January 8, 2007
In Obesity Fight, Many Fear a Note From School
By JODI KANTOR
BLOSSBURG, Pa. -- Six-year-old Karlind Dunbar barely touched her dinner, but not for time-honored 6-year-old reasons. The pasta was not the wrong shape. She did not have an urgent date with her dolls.
The problem was the letter Karlind discovered, tucked inside her report card, saying that she had a body mass index in the 80th percentile. The first grader did not know what "index" or "percentile" meant, or that children scoring in the 5th through 85th percentiles are considered normal, while those scoring higher are at risk of being or already overweight.
Yet she became convinced that her teachers were chastising her for overeating.
Since the letter arrived, "my 2-year-old eats more than she does," said Georgeanna Dunbar, Karlind's mother, who complained to the school and is trying to help her confused child. "She's afraid she's going to get in trouble," Ms. Dunbar said.
The practice of reporting students' body mass scores to parents originated a few years ago as just one tactic in a war on childhood obesity that would be fought with fresh, low-fat cafeteria offerings and expanded physical education. Now, inspired by impressive results in a few well-financed programs, states including Delaware, South Carolina and Tennessee have jumped on the B.M.I. bandwagon, turning the reports -- in casual parlance, obesity report cards -- into a new rite of childhood.
Legislators in other states, including New York, have proposed them as well, while some individual school districts have adopted the practice.
Here, in the rural Southern Tioga School District, the schools distribute the state-mandated reports even as they continue to serve funnel cakes and pizza for breakfast. Some students have physical education for only half the school year, even though 34 percent of kindergartners were overweight or at risk for it, according to 2003-4 reports.
Even health authorities who support distributing students' scores worry about these inconsistent messages, saying they could result in eating disorders and social stigma, misinterpretation of numbers that experts say are confusing, and a sense of helplessness about high scores.
"It would be the height of irony if we successfully identified overweight kids through B.M.I. screening and notification while continuing to feed them atrocious quality meals and snacks, with limited if any opportunities for phys ed in school," said Dr. David Ludwig, director of the Optimal Weight for Life program at Children's Hospital Boston.
The farmers and foundry workers here in north-central Pennsylvania have different ideas about weight than those of the medical authorities who set the standards (the percentiles are based on pre-1980 measurements because the current population of children is too heavy to use as a reference). Here, the local pizza chain is called Pudgie's. Nearby Mansfield's fanciest restaurant serves its grilled chicken salad piled with fries.
Nearly 60 percent of eighth graders in the district scored in the 85th percentile or higher in 2003-4; more than a quarter had scores in the 95th percentile or higher, meaning they were officially overweight.
As it is for adults, the body mass index for children is a ratio of height to weight, but the juvenile numbers are also classified by age and sex, and the word "obese" is not used.
Holly Berguson, the homecoming queen at North Penn Junior-Senior High School here, wears a size 20, a fact cited by her many admirers as proof of this community's generous attitude toward weight, its proud indifference to the "Baywatch" bodies on television.
"I don't care how big I am," said Holly, 17, who is insulin resistant, a condition that often precedes Type 2 diabetes. "It's not what you look like, it's who you are."
Part of the rationale behind the reports is that they are an extension of the height and weight checks that schools have traditionally conducted.
But here, the letters sent home with report cards have been a shock. Many parents threw them out, outraged to be told how much their children should weigh or unconvinced that children who look just fine by local standards are too large by official ones. Seventh graders traded scores during lunch periods. And more than a few children, like Karlind, no longer wanted to eat, students and parents said.
This year, Pennsylvania requires body mass index notification for students in kindergarten through eighth grades. Holly will graduate before it is required at the high school next fall. Her confidence about her body -- she is a lifeguard and wears a bathing suit without embarrassment -- says something about how the perception of childhood obesity has changed from earlier generations.
Among children, teasing and weight have always gone together, but now, says Doris Sargent, principal of Mansfield's elementary school, there are so many overweight children that "you can't pick on everybody." Here, two kinds of children are teased about their weight: the hugely fat and the thin.
Children who are merely big "pick on skinnier kids because they don't like their own weight," said Cassie Allen, a wiry ninth grader at Mansfield Junior-Senior High School who has been taunted as anorexic, as she and her friends sat over a lunch of brown-edged iceberg lettuce piled with artificial bacon bits and neat discs of chicken parmesan in the cafeteria.
A few miles away, at North Penn Junior-Senior High School, a cluster of bleary-eyed girls gathered before the start of classes, complaining that the letters chided them for a situation they were helpless to fix.
"It would be different if we had something to do rather than eat," said one, Shauna Gerow.
On a recent school trip to New York, the girls felt like visitors from a different, chubbier planet, they said.
"They're all this big," said Cassie Chase, holding her arms close together, "and we're all this big," she said, flinging them wide open.
The letters made some recipients feel the same way but left them unsure what to do about it.
Karen Sick, food services director for the school district, has been phasing in healthier foods despite budgetary obstacles and students who prefer white bread over whole wheat. The school district has revamped its menus, eliminating Gatorade and the powdered sugar from the funnel cakes. But it still sends a nutritionally mixed message: birthday cupcakes are discouraged while cafeterias sell ice cream sandwiches and Rice Krispie treats, which some students buy five at a time.
The district's cafeterias recently introduced kiwi and field greens, which drew enthusiastic reviews, but because of the high cost, they are now back to canned fruit and iceberg lettuce. Officials, while trying hard to address the concerns, acknowledge that change may take several more years.
Along the same lines, all students receive some form of physical education each year. But some students live 45 minutes from school: by the time they get home, it is too dark and cold to play outside. And the administrators point out that many children with weight problems also need tutoring after school, so they have to choose between extra help and team sports.
School administrators here say they do not have the resources of their counterparts in Arkansas, which slowed the rate of increase of its childhood obesity using money drawn from a state tobacco settlement windfall.
Nor can they afford exotic gym fare like the Pilates and kayaking now offered in the Miami-Dade County Public Schools, where high school students who had scores in the 95th percentile and above have lost an average of eight pounds a semester.
To successfully change students' eating habits, schools would need to counsel each child and provide "really high-quality nutrition and physical activity assessments," said Marlene Schwartz, director of research and school programs at the Rudd Center for Food Policy and Obesity at Yale. "How often are they eating fruits and vegetables? How much soda are they drinking?"
Christina Bové is the mother of three children who attend the Blossburg schools. She clutched a picture of her 9-year-old son, Christian, in a bathing suit, to prove that he was not "at risk of overweight," as his 92nd percentile score had indicated.
The letter was inaccurate -- and useless, Ms. Bové said. "The school provides us with this information with no education about how to use it or what it means," she said.
Ms. Bové is more worried about her daughter Alora, age 8, who has lately taken up carrot sticks and constant weigh-ins. "She walks out of the bathroom saying, 'I weigh 68 pounds, and none of you can say that,' " Ms. Bové said.
For the kind of young woman who counts every kernel of no-butter popcorn, the index reports can be dangerous, some experts said.
"A letter from school feels evaluative," said Kelly M. Vitousek, a professor of psychology at the University of Hawaii and a specialist in eating disorders. Declaring a weight healthy "without knowing the background of how the kid got there, you're affirming kids who have actively done something to suppress weight," she said.
The practice of reporting body mass index scores in schools has gone from pilot program to mass weigh-in despite "no solid research" on either its physical or psychological impact, and "no controlled randomized trial," said Ms. Schwartz of Yale. "Entire states are adopting a policy that has not been tested."
Individual school districts like Miami's and New York City's are issuing personalized fitness reports for students that list their abdominal crunches and the pace of their one-mile runs along with their body mass index scores.
The federal Centers for Disease Control and Prevention is expected soon to issue a policy statement on the reports, providing guidelines about their benefits and risks, an agency spokesperson said. Meanwhile, supporters of the reports said that some of the problems experienced here -- shocked parents, uncomfortable revelations -- are precisely the point.
"If families had an accurate perception of the issue, we wouldn't need B.M.I. screening," said Dr. Ludwig of Children's Hospital Boston. "There are so many overweight children that perceptions are getting distorted about what's normal and healthy."
While the body mass index is not a perfect test, Dr. Ludwig said it is an effective, low-cost screening tool. He cited a 2005 study published in The New England Journal of Medicine that suggested the current generation of children might have shorter life expectancies than their parents.
"The consequences of childhood obesity," he said, "are too great to ignore."