Arkansas' School BMI Assessment

The Center for Safe and Healthy Schools has released a new Policy Brief detailing Arkansas' BMI assessment program and the most recent reports and data.

Overweight young people face an increased risk of developing hypertension, diabetes, heart disease, and other life-threatening illnesses as they age. Arkansas has pioneered a program to systematically assess the weight of every public school student each year and report the results to parents or guardians. Praised for its methodologi- cal rigor, Arkansas’s database is providing the broadest and most precise state profile of the epidemic of childhood obesity in the nation. This information provides a useful baseline by which efforts to address the obesity problem can be measured.

The program is increasingly considered a model for other states. In 2005, the Arkansas School BMI Assessment Project was chosen one of 10 nationwide winners of the Innovation in Prevention Awards presented bythe U.S. Department of Health and Human Services.

What is BMI?

Body mass index (BMI) is a ratio of weight and height that also takes into account gender and age; it is considered a better assessment of obesitythan weight alone. BMI percentiles are used to categorize children according to whether they are underweight, healthy weight, at risk for overweight, or overweight (public health authorities do not use the term “obese” when referring to children). A BMI assessment is only a rough screening tool and further evaluation by a health professional isnecessary to determine whether or not an individual child has a weight problem that requires attention.

In a 2003 policy statement, the American Academy of Pediatrics recommended that every child every year have his or her BMI assessed.The Institute of Medicine in a 2005 report also recommended that schools conduct annual BMI assessments and make this information available to parents. So far, Arkansas is the only state to establish amandatory program in K-12 public schools.

The Arkansas Program

Annual BMI assessment is one part of a multi-pronged initiative established by the General Assembly in 2003. Act 1220 also created schoolnutrition andphysical activity committees, banned vending machines in elementary schools, required public disclosure of vending contracts inother schools,and established the Arkansas Child Health Advisory Committee.

Responsibility for conducting the program was given to an independent health policy organization, the Arkansas Center for Health Improvement (ACHI). To work out the standardized measurement proceduresand implementation strategies, ACHI convened a BMI Task Force in partnership with the Arkansas State Board of Educa- tion,Department ofEducation, Department of Health and Human Services, local school districts, Arkansas Children’s Hospital, and the University ofArkansas’ Collegeof Public Health. ACHI supplied every school with the necessary equipment (scale and stadiometer) in the first roll-out year. Certified Community Health Nurses in each educationalco-op (intermediate school district) train school health nurses and any other school personnel responsible for assessment in the appropriate methods to collect assessment data. School districts are responsible for staff costs and replacing equipment as it wears out.

According to reports published by ACHI, the initiative was initially piloted at 11 schools, and was very quickly scaled up to involve 94% of Arkansas schools and more than 426,000 students in the 2003-04 schoolyear. The proportion of participating schools has since climbed to nearly 99%. Aggregated results that are broken down by year, school district, and school can be publicly accessed online at www.achi.net.

Confidential Child Health Reports are generated for each student’s parent or guardian and made available through schools. The reports explainwhy Arkansas assesses students’ BMI levels, describe the BMI screening process, educate parents about potential obesity-related health risks facing their children, and provide simple suggestions to help families improve nutrition and increase physical activity. Depending on the student’s information, the report includes the student’sheight,weight, and BMI and a classification as underweight, healthy weight, at risk for overweight, overweight, or unable to assess.

Results

Reliable calculations of BMI were obtained for 86% of students in the 2005-06 school year. Mismeasurement accounted for less than 1% of the unassessed students, a truly impressive achievement given the logisticaland training challenges. The most common reason for lack of a calculated BMI was absence from school on the assessment day (7% of students). Only 3% of parents refused their child’s participation, and another 3% of students refused to participate.

When they were first reported in 2004, the results of the BMI assessment program garnered much media attention because a higher proportionofArkansas students were overweight than was previously appreciated by the general public, although results were broadly consistent with national trends. In the 2005-06 school year:

• Only 61% of the state’s students’ weight were considered to be healthy for their height and age;
• More than 20% of students were in the 95th BMI percentile or above, which by definition should include only 5% of students (this categoryiscalled “overweight” for young people and would be considered “obese” among adults);
• Another 17% of students were in the 85th to 94th BMI percentiles, considered “at risk for overweight;” and
• About 2% of students were underweight for their age. Looking across different student groups, 52% of Hispanic students were found to be a healthy weight, compared to 57% of African American students and 62% of white students. Males were found to besomewhatheavier than females, particularly in high school.

The BMI assessment program has shown some success in raising parental awareness of their children’s weight status. In a telephone surveyofArkansas parents conducted by the University of Arkansas’ College of Public Health, the percent of parents of overweight children whoincorrectlyidentified their child’s weight status has increased from 53% to 60%.

Other policy initiatives to increase healthy eating and physical activity at school have accompanied the BMI assessment program. In a survey ofschoolprincipals, some 40% reported recent policy changes regarding cafeteria offerings, restrictions on some specific foods, and changes tovendingmachine contents.

The number of students deemed “overweight” and “at risk for overweight” were slightly lower in the third year of the BMI assessmentprogramcompared to the first two years. Although it may be too early to consider this a definitive trend, ACHI confidently says, “the progression ofthechildhood obesity epidemic has been halted in Arkansas.”

Issues to Consider

Not a Stand-alone Program: Former Governor Huckabee made obesity prevention a hallmark of his administration and drew much public attentiontothe youth obesity issue. The state has also been conducting many other interventions to improve healthy eating and increase physical activity. Measuring BMI can be an essential tool for assessing progress, but experts warn against relying on such a program alone to address the complex problem of obesity.

Potential Social Effects: Some experts worry about unintended adverse consequences of BMI assessment at school, such as that an increasedawareness of obesity among students could result in more stigma and weight-based teasing; some parents could put their children on inappropriately restrictive diets; or some students overly concerned about body image could adopt unsafe weight loss practices. Local researchers are conscious of these potential side effects and have been actively searching for evidence of them. So far, their survey methods have failed to discover a significant increase in weight-based teasing or unsafe weight loss practices among youth.

It should be noted, however, that this issue was at least partially behind the introduction of several bills affecting the BMI program at the beginning of the 2007 Arkansas legislative session, one that would repeal the BMI program, and another that would makeitvoluntary for districts. Newly elected Governor Mike Beebe has signaled that he would support changes to the program, mostly because, as the Governor said, some children have “unintendednegativereactions, self-esteem-wise, primarily to being labeled in a certain way.”

Follow-up: In general, public health principles discourage manda- tory screening programs unless proven treatments are available for a conditionandcommunities have the necessary resources to help people access them. Weight reduction programs for young people are stillintheir infancy, and many parents lack the financial resources to access appropriate services if they are available at all.

Cost: Arkansas has not published a report on the start-up costs for the program, but some experts estimate that the initial costs for the BMI assessment program at the state level were about $1 million, not including costs borne by local districts and schools. The cost of scales and other equipment for one BMI station is about $60 per school. Some Arkansas principals complained about the program being an “unfunded mandate” that adds to the burden of overworkedschool nurses and support staff. Others question whether this program is the best use of limited prevention dollars.

Resources

• The website of the Arkansas Center for Health Improvement contains full information about the BMI measurement program at www.achi.net.
• Various obesity prevention reports and resources are available from the University of Arkansas for Medical Sciences College of Public Health at www.uams.edu/coph/reports.
• The Centers for Disease Control and Prevention (CDC) offers informa- tion about BMI at www.cdc.gov/nccdphp/dnpa/bmi.

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