Abstract
In 2003, Arkansas became the first state to require body mass index (BMI) testing in public schools to raise awareness of the growing obesity epidemic among children and adolescents. Limited information exists regarding the effectiveness of school-based BMI screening programs. The purpose of this study was to determine if BMI health report cards affected parents’ knowledge or actions regarding their child’s health and to determine the accuracy of parents’ perceptions of their child as underweight, normal weight, or overweight according to their child’s BMI. A questionnaire was developed with the help of physical educators, pediatricians, and exercise scientists to determine parents’ perceptions and behaviors regarding BMI report cards. The questionnaire was distributed to parents/guardians of children who sought medical care at two pediatrician’s offices in Arkansas. Based on responses to survey questions, parents are not making changes to their child’s diet and exercise habits if their child is classified as “at risk” or “overweight.” However, parents did report that BMI health report cards are influencing their knowledge about their child’s health. The majority of parents in the study (approximately 66%) did not accurately perceive their child’s BMI category.
Introduction
In 1998, the U.S. government declared childhood obesity an epidemic (Ikeda, Crawford, & Woodward-Lopez, 2006); almost 20 years later, childhood obesity remains a critical health issue in the United States. According to the Centers for Disease Control and Prevention (CDC; 2014), approximately 17% of children and adolescents are obese. In 2011-2012, the prevalence rate of obesity was 8.4% among 2- to 5-year-olds, 17.7% among 6- to 11-year-olds, and 20.5% among 12- to 19-year-olds (Ogden, Carroll, Kit, & Flegal, 2014). Professionals in health-related fields continue to examine the possible reasons so little change has occurred over the past 20 years regarding obesity. We now know obesity is a multifaceted disease involving both the environment and genetics. The health belief model could serve as an explanation for behavior changes that may occur following body mass index (BMI) screening and notification (Gee, 2015). The health belief model would suggest that notifying parents of their child’s weight status, especially if the child is overweight or obese, may lead to changes in parent perception of their child’s susceptibility and severity of being overweight or obese. This change in perception could serve as a prompt for behavior change. Obesity interventions, such as BMI assessments in publics, focus on raising awareness of obesity and its many health implications. Schools have become a focal point for implementing programs in an effort to combat obesity. BMI screening programs are one such type of obesity intervention program. Half of the states in the United States now have legislation requiring schools to assess BMI (Ruggieri & Bass, 2015).
Literature Review
According to a recent review of literature, the estimated incremental lifetime cost of an obese child is roughly $19,000 more compared to that of a normal weight child who remains normal weight throughout adulthood (Finkelstein, Graham, & Malhotra, 2014). Childhood BMI is significantly and strongly associated with adult BMI (Guo & Chumlea, 1999). If the current obesity trend continues, it is expected that by 2030 half or more of the adult population will be obese (Finkelstein et al., 2012). It is important to make parents aware of their child’s health status, because parents can ultimately change a child’s behavior (Chomitz, Collins, Kim, Kramer, & McGowan, 2003). The majority of children in the United States spend much of their day in school, so, public schools are also a key component in turning the tide of the obesity epidemic (Nihiser et al., 2009). Children spend roughly 6 hours a day in school, consume up to two meals at school, and have access to school nurses and physical education programs, making schools idea for intervention programs (Story, 1999).
The American Academy of Pediatrics and the Institute of Medicine have called for every child to have his or her BMI percentile assessed and provided to the parents every year in an effort to increase parents’ awareness of disease risk associated with overweight/obesity (Thompson & Card-Higginson, 2009). BMI is a disease risk indicator based on the ratio of an individual’s body mass in kilograms to height in meters squared (kg/m2). For children, a BMI measure is first converted into a percentile based on the reference population of the same age and sex, and then the percentile is compared to standards for the reference population (Kuczmarski et al., 2002). Children with BMIs that fall between the 5th and 85th percentile are considered to be at a “healthy weight.” Those with a percent between the 85th and 95th are categorized as “overweight,” and those above the 95th percentile are considered “obese” (CDC, 2015). BMI data are relatively easy and inexpensive to collect, and they allow for tracking obesity during childhood and into adulthood (Nihiser et al., 2007).
Currently, Arkansas, along with 24 other states, has legislation requiring public schools to monitor BMI (Ruggieri & Bass 2015). In Arkansas, the BMI screening is sent to parents via a health report card. The health report card contains explanatory information about BMI and the student’s assessment information including date, height, weight, and calculated BMI percentile. A graph is included so parents can compare their child’s BMI with that of other children of the same reference population. Parents are provided information on the category into which their child is placed. Also offered are steps the family could take if their child is in the “at risk” or “overweight” categories. The report contains information that reinforces good eating habits and physical activity if their child is considered “normal” or “not at risk” for disease. In the report is a statement encouraging parents to contact their child’s physician if they desire more assistance (Thompson & Card-Higginson, 2009).
It is important to know if BMI health report cards are helping with the growing obesity problem, and if it is raising parents’ awareness of their child’s health status. It should be noted that the CDC has not made a statement of support for BMI screening programs in schools; however, it has established “BMI Measurement Program Safeguards” that address concerns about school-based BMI measurement programs (Nihiser et al., 2007). The CDC (2017) identifies two types of BMI assessment programs: BMI surveillance and BMI screening. Surveillance is done to identify the number of underweight, healthy weight, overweight, and obese students in a school or school district. These data were typically anonymous and may be collected to determine the impact of school policy targeted at improving health. Screening is performed with the intent of sharing children’s BMI status with their parents. There is a lack of support for BMI screening programs, because there is not sufficient information to show BMI screening is effective. To justify the continued existence of these programs, it must be shown that they are efficient and effective. To determine program effectiveness, researchers must determine what parents do with the health report card information after they have received it. Many studies show parents often support school-based BMI; however, parents receiving information does not mean they are initiating behavior change (Kubik, Fulkerson, Story, & Rieland, 2006; Nihiser et al., 2009; Raczynski, Thompson, Phillips, Ryan, & Cleveland, 2009; Thompson & Card-Higginson, 2009).
One might assume that if a child is overweight it would be obvious to that child’s parents, so BMI report cards are not necessary. However, Eckstein et al. (2006) found few parents of overweight children accurately identified their child as being “overweight.” Nihiser et al. (2009) conducted a study in which 86% of mothers whose child had a BMI at or above the 95th percentile did not consider their child overweight. De La et al. (2009) also found that parents of overweight and obese children between the ages of 5 and 12 years often misclassify their child, with parents of boys being more likely to misclassify their child’s weight.
The purposes of this study were to determine if BMI health report cards influence parents’ knowledge or actions regarding their child’s health and to determine if parents accurately perceive their child as underweight, normal weight, overweight, or obese when compared to the child’s BMI assessment category.
Method
Prior to collecting data, this study was approved by the institutional review board at Arkansas State University. Phone calls were made to local pediatrician offices seeking permission to place questionnaire in their offices. Children’s clinics were chosen because a child’s height and weight are typically collected during each visit. By placing questionnaires in the clinic, parents would have immediate access to accurate height and weight information for their child. Parents would also have health professionals available to answer any questions they had regarding BMI measures. Instructions were given to the office manager regarding where the questionnaires were to be placed (inside each examining room attached to a clipboard) and how the completed questionnaires were to be stored to protect the privacy of all participants. Two folders were left at the receptionist’s desk, one for questionnaires and one for the consent forms. As the parents left the office, the receptionist asked participants to place the completed questionnaires and consent forms in the separate folders. The folders were then placed in a locked filing cabinet until collected by the researchers. The consent form clearly stated participants should not write their name or their child’s name on the questionnaire.
Participants included parents/guardians of children who sought medical care at two pediatricians’ offices in northeast Arkansas. An informed consent statement was placed on top of each questionnaire, which gave specific instructions on how to complete the questionnaire along with an explanation of how the information collected would be used. The consent form also stated that the research was conducted by researchers and not the pediatrician’s office. While waiting in the examination room to see their child’s physician, participants were asked to voluntarily complete a BMI questionnaire that included demographic information. They were also asked to report their child’s height and weight on this questionnaire. The questionnaire was developed by health care professionals and physical educators. It included demographic questions, 16 “yes/no” questions, and one multiple-choice question. The questionnaire focused on parents’ opinion regarding BMI assessment in schools and whether they use the BMI information in any way to make health-related changes in their child’s/family’s health habits. Participants were asked to record their child’s age, gender, height, and weight as measured by the doctor or nurse. Data were entered into a Microsoft Excel spreadsheet using randomized numbers assigned to questionnaire forms to maintain participant confidentiality.
Results
A total of 109 participants completed a consent form and returned the questionnaire. Table 1 highlights participant demographic information and child age and BMI. Participants were divided into two groups. Group 1 (n = 66) consisted of parents who reported having a child that attended school (children ages 4+ years). Group 2 (n = 43) consisted of all other parents who indicated that their child was not yet school-age. The majority of participants were Caucasian females, followed by African American females. In both groups the majority reported 4 years of college as their highest level of education.
Participant Demographic Information and Child BMI
NOTE: BMI = body mass index.
Figures 1 and 2 show responses to additional measures by group. Some participants chose not to answer all questions. Participants from both groups were asked if they knew what BMI measures, and the majority responded “yes.” All participants were asked, “Are you aware that your child’s BMI reflects his or her disease risk?” and again the majority affirmed they were aware that BMI is a disease risk indicator. Group 1 participants were instructed to answer several questions regarding BMI health report cards. Group 2 participants did not answer the questions; because their child was not yet in school they had not received a school BMI report card. When asked, “Was your child’s BMI report what you expected it to be?” 63.19% of Group 1 participants responded “yes.” Group 1 participants were also asked, “Do you believe that the BMI report card accurately shows your child’s health status?” and 52.74% reported they did not believe the BMI report accurately reflected their child’s health status. Both groups responded to the question “Do you believe that schools should be involved in educating children and parents in matters of healthy lifestyles?” and 78.4% from Group 1 and 85.68% from Group 2 responded “yes.”
Parental Responses (Group 1) to BMI Assessment and Information Questions
Parental Responses (Group 2) to BMI Assessment and Information Questions
To help determine if parents from Group 1 use the information from BMI report cards to make changes to their child’s diet/physical activity habits, parents were asked, “If your child was categorized as underweight, at risk, or overweight on the BMI report, did you change your child’s diet or physical activity habits?” Approximately 57% of parents responded with “not applicable” (NA), indicating their children did not fall into one of these categories based on their BMI report card. Less than 3% of parents of children categorized as underweight indicated they made any changes in their child’s diet or physical activity habits. However, 13.19% of parents with children categorized as “at risk” or “overweight” according to their BMI indicated they made changes to their child’s diet or physical activity habits. They were asked if they contacted a health care professional about their child’s weight status after receiving a BMI report card, and 21.6% indicated they did contact a health care professional. When asked if they sought recommendations for tips on healthy eating or physical activity from a health care professional, 16.22% reported that they did. They were asked, “Did your child’s BMI report lead you to think about your family’s health habits?” and approximately 33% replied that it did.
Researchers were also interested in determining if parents would accurately identify their child’s BMI status/disease risk status with access to current height and weight information for their child. Parents from both groups were asked to record their child’s height and weight measured by the doctor or nurse at the clinic on the questionnaire. Parents were then asked to select from the terms underweight, normal weight, overweight, obese, or unsure in response to the question, “In my opinion, I feel my child is ___ for his or her age.” BMI was then calculated to determine if the parents’ responses were accurate when compared to the child’s BMI category. Table 2 shows parents’ responses compared to their child’s calculated BMI category. Calculated BMI categories of children whose parents participated in this study were approximately 13%, 33%, 16%, and 38% for underweight, normal weight, overweight, and obese, respectively. Approximately 66% of parents did not select the correct category for their child based on their child’s measured BMI. As shown, 13% of parents of whose child was categorized as overweight and 21% of parents whose child was categorized as obese identified their child as “normal weight.”
Child’s Perceived Versus Calculated BMI Category
NOTE: BMI = body mass index.
Discussion
The increase in childhood obesity is caused by a variety of factors, including individual decisions made by parents and children affected by genetics, culture, and sedentary lifestyles (Phillips, 2012). Several states have adopted the use of BMI report cards as a method of providing parents with health-related information about their child. This study supports previous research that shows parents often support BMI screening in their child’s school (Chomitz et al., 2003; Kubik et al., 2006; Kubik, Story, & Rieland, 2007; Murphy & Polivka, 2007). Over 78% of participants in this study believe that schools should be involved in educating children and parents in matters of healthy lifestyles. However, not all participants in this study had children who were old enough to attend school, so generalizability of the response to this question to parents of school-aged children is limited. As BMI screening programs become more prevalent and efficient, support will likely continue to grow for these programs (Henningsen, Boros, Ingvalson, Fontana, & Matvienko, 2015). A large percentage of participants also indicated they understood BMI is a disease risk indicator, yet over half of the participants in Group 1 did not believe their child’s BMI report card accurately reflected their child’s health status.
Schools send parents BMI report cards to inform and encourage positive changes in health-related behaviors of children such as increased physical activity that could improve body composition (Henningsen et al., 2015). In an effort to expand the existing literature regarding parents’ use of the information after receiving BMI report cards, we asked if they made any changes to their child’s physical activity/dietary habits. A small percentage of parents (13.2%) receiving a BMI report card that categorized their child as “at risk” or “overweight” reported making changes to their child’s diet or activity habits. Other studies have shown some parents make changes in their child’s physical activity after receiving a BMI report (Grimmett, Croker, Carnell, & Wardle, 2008; Johnson, Pilkington, Lamp, He, & Deeb, 2009; Kaczmarski, DeBate, Marhefka, & Daley, 2011). Additionally, previous research from Arkansas has shown families become more aware of weight-related health problems; therefore, BMI screening programs may encourage families to make physical activity more of a priority (Justus, Ryan, Rockenbach, Katterapalli, & Card-Higginson, 2007; Thompson & Card-Higginson, 2009). The effectiveness of BMI screening programs in schools continues to be debated, because schools often implement additional policies that affect health behaviors, making it difficult to determine which programs are responsible for behavioral change (Ruggieri & Bass, 2015).
Participants were asked to record their child’s height and weight measured by the doctor or nurse while at the clinic. In an effort to determine parents’ perceptions of their child weight status, they were asked to complete the following statement: “In my opinion, I feel my child is ____ for his or her age.” They were instructed to select one of the following options: underweight, normal weight, overweight, obese, or unsure. BMI was calculated, and the CDC (2010) growth charts for males and females age 2 to 20 years were used to compare parents’ perceived BMI category to the child’s measured BMI category. Percentages where calculated to show the number of parents that correctly identified their child’s weight status (see Table 2). Over 65% of parents did not accurately identify their child’s weight status. Approximately 13% of parents of children who were categorized as “overweight” identified their child as “normal weight,” and 21.4% of parents of children that were categorized as “obese” perceived their child to be “normal weight.” These findings are in agreement with previous research that shows parents of overweight or obese child oftentimes do not accurately identify their child’s weight status (Binkin, Spinelli, Baglio, & Lamberti, 2013; Eckstein et al., 2006; Lopes, Santos, Pereira, & Lopes, 2013; Rietmeijer-Mentink, Paulis, Middelkoop, Bindels, & Wouden, 2013). Binkin et al. (2013) found mothers who live in areas with higher levels of obesity perceive obesity as “normal” and therefore were less likely to identify their child as overweight or obese. As more children and adolescents in the United States become overweight, fewer parents may recognize their child as being overweight or obese.
It should be noted that the CDC (2010) feels there is not enough evidence to conclude whether school-based BMI assessment programs are effective tools for reducing or preventing childhood obesity. The CDC also states there is insufficient evidence to determine if these programs have negative consequences such as increasing the stigma of obesity or whether they cause children and teens to engage in unsafe weight control behaviors. Safeguards such as involving parents in the planning stages of programs and clearly communicating the purpose of the program are essential to a BMI assessment program’s success. It is imperative parents know the assessments are performed out of concern for their child’s health. It is also essential that assessment results be kept confidential; parents, not children, should be the ones to receive the child’s BMI report.
Conclusion
The majority of participants in this study reported that they understood BMI is a measure of disease risk, and the majority with school-aged children reported their child’s BMI report card was what they expected it to be. However, over 50% of these participants did not believe their child’s BMI accurately reflected his or her health status. Though parents support receiving BMI report cards, they may not accurately interpret the information they receive. If parents were given the opportunity to visit with health care professionals, such as school nurses or physical educators, at various times throughout the school year, they may have a better understanding of the information they receive. Parents could benefit from having professionals available during school registration or at parent–teacher conferences to discuss their child’s BMI. Parents should be encouraged to ask questions and seek advice from individuals qualified to discuss the significance of BMI measures and provide information on how to make changes in diet and exercise habits to improve their child’s health. Schools that provide BMI report cards to parents should be willing to provide opportunities for parents to follow up on the information they receive.
Though parents in this study support receiving BMI report cards and believe schools should be involved in educating child and parents in matters of healthy living, only a small percentage of those with children considered “at risk” and “overweight” reported contacting a health care professional to seek advice on healthy eating or physical activity. These findings are similar to those of Kubik et al. (2006) that showed only a small number of parents planned to seek medical services after receiving a BMI report. Parents may not seek advice from heath care professionals for a number of reasons including lack of access or lack of understanding the information they received. Another reason parents may not seek advice is that they believe their overweight child will “outgrow” this problem. Pediatricians, school nurses, and physical educators should be prepared to help parents recognize when their child is overweight and to understand that obese children have a 70% higher chance of becoming an obese adult (CDC, 2013).
Participants in this study were unable to correctly identify their child’s BMI category, lending support to previous research that shows parents of overweight and obese children often do not accurately perceive their child’s health status (Binkin et al., 2013; Eckstein et al., 2006; Lopes et al., 2013; Rietmeijer-Mentink et al., 2013). As more adults and children in the United States become overweight, our perception of what is considered “normal weight” may be influenced by what we see in our environment. Parents and children need information to help them understand being overweight as a child increases health risks such as developing type 2 diabetes and hypertension that can increase one’s risk for heart disease and stroke (CDC, 2013).
Schools are a critical link in improving the health of children through programs such as BMI health reports. However, if schools take on the responsibility of sharing BMI report cards with parents, they must also be willing to provide some support and act as a resource for parents. If the goal of BMI screening programs is ultimately to change the body composition of children and adolescents, schools should consider providing more information and programming to parents and students enabling them to act on the information they receive.