There has been a steady increase in the prevalence of overweight and obesity in the United States, and many political activities related to tackling obesity policy has been taking place within state legislators. Screening body mass index (BMI) at school is one of the strategies to address childhood obesity, and hence, school-based obesity prevention policies receive much attention from researchers, school officials, legislators, and the media. Employing effective preventive measures is crucial for safeguarding the health of our future generation and reducing the ensuing social and economic costs from the treatment of obesity. Although many school-based policies and strategies are in place to prevent the obesity epidemic, analysis of some school wellness programs showed that many district policies are lacking timeframes and measurable objectives to evaluate the programs. Because of the complexity of the obesity problem more research is needed for ascertaining how cost-effective interventions can be developed for the prevention and treatment of different groups. Hence, cost-effective policy interventions specific to school-aged children that are also comprehensive and school-based should be implemented to prevent the further prevalence of obesity.
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Obesity has assumed epidemic proportion, even though it is a non-communicable disease, and it is spreading rapidly among infants and children. According to WHO experts “Obesity is a global problem which varies according to local context” and policies to prevent obesity and promote health will require the participation of many sectors. (Policy Options to Prevent Child Obesity, 9). The consequences of obesity are not only physical but psychological and economic as well. Obesity is associated with chronic conditions like coronary heart disease, type 2 diabetes, orthopedic disorders, and certain types of cancer. Psychological consequences are associated with lower self-esteem, emotional distress, and anxiety. The economic consequences, both for the health care sector and individuals, associated with obesity are preventive and treatment costs, besides income lost from decreased productivity and absenteeism.
Studies indicate that there has been a steady increase in the prevalence of overweight and obesity in the United States, and between 1980 and 2000 childhood overweight “more than doubled among 2-through 11-year olds and tripled among 12-through 19-year olds” (Brownson, et al). Literature in obesity studies asserts that “obesogenic environments have increased owing to the consumption of calorie-dense foods and low nutritional value and the reduction of daily physical activity” and the increasing public awareness of the childhood obesity epidemic insist health policies address this issue (Brownson et al, 2007; Dietz, Benken, and Hunter, 2009).
It is evidenced that economic and market changes may contribute to ‘increased calorie consumption, sedentary lifestyles, or overweight.’ Cawley (2006) identifies that falling food prices, changes in the “opportunity cost” of time spent cooking that promote a shift away from home-cooked meals to processed food, cheap energy-dense foods, increase in portion size, eating out, farm policies that help increase production and reduce commodity price, and augmented food advertisements aimed at children may be linked to increased prevalence of obesity. In this context, the World Health Assembly agreement (Geneva 2004), which was adopted after deliberations of member nations for a ‘Global Strategy on Diet, Physical Activity and Health,’ binds all its member governments to draw up national guidelines on diet and physical activity and develop strategies for their promotion. It emphasizes the need for developing “national strategies with a long-term, sustainable perspective to make the healthy choices the preferred alternatives at both the individual and community level.” (What are the Key Issues Addressed by the Strategy?).
Regulatory and legislative actions to address obesity reduction encompasses “labeling of the nutritional content of food served in restaurants, imposing advertising restrictions, mandating school nutrition and physical education programs, regulating competitive foods and vending machine contracts in schools, enforcing mixed-use zoning, and improving opportunities or incentives for nonmotorized transportations” (Brownson et al). It is worth noting that the majority of political activities related to obesity policy in the United States have been taking place within state legislators through legislative and regulatory actions of the state government. As per the data cited by Kropski et al (2008), 42 states in the U.S introduced “legislation aimed to provide nutritional guidelines to schools”, which has been enacted in 21 states; bills offering guidance for physical education or activity levels introduced in 44 states and passed in 22; and 19 states proposed child BMI reporting to parents that have been enacted in three states during the year 2005. (Kropski, et al). Several states such as Arkansas, Florida, Pennsylvania, and Tennessee have passed legislation to support schools in their new Endeavour, but there is concern about the “potential unintended negative consequences.” (Kalich et al).
School-based body mass index (BMI) measurement for surveillance and screening purpose is one of the policies that have received much attention from researchers, school officials, legislators, and the media. BMI surveillance programs, a typically anonymous data, assess the weight status of a specific student population “to identify the percentage of students who are potentially at risk for weight-related health problems.” (Nihiser, et al, 652).
BMI measurement, which is the ratio of an individual’s weight to height squared, is widely used to estimate a person’s risk of weight-related health problems because it is considered ‘easy, inexpensive, non-invasive, and quick’ (Nihiser, et al).
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However, a comprehensive review by the expert panel convened by the Centres for Disease Control observed that “BMI screening is not necessary for obesity monitoring at the national level, although the practice could provide useful information for monitoring trends at the state and local level” (Kalich et al). Since the active participation of school authorities, parents, and children are crucial for the success of the BMI screening program, it is essential to evaluate their perceived roles as well as comfort, utility, and impact of the program from their perspective.
Guidelines for school health screening programs have been issued by the Maternal and Child Health Branch (MCH) of the US Department of Health and Human Services. The school environment is considered suitable for screening various health-related problems, and fundamental principles for health screening are “an inclusive, respectful school climate; school policies consistent with laws; and, protection of student and staff confidentiality. (Ikeda et al). Schools are considered as “ideal setting for population-based interventions to address obesity,” and ‘School Nutrition Policy Initiative”, a multi-component program that comprises school self-assessment, nutrition education, nutrition policy, social marketing, and parent outreach is found to be effective in preventing the development of overweight among school-aged children (Foster, et al).
It is presumed that creating awareness of the necessity “to make lifestyle changes increases behavioral intention and gradually results in behavior change,” which is the basic tenet of school-based BMI reporting to parents (cited by Kalich). But the practice of issuing BMI report cards by schools remains controversial. It is criticized that among the list of 10 key strategies that schools can adopt to promote physical activity and healthy eating prescribed in ‘Healthy Youth Initiative’ does not include any recommendations or instructions regarding screening student’s BMI and sending report cards to parents. Though the warning signals received through BMI reports may influence parents and children to seek medical support or lifestyle changes, it is suspected that “weight status information may encourage unsupervised restrictive dieting, disordered eating, or have negative psychological impact” in children (cited by Kalich). The study by Kalich and colleagues found that “mixed weight middle school students were reasonably comfortable with weight screening”, however overweight and at-risk increased children showed “greater discomfort of screening, as well as heightened intentions to participate in potentially risky weight control behavior.”
Another argument against school BMI screening is concerning ‘the relative efficiency of the screening procedure’. Though school nurses are the most appropriate persons to conduct school health screenings, the shortage of school nurses forces school authorities to transfer the responsibility to un-licensed or untrained employees, which may lead to poor quality of care and exposing schools to legal risk. It is found that teachers, teaching assistants, and even volunteers are conducting BMI screening of students in the U.S. Whereas, school nurse-managed screening will have professional accuracy and will be conducted in a caring and sensitive manner since nurses are trained to use established protocols for conducting health screening. So far as school administrators are concerned, they suggest that the process should be well organized and managed and require funds for the purchase of pieces of equipment and well-trained staff. Even though there are detailed instructions issued by the ‘Centre on Weight and Health’ for uniformly collecting data, taking measurements and calculating BMI is found to be a cumbersome process. Moreover, reporting BMI data to parents also consumes scarce resources. Since most of the schools experience financial crunch, it is essential to analyze the cost-effectiveness of the program.
Parents perceive that schools have primary responsibility and a major role to play in reducing childhood obesity. Studies investigating acceptance of BMI screening from parent’s perspectives found that the majority supported the practice, but preferred ensuring that “screening was private and respectful, and that results be provided to parents in a neutral, non-judgmental manner that avoided labeling” (cited by Kalich et al). However, the reactions of parents after receiving the BMI report card are worth observing. The study carried out in Cambridge, MA, the USA with a group of families with diverse backgrounds found that about half of the families with overweight children were concerned about their child’s overweight; more likely to plan weight control strategies; not apt to adopt preventive lifestyle behaviors. On the contrary, some parents adopt unscientific diet restrictions that may result in binging when there is unlimited access to food and stunting growth in height. An alarming trend noticed was that 40% of the families neither plan to seek medical advice nor try to control their children’s weight through dieting, which means that educating parents in preventing their child’s weight gain is paramount for successful obesity prevention programs.
Interpreting BMI information is the most challenging task because a study conducted by federal agencies expressed concern that “schools may falsely mislabel a needless number of children as overweight based on BMI screening” (Ikeda et al). An important observation regarding the inadequacy of BMI measure to classify an individual child as overweight or obese is made by UK experts, who opine that “a single BMI measure is difficult to interpret and needs to be used in conjunction with other findings” Most adverse effect of BMI card is the development of negative attitudes in school staff about obese children, and discriminatory actions that obstruct an ‘inclusive, respectful climate’ in the school environment. There may also be increased social pressure on children to achieve a ‘perfect body’, failing which will lead to disordered eating habits, lowered self-esteem, and body dissatisfaction.
It is argued that wellness policy law makes no mention of a role for state agencies in promoting school wellness policies, which allows school authorities to formulate programs suitable and convenient for them, which may lead to inconsistency in program benefits and effectiveness. According to UNESCO, specifying responsibilities for “implementing and enforcing policies, and for evaluating their effectiveness, are necessary to ensure the compliance and support” of those intended beneficiaries. (Focusing Resources on Effective School Health). Critics observe that there is a dearth of research findings supporting effective intervention to prevent or manage obesity in children and adults in the U.S because the obesity problem is multifaceted. It is also argued that the cost-effectiveness of the interventions is difficult to ascertain because of the lack of outcome measures that are amenable to health economic evaluations. Evaluation and monitoring of long-term projects, actions being undertaken at the local level, and many potentially important broader community policies are another area requiring attention to explore their effectiveness and health impact.
Based on the deliberations of the ‘National Summit on Legal Preparedness for Obesity Prevention and Control’, convened by the Centers for Disease Control in June 2008, white papers that “identify actionable options” have been prepared. The summit identified that “law has played a critical role in the control of chronic diseases” and “the use of legislation, regulation, and policy to address the multiple factors that contribute to obesogenic environments” can assist multifaceted activities for obesity prevention (Dietz, Benken, and Hunter, 2009). They conclude that it is too early to comment on the efficacy of public health-focused legal approaches. After analyzing the pros and cons of a school-based BMI reporting program it derives that though the screenings could provide valuable information for monitoring trends at the state and local level, it is not ideal at the national level in the United States. Preventing childhood obesity is the real American dilemma that requires more research and concerted effort by all concerned. Since even small behavior changes introduced now could substantially decrease childhood obesity in future decades, policymakers must initiate more cost-effective policy interventions specifically appropriate for school-aged children. As children spend ‘approximately half of their waking hours in schools; schools provide 1 to 2 meals daily; are a natural settings for healthy food choice education, there is no other ideal setting than schools for introducing obesity prevention interventions.
Brownson, Ross C., et al. Patterns of childhood Obesity Prevention Legislation in the United States. Preventing Chronic Disease, 4.3. 2007. Web.
Cawley, John. Markets and Childhood Obesity Policy: Economic Rationales for Market Intervention. 2009. Web.
Dietz WH., et al. Public health law and the prevention and control of obesity. NCBI. 2009. Web.
Focusing Resources on Effective School Health. United Nations Educational, Scientific and Cultural Organization. 2009. Web.
Ikeda, Joanne P., et al. Health Education Research: MI Screening in Schools: Helpful or Harmful. Oxford Journals. 2006. Web.
Kalich, Karrie A., et al. Comfort and Utility of School-Based Weight Screening: The Student Perspective. PubMed Center. 2008. Web.
Kropski, Jonathan A., et al. School-Based Obesity Prevention Programs: An Evidence Based Review. Nature Publishing Group. 2008. Web.
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Nihiser, Allison J., et al. Body Mass Index Measurement is Schools. Special Article. American School Health Association. 2007. Web.
Policy Options to Prevent Child Obesity. European Heart Network. 2006. Web.
What are the Key Issues Addressed by the Strategy? WHO. 2009. Web.