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“Fat Letters” in Public Schools: Public Health Versus Pride

Michael R. Flaherty, DO

(doi: 10.1542/peds.2013-0926)

The American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007

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“Fat Letters” in Public Schools: Public Health VersusPride

Recently, BMI screening in public schools has stirred sharp contro-versy with the emergence of letters sent home to parents indicatingtheir child’s BMI percentile and weight category. In Massachusetts,these letters have been deemed, “fat letters,” and have appeared onlate night comedy shows, newspapers, and televised news reports.Not only has screening come under harsh criticism, but the in-creasing prevalence of obesity in our nation’s children has beenchallenged based on misinformed assumptions that BMI is an in-accurate measure of a child’s body fat. Massachusetts representativeshave submitted House Bill H.2024, which would ban that state’s de-partment 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 recommendationsregarding the collection of height and weight data or assessment ofbody 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, BMIscreening has beenmandated in all public school districts since 2009, withthe measurement of height and weight performed by school nurses andthe child’s BMI then calculated. A subsequent confidential letter (Sup-plemental Information) is mailed directly to parents indicating theirchild’s weight status and encouraging discussion with his or her healthcare provider. Arkansas was the first state to pass such a law requiringBMI measurement in its public school systems as a response to therising epidemic of childhood obesity in 2003. In 2005 and 2007, severalbills were brought to the Arkansas General Assembly that sought tocompletely eliminate BMI measurements in schools. These bills wereultimately defeated, but the original act was modified in 2007 to reducethe periodicity of BMI screenings, as well as to implement a standardizedparent refusal process.1 Similar legislation has been brought forth inOhio, based on controversies surrounding BMI measurement mandates.In states like Michigan, proposed BMI measurement requirements havebeen defeated even before implementation, furthering highlighting theneed for education and awareness.

The idea of BMI screening in public schools as a measure to combatchildhood obesity has long been overshadowed by debate and con-troversy. In 2005, the Institute of Medicine called on the federal

AUTHOR: Michael R. Flaherty, DO

Baystate Medical Center, Springfield, Massachusetts, and TuftsUniversity School of Medicine, Boston, Massachusetts

KEY WORDSBMI, mass screening, obesity

The content of this manuscript is solely the responsibility of theauthor and does not necessarily represent the official views ofBaystate Medical Center or Tufts University School of Medicine.www.pediatrics.org/cgi/doi/10.1542/peds.2013-0926

doi:10.1542/peds.2013-0926

Accepted for publication Apr 25, 2013

Address correspondence to Michael Flaherty, DO, Department ofPediatrics, Baystate Medical Center, 759 Chestnut St, Springfield,MA 01199. E-mail: michael.flaherty@baystatehealth.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

PEDIATRICS Volume 132, Number 3, September 2013 403

PEDIATRICS PERSPECTIVES

government to help design and guideBMI-measurement programs in schools.2

An extensive literature review wasperformed by the Centers for DiseaseControl and Prevention to develop asubsequent report on the purposes ofscreening, recommendations based onevidence, and safeguards needed toguide appropriate BMI-measurementprograms.3 The design of such pro-grams would be twofold: surveillanceand screening. The surveillance piecewould allow for the collection, analy-sis, and interpretation of data re-garding students’ height, weight, andBMI percentile to identify the percen-tages of students in the populationwho are obese, overweight, normalweight, and underweight. Screeningprograms would identify children atrisk for weight-related health prob-lems and notify parents to bringthe issue up with their child’s pedi-atrician.

Recent data indicate that 31.9% of USchildren and adolescents are over-weight or obese.4 The challenge ofidentifying children at risk for adultobesity and weight-related problems isfinding an accurate and reliable mea-sure of determining body fat, as well ascorrelating these measures with long-term outcomes, such as the develop-ment of coronary artery disease anddiabetes. In 2005, the US PreventiveServices Task Force found that BMIpercentile for age and gender is thepreferred measure for detecting over-weight children because of its feasibil-ity and long-term tracking with adultobesity measures.5 Many critics haveargued that BMI should not be usedbecause of its misclassification of somemuscular, athletic children. Althoughchildren with a higher lean body mass

may fall into higher BMI percentilesand be categorized as overweight, thisis relevant only for a small proportionof the population and highlights theimportance of using the value forscreening and not diagnosis.5 BMI hasbeen found to be strongly associatedwith levels of adiposity derived fromother measures, such as dual energyx-ray absorptiometry.6 Several studieshave since been conducted that haveshown that childhood BMI, especially inthe highest percentiles, correlates withadult obesity and the subsequent de-velopment of coronary artery disease.7

Critics of public school measurement ofheight and weight in children point outpotential problems with bullying, in-creased prevalence of eating disorders,and invasion of government into an is-sue felt to be strictly between familiesand their doctors. However, several ofthe most successful public health pro-grams in children have been imple-mented using the public school system.Mandatory school entrance vaccina-tions, dental examinations, and visionand hearing screening are just a fewexamples of successful initiatives aimedat keeping our children healthy andreducing problems early in their lives.BMI screening letters are an additionalawareness tool to promote conver-sations about healthy eating habits,exercise, and weight in the safety andconfidential environment of the child’shome. In Arkansas, where BMI screen-ing has been most studied, surveys ofschool personnel, parents, and over-weight adolescents have failed toidentify negative consequences over 4years of the program, including anyincreases in inappropriate dieting.1

These studies have found the percent-age of parents who signed their chil-

dren up for sports or exercise classesincreased significantly, and revealedimprovements in family diet and nutri-tion patterns.1 Although pediatriciansattempt to identify weight problemsand promote healthy lifestyles, child-hood well visits are typically conductedonly on an annual basis, necessitatingthe need for additional ways to reachparents. The labeling of BMI screeningletters as “fat letters” by the publicand media is further stigmatizing ourchildren and interfering with opendiscussions regarding healthy weightand chronic disease prevention.

There are no doubts that BMI-measurement programs are fraughtwith social and political concerns. Thereremain to be any large-scale studiesdemonstrating their effectiveness in re-ducing pediatric obesity. However, thegrowing number of children and adoles-cents seen daily in our clinics with weightmanagement issues, decreased physicalactivity, and increasing screen time isalarming. Obesity is an epidemic in ourcountry, and one that is compromisingthe health and life expectancy of ourchildren. The passage of legislation toprevent BMI surveillance and screening inour public school systems would furthercompromise efforts to track long-termBMI data, evaluate these programs, andempower parents with the knowledgeand resources to promote healthy life-styles early in the lives of their children.No parent would be proud to receivea letter stating their child is in theoverweight or obese category, but theawareness and acknowledgment thathe or she could have a weight problembegins the process of a multidisciplinaryapproach to change. It is time to put asidethis pride for the future of our children’shealth.

404 FLAHERTY

REFERENCES

1. Thompson JW, Card-Higginson P. Arkansas’ ex-

perience: statewide surveillance and parental

information on the child obesity epidemic.

Pediatrics. 2009;124(suppl 1):S73–S82

2. Institute of Medicine. Preventing Child-

hood Obesity: Health in the Balance.

Washington, DC: National Academies Press;

2005

3. Nihiser AJ, Lee SM, Wechsler H, et al. BMI

measurement in schools. Pediatrics. 2009;

124(suppl 1):S89–S97

4. Ogden CL, Carroll MD, Kit BK, Flegal KM.

Prevalence of obesity and trends in body

mass index among US children and adoles-

cents, 1999–2010. JAMA. 2012;307(5):483–

490

5. Barlow SE, and the Expert Committee. Expert

committee recommendations regarding the

prevention, assessment, and treatment of

child and adolescent overweight and obe-

sity: summary report. Pediatrics. 2007;120

(suppl 4):S164–S192

6. Lindsay RS, Hanson RL, Roumain J, RavussinE, Knowler WC, Tataranni PA. Body mass in-dex as a measure of adiposity in childrenand adolescents: relationship to adiposity bydual energy x-ray absorptiometry and tocardiovascular risk factors. J Clin Endo-crinol Metab. 2001;86(9):4061–4067

7. Freedman DS, Khan LK, Dietz WH, SrinivasanSR, Berenson GS. Relationship of childhoodobesity to coronary heart disease risk fac-tors in adulthood: The Bogalusa Heart Study.Pediatrics. 2001;108(3):712–718

FURTHER READING

1. McGonigle B. Fighting the fat letters.February 22, 2013. Available at: http://northandover.patch.com/articles/fighting-the-fat-letters. Accessed March 13,2013

2. Epstein E. Don’t label school kids, “obese”, Mas-sachusetts lawmakers say. February 27, 2013.Available at: http://news.msn.com/politics/dont-label-school-kids-obese-massachusetts-lawmakers-say. Accessed March 13, 2013

3. Massachusetts Department of Public Health.BMI screening guidelines for schools. Avail-able at: www.mass.gov/eohhs/docs/dph/com-health/school/bmi-screening-guidelines-for-schools.pdf. Accessed March 28, 2013

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