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Arkansas led the nation in measuring obesity in kids. Did it help? : Shots

Since Arkansas began sending obesity letters to parents, childhood obesity rates in the state have increased from 21 percent to nearly 24 percent. During the pandemic, the state’s obesity rate peaked at more than 26%.

Mr. Spencer Green/AP


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Mr. Spencer Green/AP


Since Arkansas began sending obesity letters to parents, childhood obesity rates in the state have increased from 21 percent to nearly 24 percent. During the pandemic, the state’s obesity rate peaked at more than 26%.

Mr. Spencer Green/AP

LITTLE ROCK, Ark. — Sixth-grade boys lined up to be measured in the library at Mann Arts and Science Magnet Middle School. As they took off their shoes and emptied their pockets, they joked that they were the biggest.

“It’s an advantage,” said one of them. “You can play basketball,” said another. “A bigger guy can get more girls!” suggested a third student.

Everyone laughed. What they weren’t joking about was their weight.

Annrea Veasley, the school’s registered nurse, got them up one by one. One boy, Christopher, slumped over as she measured his height. “Raise your head slightly,” she said. Then Veasley asked him to stand back on a scale so he couldn’t see the numbers. She silently noted his height at just under 4 feet 7 inches and his weight at 115.6 pounds.

His parents would later be among thousands to receive a letter beginning: “Many Arkansas children have health problems caused by their weight.” The letter includes each student’s measurements as well as their calculated body mass index. The BMI number classifies each child as “underweight,” “normal,” “overweight,” or “obese.” Christopher’s BMI of 25.1 places him in the obese category.

In 2003, Arkansas became the first state to send BMI reports to all students as part of a broader initiative to combat obesity. But in the 20 years since, childhood obesity rates in the state have risen from 21 percent to nearly 24 percent, reflecting a similar, albeit higher, trajectory than national rates. During the pandemic, the state’s obesity rate peaked at more than 26%.

Yet at least 23 states have followed Arkansas’ lead and required an assessment of students’ height and weight. Some have since scaled back their efforts after their parents raised concerns.

A Wyoming school district used to include a child’s BMI score on school report cards, a practice it has since abandoned. Ohio allows districts to opt in, and last year only two of 611 school districts reported BMI information to the state. And Massachusetts stopped sending letters home. Even Arkansas changed its rules to allow parents to opt out.

Numerous studies have shown that these ratios, or “big letters” as they are sometimes mockingly called, had no effect on weight loss. And some nutritionists, psychologists and parents have criticized the letters, saying they can lead to weight stigma and eating disorders.

BMI as a tool has also come under scrutiny because it does not take into account differences between racial and ethnic groups, sex, gender and age. In 2023, the American Medical Association called BMI “flawed” and suggested using it alongside other tools such as measuring visceral fat, body composition, and genetic factors.

All of this highlights one question: What are the school BMI measurements and letters for? Nearly 20% of American children were classified as obese just before the pandemic – compared to just 5% around 50 years ago – and lockdowns have made the problem worse. It is unclear what types of interventions could reverse the trend.

Joe Thompson, a pediatrician who helped create the Arkansas program and now directs the Arkansas Center for Health Improvement, said the BMI letters are meant to be a screening tool, not a diagnostic test, to inform parents if their child is at risk of developing a serious illness. health problems, such as heart disease, diabetes and respiratory problems.

Sharing this information with them is essential, he said, given that many don’t see it as a problem due to the prevalence of obesity. Arkansas is also a rural state, so many families don’t have easy access to pediatricians, he said.

Thompson said he has heard from many parents who have responded to the letters. “To this day, they remain our strongest advocates,” he said.

The program has also led to new efforts to reduce obesity. Some Arkansas school districts have instituted “movement breaks,” while others have added vegetable gardens, cooking classes and walking trails. One district sought funds to purchase bicycles. The state does not study whether these efforts work.

Researchers say BMI data also plays an important role in illuminating population-level trends, even if it isn’t useful to individuals.

Parents are generally supportive of their children weighing at school, and the letters have helped increase their awareness of obesity, research shows. At the same time, few parents followed up with a health care provider or changed their child’s diet or physical activity after receiving a BMI letter, according to several other studies.

In what is considered the landmark BMI letter study, published in 2020, California researchers found that taking home letters had no effect on students’ weight. Hannah Thompson, an assistant professor at the University of California, Berkeley and co-author of the study, said most parents don’t even remember receiving the letters. “This is a very minimal behavioral intervention,” she said.

Arkansas now measures all public school students in even-numbered grades each year — except for 12th graders, because at that point, pediatrician Joe Thompson said, students are “beyond the possibilities for schools to have an impact. The change also came after many boys at one school were wearing leg weights under their jeans as a prank, he said.

Kimberly Collins, 50, remembers being baffled by BMI letters sent to her by the Little Rock school district, stating that all of her children were overweight and that one of her daughters was considered obese.

“It offended me as a mother,” she said. “I felt like I wasn’t doing my job.”

She didn’t think her children looked overweight, and the family pediatrician never raised concerns about it.

Hannah Thompson, the California researcher, said that’s the biggest problem with IMC letters: Parents don’t know what to do with the information. Without support to help change behavior, she said, letters don’t do much.

“You find out your child has asthma and you can get an inhaler, right? ” she says. “You find out your child is overweight and where do you go from there? What do you do?”

Kevin Gee, a professor at the University of California-Davis who has studied the IMC letters, said the letters lacked cultural nuance. In some communities, for example, people prefer their children to be heavier, associating this with comfort and happiness. Or, some eat foods that they know are not very nutritious, but are an important way to express their love and traditions.

“We know there are many rich contextual elements that influence obesity rates,” Gee said. “And so how can we balance this information?”

Collins’ daughter, now 15, said that as she grew older, she felt increasingly self-conscious about her weight. People look at it and sometimes make comments. (Collins’ mother asked that her daughter’s name not be published due to her age and the sensitive nature of the subject.)

“On my birthday, I went to get my allergy shot and one of the nurses said to me, ‘You’re getting chubbier,'” she said. “It didn’t make me feel any better.”

Collins said it hurt her to see her soft-spoken daughter cover herself with her arms as if trying to hide. The teen also began hiding food and avoiding the mirror by refusing to turn on the bathroom light, Collins said. The girl signed up for tennis but quit after other children made fun of her, her mother said.

Looking back, Collins said that while she would have liked to have paid more attention to the BMI letters, she would also have liked practical suggestions on what to do. Collins said she has already followed the short list of recommended healthy practices, including feeding her children fruits and vegetables and limiting screen time. She doesn’t really know what else she could have done.

Now, everyone has an opinion on their daughter’s weight, Collins said. Someone told him to lock the refrigerator. Another told him to buy vegan snacks. His mother bought them a scale.

“It’s a total climb,” Collins said with a sigh.

This article was produced as part of a project for the Spencer Education Journalism Scholarship.

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the major operating programs of KFF — the independent source for health research, polling and policy…

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