Parent reactions to a school-based body mass index screening program.(Research Article)(Report)

In the last 30 years, childhood obesity has reached epidemic proportions, doubling for preschool children and adolescents and tripling for children aged 6-11. (1-3) This epidemic's health consequences are enormous: asthma, hypertension, dyslipidemia, glucose intolerance and insulin resistance, sleep apnea, and orthopedic problems, to name a few. (2) Because childhood obesity tracks into adulthood, (4) its long-term consequences are a major public health problem.

Although many adults appear to appreciate the health risks of childhood obesity, (5,6) parents often fail to recognize their own child's overweight status. (5,7-9) As suggested by the Institute of Medicine's (IOM) Committee on Prevention of Obesity in Children and Youth, school health services could play a more prominent role in addressing the obesity epidemic by measuring each student's weight, height, and sex- and age-specific body mass index (BMI) percentile and making this information available to parents and to the student (when age appropriate). (2) Although the number of school districts conducting BMI assessments is increasing, school-based BMI measurement with parent notification remains controversial. Critics worry about stigmatization of overweight children, misinterpretation of BMI results sent home to parents, and placement of children on harmful diets. (10) Systematic reviews have highlighted the absence of research documenting the effect of screening for childhood overweight and obesity in schools. (11) However, the few published studies addressing this issue provide some initial support for the IOM's Committee on Prevention of Obesity in Children and Youth's recommendations. (2) Chomitz et al reported that parents of overweight children who were notified of their child's BMI through a school-based health report card were more likely to recognize their child as being overweight and report plans to do something about it (eg, seek medical help, make changes in the child's diet or physical activity). (7) A recent evaluation of Arkansas' statewide BMI assessment and parent notification program found that parents were generally accepting of the program and found it helpful; there was no evidence that parents placed their children on harmful diets in response to BMI screening. (12) In a Minnesota study, most parents surveyed supported school-based BMI annual assessments and the provision of this information to the child's parents. (13)

In the fall of 2004, the Leon County school system in Tallahassee, Florida, conducted BMI testing for all children in grades kindergarten through eighth. Based on age- and sex-specific BMI percentiles, children were placed into 1 of 4 categories as defined by the Centers for Disease Control and Prevention (CDC); (14) 19% were overweight, 17% were at risk of overweight, 62% were normal weight, and 2% were underweight. (15) Parents were sent letters with the child's BMI screening results in the spring of 2005. In this study, we conducted follow-up structured telephone interviews to assess parental reactions to school-based BMI screening of children falling into each of the 4 CDC weight classification groups: overweight, at risk of overweight, normal weight, and underweight.

METHODS

BMI Screening

Nursing staff from the district's health office performed screening in schools. Height was measured to the nearest 0.25 inches using a portable stadiometer (Seca 214; Seca Corp., Hanover, MD). Weight was measured to the nearest 0.5 pounds using a portable digital scale (Health-o-meter 320KL; Sunbeam Products Inc., Boca Raton, FL). The child's BMI and age- and sex-specific BMI percentile were calculated using the Epi Info's NutStat program obtained from the CDC (Atlanta, GA). (16) Children were measured and weighed facing away from the stadiometer and the scale's digital output.

Parent Notification

Children were not informed of the results of the BMI screening, but screening results were mailed home in a letter to each child's parent or legal guardian. The first page of the letter described the school's health screening program and provided each child's height, weight, BMI, BMI for sex and age percentile, and 1 of 3 summary statements about the results of the child's screening: Excess weight for age and sex (sent when the child's BMI was [greater than or equal to] 85%)--may create health risks; Underweight for age and sex (sent when the child's BMI was <5%)--may create health risks; or Average weight for age and sex (sent when the child's BMI was [greater than or equal to] 5 - < 85%). The second page of the letter described how to read the child's BMI results, including a table that provided 4 BMI percentile ranges, a label, and a recommendation (Table 1). A telephone number to call if the parent had any questions or concerns was provided. Of 17,000 letters sent home, fewer than 50 parents or guardians called to express concern over the school district's decision to conduct BMI screenings.

Parent Telephone Interviews

To gather additional information on parental reactions to school-based BMI screening, a structured telephone interview was developed. Interview questions assessed parental recall and reactions to the letter (eg, does vs does not recall ever getting the letter, recalls the child's weight status accurately vs inaccurately; pleased vs displeased with school-based BMI screening with parental notification), parental concerns about the child's weight, and parental actions taken in response to the letter, if any (eg, talked to the child, took child to the doctor, changed child's diet or physical activity), interest in wellness programs (eg, afterschool physical activity programs for the child, family cooking and exercise classes), and child (age, sex, race, free or reduced-price lunch status) and parental (age, race, sex, weight, height, marital status, education) characteristics.

All parents of Leon County school children who had undergone BMI screening were sent a postcard indicating that someone from the Florida State University College of Medicine might be calling them to get their opinions about the BMI screening program.

Parent Sample Selection

Based on their age- and sex-specific BMI percentile, children were placed into 1 of 4 groups: underweight (< 5th percentile), normal weight ([greater than or equal to] 5th - < 85th percentile), at risk of overweight ([greater than or equal to] 85th - < 95th percentile), and overweight ([greater than or equal to] 95th percentile). Equal numbers…