Recently, BMI screening in public schools has stirred sharp controversy with the emergence of letters sent home to parents indicating their child’s BMI percentile and weight category. In Massachusetts, these letters have been deemed, “fat letters,” and have appeared on late night comedy shows, newspapers, and televised news reports. Not only has screening come under harsh criticism, but the increasing prevalence of obesity in our nation’s children has been challenged based on misinformed assumptions that BMI is an inaccurate measure of a child’s body fat. Massachusetts representatives have submitted House Bill H.2024, which would ban that state’s department of public health from collecting any data on height, weight, or calculating BMI in public school children.
Currently, 21 states have enacted policies or made recommendations regarding the collection of height and weight data or assessment of body composition in public schools (Alabama, Arkansas, California, Florida, Georgia, Illinois, Kentucky, Maine, Massachusetts, Mississippi, Missouri, Nebraska, Nevada, New York, New Jersey, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, West Virginia). In Massachusetts, BMI screening has been mandated in all public school districts since 2009, with the measurement of height and weight performed by school nurses and the child’s BMI then calculated. A subsequent confidential letter (Supplemental Information) is mailed directly to parents indicating their child’s weight status and encouraging discussion with his or her health care provider. Arkansas was the first state to pass such a law requiring BMI measurement in its public school systems as a response to the rising epidemic of childhood obesity in 2003. In 2005 and 2007, several bills were brought to the Arkansas General Assembly that sought to completely eliminate BMI measurements in schools. These bills were ultimately defeated, but the original act was modified in 2007 to reduce the periodicity of BMI screenings, as well as to implement a standardized parent refusal process.1 Similar legislation has been brought forth in Ohio, based on controversies surrounding BMI measurement mandates. In states like Michigan, proposed BMI measurement requirements have been defeated even before implementation, furthering highlighting the need for education and awareness.
The idea of BMI screening in public schools as a measure to combat childhood obesity has long been overshadowed by debate and controversy. In 2005, the Institute of Medicine called on the federal government to help design and guide BMI-measurement programs in schools.2 An extensive literature review was performed by the Centers for Disease Control and Prevention to develop a subsequent report on the purposes of screening, recommendations based on evidence, and safeguards needed to guide appropriate BMI-measurement programs.3 The design of such programs would be twofold: surveillance and screening. The surveillance piece would allow for the collection, analysis, and interpretation of data regarding students’ height, weight, and BMI percentile to identify the percentages of students in the population who are obese, overweight, normal weight, and underweight. Screening programs would identify children at risk for weight-related health problems and notify parents to bring the issue up with their child’s pediatrician.
Recent data indicate that 31.9% of US children and adolescents are overweight or obese.4 The challenge of identifying children at risk for adult obesity and weight-related problems is finding an accurate and reliable measure of determining body fat, as well as correlating these measures with long-term outcomes, such as the development of coronary artery disease and diabetes. In 2005, the US Preventive Services Task Force found that BMI percentile for age and gender is the preferred measure for detecting overweight children because of its feasibility and long-term tracking with adult obesity measures.5 Many critics have argued that BMI should not be used because of its misclassification of some muscular, athletic children. Although children with a higher lean body mass may fall into higher BMI percentiles and be categorized as overweight, this is relevant only for a small proportion of the population and highlights the importance of using the value for screening and not diagnosis.5 BMI has been found to be strongly associated with levels of adiposity derived from other measures, such as dual energy x-ray absorptiometry.6 Several studies have since been conducted that have shown that childhood BMI, especially in the highest percentiles, correlates with adult obesity and the subsequent development of coronary artery disease.7
Critics of public school measurement of height and weight in children point out potential problems with bullying, increased prevalence of eating disorders, and invasion of government into an issue felt to be strictly between families and their doctors. However, several of the most successful public health programs in children have been implemented using the public school system. Mandatory school entrance vaccinations, dental examinations, and vision and hearing screening are just a few examples of successful initiatives aimed at keeping our children healthy and reducing problems early in their lives. BMI screening letters are an additional awareness tool to promote conversations about healthy eating habits, exercise, and weight in the safety and confidential environment of the child’s home. In Arkansas, where BMI screening has been most studied, surveys of school personnel, parents, and overweight adolescents have failed to identify negative consequences over 4 years of the program, including any increases in inappropriate dieting.1 These studies have found the percentage of parents who signed their children up for sports or exercise classes increased significantly, and revealed improvements in family diet and nutrition patterns.1 Although pediatricians attempt to identify weight problems and promote healthy lifestyles, childhood well visits are typically conducted only on an annual basis, necessitating the need for additional ways to reach parents. The labeling of BMI screening letters as “fat letters” by the public and media is further stigmatizing our children and interfering with open discussions regarding healthy weight and chronic disease prevention.
There are no doubts that BMI-measurement programs are fraught with social and political concerns. There remain to be any large-scale studies demonstrating their effectiveness in reducing pediatric obesity. However, the growing number of children and adolescents seen daily in our clinics with weight management issues, decreased physical activity, and increasing screen time is alarming. Obesity is an epidemic in our country, and one that is compromising the health and life expectancy of our children. The passage of legislation to prevent BMI surveillance and screening in our public school systems would further compromise efforts to track long-term BMI data, evaluate these programs, and empower parents with the knowledge and resources to promote healthy lifestyles early in the lives of their children. No parent would be proud to receive a letter stating their child is in the overweight or obese category, but the awareness and acknowledgment that he or she could have a weight problem begins the process of a multidisciplinary approach to change. It is time to put aside this pride for the future of our children’s health.
- Accepted April 25, 2013.
- Address correspondence to Michael Flaherty, DO, Department of Pediatrics, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199. E-mail:
The content of this manuscript is solely the responsibility of the author and does not necessarily represent the official views of Baystate Medical Center or Tufts University School of Medicine.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Thompson JW,
- Card-Higginson P
- ↵Institute of Medicine. Preventing Childhood Obesity: Health in the Balance. Washington, DC: National Academies Press; 2005
- Nihiser AJ,
- Lee SM,
- Wechsler H,
- et al
- Barlow SE
- Lindsay RS,
- Hanson RL,
- Roumain J,
- Ravussin E,
- Knowler WC,
- Tataranni PA
- Freedman DS,
- Khan LK,
- Dietz WH,
- Srinivasan SR,
- Berenson GS
- McGonigle B
- Epstein E
- Massachusetts Department of Public Health. BMI screening guidelines for schools. Available at: www.mass.gov/eohhs/docs/dph/com-health/school/bmi-screening-guidelines-for-schools.pdf. Accessed March 28, 2013
- Copyright © 2013 by the American Academy of Pediatrics