School Reporting of BMI to Parents: Helpful, Intrusive or Dangerous?
Although knowing may be half the battle, providing knowledge of a child’s weight to parents via school-based programs is a tactical quagmire in the fight against obesity. In 2003, the US State of Arkansas made history with controversial legislation requiring BMI screening of children in schools and subsequent reporting to parents. The editorial in Pediatrics today discusses more widespread uptake of school reporting of child obesity to parents (Flaherty).
The idea behind school-based BMI screening is based both on the successful implementation of other public health-related programs via schools, and findings that parents often are not aware of whether their child’s weight is healthy (see a review from Cloutier, and recent reports of this phenomenon from Heimuli, De La O, and Hudson). However, there are some critics of the programs. Parents are concerned about the intrusions of government and schools into the private sphere, potential increases in eating disorders and bullying, and the misclassification of children using BMI. In 2005, the US Preventive Services Taskforce found a lack of data on the effectiveness of school-based interventions in reducing the rate of obesity. In the meantime, the experience in Arkansas has started to provide some data on whether these programs are effective.
A key publication on the Arkansas program reports on the first four years of the voluntary program. Data are reported for each of the four years. Over 90% of parents approved their child’s participation, however due to absences only around 85% of students participated in any given year. Awareness of the BMI measurements by parents increased over four years, and 95% of parents read at least some of their child’s BMI report. The most significant changes appear to be at the school level; access to and number of vending machines decreased, and policies regarding physical activity improved. Parents offered fewer discretional calories in the form of soft drinks, chips or sweets, and parents limited child screen time to encourage physical activity. Students also reported an increase in physical activity. The survey did not find increases in unhealthy diet behavior or concern about weight among students that were healthy. There was in fact a decline in the number of parents who reported that they put their child on a diet during the survey. Although one report seems to indicate that the prevalence of overweight and obesity increased between 2003 and 2007 in Arkansas (Singh, Kogan and van Dyck), it was based on self-reported data. Self-reported data tends to underestimate weight; being provided with annual reports of weight is likely to increase weights reported. Actual measurements made during the program indicated that the prevalence of overweight and obesity remained steady (Arkansas Center for Health Improvement) at a time when overall prevalence of obesity increased nationally.
The BMI measurement is relatively simple, requiring equipment that is easy to obtain and use. The measurement can also misclassify people with a muscular build as obese. In a study of adolescent athletes, this was found to be the case to a small extent. Etchison and colleagues report that of almost 34,000 student athletes aged 11 to 19, 13% were classified as obese according to BMI, whereas only 6% were obese using the more specific skinfold measurement. This means that only 7% of athletes were misclassified. In the non-athletic population, the percent misclassified is likely to be much lower. Concerns about classifying muscular children as obese are unfounded, and also addressed in information to parents.
A school-based BMI screening program is not a silver-bullet solution in obesity prevention. Although adverse effects of the program have not been found, the cultural context in which personal information related to obesity is important and potential unintended effects should continue to be monitored to answer the question more definitively. BMI screening programs do offer a good opportunity to identify students at risk of obesity, advise parents, and monitor trends in childhood obesity. Obesity screening can be a useful addition to a comprehensive program to reduce overall obesity levels in a population.
Michael R. Flaherty. “Fat Letters” in Public Schools: Public Health Versus Pride. Pediatrics peds.2013-0926; published ahead of print August 19, 2013, doi:10.1542/peds.2013-0926
Cloutier MM, Lucuara-Revelo P, Wakefield DB, Gorin AA. My Weight Ruler: A simple and effective tool to enhance parental understanding of child weight status. Prev Med. 2013 Jul 17. pii: S0091-7435(13)00256-9. doi: 10.1016/j.ypmed.2013.07.014. [Epub ahead of print]
De La O A, Jordan KC, Ortiz K, Moyer-Mileur LJ, Stoddard G, Friedrichs M, Cox R, Carlson EC, Heap E, Mihalopoulos NL. Do parents accurately perceive their child's weight status? J Pediatr Health Care. 2009 Jul-Aug;23(4):216-21. doi: 10.1016/j.pedhc.2007.12.014. Epub 2008 Mar 4.
Fitzgibbon ML, Beech BM. The role of culture in the context of school-based BMI screening. Pediatrics. 2009 Sep;124 Suppl 1:S50-62. doi: 10.1542/peds.2008-3586H.
Heimuli J, Sundborn G, Rush E, Oliver M, Savila F. Parental perceptions of their child's weight and future concern: the Pacific Islands Families Study. Pac Health Dialog. 2011 Sep;17(2):33-49. 10.1016/j.pedhc.2007.12.014. Epub 2008 Mar 4.
Hudson E, McGloin A, McConnon A. Parental weight (mis)perceptions: factors influencing parents' ability to correctly categorise their child's weight status. Matern Child Health J. 2012 Dec;16(9):1801-9. doi: 10.1007/s10995-011-0927-1.
Singh GK, Kogan MD, van Dyck PC. Changes in State-Specific Childhood Obesity and Overweight Prevalence in the United States From 2003 to 2007. Arch Pediatr Adolesc Med. 2010;164(7):598-607. doi:10.1001/archpediatrics.2010.84.