By C. Meghan McMurtry and Elissa Jelalian
January 2010. Vol. 26, No. 1
Pediatric obesity has increased dramatically over the past 30 years. In addition to numerous physical health risks, pediatric obesity is associated with psychosocial risk factors such as decreased self-esteem and increased behavioral difficulties. A significant percentage of obese adolescents experience weight-related teasing by peers and family members and are more likely to be socially marginalized.
January 2010 Vol. 26, No. 1
This article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.
Body mass index (BMI) (defined as kg/m2) is used to quantify weight status, and overweight/obesity for children and adolescents is defined with reference to age and sex specific norms. Slightly over 16% of U.S. children 2-19 years old are obese (BMI ≥ 95th percentile) 34% are either overweight or obese (BMI ≥ 85th percentile). Due to the immediate and long-term negative health consequences, pediatric obesity has been labeled an epidemic in need of primary and secondary prevention efforts.
Given the considerable time that children spend in school, the school environment has been identified as a potential site for improving children's nutritional health and addressing pediatric obesity. During the last 5 years, a significant number of states have enacted legislation targeted at preventing childhood obesity, with the majority focused on establishing nutrition standards for à la carte and vending foods available within schools.
A more controversial strategy adopted by schools is BMI reporting. While specific implementation varies significantly, this policy generally involves measuring children's height and weight within the school setting and providing feedback to parents and/or students individually regarding weight status (e.g., providing BMI percentile or using a descriptive term such as "overweight"). The report may also include nutrition/physical activity recommendations and referral information.
Historically, many U.S. school districts have measured children's weight and height; however, these results are not conveyed to parents. Arkansas was the first state to complete "BMI report cards" and several other states have adopted a similar policy.
Whose responsibility is it to monitor children's weight? And what role, if any, should schools play in the prevention and treatment of obesity? The issue of BMI reporting has generated considerable public debate and the policy continues to provoke very strong negative reactions, primarily from parents. The idea that schools should highlight a potential or existing health problem is logical, given that schools perform screening for other health markers such as hearing and vision tests. From the vantage point of schools, sending a BMI report card is intended to increase parental awareness of children's weight status and encourage parents to support healthy dietary and physical activity habits in their children. Although it may seem unnecessary to inform parents of their own child's weight status, a significant proportion of parents appear to be inaccurate judges of this (Nihiser et al., 2007).
While there is an apparent logic to school screening of weight status, there are a number of arguments against this practice. Schools do not monitor how many hours of sleep children get per night or how many hours of television they watch, both of which arguably relate to health status. Some parents contend that it extends beyond the school's purview to inform them that their child is overweight/obese and that resources involved in screening could be allocated to better use - e.g., increasing physical education time. A majority of parents appear to support school-based obesity prevention strategies such as the presence of physical education classes, nutritional education, and eliminating "junk food" from vending machines; however, support for other interventions (e.g., treatment recommendations for obese children) is less prevalent. Report cards from schools are evaluative in nature, which becomes problematic when considering the sensitive nature of BMI reporting.
As obesity tends to cluster in families, there may be a perception of blame among parents. Furthermore, the policy treads on issues of individuality, cultural, and ethnic differences, as well as social economic status, which are of particular concern given the increased risk of obesity among minority youth. Questions are raised regarding where individuality and acceptable cultural differences end and overall health concerns begin.
Another concern is the extent to which parents and children understand and appreciate the implications of the information provided. It may be considered irresponsible to report a child's BMI without ensuring that the parent understands its meaning and implications. Related to this issue is consideration of who receives the information.
In an article appearing in the New York Times (2007), there were anecdotal stories of children misinterpreting their BMI, including that of a 6-year-old with a BMI at the 80th percentile who subsequently refused to eat. There are concerns that BMI reporting may lead to ineffective or harmful weight-loss practices (Nihiser et al., 2007), which is partially supported by research suggesting that when parents are informed of their child's overweight status, a significant minority may implement dieting strategies without medical oversight (Chomitz et al., 2003).
From a student's perspective, BMI reporting may be perceived as a violation of privacy. Is the information kept on the public education record or as part of a medical file? If maintained as part of the education record, there is risk of the information being disclosed to unintended parties. In addition, ongoing concerns involve the self-esteem of children labeled as overweight/obese.
Children's responses will likely be impacted by the sensitivity with which weight status issues are raised by parents. To the extent that children feel "blamed" and negatively labeled, without appropriate family or school-based support for healthy behaviors, the policy could promote helplessness and increased body dissatisfaction, particularly among adolescents (Nihiser et al., 2007).
Pediatricians have mixed perspectives regarding implementation of BMI reporting. While physicians have been some of the key supporters of decisions to implement BMI reporting in school districts, they have also been vocal opponents. From the latter vantage point, reporting BMI is not considered an appropriate activity for schools. Although schools are able to document height and weight at one point in time, there is no context provided for interpreting these data.
It has been argued that pediatricians have a more thorough and educated approach to understanding BMI, including consideration of the child's personal history, family risk factors, evaluation of children's diet and activity, and access to more sophisticated strategies for measuring obesity (Ikeda et al., 2006). Current recommendations for management of pediatric overweight/obesity include specific intervention approaches depending on level of obesity and existence of co-occurring medical risk factors. Communication of BMI through a simple letter is unlikely to accurately convey the complexity of such recommendations. On the other hand, to the extent that parents pursue concerns regarding weight status with the child's pediatrician, the BMI report is potentially the beginning of a useful dialogue.
While there are some data to suggest that providing personalized BMI information serves to increase parental awareness of child overweight (Chomitz et al., 2003), there is no research examining whether BMI report cards actually have the intended effect of lowering the rate of pediatric obesity (Nihiser et al., 2007). Simply reporting on children's BMI status without an overall program to increase healthy habits is unlikely to result in positive change.
To be useful, BMI reporting should be one facet of a comprehensive program targeting healthy lifestyle, including increased opportunities for physical activity, healthy food choices in the cafeteria and vending machines, and educational campaigns (Nihiser et al., 2007). Even if an overall campaign is present, it remains imperative to establish the cost and overall effectiveness of BMI report cards in addressing obesity (Ikeda et al., 2006; Nihiser et al., 2007).
For school districts that do adopt BMI reporting policy, recommendations for effective implementation are available. If a BMI report card policy is to be enacted, it is important to provide parents advance notice as well as an option to opt-out of the reporting practice (Nihiser et al., 2007). When such a process has been used, few parents actually opt-out. In terms of a specific reporting strategy, there are some data to suggest that parents have a preference for a letter from the school nurse. Responsible reporting of BMI statistics should also consider developmental status of the child, with information for younger children directed exclusively to parents. Finally, if BMI recording and reporting is done in a responsible and sensitive manner, the confidentiality of information should be maintained and school personnel and students should not be aware of a peer's BMI or weight categorization.
The American Academy of Pediatrics has established criteria to determine whether a given health condition should be screened in schools. While the practice of BMI reporting meets some of these criteria (i.e., it is an important public health problem with a high prevalence rate, people can be trained to conduct a sensitive screen that is reliable and specific, and schools are an appropriate site for the screen), several key criteria are not fulfilled (Nihiser et al., 2007). Specifically, a referral mechanism is absent, effective treatment programs are not established or widely available, and both the overall effectiveness and cost effectiveness of BMI reporting are uncertain. Thus, the final grade for BMI report cards remains unknown.
C. Meghan McMurtry is a Clinical Psychology Intern, at the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University.
Dr. Elissa Jelalian is an Associate Professor in the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University.
Chomitz VR, et al.: Promoting healthy weight among elementary school children via a health report card approach. Arch Pediatr Adol Med 2003; 157:765-772.
Ikeda JP, et al.: BMI screening in schools: Helpful or harmful. Health Edu Res Theory Practice 2006; 21:761-769.
Nihiser AJ, et al.: Body mass index measurement in schools. J School Health 2007; 77:651-671.