BMI Measurement in Schools

 
SUPPLEMENT ARTICLE

BMI Measurement in Schools
CONTRIBUTORS: Allison J. Nihiser, MPH,a Sarah M. Lee,
PhD,a Howell Wechsler, EdD,a Mary McKenna, PhD,b Erica
Odom, MPH,a Chris Reinold, PhD, RD,c Diane Thompson,
                                                                   abstract
MPH, RD,c and Larry Grummer-Strawn, PhDc
                                                                   BACKGROUND AND OBJECTIVE: School-based BMI measurement has
                                                                   attracted attention across the nation as a potential approach to ad-
Divisions of aAdolescent and School Health and cNutrition,
Physical Activity, and Obesity, Centers for Disease Control and    dress obesity among youth. However, little is known about its impact or
Prevention, Atlanta, Georgia; and bDepartment of Kinesiology,      effectiveness in changing obesity rates or related physical activity and
University of New Brunswick, Fredericton, New Brunswick,           dietary behaviors that influence obesity. This article describes current
Canada
                                                                   BMI-measurement programs and practices, research, and expert rec-
KEY WORDS
body mass index, obesity, growth and development, school
                                                                   ommendations and provides guidance on implementing such an
health services, child, adolescent                                 approach.
ABBREVIATIONS                                                      METHODS: An extensive search for scientific articles, position state-
CDC—Centers for Disease Control and Prevention                     ments, and current state legislation related to BMI-measurement pro-
IOM—Institute of Medicine
AAP—American Academy of Pediatrics                                 grams was conducted. A literature and policy review was written and
This article is based on a longer article first published in the
                                                                   presented to a panel of experts. This panel, comprising experts in
Journal of School Health (Nihiser AJ, Lee SM, Wechsler H, et al.   public health, education, school counseling, school medical care, and
Body mass index measurement in schools. J Sch Health. 2007;        parenting, reviewed and provided expertise on this article.
77[10]:651– 671; quiz 722–724).
                                                                   RESULTS: School-based BMI-measurement programs are conducted
The findings and conclusions in this report are those of the
authors and do not necessarily represent the official position of   for surveillance or screening purposes. Thirteen states are implement-
the Centers for Disease Control and Prevention.                    ing school-based BMI-measurement programs as required by legisla-
www.pediatrics.org/cgi/doi/10.1542/peds.2008-3586L                 tion. Few studies exist that assess the utility of these programs in
doi:10.1542/peds.2008-3586L                                        preventing increases in obesity or the effects these programs may
Accepted for publication Apr 29, 2009                              have on weight-related knowledge, attitudes, and behaviors of youth
Address correspondence to Allison J. Nihiser, MPH, Centers for
                                                                   and their families. Typically, expert organizations support school-
Disease Control and Prevention, Division of Adolescent and         based BMI surveillance; however, controversy exists over screening.
School Health, 4770 Buford Hwy NE, Mailstop K-12, Atlanta, GA      BMI screening does not currently meet all of the American Academy of
30341. E-mail: anihiser@cdc.gov
                                                                   Pediatrics’ criteria for determining whether screening for specific
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).    health conditions should be implemented in schools.
Copyright © 2009 by the American Academy of Pediatrics
                                                                   CONCLUSION: Schools initiating BMI-measurement programs should
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
                                                                   adhere to safeguards to minimize potential harms and maximize ben-
                                                                   efits, establish a safe and supportive environment for students of all
                                                                   body sizes, and implement science-based strategies to promote phys-
                                                                   ical activity and healthy eating. Pediatrics 2009;124:S89–S97

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Obesity among youth has become 1 of          tion, school counseling, school                 and/or subpopulations in a school,
the most critical public health prob-        medical care, and parenting. This arti-         school district, state, or nation;
lems in the United States. Schools can       cle presents an overview of the CDC’s        ● identify demographic or geographic
play an important role in preventing         guidance on this topic; it describes the        subgroups at greatest risk of obe-
obesity because ⬎95% of young peo-           purposes of BMI-measurement pro-                sity to target prevention and treat-
ple are enrolled in schools,1 and            grams, examines current practices,              ment programs;
schools have historically promoted           reviews existing research, summa-
                                                                                          ● create awareness among school
physical activity and healthy eating. Re-    rizes expert recommendations, identi-
                                                                                             and health personnel, community
search has shown that well-designed,         fies research gaps, and provides guid-
                                                                                             members, and policy makers of the
well-implemented school-based pro-           ance and safeguards for implementing
                                                                                             extent of obesity among the youth
grams can effectively promote these          BMI-measurement programs.
                                                                                             they serve;
behaviors,2–4 and the Centers for Dis-
ease Control and Prevention (CDC) has        PURPOSES OF COLLECTING BMI                   ● provide an impetus to improve poli-
identified strategies that schools can        DATA                                            cies, practices, and services to pre-
use to prevent obesity.5                                                                     vent and treat obesity among youth;
                                             BMI is the ratio of an individual’s
Measuring the BMI of students in             weight to height squared (kg/m2) and         ● monitor the effects of school-based
schools is an approach to addressing         is used to estimate a person’s risk of          physical activity and nutrition pro-
obesity that is attracting attention         weight-related health problems. It is           grams and policies; and
across the nation from researchers,          often used to assess weight status, be-      ● monitor progress toward achieving
school officials, legislators, and the        cause it is relatively easy to measure          health objectives (eg, US Healthy
media.6–12 Because little research has       and correlates with body fat.19–23 After        People 2010 objectives) related to
been conducted on the impact of this         BMI is calculated for a child or adoles-        childhood obesity.
approach, it is not included in the          cent, it is plotted by age on a gender-
CDC’s recommended strategies. How-           specific growth chart (see www.cdc.           Screening
ever, some states, cities, and commu-        gov/growthcharts for the CDC’s BMI-          BMI-screening programs in schools
nities have established school-based         for-age growth charts for girls and          are designed to assess the weight sta-
BMI-measurement programs in recent           boys aged 2–20 years). BMI measure-          tus of individual students to detect
years, and many others are consider-         ment in schools may be conducted for         those who are at risk for weight-
ing the merits of initiating such pro-       surveillance and screening purposes.         related health problems. Screening
grams.                                                                                    programs provide parents with per-
In 2005, the Institute of Medicine (IOM)     Surveillance                                 sonalized health information about
called on the federal government to de-      Surveillance refers to the systematic        their child. Screening results are sent
velop guidance for BMI-measurement           collection, analysis, and interpretation     to parents and typically include the
programs in schools.13 The CDC con-          of data from a census or representa-         child’s BMI-for-age percentile; an ex-
ducted an extensive search for scientific     tive sample (ie, a sample that has been      planation of the results; recommended
studies that evaluated school-based          scientifically selected to represent a        follow-up actions, if any; and tips on
BMI-measurement programs; col-               specified population). Typically, the         healthy eating, physical activity, and
lected related position statements                                                        healthy weight management.9,24–27 Re-
                                             data are collected anonymously. The
published by expert organizations                                                         sults from screening programs also
                                             purpose of BMI surveillance in schools
from public health, medicine, and edu-                                                    can be used to develop reports similar
                                             is to identify the percentages of stu-
cation; and reviewed sources to iden-                                                     to those developed by surveillance
                                             dents in the population who are obese,
tify state legislation on these pro-                                                      programs.28,29
                                             overweight, normal weight, and under-
grams including policy-tracking
                                             weight; surveillance does not involve        Goals of BMI-screening programs in
services, state general assembly legis-
                                             informing parents of their child’s           schools include
lative databases, and staff in state ed-
                                             weight status.                               ● preventing and reducing obesity in
ucation or health departments.14–18 An
expert panel, convened by the CDC in         School-based BMI-surveillance data              a population;
2005, provided input on an earlier ver-      can be used to                               ● correcting misperceptions of par-
sion of this article. The panel com-         ● describe trends in weight status              ents and children about the chil-
prised experts in public health, educa-         over   time    among     populations         dren’s weight;

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● motivating parents and their chil-        nia Code §23.21, 2004). In 1995, Califor-      measurement programs in preventing
  dren to make healthy and safe life-       nia initiated statewide surveillance of        increases in obesity among youth. A
  style changes;                            student physical fitness levels, which          few jurisdictions have monitored the
● motivating parents to take children       includes BMI assessments and tests of          prevalence of obesity through child-
  at risk to medical care providers for     aerobic capacity, flexibility, and mus-         hood obesity interventions that in-
  further evaluation and, if needed,        cle strength.32 In Illinois, the Depart-       clude BMI screening; however, the
  guidance and treatment; and               ment of Public Health is in the process        independent effects of the BMI-
                                            of developing a child health examina-          screening program on obesity are not
● increasing awareness of school ad-
                                            tion surveillance system. This system          clear.9,28,32 Arkansas is evaluating the im-
  ministrators and school staff of the
                                            will aggregate BMI and possibly other          pact of its multicomponent, childhood
  importance of addressing obesity.
                                            health information collected during            obesity program that includes a state-
Schools sometimes include BMI re-           students’ school physical examina-             wide BMI-screening and -surveillance
sults with results from other health        tions by their medical care providers          program. The percentage of Arkansas
screening examinations, such as vi-         (Illinois 93rd General Assembly, Public        students classified as obese was 20.8%
sion or hearing tests, in reports to        Act 93– 0966, SB 2940, 2004).                  in 2003–2004, the first year of implemen-
parents.30
                                                                                           tation, 20.7% in 2004 –2005, 20.4% in
                                            CONCERNS
CURRENT PRACTICES                                                                          2005–2006 and 20.4% in 2006 –2007, and
                                            A number of concerns have been ex-             20.5% in 2007–2008.38
The CDC’s 2006 school health policies       pressed about school-based BMI-
and programs study found that 22% of                                                       A small body of research has ad-
                                            screening programs, including that
states required schools or school dis-                                                     dressed issues related to school-
                                            they might intensify the stigmatization
tricts to measure or assess students’                                                      based BMI-measurement programs in-
                                            already experienced by many obese
height and weight or body mass, and                                                        cluding perceptions of weight status,
                                            youth, increase dissatisfaction with
73% of those states required parent                                                        parental perceptions of BMI-screening
                                            body image, and intensify pressures to
notification of the results.31 Nation-                                                      programs, and student and parental
                                            engage in harmful weight-loss prac-
wide, ⬎40% of schools reported that                                                        responses to the results. Additional re-
                                            tices that could lead to eating disor-
they measure the height and weight or                                                      search is needed on possible psycho-
                                            ders.6–8,10–12,33–36 Another concern is
body mass of their students.31 The                                                         social effects of BMI screening on
                                            that parents might respond inappro-
study did not determine how fre-                                                           students.
                                            priately to BMI reports by, for example,
quently students are assessed,              placing their child on a restrictive and
whether BMIs are calculated from the                                                       PERCEPTIONS OF WEIGHT STATUS
                                            potentially harmful diet without seek-
height and weight data, or the purpose      ing medical advice.7,8,12,25 Other con-        Several studies have found that par-
of the data collections.                    cerns are that these programs might            ents and children commonly misclas-
At least 13 states have legislation and     be ineffective, waste scarce health-           sify children’s weight status.29,39–44 A
are implementing school-based BMI-          promotion resources, and distract at-          study of 742 mothers of adolescents
measurement programs (Arkansas,             tention from other school-based                found that 35% underestimated their
California, Delaware, Florida, Illinois,    obesity-prevention activities such as          child’s weight status and 5% overesti-
Louisiana, New York, Pennsylvania,          improvements to the school physical            mated it; 86% of mothers whose child
South Carolina, Tennessee, Texas, Ver-      activity and nutrition environment.37          had a BMI at ⱖ95th percentile did not
mont, and West Virginia). Arkansas im-      More research is needed to assess              identify their child as overweight.40 A
plemented a statewide BMI-screening         the validity of these concerns. BMI-           study of 2032 high school students
and -surveillance program in 2003           surveillance programs are less con-            found that 26% of obese students per-
(State of Arkansas, 84th General As-        troversial, because they do not involve        ceived themselves as underweight,
sembly, regular session, Act 1220 of        the communication of sensitive infor-          and another 20% perceived them-
2003, HB 1583). Pennsylvania began to       mation to parents and do not require           selves as “about the right weight”; only
phase in a BMI-screening and                follow-up care.                                6% of normal-weight students per-
-surveillance program (28 Pennsylva-                                                       ceived themselves as overweight.41 The
nia Code §23.7) for all students in         RESEARCH ON BMI-MEASUREMENT                    evaluation of the Arkansas statewide
the 2005–2006 school year (Common-          PROGRAMS                                       BMI-screening program found that the
wealth of Pennsylvania, Height and          Studies have not yet adequately evalu-         percentage of parents who classified
Weight Measurements, 28 Pennsylva-          ated the utility of school-based BMI-          their child accurately as overweight or

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at risk of overweight increased from          ementary schools in preventing child-         school nurses about their child’s BMI,
40% at baseline to 53% after the first         hood obesity and found that parents           and most family practitioners and pe-
year of screening.29                          were least likely to support BMI-             diatricians surveyed reported that
                                              related activities. Parents rated the         they were not contacted by a substan-
PARENTAL PERCEPTIONS OF BMI                   importance of 37 actions schools can          tial number of parents wanting to dis-
SCREENING IN SCHOOLS                          take to address obesity through health        cuss their child’s weight status.29 How-
Five studies included parent inter-           education, food services, and physical        ever, parents did not put students on
views and found that most parents             education. Using a Likert-type scale          diets with a greater frequency than
support and respond positively to             (eg, not important to very important),        they did before the program.48
BMI screening in their children’s             the lowest-rated actions were collect-
schools.25,29,35,45,46 One of these studies   ing height and weight measurements            RECOMMENDATIONS FROM EXPERT
analyzed focus-group discussions with         and informing parents of their child’s        ORGANIZATIONS
parents of elementary school children         height and weight.47                          The use of BMI measurement for sur-
in Minnesota. The investigators con-                                                        veillance purposes, regardless of set-
cluded that parents in this study were        STUDENT AND PARENTAL                          ting, has been endorsed by the Ameri-
receptive to BMI screening in schools         RESPONSES TO BMI SCREENINGS                   can Public Health Association, The
provided it is done with care and par-        Arkansas evaluated its statewide pro-         American Heart Association and the
ents are involved in developing the pro-      gram for any negative psychosocial            IOM.13,50,51 However, views on BMI
gram.35 Parents would support pro-            consequences that may have been ex-           screening vary. The US Preventive Ser-
grams if they receive advanced notice         perienced by the students. After 4            vices Task Force concluded that insuf-
about the BMI measurement, have the           years of BMI screenings, Arkansas stu-        ficient evidence exists to recommend
opportunity to decline consent, receive       dents reported no increases in weight-        for or against BMI-screening pro-
assurance that the measurements               related teasing, no increases in con-         grams for youth in clinical settings as
would be collected in a private and re-       cerns about weight, and no increases          a means to prevent adverse health out-
spectful manner that minimizes                in dieting or using diet pills.48 However,    comes such as adult cardiovascular
weight-related teasing, and receive the       obese students were significantly              disease risk.52 However, authors of the
results in a letter mailed to all parents     more likely to be embarrassed by BMI          2007 report of an expert committee on
that uses a neutral tone and does not         measurement.                                  childhood obesity convened by the
assign blame.35 A pilot BMI-screening         Three school-based screening pro-             American Medical Association recom-
program was developed on the basis            grams that evaluated parental re-             mended that primary care providers cal-
of the findings of these focus groups; 4       sponses observed that parents do not          culate and plot BMI at least annually; this
elementary schools were recruited to          consistently follow-up with a medical         has been endorsed by 12 organiza-
examine parental reaction to BMI mea-         care provider after receiving their           tions.53–56 For school-based programs,
surement.45 All 4 schools conducted           child’s screening results.25,29,49 An eval-   the IOM recommends annual BMI
height and weight measurements;               uation of a school-based health “re-          screening,13 whereas other organiza-
however, the 2 intervention schools           port card” revealed that the parents          tions encourage schools to exercise cau-
mailed BMI results to parents,                who received their child’s BMI results        tion before adopting BMI-measurement
whereas the remaining 2 schools did           were more likely than parents who did         programs.33,50,57
not mail results to the home. A               not receive the results to report that        The American Academy of Pediatrics
follow-up survey found that 78% of par-       they had initiated or intended to initi-      (AAP) developed criteria to guide deci-
ents in all 4 schools believed it was         ate clinical services, dieting, or physi-     sions on whether schools should im-
important for schools to assess and           cal activity as weight control for their      plement a screening program for any
mail BMI results to the home as part of       children. However, 7 of the 19 families       pediatric health problem (Table 1).58
annual student health-screening re-           planning to initiate dieting reported         BMI screening meets some of the cri-
ports. Parents of girls and older chil-       that they planned to do so without            teria: obesity is an important and
dren were less likely than parents of         seeking medical counsel despite               highly prevalent condition59,60; BMI
boys and younger children to want an-         strong recommendations against                is an acceptable measure20,22; and
nual BMI-screening information.45             such actions.25 The evaluation of Ar-         schools are a logical measurement
A study conducted in Ohio examined            kansas’ statewide screening program           site, because they reach virtually all
parents’ perceptions on the role of el-       revealed that parents did not consult         youth.1 However, BMI-screening pro-

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TABLE 1 AAP Criteria for a Successful Screening Program in Schools58
          Aspect                                                    Criteria for a Successful Screening Program in Schools
Disease                          Undetected cases must be common or new cases must occur frequently, and the disease must be associated with adverse
                                    consequences.
Treatment                        Effective treatment must be available, and early intervention must be beneficial.
Screening test                   The test should be sensitive, specific, and reliable.
Screener                         The screener must be well trained.
Target population                Screening should focus on groups with high prevalence of the condition/disease in question or in which early intervention
                                    will be most beneficial.
Referral and treatment           Those with a positive screening test result must receive a more definitive evaluation and, if indicated, appropriate treatment.
Cost/benefit ratio                The benefit should outweigh the expenses (ie, costs of conducting the screening and any physical or psychosocial effects on
                                    the individual being screened).
Site                             The site should be appropriate for conducting the screening and communicating the results.
Program maintenance              The program should be reviewed for its value and effectiveness.

grams typically do not meet other AAP               ● There is a universal bullying-                        the likelihood of a positive impact
criteria: effective treatments for obe-                prevention program that addresses                    on promoting a healthy weight, all BMI-
sity are not available,8,23,61 research                weight discrimination.                               measurement programs should adhere
has not established the effectiveness               ● Curricula foster acceptance of                        to the following safeguards.6,26
and cost-effectiveness of these pro-                   healthy weight by countering social                  ● Introduce the program to school
grams, and communities typically do                    pressures for excessive thinness.                        staff and community members and
not have resources in place to help in-                                                                         obtain parental consent.
                                                    ● Teachers, school counselors, school
dividuals at risk access treatment.13                                                                       ● Train staff in administering the pro-
                                                       nurses, coaches, and other staff re-
The AAP specifies that schools should                                                                            gram (ideally, implementation will
                                                       ceive the professional development
not implement screening if resources                                                                            be led by a highly qualified staff
                                                       and resources they need to provide
for follow-up do not exist.                                                                                     member such as a school nurse).
                                                       useful guidance to students with
                                                       weight-related concerns.                             ● Establish safeguards to protect stu-
GUIDANCE ON MEASURING BMI IN
                                                                                                                dent privacy.
SCHOOLS                                             If schools raise awareness about obe-
                                                                                                            ● Obtain and use accurate equipment.
Before launching a BMI-measurement                  sity through a BMI-measurement pro-
program for surveillance or screen-                 gram, they need to have in place an                     ● Accurately calculate and interpret
ing, decision-makers need to consider               environment that helps students make                        the data.
whether the anticipated benefits (eg,                healthy dietary and physical activity                   ● Develop    efficient data-collection
preventing obesity, correcting misper-              choices. For example, Arkansas re-                          procedures.
ceptions of weight) outweigh the ex-                quired all elementary schools to re-                    ● Avoid using BMI results to evaluate
pected costs (eg, monetary, psycho-                 move vending machines from schools                          student or teacher performance.
social consequences). To minimize                   concurrent with implementing the                        ● Evaluate the program regularly for
potential harm and maximize benefits,                statewide BMI-measurement program.62                        its intended outcomes and unin-
schools should not launch a BMI-                    California’s physical performance                           tended consequences.
measurement program unless they                     tests influenced the adoption of state-
                                                                                                            Those who implement BMI-screening
have established a safe and supportive              wide, grade-specific physical educa-
                                                                                                            programs should ensure that all par-
environment for students of all body                tion content standards.63 The CDC has
                                                                                                            ents receive a clear and respectful ex-
sizes; are implementing comprehen-                  identified 10 comprehensive strate-                      planation of the results and appropri-
sive strategies to address obesity; and             gies that schools can implement to                      ate follow-up actions, and that
have put in place safeguards that ad-               prevent obesity by promoting physical                   resources are available for safe and
dress the concerns raised about such                activity and healthy eating (www.cdc.                   effective follow-up. Greater detail of
programs.                                           gov/healthyyouth/keystrategies).5                       these safeguards are described in the
The following are some key character-               To ensure respect for student privacy                   longer version of this article in the De-
istics of a safe and supportive environ-            and confidentiality, protect students                    cember 2007 issue of the Journal of
ment for students of all body sizes26:              from potential harm, and increase                       School Health.64

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Research is needed to address out-          There is a need for researchers in aca-                relation to the needs of their jurisdiction
standing issues regarding school-           demia, government, and scientific orga-                 and resources available.
based BMI-surveillance and -screening       nizations to develop a research agenda
programs, including                         around school-based BMI-measurement                    ACKNOWLEDGMENTS
● program impact on preventing and          programs, document the impact of data
                                            collection on obesity-prevention policies,             We thank Laura Dobbs (past president,
  reducing obesity;
                                            study the data currently being collected,              Georgia Parent Teacher Association),
● the types of follow-up actions taken                                                             Joyce Epstein, PhD (director, Center on
                                            and define safe, effective, and accessible
  by parents and students;                                                                         School, Family, and Community Part-
                                            follow-up services.
● the programs’ intended and unin-                                                                 nerships), Suzanne Bennette Johnson,
  tended physical, social, and psycho-      CONCLUSIONS                                            PhD (professor and chair, Department
  logical effects;                          School-based BMI-surveillance pro-                     of Medical Humanities and Social Sci-
● student perceptions of and atti-          grams are less controversial than                      ences, Florida State University College
  tudes toward height and weight            screening programs, but they still must                of Medicine), Martha Kubik, PhD (asso-
  measurement in schools;                   adhere to the safeguards identified. Sur-               ciate professor, School of Nursing, Uni-
● the role and capacity of the school or    veillance programs can provide valuable                versity of Minnesota), Maryann Mason,
  school district nurse to implement        prevalence and trend data; samples                     PhD (associate director, Center for
  and manage the BMI-measurement            should be selected carefully to ensure                 Obesity Management and Prevention,
  program;                                  representativeness and to minimize pro-                Mary Ann and J. Milburn Smith Child
                                            gram costs.                                            Health Research Program, Children’s
● the effects of BMI-measurement
  programs on school-based efforts          More research needs to be conducted to                 Memorial Research Center), Mary Pat
  to promote nutrition and physical         evaluate the impact of BMI-screening                   McCartney, PhD (former elementary
  activity and link parents with medi-      programs on weight-related behaviors                   vice-president, American School Coun-
  cal services in the community;            and outcomes. Legitimate concerns                      selor Association), Martha Phillips,
                                            have been raised about the potential                   PhD (assistant professor, Department
● the effectiveness of treatment for
                                            harm that might be caused by BMI-                      of Psychiatry and Epidemiology, Uni-
  youth identified as obese, over-
                                            screening programs; more research is                   versity of Arkansas for Medical Sci-
  weight, or underweight;
                                            needed to assess whether these harms                   ence), Shirley Shantz, EdD, ARNP
● cost/benefit analyses of these pro-                                                               (nursing projects director, National
                                            occur. BMI-screening programs do not
  grams compared with alternative                                                                  Association of School Nurses), Howard
                                            yet meet AAP criteria for a successful
  strategies;                                                                                      Taras, MD (professor, School of Medi-
                                            school screening program. The CDC en-
● relative efficiency of using schools       courages additional research and evalu-                cine, University of California San Di-
  as a BMI-measurement site; and            ation on school-based BMI-screening                    ego), and Gail Woodward-Lopez, MPH,
● effectiveness of different methods        programs. Before initiating BMI-                       RD (associate director, Center for
  for communicating BMI results and         measurement programs, decision-                        Weight and Health, University of Cali-
  related risk information to parents       makers should consider the benefits                     fornia Berkeley), for their review and
  and youth.                                and disadvantages of these programs in                 expertise.

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BMI Measurement in Schools
Allison J. Nihiser, Sarah M. Lee, Howell Wechsler, Mary McKenna, Erica Odom,
           Chris Reinold, Diane Thompson and Larry Grummer-Strawn
                             Pediatrics 2009;124;S89
                          DOI: 10.1542/peds.2008-3586L
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
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BMI Measurement in Schools
Allison J. Nihiser, Sarah M. Lee, Howell Wechsler, Mary McKenna, Erica Odom,
           Chris Reinold, Diane Thompson and Larry Grummer-Strawn
                             Pediatrics 2009;124;S89
                          DOI: 10.1542/peds.2008-3586L

The online version of this article, along with updated information and services, is
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