School-based BMI Screening to Prevent Childhood Obesity
By Ann Johnson, MSN, CSN
In 2005, the Institute of Medicine released its report Preventing Childhood Obesity: Health in the Balance stating that childhood obesity is a critical national health problem which requires an immediate population-based preventive approach to curb the ever-increasing number of overweight children. A solution to the obesity epidemic will require action on the part of families, schools, industry, communities, and government. Five years prior to the release of this report, school nurses and administrators in a school district in Pennsylvania had already launched a school initiative to address the issue of childhood obesity.
In the fall of 2000, the East Penn School District in Emmaus, PA, set in motion a process to establish a wellness program for students. At the center of the initiative was a plan to expand annual growth screening, which consisted of measuring each child's height and weight, to include:
- calculating individual Body Mass Index (BMI) for each child
- determining each child's BMI percentile for gender and age
- reporting the information to each child's parents by means of a letter mailed home
The goal was to increase awareness of childhood obesity and identify individual children who may require further assessment by their family healthcare provider. The district has accrued six years of experience screening and reporting BMI percentiles to parents, an initiative that was initially met with criticism and resistance. Data collected each year indicates a decrease in the mean number of students with BMI percentiles > 95% (See Table 1). Because of the success of the program, I would like to share our rationale, strategies, and materials so that other school communities may utilize them.
The U.S. public school system provides an ideal setting for population-based health screening of children and adolescents. The purpose of this screening is to increase the level of health in the population by identifying early on those individuals who may require individual attention for a specific problem, before it requires an intensive and costly intervention. A health screening is meant to be the catalyst for further assessment, not a definitive diagnosis, nor a solution. Mass screening of children may also reduce disparities in access to health care. In many instances, contact with the school nurse is the only time a child sees a healthcare professional, particularly in the mid-childhood and adolescent years.
Precedence exists for school-based mass screenings: 70% of states require annual vision and hearing screening of all students; 45% screen for scoliosis; 17% require oral health screening; and 26% routinely measure height and weight, and sometimes BMI.1 The screening, tracking and reporting of BMI can identify a problem that has the potential to negatively impact every aspect of a developing child's life. Schools generally have facilities and health personnel trained to conduct health screenings with accuracy and confidentiality. To conduct BMI screening, the school may need to purchase stadiometers and digital scales to increase accuracy of measurements. Tools to calculate BMI and plot BMI percentile are readily available free of charge online or for purchase. Age- and gender-specific BMI percentile charts are available from the Centers for Disease Control.
We have found that a cumulative, annual report of a student's height, weight, BMI and percentile range is an effective means to communicate important information to parents. Parents of overweight or obese children do not always recognize their child's weight status and many are unaware of the adverse consequences of overweight.2 There is evidence that parental notification of height, weight, and BMI status increases awareness and the probability that they will take action, although it does not necessarily increase the probability that parents will make changes in lifestyle.3
A recent study found considerable parental support for school-based BMI screening and written parental notification programs. Almost all of the parents who received a BMI letter reported reading all or most of the letter, indicating that an individualized letter is an effective means to engage parents in reflecting on their child's health status.4 The letters utilized by the East Penn School District to notify parents of their child's BMI status have proved to be a useful tool in increasing parental awareness and in tracking a child's development over time. If community resistance is anticipated, parents may be offered the option not to be notified of their child's screening results. This may prevent unintentionally alienating families who may be most in need of supportive health advisement.
A school-based BMI screening program must occur within the context of partnerships with parents, healthcare professionals and the community. It is critical to enlist administrative support in order to develop a sustainable wellness program to support the screening process. A BMI screening program should be preceded by a multi-faceted educational drive to inform parents of the purpose and rationale for the screening. Schools need to be prepared to develop comprehensive resources — including lists of qualified health care professionals — for referrals of children and their parents once a problem is identified. Conversely, parents and older students can become advocates for changes in their schools and communities that will support healthy eating and increased physical activity for children. Ongoing educational efforts based on current research and treatment developments must be made available to families and students to support changes in lifestyle.
Editor's Note: An article on the East Penn School District's BMI screening program was published in the November/December 2006 issue of Nutrition Today. To purchase a copy of "School-Based Body Mass Index Screening Program" by Ann Johnson, MSN, CSN and George A. Ziolkowski, PhD, go to http://nutritiontodayonline.com
Ann Johnson, MSN, CSN, has been a school nurse in the East Penn School District for the past 9 years.