The Centers for Disease Control and Prevention (CDC) reports that more than one-third of children and adolescents in the United States are considered overweight or obese, a condition that can lead to asthma, high blood pressure, diabetes and other physical illnesses. The CDC reports further that 70 percent of obese children had, at minimum, one risk factor for cardiovascular disease and 39 percent had two or more. In some states, school systems have been introducing body mass index (BMI) report cards as a means of evaluating and monitoring a child’s weight. Although well intentioned, these reports are drawing a mixture of kudos and criticism.
In April 2009, Massachusetts established a BMI screening initiative for children. Four years later, school nurses in 160 schools in the Essential School Health Services (ESHS) districts conducted these screenings on 190,865 students in grades 1, 4, 7 and 10. The findings show that 32.2 percent of the students screened were overweight or obese (16.0 percent were obese; 16.2 percent were overweight), according to the Massachusetts Department of Public Health.
Renee Bazinet-Nelson, Psy.D. director of adolescent intensive outpatient programs at Walden Behavioral Care, cautions that these reports should not be viewed as stand-alone documents, but rather should be considered as one factor on a historic timeline. “You need to look at where the child falls on a growth chart with regard to height, weight and BMI. If the child is on the high end, but his eating is normalized, this might be where his natural body weight is,” she says.
Recommending a child lose weight without considering all the other factors could be counter-productive and may lead to an eating disorder. “Having a little bit of information and extrapolating without knowing the full story is not good. One indicator can oversimplify the status,” Bazinet-Nelson says. Furthermore, predicting psychological repercussions of the BMI report cards is dependent on a variety of factors and therefore, difficult to do.
Depending on the situation, some parents have reacted negatively to the idea of BMI screening, while others find the measurement useful. “Some parents might be feeling disempowered and feel that the school is taking on the parents’ role, although for others it could be a helpful eye opener,” Bazinet-Nelson says. “Sometimes it’s hard for parents to see a mental health diagnosis or an eating disorder so it’s helpful for someone else to say there’s a problem. It could be what gets a child into treatment or clued in to something else that’s going on in the child’s life.”
To reduce the risk of problems with parents, Jaci Van Heest, Ph.D., an exercise physiologist and associate professor in the NEAG School of Education at the University of Connecticut, recommends that schools counsel parents before the BMI letters are sent home. In Massachusetts, parents received a pre-screening notice from the school, informing them of the process and explaining what the measure is, why and how is it being done. The letter provided contact information and a state Web site if parents have additional questions or concerns. Parents could opt out of the screening if they choose.
In spite of prior notice, there may still be parental pushback, which Van Heest attributes to personal experience. “Parents with children who have weight issues tend to have weight issues themselves. They may have gone through stigmatization as kids and adults. The BMI report card becomes a ‘grade’ of the child and of them. It brings back countless negative memories and emotions,” she says. “There’s also a group of parents who don’t feel the schools should be in the business of medicine. [The reasons for pushback] run the gamut from very personal to theoretical.”
Additionally, Van Heest believes a BMI screening program can only be successful if resources, i.e., personnel, programs and financial aid, are available for follow up. “My view of the world is collaboration. There should be a clear sense of role and where expertise ends. School psychologists should be very much a part of the group. They may not be an exercise programmer, but they could run a behavioral program. The responsibility should not be in the lap of any single person. There should be a team inside and outside the school to serve both ends,” Van Heest says. “If a school makes a decision to do BMI, there has to be run-up before of resources and a team of outside support. It’s a resource heavy endeavor.”
Van Heest thinks BMI screenings are a good idea overall. “If you look around, there are many medical groups that support it, but like any type of report card, it can be fraught with risks,” she says.
Given the fact that between 80 to 90 percent of children who are overweight by age 12 will be overweight as adults, some type of early intention could be beneficial, according to Van Heest. She says, “You start to develop co morbidities if you wait to address the problem. It’s better to change behavior before it is more ingrained.”
As New England Psychologist went to press, parental opposition to the BMI report cards prompted the Massachusetts Public Health Council to nix the program on Oct. 16. However, schools in the Commonwealth will still be mandated to collect student weight and height measurements for students in grades 1, 4, 7 and 10. Parents who want access to this information must present a written request to the school.
One issue related to the letters was breach of confidentiality. To reduce expenses, some schools opted to send the letters home with the students rather than mailing them. In some cases, that information became public and led to teasing and embarrassment. Sensitive to potential confidentiality issues, the Public Health Council issued a provision that local school committees or boards of health may implement safeguards to protect the information. And, some health organizations and nurses continue to voice support for the program.
Mark J. Gorman, Ph.D., staff psychologist at the MGH Weight Center and at the Behavioral Medicine Service at Massachusetts General Hospital, explains that what the schools and parents do with the information they receive post-screening is critical to the success of the program and for the child’s health. “The schools shouldn’t send a letter home without some information or guidance about healthy weight management. You’d want to make sure that BMI information doesn’t result in parents over-restricting food, but that ultimately they discuss the BMI results with their child’s doctor,” he says.
Furthermore, Gorman explains that obesity, which is a complex disorder, is often misunderstood. “Some people view obesity as eating too much or exercising too little,” he says, but notes that the condition is complicated by environmental, psychosocial, medical and genetic factors. “We have to help people understand this to remove some of the stigma.”
While screening for BMI in the schools may have its benefits, Gorman says that the issue is multifaceted. “There is a lot of room for further investigation before drawing any conclusions,” he says.
By Phyllis Hanlon