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The spring round of body-mass index (BMI) testing – the ratio between a student’s height and weight – in the schools is just a few weeks away. School District 65 Head of Physical Education Denise Rossa updated the Board on how the District will protect students’ privacy and reach out to families whose children are deemed at risk of developing health problems.

About a year ago, several Board members, parents and health-care professional raised strong objections to the District’s BMI testing because of the lack of privacy in revealing the results, the potential for bullying and actual bullying that occurred in some schools, the absence of strong proof that BMI testing produces positive results, and the fact that the District had no meaningful follow-up for children found to be at risk.

The Board therefore directed that the program not be expanded, that steps be taken to ensure students’ numbers are kept private, and that the District develop ways to connect families without doctors with health-care providers.

Measuring BMI is one part of the Fitnessgram software program the District uses in its middle-school health/physical education curriculum. The Fitnessgram program assesses students in five health-related fitness components – cardiovascular fitness, muscular strength, muscular endurance, flexibility and body composition, the results of which place a student in the “healthy fitness zone,” or “needs improvement’ or has a “health risk.”

At the beginning of the year, parents received a packet of information about the Fitnessgram testing, including an “opt out” form for the BMI segment.

Measuring the Students

This year, Ms. Rossa said, teachers were trained, scales calibrated and equipment coordinated. Two teachers – one to supervise, the other to measure – were assigned to the weighing of each student; social workers were on call for support as needed. Information is then shared with parents mostly through a secure website but by letter to families without Internet connection, she said.

This process, with its individualization and sharing of information on a personal basis, is called “BMI screening.” A less personalized procedure, involving weighing and measuring but not sharing individual information, is called “BMI surveillance,” and is used to track trends in obesity, health risks, etc.

The Centers for Disease Control (CDC) endorses BMI surveillance for schools. It strongly cautions against BMI screening in schools, however, because of the risk of teasing, bullying and stigmatization. The CDC emphasizes that a school implementing BMI screening should have a strong anti-bullying curriculum and other safeguards in place. Ms. Rossa said teacher-training in the fall contained a bullying component.

The District compiles and crunches the data from all the Fitnessgram tests and produces a spectrum from “healthy fitness zone” to “health risk.” Families receive the data within about two weeks.

“Based on what the Board had asked last year – that we ensure privacy – we sent an email to parents” with information about how to log onto a secure website to obtain their children’s information, said Ms. Rossa. Families without Internet access receive a letter, she said. After that, each class discusses “why we do [the testing], staying healthy and getting healthy,” said Ms. Rossa. “We want to have the discussion as part of the curriculum. The general discussion is basically self-reflection.”

Even students who have opted out of the BMI testing, she said, “can still talk … about being healthy. … No scores are given to anybody; we’re not having any personal comments.” Ms. Rossa said students learn the difference between BMI and body composition, a “much more accurate way” to get a picture of one’s condition. Students, she added, can ask questions either in class or privately with a teacher.

The Data

Ms. Rossa presented data that showed that of the 2,055 students eligible for testing last fall, 1,988 were tested and 117 opted out. Across the District, she said, about a third of those tested did not make it to the Healthy Fitness Zone: 11 percent “need improvement” and 22 percent were at a “health risk.”

 “We’re concerned about the ‘health risk’ category because that’s where we fall into the risk of preventable diseases associated with obesity,” Ms. Rossa said. “The fact that twice as many students are in the ‘health risk’ category … is very scary to me.”

Ms. Rossa said, though, that some students move into the healthy fitness zone over the course of the year, and she is eager to compare the spring data with next fall’s to see what effect summer activities have on students. “I’m very interested I seeing what the larger trend is and … in seeing what we can do with the curriculum [once that data is provided].”

Bullying

Ms. Rossa said she believed the fall testing was generally without incidents of bullying. “I wasn’t made aware of any bullying situations. I was made aware of some self-esteem issues in the fall. … As for bullying, it makes it more important for us is to say, ‘Healthy comes in all shapes and sizes.’”

Board President Tracy Quattrocki asked if Ms. Rossa were aware of an issue arising at about the same time the spring BMI testing is to take place. Ms. Quattrocki said, “On the Nichols [Middle School] list-serve [now] there is a lot of parent chatter about weight-related bullying. … [T]hey’re calling a special PTA meeting because of the concerns of parents about students being singled out because of their weight.” Ms. Quattrocki suggested that Ms. Rossa or a member or her staff attend the Nichols meeting and explain the District’s procedures.

Ms. Quattrocki said the log-ins and passwords used by parents are shared or easily discovered. She said last year the Board said it “wanted to do as Evanston Township High School does, which is either send a letter or an email to the parents, so it would be a one-time thing [that is, not posted on a website], because I have heard from middle-school students that they know each other’s passwords and they get a look at each other’s numbers. … It seems that this is a weakness in the procedure.”

Board member Richard Rykhus suggested that Ms. Rossa and her staff find ways to make the log-ins and passwords more secure.

 “Can you give [parents] another log-in?” asked Ms. Quattrocki.

“I think that’s a great idea, but it’s not my call,” said Ms. Rossa.

Assistant Superintendent Susan Schultz said the District can work with Fitnessgram on that issue.

Notifying Parents

Parents of students in the “needs improvement” – 215 students – or “health risk” – 434 students – categories will receive letters, said Ms. Rossa. Board members pored over the proposed letters to parents – both the informational one to be sent in the fall and the proposed notification of the results –and some focused on two aspects they felt were either inappropriate or inaccurate.

The proposed notification letter stated in part: “…     [C]hildren in these 2 categories need to be evaluated by a pediatrician, as a high BMI is associated with increased risk for cardiovascular disease, diabetes, cancer and other medical problems, and a low BMI may be associated with eating issues.”

The proposed informational letter promised, “If the PE staff and/or school social worker (ssw) are concerned about the … results of the Fitnessgram for your child, the ssw will contact you and review their concerns. … Additionally, you will be personal contacted by the PE teacher if results show that a student’s health is significantly at risk based on the data analysis. At that time, immediate medical follow-up will be recommended, and you will be directed to the Coordinator of Health Services if your child does not already have a health-care provider and you would like assistance in finding one.”

Board member Candance Chow, who last year had pushed for the District to connect families to health-care providers when needed, said, “I would be very curious, when you send these letters, [to know] how many referrals you actually make.”

Ms. Quattrocki said she had a question about “a letter coming from a PE teacher telling [parents] that their child is at risk for cancer or diabetes.” She said, “That seems like the reach of the health-care professional. I could imagine saying ‘You need to talk to your pediatrician or your health-care professional’ … but to actually spell out cancer, diabetes and cardiovascular health risks … seems inappropriate for a gym teacher.”

Ms. Rossa said the two physicians on the Steering Committee (see sidebar, page 30) had requested that language.

Board member Suni Kartha, a member of the Steering Committee, echoed that both physicians had requested that language and said, “I think they felt strongly that there needed to be [the message], ‘This is something that you need to have checked.’”

Ms. Quattrocki and Mr. Rykhus also said they felt the District needed to be “more proactive” about connecting families to health-care professionals. “Since a main focus last spring was connection and trying to help kids … truly at risk … it seems to me we need to be a little more proactive than saying, ‘Call the school if you don’t have a doctor.’ It might take outreach from the nurse or someone. … Are we just waiting for [parents] to call the school, or is there anything more?”

Ms. Rossa said, “We haven’t sent the letter yet, and it is something that we can, yes, look at.”

Mary Larson, RN, BSN, ILCSN, coordinator of Health Services for D65, said, “Health services are a part of every school. We do referrals all the time. When somebody fails vision screening, they can contact us if they don’t have a doctor. With hearing screening, we’ve got things set up. … [Y]ou don’t want to keep hounding people. … But are you asking that we call everybody to see if they have a physician? I’m not quite sure how you want us to reach out to them.”

“I’m not quite certain,” said Ms. Quattrocki. “I’m just wondering if you have a plan.”

“We have a list of physicians who take private insurance and AllKids [insurance]. They’re not recommendations. They’re just area physicians. People can look at them and decide what they want to do.”

“But you’re waiting for the call?” asked Ms. Quattrocki.

“For the most part, yes,” said Ms. Larson.

  “We reach out by forming relationships, and we depend on the PE teachers for those relationships,” said Ms. Larson. “We can see how it evolves. … I think getting the [information out] and seeing how people respond to it will help lead the path,” said Ms. Larson.

“If you have 22% [at risk], that’s something you should really look at,” said Board member Claudia

Garrison. She suggested this sort of needed connection between the District and families needing health-care professionals could become part of the Evanston Cradle-to-Career Initiative.

“So are you suggesting calling everyone who is in that 22% and asking if they have a physician?” asked Ms. Kartha. “Because you’re presuming they don’t have one.”

Ms. Quattrocki said, “I think if you are in the process of trying to identify the kids you feel are the most in need, you might be reaching out to the parents, saying, ‘Are there resources you need? Do you have a physician?’”

Ms. Chow referred to the section of the letter saying parents would be contacted by a PE teacher if the results of the Fitnessgram testing show a child at risk. “Isn’t that what’s going to happen?” she asked. “[Ms. Rossa], the letter is coming from you, so what’s the intent – to have the PE teachers call?”

Ms. Rossa said that, while the next step is to reach out, “We have decided it’s not the PE teachers’ qualification to decide [and make the call].” She said there was some concern about what would be said and how it would be said.

So are you changing the letter?” asked Ms. Chow. “Because it shouldn’t say that if you’re not going to make the call.”

Ms. Schultz said the PE teachers said they did not feel comfortable about making the calls, and the “personal contact” would be the letter itself. She said, “They aren’t calling all of them. The letter will let them know … that they would have an opportunity to contact the [PE] teacher if they do not have medical [insurance]. … The only other option we have is what Ms. Kartha says: We call all these parents and say, ‘Do you or do you not have a doctor? Can we recommend one?’ And I don’t think we are ready to do that at this time. I think we should go … at least through the end of the year … with this letter and see what happens, how many of the parents reach out to us.”

“The letter does need to be clarified,” said Mr. Rykhus. “There was agreement, I thought, last spring, about the importance of connecting [families] to a health-care professional. And I get it that some may have [one] and others may not, but that was an important focus of the conversations. … And since the point of this was if these kids’ health is at risk, we do what we can to help them and not just wait for a phone call [from a parent].”

Mr. Rykhus continued, “So I’m wondering if the Steering Committee would be willing to just revisit how we might be more proactive to reach out to these families of children at risk. At a minimum you could include referrals in a letter, if you can’t make the calls – as well as a phone number.”

Board member Katie Bailey thanked Ms. Rossa and the Steering Committee for their work and said she supported Mr. Rykhus’s call for adding referrals to the parent-notification letter.

“It sounds like we’ve done a lot of work and we’re getting the procedures to be uniform and we’re collecting data and … making the connection to health-care professionals and monitoring the students’ … potential bullying problems,” said Ms. Quattrocki. “It sounds like next year will be the first year we’ll be able to capture data [to see whether this] is paying off. So I assume that until we have the data telling us it’s working, we are not going to expand the program.”