Mandating Body Mass Index Reporting in the Schools

Mandating Body Mass Index Reporting in the Schools Country: USA Partner Institute: Department of Behavioral Science and Health Education, Rollins School of Public Health, Emory University Survey no: (15) 2010 Author(s): Elena Conis Health Policy Issues: Prevention, Funding / Pooling Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract Last year, New York was one of several states to enact a law requiring surveillance or screening of body mass index for all children enrolled in school. The measuring and monitoring of BMI is viewed as one approach to begin reducing the prevalence of childhood obesity, which places children at risk of high blood pressure, high cholesterol, and diabetes. States have begun to require BMI surveillance and reporting in schools as a facile means of assembling data on all children. 2. Purpose of health policy or idea Last year, New York state enacted an amended education law that now requires that body mass index (BMI) and "weight status group" be assessed as part of students' routine school health examination, and be reported to schools on required school health certificates. BMI is a measure of body weight relative to height, and is used to place children (and adults) into the diagnostic categories of underweight, healthy weight, overweight, obese, or severely obese. In New York, this information must now be furnished to schools at school entry and in specified grades. The summary data is reportable to the state health department. The New York law makes it incumbent upon parents to obtain physical exams for their children and submit completed health certificates to schools. New York's school-based BMI surveillance program is distinct from school-based BMI screening programs, which, in other states, have required the schools to report BMI and weight status category to parents. New York's law does not require doctors or schools to report BMI or weight status category to parents; if physical exams are performed at school, school based health care providers may notify parents of their child's BMI or weight status category. School-based BMI screening and surveillance laws and regulations have been passed in a large number of states in recent years as a preliminary step in broader obesity prevention and treatment plans. Schools offer a ready and convenient location for gathering weight data on virtually all children; because health certificates are already required by all schools, adding BMI to existing forms help ensure that the data will be collected. The main objective of such laws is to identify areas of high obesity prevalence in order to target obesity-prevention resources and interventions. Both BMI screening and surveillance programs are designed to improve upon existing, limited data on childhood obesity prevalence, which health experts see as crucial to designing targeted interventions to reduce obesity and related diseases. According to authors of a recent Health Affairs article that analyzed several BMI surveillance - 1 -

models, "High-quality prevalence and trend data are essential tools to guide public health responses. Few such data exist at state and local levels, yet they are essential to identifying and tracking disparities, designing and evaluating targeted interventions, and advocating for policy changes and funding." (Longjohn, M et al, 2010). Main objectives The New York law's main objective is to provide comprehensive data on childhood obesity prevalence, so that obesity prevention activities and policies can be better designed and targeted. Ostensibly, this data would be widely available for use by both state agencies and local organizations working to prevent obesity. Not only would it benefit those wishing to target their efforts, it would also facilitate monitoring and evaluation of interventions. Because obesity has become a top public health priority on the national level, New York's reporting program could help the state attract federal funds for local efforts to combat the epidemic. Type of incentives None. (Students who do not provide health certificates may be examined in school.) Groups affected Children enrolled in state schools and their parents, Schools and school health care staff, Physicians and pediatric primary care providers 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral By requiring BMI data to be collected for all students, New York's law will likely make parents more aware of obesity as a health issue. Because the new requirement builds on an existing requirement -- the submission of health certificates by all students on a regularly basis -- it has little systemic impact and has been, by and large, uncontroversial. 4. Political and economic background New York Education Law requires students to furnish schools with health and dental certificates the first time they enter school and in grades 2, 4, 7 and 10. The dental health certificate certifies, for instance, whether students have treated or untreated cavities or oral health problems that interfere with a student's ability to speak or chew. Health certificates specify food and medication allergies, list the results of tests that screen for sickle cell disease and elevated blood lead, document vision or hearing impairments, and include data on immunizations, which are required for school enrollment. The addition of BMI to the health certificate provided a systematic means of collecting uniform weight data on all children in New York Schools. School health certificates thus provided policymakers a convenient means for complying with the obesity-prevention recommendations of the American Academy of Pediatrics (AAP), the - 2 -

Centers for Disease Control (CDC), and the Institute of Medicine (IOM), described below. 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea In 2003, the American Academy of Pediatrics issued a set of health supervision and advocacy recommendations for prevention of pediatric overweight and obesity. The list of health supervision recommendations included promoting breast feeding, physical activity, and limitation of television and video time to no more than two hours a day, and annual calculation and plotting of BMI, in order to identify excessive weight gain. In 2007, the Expert Committee on childhood obesity convened by the American Medical Association, the Health Resources and Services Administration, and the CDC issued an updated set of recommendations on the assessment, prevention and treatment of childhood and adolescent overweight and obesity. The committee's recommended action steps for obesity prevention included, in addition to physical exam and assessment of dietary behaviors, the calculation of BMI on a yearly basis and the use of BMI to diagnose weight status category. (Children are considered overweight if they are above the 85th percentile for BMI, and obese if they are at the 95th percentile or above.) Arkansas was the first state to pass and implement a law mandating annual BMI screening and weight status category diagnosis for all public school students. Screening was performed in schools by trained school and community health personnel, who entered the data into a statewide reporting system. The program also notified all parents of their children's BMI and weight status category, and provided parents with information on the health risks associated with childhood obesity. Since Arkansas enacted its law in 2003, at least 20 additional states have implemented childhood BMI data collection initiatives. Some states have passed laws requiring BMI reporting or surveillance; in others, state health departments issued relevant rules or regulations. According to the analysis in Health Affairs, these laws and regulations have required either school-based data collection, the use of an existing disease registry, or a combination of both. Massachusetts and Pennsylvania have passed laws requiring annual collection of weight and height measurement from all students, every year, but in neither state has this plan been fully implemented. Other states, including Iowa and Louisiana, as well as New York, limit BMI screening to students in either select schools or grades. In some states, such as California, BMI is collected as part of routine fitness screenings that take place at periodic intervals -often once in elementary school, once in junior high, and once in high school. Initiators of idea/main actors Government Patients, Consumers Scientific Community Approach of idea The approach of the idea is described as: renewed: New York's law mimics similar laws adopted in approximately 20 states. Stakeholder positions Some parents have expressed frustration with the new BMI reporting requirements, arguing that it places the blame - 3 -

and responsibility for their children's weight on them, instead of on schools, agricultural policies, and food corporation marketing practices. Some have also argued that the emphasis on BMI is misguided, as some children with high BMIs are in otherwise good health. Public health officials say reporting is an important starting point for addressing widespread and increasing obesity. Schools have thus far supported the measure. Actors and positions Description of actors and their positions Government NY State Health Department very supportive strongly opposed NY State Department of Education very supportive strongly opposed Patients, Consumers Parents very supportive strongly opposed Students very supportive strongly opposed Scientific Community American Academy of Pediatrics very supportive strongly opposed Institute of Medicine very supportive strongly opposed U.S. Preventive Services Task Force very supportive strongly opposed Influences in policy making and legislation Recommendations by the AAP, CDC, and IOM were influential in shaping the content of the New York Law, as were the experiences of other states, such as Arkansas. Obesity has also been a top priority for federal and local health experts; childhood obesity and nutrition in particular are two key issues receiving special attention and support from First Lady Michelle Obama. Implementation of the New York law was funded in part by the so-called stimulus bill, the federal American Recovery and Reinvestment Act of 2009. Legislative outcome Actors and influence Description of actors and their influence Government NY State Health Department very strong none NY State Department of Education very strong none Patients, Consumers Parents very strong none Students very strong none Scientific Community American Academy of Pediatrics very strong none Institute of Medicine very strong none U.S. Preventive Services Task Force very strong none Positions and Influences at a glance - 4 -

Adoption and implementation Last year, New York's Department of Health notified all state licensed pediatricians, family physicians, residents and nurse practitioners of the new reporting requirement, which went immediately into effect. Monitoring and evaluation State legislators budgeted US $2 million for implementation of the new BMI surveillance requirement. The law that created the new requirement also provided US $1 million in funding to support community-based obesity prevention activities. Selected school districts were requested to submit summary (non-identifying) information on student weight status category to the New York State Department of Health in January 2010. The state plans to use the data to map the distribution and severity of obesity across the state, and thereby target obesity prevention activities. The collection of summary data over time will be used to monitor the progress and impact on obesity prevalence of new policies that, for example, aim to improve access to healthful foods or time spent engaged in physical activity. Results of evaluation Evaluations of the BMI screening program in Arkansas revealed that the state's program did increase awareness of obesity and its related health risks among students and parents. Evaluations also showed that the program did not increase stigma or lead to unhealthy weight loss behaviors. The program did, however, place an unsustainable burden on school staff, and in 2007 the Arkansas law was amended to require reporting every other year, instead of every year. - 5 -

6. Expected outcome According to the CDC, approximately 17 percent of U.S. children are currently obese. Prevalence has tripled since 1980, when just 6 percent of children were obese. By some estimates, the prevalence of obesity in the population as a whole results in health problems that account for 10 percent of total health care spending. In parts of New York, and among subsets of its youth population, the rate of obesity is markedly higher than the national average. According to a 2004 survey published in the American Journal of Public Health, 24 percent of children in New York City public schools were obese; the rate was highest among Hispanic children in the city's public schools, 31 percent of whom were obese. BMI screening and surveillance programs have been widely adopted as a means of addressing the growing prevalence of childhood obesity. Critics have argued that they can be costly and pose privacy concerns - two critiques that applied to the Arkansas screening program in particular. New York's law does not report identifying information to the state health department; however, reporting requirements do place an added burden on some school staff members. However, according to the CDC, "no consensus exists on the utility of BMI screening programs for young people." Aside from the results evaluation of Arkansas' program, there is limited information on the effects of such programs on knowledge, attitudes and behaviors regarding weight and weight gain; little is likewise known about their costeffectiveness. While the U.S. Preventive Services Task Force does not officially recommend BMI screening programs, both the American Academy of Pediatrics and the Institute of Medicine do support them, urging that detailed, standardized data on the scope of the epidemic is crucial to curtailing it. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high The cost-effectiveness of BMI surveillance and screening programs remains unknown; however, if programs such as New York's translate into effectively targeted obesity prevention programs, BMI surveillance will have proved its worth in the long term. Theoretically, interventions that are targeted on the basis of comprehensively collected data should result in a system that provides obesity-prevention services and education on a more equitable basis. 7. References Sources of Information Altarum Institute. "Childhood Obesity Prevention - A Promising New Method for Tackling the Epidemic." http://blog.altarum.org/childhood-obesity-prevention-a-promising-new-method-for-tackling-the-epidemic/. Centers for Disease Control. Childhood Overweight and Obesity. http://www.cdc.gov/obesity/childhood/index.html Longjohn, M et al. "Learning From State Surveillance Of Childhood Obesity." Health Affairs March 2010, Vol. 9, Issue 3, p. 463. Author/s and/or contributors to this survey - 6 -

Elena Conis Suggested citation for this online article Elena Conis. "Mandating Body Mass Index Reporting in the Schools". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/us/a15/2-7 -