Guess What F Is For? Fat

By Claudia Wallis

The way state representative Gary Biggs sees it, things in Arkansas had pretty much reached critical mass. Not only were 60% of adults in the state overweight or obese, but their kids were catching up fast: a quarter of Arkansas' high school students are overweight or "at risk." The state health director estimates that Type 2 diabetes, formerly known as the adult-onset variety, is up 800% in kids over the past decade. Even the state's preschoolers have grown shockingly plump: almost 10% are overweight. Says Biggs: "I have been on the house public-health committee for three terms, and I got tired of hearing 'Thank God for Mississippi'"--which has an even higher obesity rate than Arkansas does. Something had to be done.

Something was. As the state's 1,139 public schools opened their doors for a new year, they faced a new task. For the first time they will be asked to issue each student a health report card in the form of a body mass index, or BMI (see box). As lawmakers initially envisioned the plan when they passed the Biggs-sponsored bill in April, schools were to literally add a section to report cards--alongside the traditional assessments in reading, writing and 'rithmetic--for this measure of a child's body. At a time when schools are increasingly taking on responsibilities once left to parents--from teaching about sex and drugs to enforcing dress codes--this development was perhaps not all that surprising. But feeding a child is arguably a parent's most elemental task, so the prospect of schools' intruding in such an intimate matter and issuing F-is-for-fat grades was mortifying to many.

"There was concern among some parents of overweight children that the report card would be snatched from the child's hand and passed around for everyone to see, and the child would be tormented," explains state PTA president Kathy McFetridge. So last week Arkansas' new child-health advisory committee voted to modify the plan. Health reports will be mailed separately to parents, and families may even opt out of the program. In addition, chastened policymakers agreed to begin pilots of the policy in a few schools this fall before rolling it out statewide in the spring.

Arkansas is the first state to embrace, however gingerly, the health-report-card approach, but other states are exploring similar policies and other steps to control childhood obesity. They are propelled by some remarkably scary statistics. Nationally, 15% of children ages 5 to 19 are overweight, triple the rate of 20 years ago. Research suggests that fat adolescents have a 70% to 80% chance of becoming fat adults. They face higher rates of atherosclerosis, hypertension and diabetes. "These kids could need coronary bypass in their 20s," says Kelly Brownell, director of the Yale University Center for Eating and Weight Disorders. "This could be the first generation of American children to lead shorter lives than their parents."

The medical community has been sounding the alarm for several years. Just last month the American Academy of Pediatrics (A.A.P.) formally recommended that doctors make BMI assessments a routine part of annual physicals. No one doubts that the pediatrician's office belongs on the front lines of confronting the epidemic, but is school the right place to fight this battle? And can weigh-ins at the nurse's office be helpful without causing a lot of collateral damage to tender egos?

Many obesity experts argue that the lunchroom and gym are the spots where schools should focus their energies. "Are we offering enough P.E. classes? How do we get more nutritious lunch meals into schools? How do we promote a healthy, active lifestyle without stigmatizing overweight children?" asks Dr. Nancy Krebs, a University of Colorado pediatrician who helped draft the A.A.P.'s new weight-screening recommendation. Krebs suspects that the most valuable part of Arkansas' anti-obesity campaign is not the health report card but a provision in the same law that forbids access to vending machines in elementary schools during school hours. Others say this measure, though well intentioned, is too limited. "It's ridiculous not to address the problem in middle schools and high schools," says Brownell, author of the new book Food Fight: The Inside Story of the Food Industry, America's Obesity Crisis and What We Can Do About It (McGraw-Hill/Contemporary Books). "That's where most of the vending machines are, and that's where kids have the discretionary income to use them."

As for the use of health report cards, experience so far is limited, and results are mixed. Cambridge, Mass., is the only community that has conducted a scientific study of their impact. Like many other towns, Cambridge had been weighing and measuring its students for decades, feeding the results back to state health officials, not parents. "Believe it or not, this was originally designed to catch underweight and failure to thrive," muses Virginia Chomitz, a senior scientist at Cambridge's Institute for Community Health. In 2001 Chomitz worked with phys-ed teachers and school nurses in three Cambridge elementary schools to test parents' reactions to three approaches to weight screening: issuing BMI-based health reports on individual kids and following up with phone calls home for kids at risk; providing general health information; and not intervening at all. The results, published in the current issue of Archives of Pediatrics and Adolescent Medicine, showed that parents of overweight students were significantly more likely to say they planned to seek medical help, increase physical activity and work on a diet plan for their children if they received a BMI report card. Whether parents actually take the actions they planned and whether kids actually benefit are the subjects of a future study.

In Michigan, where some districts have experimented with health report cards, educators have learned some hard lessons. For example, in Livonia, just west of Detroit, parents complained to the state that kids had been traumatized by in-school weigh-ins. They also quashed the school superintendent's plan to expand fitness evaluations. Around the state, "we have seen students both thin and heavy going on extreme diets after getting their scores," says Karen Petersmarck, a nutritionist who consults with the Michigan department of community health. Petersmarck served on a task force that developed exacting guidelines for Michigan schools that choose to undertake weight screening. Among them: creating a process that maintains privacy, avoids labeling students, involves only trained staff members and provides an overall context for teaching kids that healthy people come in many shapes and sizes. "Some members of the task force argued that it's almost impossible for schools to put all these guidelines into action," says Petersmarck. "We said, 'Good!' Because everybody who does weight screening at schools has to understand that this is not a trivial thing to do."

Folks in Arkansas are beginning to get that message. "The BMI puts a cloud on what is otherwise a good piece of legislation," says Daniel Whitehorn, principal of the Pulaski Heights Middle School in Little Rock. While he supports the state's focus on improving nutrition and physical-activity programs at schools, which is also part of the new legislation, he is worried about stigmatizing kids. "Right before puberty, we have a lot of kids who tend to bulk up a little bit," he says. "You can prematurely label a kid. And these kids are so sensitive." Whitehorn's students seem to share his concerns. "Some people are not strong enough to handle the teasing," says eighth-grader Alex Weems, 12. "People should be allowed to be different." Neither Alex nor his peers are looking forward to having to make the grade in fitness. With reporting by Steve Barnes/Little Rock and Stefanie Friedhoff/Ann Arbor

With reporting by Steve Barnes/Little Rock and Stefanie Friedhoff/Ann Arbor