Remember the BMI report card debate?

When Arkansas enacted Act 1220 in 2003, it was done with great fanfare and national attention. So began the largest and most comprehensive statewide school-based childhood obesity initiative ever enacted in the country. Act 1220 was to provide the proof needed that the war on childhood obesity could be won. The fourth annual report evaluating the effectiveness of the Arkansas Act 1220 was quietly released recently.

Quietly, perhaps, because the news wasn’t encouraging...

Never in the history of our country have there been such vast amounts of public health and education funds and resources — and more policies addressing every facet of communities, homes and school environments — devoted towards addressing childhood obesity. The Arkansas Act is held up as the model for childhood obesity programs affecting every child in the country. So, the report evaluating its effectiveness, and potential detrimental effects on families or young people, should have been front page news and reached every parent and taxpayer in the country.

But if you heard nothing about it, you weren’t alone. A scattering of local news stories reported that the law was a “Big Success” in creating healthier school environments, noting that junk foods and sodas were being prohibited in growing numbers of schools, and more parents and kids understood BMI and the health risks of obesity and were making changes to eat healthier and exercise more. A lead author of the evaluation report, Jim Raczynski, Ph.D., dean at the Fay W. Boozman College of Public Health, told media that the changes that have taken place in Arkansas schools are probably more extensive than anywhere else in the country and that Arkansas is leading the national trend, with the entire country looking to Arkansas as a model for their own public policies.

Reading closely, of course, those claims of success are based on processes, not actual clinical outcomes improving children’s health or even addressing the Act’s key goal: reducing rates of childhood obesity.

Background

Act 1220 was signed into Arkansas law by former Governor Mike Huckabee in April 2003, which launched this far-reaching program to combat childhood obesity. Its main provisions included annual BMI screenings of all public school students with reports sent to their parents; the implementation of policies restricting access to vending machine junk food and sugary drinks in public schools; the creation of community partnerships and a Child Health Advisory Committee to develop nutrition and physical activity standards and wellness programs in schools and communities; and intensive curriculums on the health risks of obesity and to promote weight control and healthy lifestyle behaviors in youth and their families. The Robert Wood Johnson Foundation supports the collection of BMI and evaluation data and its reporting.

The third annual evaluation report on Act 1220 revealed that, despite including everything popularly believed necessary to eradicate childhood obesity, the program had had no effect in reducing rates of overweight among young people. Nor was it able to demonstrate any positive effects on children’s health or health behaviors. It did, however, uncover evidence suggesting that the Act was having harmful effects on Arkansas’ young people. A major CDC review of school-based BMI screening programs found similar failures and causes of concern. [See reviews here and here.]

The latest evaluation of Act 1220 actually comes in the form of two reports. One is the technical report on the BMI assessments and on the program’s success in achieving its main goal: reducing rates of obesity among young people in Arkansas. The other, is the complete, four-year evaluation of Act 1220, specifically examining how the program has affected the health and welfare of children. Here’s a look at both.

Assessment of Childhood and Adolescent obesity in Arkansas Year Four (Fall 2006–Spring 2007)

This publication reported the detailed BMI assessment data and weight classifications among students from each of the counties and school districts for the 2006–2007 school year. It was authored by the Arkansas Center for Health Improvement (ACHI), a policy center supported by the Arkansas Department of Health and Robert Wood Johnson Foundation. ACHI’s function has been to help implement Act 1220 and evaluate its effectiveness.

According to this report, 99.1% of Arkansas public schools had participated in the statewide BMI Assessment program. The report from this last school year was based on data from 77.6% of the students (down from 85.5% the prior year). [The authors refuted concerns that this was fading support for the program, but said that the 2007 legislative session debate on whether to discontinue the program may have resulted in all but the most ardent districts delaying BMI assessments until the controversy was resolved. But this would also be more apt to favorably affect the findings.]

The primary finding of this Assessment report was that since 2003, the Arkansas Act 1220 has had no effect on children and adolescent weight classifications. There has been no reduction in ‘childhood obesity’. More specifically, there’s been no change in the rates of young people whose BMIs fall in the ‘overweight’ (≥95^th percentile) or ‘at-risk-for-overweight’ (≥85^th percentile) categories on BMI growth curves.

Just as in 2003 when this sizeable program began, about 20% of Arkansas young people were classified as ‘overweight’, 17% as ‘at risk’, 60% as ‘healthy weight’, and 1.8% as ‘underweight’ (≤5th percentile on growth curves).

The report’s conclusions state that the findings “show that together we have continued to halt the progression of childhood obesity statewide.” Digging deeper, however, reveals that the same indications of possible harm and disparities suggested in the third evaluation, were even more prominent in this report. Yet, unlike the third report, this report’s text didn’t mention them at all — they’re buried in the data tables at the back.

It appears that the Arkansas program may have most “failed” children at both ends of the socio-economic spectrum, but in different ways.

The counties and school districts with the lowest reported rates of students classified as ‘overweight’ and ‘at-risk-of-overweight’, had the highest rates of ‘underweight’ students. This correlation is a worrisome indication that the intense focus on weight and healthy lifestyles could be leading some young people to adopt unhealthy efforts to control their weight to the extreme. Rates of underweight young people in Perry country, for example, were 3.14%, with a total of 33.87% of young people with BMIs at or above the 85^th percentile. Rates of underweight in Conway county were 2.76%, and in Madison country 2.52%. These counties are also those with primary white populations: 95.62%, 83% and 95.94%, respectively.

In Arkansas, race/ethnicity is roughly a measure of socioeconomic status, with StateHealthFacts reporting that minority children in Arkansas live with 2 ½ times the poverty of white children.

Similarly, the program has had no effect in reducing higher rates of ‘overweight’ in areas of social-economic disadvantage, despite the healthful behaviors of the heavier children. Sevier county, for example, had rates of underweight of only 0.97%, but the highest rates of children with BMIs at or above the 85^th percentile (45.13%). Whites make up only 79.61% of the county’s population, while 11.84% are of Pacific Island descent. Only 1.8% of young people in Lee county (with 57.24% black population) are underweight, while 47.95% of the children were reported as falling in the higher BMI categories.

Year Four Evaluation: Arkansas Act 1220 of 2003 to Combat Childhood Obesity

This publication summarized the most recent findings of researchers at the Fay W. Boozman College of Public Health at the Arkansas for Medical Sciences who’ve been conducting evaluations since the Act was implemented. This work was also funded by the Robert Wood Johnson Foundation.

The report’s synopsis said that “while this evaluation does not assess the impact of individual components of the Act, there has been no evidence of an increase in negative consequences of any Act 1220 mandates over the past four years.” The broad-scale changes impacting students “support a healthier school environment.”

A critical look at the report, however, paints a less rosy evaluation.

Parental reviews. Interviews of a randomly selected, representative sample of parents have been conducted since the program began. The report said that the percentage of parents stating they were comfortable with getting a BMI report from their child’s school has been dropping and is now down to about half of parents. More than half (54%) of parents also said they didn’t find the BMI reports even “somewhat helpful.”

Parents of larger children were even less enamored by receiving a BMI report on their child as compared to parents of smaller size children, with nearly 50% more of them saying that they were concerned about the confidentiality of the reports. Parents of larger children, though, were no less “aware of the health problems faced by overweight children” than other parents, nor did they differ in viewing the BMI reports as unhelpful. The unrelenting information about the health dangers of childhood obesity, however, had left them nearly three-fold as fearful for their own children.

Increased weight concerns among the children. Nearly 20% of parents interviewed said that their child had expressed concerns about his/her weight that year. Among those parents, 62% said that their “child’s concerns had not been expressed before BMI assessments began at school.” Not only were students more likely to have expressed concerns about their weight after the BMI assessments began, but the younger pupils had been the most adversely affected by the program and become worried about their weight. For example, 31% of children under age 10 reported being concerned about their before the BMI assessments began, compared to 69% four years into the program. There is no evidence that this is healthful or beneficial for youngsters.

Parental concerns. More than one-third of parents (38%) said that they worried their child was more concerned about his/her weight than their child should be, and 20% of parents were very worried about their child’s level of weight concern.

Healthcare professionals, however, may also find other reasons for disquiet in the parental misunderstandings exhibited by these next findings. While it’s a concern when a child of any size expresses fears about their bodies, especially fears of “feeling too fat,” parents of students in the ‘underweight’ category were typically less worried about their child’s concerns about their weight [not defined] than were parents of ‘overweight’ and ‘at-risk’ students. More than half (51%) of parents with ‘underweight’ children said they were not at all concerned about their children expressing weight concerns. And 39% of the parents of ‘overweight’ children weren’t concerned because they believed their child “needs to lose weight.”

Raising questions about the quality of the information parents are hearing about BMIs and health problems surrounding children’s weights, the evaluation report found that the percentage of parents saying they believed that childhood diabetes is a health problem for overweight children had increased to 81%, up from 66% in 2004.

The authors viewed favorably the fact that nearly two-thirds of parents reported that they were trying to make their family’s diets healthier, with the greatest reasons parents gave for “changing the family to a healthier diet” were to manage weight and become healthier (29%). However, even these changes sought by the program were already waning, down by one-quarter just from 2006.

Students’ perceptions. The percentage of students “not at all comfortable” with getting BMI reports had increased to 25%. But, just as polling results give only part of the story, this report one didn’t reveal the range of young people’s feedback. How many admitted they were somewhat uncomfortable?

The percentage of children reporting being teased had increased, with 12% teased because of their weight (up from 6% in 2006) and 25% of children teased for other reasons (up from 19% in 2006). Are these indications that this program could be heightening body and health concerns among already body-conscious young people and increasing bullying and stigma of fat, less athletic or disabled children?

Another of the key concerns of childhood obesity programs is that they can increase dangerous weight control behaviors and eating disorders. “As part of the evaluation of the impact of Act 1220, findings from the biennial Youth Risk Behavior Survey (YRBS) also are monitored,” this report explains. The YRBS is a biannual survey administered by the CDC and state and local agencies of a representative sample of U.S. high school students in each state, to evaluate six categories of health risk behaviors. It includes specific questions about weight control behaviors.

The year 4 evaluation report states that, according to the YRBS data it presented, “weight control behaviors among Arkansas youth have been essentially consistent since 2001 and are not significantly different from behaviors observed in the nation as a whole.”

But this statement should be viewed with reservation, as it gives an incomplete picture.

‘First do no harm’

Nationwide, the percentage of teens engaging in risky weight control behaviors, according to YRBS data, had mostly dropped nationwide. But not in Arkansas. The Act 1220 evaluation report said that in 2005, 12% of Arkansas teens admitted to having taken diet pills — this is twice that of their peers nationwide. Nine percent of Arkansas adolescents were reported as having vomited or taken laxatives (up from 5% in 2001), compared to 5% nationwide; and 16% of Arkansas teens reported having fasted in 2005, compared to 12% nationwide. In other words, higher percentages of Arkansas youth were engaging in risky behaviors to control their weight.

But even this snapshot is incomplete, as it only reports the YRBS data to 2005. The 2007 YRBS data, released in the CDC Morbidity and Mortality Weekly Report on June 6, was not included. The latest 2007 YRBS report said that “the prevalence of most risk behaviors does not vary substantially among cities and states.” Arkansas was comparable to the rest of the country in most all of the surveyed behaviors, except for distinct differences in weight control behaviors.

Rather than these Act 1220 interventions to encourage healthful eating and physical activity showing favorable effects on the young people of Arkansas, the most recent 2007 YRBS data provides the most troubling indications to date of the adverse effects these programs are having. Arkansas teen girls, for example, were about 20% more likely to engage in unhealthful and risky behaviors trying to lose weight as compared to their peers nationwide — even though they were not fatter. [In fact, according to the 2007 YRBS data, slightly fewer of them fell in the ‘overweight’ category compared to teen girls nationally (9.1% versus 9.5%).] For example:

● 16.9% of Arkansas teen girls admitted to going without eating for 24 or more hours to control their weight (compared to 15.8% national average).

● 9.2% of Arkansas teen girls admitted to taking diet pills and liquids (compared to 7.5% national average)

● 8.1% of Arkansas teen girls admitted to vomiting or taking laxatives to manage their weight (compared to 6.9% nationwide)

In addition to the evidence suggesting that teen girls are being most harmed by the Arkansas program, so too have the teens who are heavier than their peers. These young people were nearly four times more likely to be embarrassed by the BMI measurements, 2 ½ times more likely to be dieting and 33% more likely to report feeling concerned about their weight. Yet, their health behaviors were generally “better” than their thinner peers. For example, 89% of the larger teens (≥85^th percentile) hadn’t purchased any snacks from vending machine in the past month, compared to 42% of their peers; and 46% hadn’t purchased a beverage, compared to 26% of their peers. The percentage of heavier children who’d consumed soda in the past 24 hours dropped between 2004-2007, but had increased 27% among their thinner peers.

This report supports concerns raised for years by childhood development and eating disorder experts that young people are not ready to grasp or appropriately act on even positive nutritional messages. It also sadly bears out the admonitions of the Childhood Obesity Working Group of the U.S. Preventive Services Task Force to professionals and government health officials forging ahead with BMI screening and childhood obesity interventions before they have evidence of being beneficial, that they may put young people at risk of harm. For those who believe that these programs to teach healthy eating and physical activity are urgently necessary, proven to be beneficial and harmless, they are not.

Despite their good intentions, this report provides no indication that after four years, the extensive statewide Act 1220 measures have resulted in “healthful” behavioral changes, either. In fact, Arkansas adolescents reportedly eat fewer fruits and vegetables, drinking less milk and more soda than teens across the country. Yet, this report neglected to include any of this information — it’s found in YRBS data.

Certainly, if the program had resulted in young people eating “healthier,” it would have been trumpeted far and wide. Instead, according to the 2007 YRBS data:

● 13.3% of Arkansas high school students ate 5 or more servings of fruits and vegetables a day, compared to the average of 17.9% among teens nationwide

● 10.5% of Arkansas high schoolers drank 3 or more servings of milk a day, compared to 14.5% national average.

● 39.4% reporting drinking a soda at least once a day, compared to 29.5% national average.

The Act 1220 4-year evaluation said that the percentage of Arkansas children reporting that vending machines were available at school dropped by nearly half, with correspondingly fewer purchases. But what kids eat during the school day is not equivalent to their overall diets. Success in reaching policy goals is not support of the soundness of those goals. The Act 1220 evaluation report also revealed a substantial increase in the percentage of Arkansas teens who report they don’t participate in physical education classes in school (from 3% in 2003 to 46% in 2007), a reduction in PE participation (from 71% to 41%), and no change in leisure-time activity during the 4-year evaluation period.

Bottom line

Since Act 1220 was enacted in 2003, it has failed to have any measurable effect on children’s weight status; it has failed to demonstrate meaningful improvement in their overall diets or physical activity levels; it has failed to demonstrate improved health outcomes; and there are growing indications that it’s having unintended consequences. Parents, healthcare and educational professionals, as well as taxpayers, might rightfully question if the costs for these school-based initiatives might be better utilized in efforts to help improve the future of Arkansas’ children.

Might school days better benefit young people, focused on education, rather than diets and exercise? Math scores among Arkansas 8^th grade students, for instance, are below national averages and haven’t demonstrated the increases seen elsewhere in the country. According to the latest 2007 National Center for Education Statistics (NCEP) report, average NCEP math scores for Arkansas 8^th grade students showed that only 4% had achieved advanced scores and less than a quarter (21%) even scored proficient – these compare to national rates of 7% and 24% , respectively. Even more concerning, more than one-third (35%) of Arkansas’ 8^th graders scored below basic proficiencies.

The year four evaluation report concluded by saying that the findings of the continued efforts under this Act and related initiatives to address childhood obesity will help inform decision makers.* Without complete information reaching policy makers on the effects of this Act, however, how likely will they be to make evidence-based policy decisions? And how likely will the vast network of stakeholders be to? The work of the BMI assessments and evaluation reports have been funded for an additional five years by Robert Wood Johnson Foundation.

RWJF President and CEO Risa Lavizzo-Mourey, M.D., said in an earlier press release: “There are ‘natural experiments’ taking place... but we can’t afford to surrender an entire generation of kids to the obesity epidemic while we wait for perfect answers.” Parents might not agree that they want their children to be test subjects, but how many even know they are?

© Sandy Szwarc. All rights reserved.

* The uncritical evaluations of Act 1220, sponsored by RWJF, are being used to support expanded childhood obesity policies and funding for more school-based diet and wellness programs. For instance, they were repeated in the report, Fit Not Fat 2008, recently released by the Arkansas Advocates for Children and Families.** This paper recommends the state expand the Coordinated School Health Program and community partnerships, support the development of curriculums and products to encourage healthy food choices or increased physical activity, provide for community infrastructure to address childhood obesity, and fund more after-school programs. This organization is a member of the Child Health Advisory Committee, which Act 1220 had given broad authority to guide public health policy and use of children’s health programs, including obesity; to develop the implementation systems, monitor the data and report outcomes. It was the CHAC which developed the school wellness requirements adopted by the AK Dept. of Education and AK Dept. of Health.

** Arkansas Advocates for Children and Families is financed by the Blue Cross Blue Shield “Blue & You Foundation for a Healthier Arkansas” and Arkansas Children’s Hospital.