AMA Journal of Ethics^®

Case

Sarah is a pleasant, happy-go-lucky 8-year-old at Brookline Elementary School who came home one day with a note from the nurse's office. It warned her parents that their daughter, who weighed 70 pounds and stood 4 feet tall, had a body mass index (BMI) that placed her in the 90th percentile of kids her age. In other words, the note indicated, she was “at risk of becoming overweight.”

Sarah's parents were outraged. Although they considered Sarah to be somewhat pudgy, they weren't worried about her health because they knew that Sarah was an active child who played outdoors, rode her bicycle, and ate healthy meals prepared by her mother, both at home and school.

Sarah herself was deeply disturbed by the letter, convinced that her teachers were rebuking her for eating too much at home or being lazy in school. Her parents then noticed that she began eating less and skipping meals.

After calling the school to complain, Sarah's parents found out that the school had recently instituted a policy under which all children with BMIs above the 85th percentile were referred for a regimen of weight management, behavioral counseling, and other staged interventions under the guidance of a primary care physician to help them achieve certain goals for lifestyle and health consciousness. Even though Sarah's parents were convinced there was nothing wrong with their daughter's health or weight, they made an appointment with Sarah's pediatrician, Dr. James, to discuss the matter.

Having been the family pediatrician for nearly a decade, Dr. James had monitored Sarah's growth and health carefully for most of her life and had always thought of her as a relatively healthy child. When he learned about Sarah's predicament at school, he realized that to comply with the school's expectations of care for children they deemed “overweight” or “obese,” he would have to monitor Sarah's health far differently than he typically did for a child her age. On her regularly scheduled visits, he would have to perform complete work-ups for all obesity-related risk factors; labwork would include blood pressure, lipid profile, fasting glucose, and a variety of other tests. Not only that, he would also have to assess her eating behaviors, including how often her family ate meals away from home, how many sweetened beverages she drank, and how frequently she snacked.

After Dr. James discussed all this with Sarah's family, they found it unjustifiably intrusive into their lives. Sarah was horrified at the idea that she would have to endure so many visits to the doctor and so many questions about her life when she didn't even understand what was wrong.

Commentary

This case poses two important questions. First, do schools have the right (or the duty) to monitor health indices and require action from parents? Second, what is the role of the physician in this context? The overarching issue is, of course, society's responsibility in monitoring and protecting the health of its members.

In our individualistic society based on private health care, there is little tolerance for public health decisions that affect large segments of the population. Health education is based primarily on individual responsibility: for example, to prevent drug abuse, “just say no.” In this context, it is not surprising that collective initiatives such as monitoring body mass index (BMI) in schools and informing parents have created controversy. The Emmaus, Pennsylvania, school district was one of the first to implement this measure [1]. In the year 2000, schools in that district measured BMI in all children and sent letters to parents of those with BMI levels above the 85th percentile (also to the few with BMI levels below the fifth percentile, the cutoff for undernutrition). There was a strong negative reaction from parents, similar to the one described in this case.

After the learning experience of the first year, the school district made several important changes in the program. First, it sent a preliminary notice to parents giving them the opportunity to opt out of the BMI letter. Next, it sent the BMI results to all parents, not just to those with BMI above or below the acceptable range, transforming the “bad report card” concept of the program to an information- and education-based one. Third, the BMI measurement activity was preceded by an intense educational campaign that involved parents, teachers, health care providers, and community organizations. Finally, major initiatives were introduced at schools, including revision of the school menus, promotion of physical activity, and creation of a health coordinating committee. In two years, the number of families participating in the program increased dramatically, and less than 2 percent of parents chose not to receive the BMI results [1].

The key lesson is that informing parents should not be simply a means to shift responsibility from the school to the home, but rather an invitation to join school and community officials in dealing with the problem of obesity. For this, parents must see that multiple efforts are being made to educate kids and their families and help them maintain a healthy lifestyle and body weight.

Physicians' Responsibilities

The second issue, the role of the physician and other health care professionals, is more complex. Our health care system exhibits a substantial disconnect between public health and private practice. Doctors may not be well informed about the public health issues in their communities or their state. Their perception of the prevalence of diseases in their community may be largely based on their own experience with patients, which can vary substantially from one practice to another. Medical school provides limited training on prevention assessment and intervention, and most insurers' compensation policies discourage prevention activities during office visits. Furthermore, insurers usually do not cover weight loss programs, unless associated disorders such as high blood pressure or dyslipidemia are already present.

Several organizations have proposed recommendations on how the primary care physician should approach a child with high BMI [2]. The ideal method should consider not only BMI but the presence of comorbidities such as high blood pressure and dyslipidemia and should check for parental obesity. Management can range from simple observation to dietary counseling or weight management. Serious weight problems should be handled by a team with experience in pediatric obesity, which usually includes a dietitian, a behavioral therapist, and a physical therapist. Involvement of the whole family is crucial.

Due to the high cost and low long-term success rate of treatment, the response to the obesity epidemic should be prevention. For this we must refocus our health care system toward preventive care and expand opportunities for healthy behaviors in the workplace, schools, and the community. In this context, as the experience of the Emmaus district shows, a “BMI letter” should be regarded not as an intrusion but as an invitation to join the general efforts to improve health and prevent obesity among our children.