the school nurse may be the only health care provider for the students.
“BMI screening programs, while they are not perfect, can be a really valuable resource for making parents aware of where their child’s weight health stands and for opening communication and dialogue with their children, with their children’s doctor, and making positive family health changes,” Dr. Ruggieri concludes.
1. Nihiser AJ et al. Body mass index measurement in schools. J Sch Health. 2007 Dec;77(10):651-671.
2. Ruggieri DG, Bass SB. A comprehensive review of school-based body mass index screening programs and their implications for school health: do the controversies accurately reflect the research. J Sch Health. 2015; 85: 61-72.
Dr Petrou is a freelance medical writer based in Budapest, Hungary. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.