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The golden mean or golden ratio – that ultimately fascinating and aesthetically pleasing proportion – is being replaced in some health circles by a cruder ratio – the body mass index, or a ratio involving height and weight. Designed to show whether a person is at risk of obesity or other health problems, BMI is making its way from the physician’s office into the health/physical education classroom. At the local level, School District 65’s practice of collecting and sharing BMI data has become a topic of concern.
Statistics show that a significant percentage of the population of Illinois is overweight, including many children. The District 65 physical fitness curriculum now emphasizes healthy living through proper nutrition and exercise. As part of the curriculum, physical education teachers at most District 65 middle schools conduct BMI screenings – weighing and measuring sixth-graders, calculating each student’s BMI and sharing that information with individual students and their parents.
The District’s BMI screening policy will be on the agenda at the March 13 meeting of the Board’s Policy Committee.
District 65 Practices and Policy
The Centers for Disease Control (CDC), the Illinois Department of Public Health and Pioneering Healthier Communities-Evanston are all concerned in some fashion about addressing the problem of childhood obesity. Studies of BMI measurement distinguish between “surveillance” – conducted to get a picture of a certain segment of a population, using aggregate BMI numbers – and “screening” – which involves collecting and sharing individual BMI data.
Last October, parental concerns about the District’s BMI screening prompted a letter from District 65 Superintendent Hardy Murphy, which included information about that part of the curriculum from Denise Rossa, the middle school Physical Education Department chair.
The letter said “Composition, Physical Activity, and Nutrition,” a chapter in the District’s middle-school physical education textbook, discusses BMI and how to calculate it.
The District uses FITNESSGRAM, “a widely utilized and respected software testing program from Human Kinetics,” Ms. Rossa said in the letter. FITNESSGRAM is also recommended by the Illinois Department of Public Health for use by public schools.
FITNESSGRAM assesses students in five health-related fitness components – cardiovascular fitness, muscular strength, muscular endurance, flexibility and body composition. The results of tests in each of these five areas tell whether a student is in the “healthy fitness zone,” said Ms. Rossa in the October letter.
After the information is compiled, it is made available to parents through a secure website, said Ms. Rossa. A letter containing this information is sent to parents who lack Internet access. Two weeks after parents are notified, at least one class session is devoted to students’ accessing their own BMI data, also through the secure website, followed by a class discussion.
The discussion of BMI data avoids mention of any student’s specific data,
Ms. Rossa said. In both instances the data is shared in a manner designed to ensure privacy and with language that is respectful and non-judgmental, she added. Reports “use carefully worded terminology … to help parents and youth understand possible risks associated with higher levels of body fatness … [and that] helps to minimize comparisons between children and to emphasize personal fitness for health rather than goals based solely on performance.”
Yet at least one outspoken parent has asked the District to reconsider whether a middle-school classroom is the best place to collect and share BMI information or whether it is possible to teach healthy living and promote a healthy lifestyle without giving that information in a classroom setting.
The place and the role of BMI screening are unclear at the national level – the CDC does not endorse the practice – as well as here.
A report on the CDC website, “Body Mass Index Measurement in Schools,” published in 2007 in the Journal of Health, found that using “school-based BMI measurement for surveillance purposes, that is, to identify the percentage of students in a population who are at risk for weight-related problems, is widely accepted.”
The study also acknowledged that “considerable controversy exists over BMI measurement for screening purposes, that is, to assess the weight status of individual students and provide this information to parents with guidance for action. Although some promising results have been reported, more evaluation is needed to determine whether BMI screening programs are a promising practice for addressing obesity.”
The report concluded that, based on the information available, “BMI screening meets some but not all of the criteria established by the American Academy of Pediatrics for determining whether screening for specific health conditions should be implemented in schools.” It also concluded that schools that use BMI screening should “adhere to safeguards to reduce the risk of harming students, have in place a safe and supportive environment for students of all body sizes, and implement science-based strategies to promote physical activity and healthy eating.”
Concern About Numbers
The District has several policies and practices to ensure privacy in screening students for BMI. But Michelle Hayes, parent of a sixth-grader at Chute and a member of the District’s Wellness Committee, spoke at the January meeting of the District’s Policy Committee in opposition to the District’s collecting and sharing BMI information.
While Ms. Hayes said she did not believe there was a breach of privacy by the District, she said, “Kids talk. If kids are given numbers in a social setting, they talk about it.
“This is an issue close to my heart. My concern is that there is a lot of focus on numbers and body shame, when the real issues – and I think the real focus of FITNESSGRAM – is healthy behavior.”
Ms. Hayes said, “Considering the amount of pressure that girls are under to be thin, what are these sixth-grade girls saying? … I don’t know that there is a way to share the numbers where it is not going to become an issue.”
Ms. Hayes also expressed worries about the District’s quantifying health-related issues into “numbers and shapes” because “I don’t know that middle-school students have the means to process this. … As a parent I do not think a student would look at anything but the numbers…. I don’t think you can do anything to undo that message. I would like my kids to get information on healthy living – without giving the numbers.”
Discussion of the topic is expected to continue at the March 13 Policy Committee Meeting.Literature on the CDC website describes the concerns of parents, legislators and others about the potential for harm posed by the screening process itself. Local medical experts consulted by the RoundTable, however, said they see the value of BMI data in assessing potential health risks but did not comment on concerns about procedures.
Value of BMI Data
Both the American Public Health Association and the Institute of Medicine endorse BMI measurement for surveillance purposes – that is, for a picture of a certain population – to monitor trends and progress in reducing childhood obesity and to identify populations at risk of childhood obesity, according to “Body Mass Index Measurement in Schools,” a 2007 article in the Journal of School Health that appears on the CDC website.
Marjorie Fujara, M.D., who has worked on the Child Protective Services Team at Stroger Hospital for the past 10+ years, told the RoundTable, “BMI is a very useful tool for assessing overall health and, specifically, a child’s degree of ‘fatness.’… I do not see how awareness of BMI would lead to unhealthy behaviors, particularly when they are learning about healthy behaviors in PE, Wellness Team, etc.”
Evonda Thomas, health director for the City of Evanston, told the RoundTable, “I would be wary of any effort to hide this information [BMI index] from someone.”
Dr. Bruce Doblin, director of Erie Family Health Clinic, told the RoundTable BMI “would be only one measure of health. … It tells you nothing about [a person’s] medical history, fitness level, mental health or family history. It tells you nothing about what medications they take, what allergies they may have, if they smoke or drink alcohol or their vaccination history. I would think these would add to the determination of a child’s health and wellness. BMI is useful as a predictor of health, but it is of very limited value as an overall comment on a child’s health.”
Dr. Fujara said, “The other advantage of using BMI is that you can follow it through a lifetime as a gauge of your overall health.”
Dr. Doblin said, “The issue is getting the most complete data set. … If we avoid collecting data at the school level, we miss out on a valuable single source of data.”
Potential Fallout: Teasing, Bullying and Skewed Body Image
But because preteens and young teens are emotionally vulnerable, and because girls in particular are sensitive about their body image, some School District 65 parents have voiced concerns that the collateral damage from collecting BMI information – particularly in a middle-school setting where bullying can be prevalent and privacy scarce – may overshadow expected health benefits.
“Challenges to BMI Measurement Programs,” one section in the article “Body Mass Index Measurement in Schools” found on the CDC website states, “some authors, parents and legislators have expressed concern that [BMI screening] might have unintended, negative consequences for youth.” Among these are teasing and bullying of overweight children and “disordered eating,” all of which can result from skewed body image, stigmatization and peer pressure.
BMI testing, particularly screening, in a school setting, it says, “might stigmatize students and lead to harmful behaviors. …Obese children are at increased risk of being teased, bullied, or socially isolated and having low self-esteem or depression. By placing heightened attention on weight, BMI measurement programs might intensify the stigmatization already experienced by many obese youth, putting them at even greater risk of being discriminated against or bullied and having psychological problems; dissatisfaction with body image; pressure to engage in harmful weight loss practices that could lead to eating disorders.”