If their kids are frequently tardy, truant or failing to turn in homework, parents of US schoolchildren expect to be notified. And in some districts, they might be contacted about yet another chronic problem: obesity.
The "fat letter" is the latest weapon in the war on childhood obesity, and it is raising hackles in some regions, and winning followers in others.
"Obesity is an epidemic in our country, and one that is compromising the health and life expectancy of our children. We must embrace any way possible to raise awareness of these concerns and to bring down the stigmas associated with obesity so that our children may grow to lead healthy adult lives," said Michael Flaherty, a paediatric resident physician in the department of paediatrics at Baystate Medical Center in Springfield, Massachusetts.
About 17% of US teens and children are obese three times the number in 1980, according to the federal Centers for Disease Control and Prevention. And one in three is considered overweight or obese. Being overweight or obese puts kids at risk of developing serious health problems, such as heart disease. Too much weight can also affect joints, breathing, sleep, mood and energy levels, doctors say.
Massachusetts which has had a weight screening program since 2009 is one of 21 states that have implemented statutes or advisories mandating that public schools collect height, weight, and/or BMI (body mass index) information. Some states further require that parents receive confidential letters informing them of the results, advising that they discuss the findings with a health care provider.
But some parents in the Bay State and elsewhere consider such policies an unwelcome intrusion into private family matters. Other objectors say "fat letters", as they are sometimes called, have the potential to trigger bullying or eating disorders among the very children they're trying to help.
In Massachusetts, where parents are letter-informed of BMI results for students in grades 1, 4, 7 and 10, the state department of public health is currently debating a possible repeal of the letter portion of its screening protocol.
This would be a grave mistake, Flaherty believes. "The growing number of children and adolescents seen day in and day out in our clinics with hypertension, high cholesterol, diabetes, and musculoskeletal issues secondary to weight do not lie," he said.
Flaherty, a clinical associate at the Tufts University School of Medicine, outlines his thoughts in a "perspective" piece published online on 19 August in Pediatrics.
While acknowledging that the effectiveness of such programs remains to be determined, Flaherty notes that school screenings are nothing new, with many states having done so for many years. And in 2005, the U.S. Preventive Services Task Force determined that calculating a child's BMI – a calculation of body fat based on height and weight – should be considered the "preferred measure" for tracking weight issues.
What's more, he suggests that parental fears that BMI assessments may accidently identify healthy muscular children as overweight is a misplaced concern over a relatively rare phenomenon.
"Additionally, no studies have shown any increased risk in bullying, eating disorders or unhealthy dieting patterns," Flaherty noted. "While these risks exist, they have not been proven in states where these programs have existed for several years."
The very point is to have a "confidential way of mailing letters directly home to parents where these issues can be addressed in the privacy of the home without any other students being aware of other children's BMI," he said.
Other specialists are less enthusiastic about school BMI screenings.
Dr David Dunkin, an assistant professor of paediatric gastroenterology at the Icahn School of Medicine at Mount Sinai in New York City, cautions that simply legislating parental notification of school screening results will not help curb the obesity crisis without comprehensive and well-designed follow-up.
"While I feel that the intention is good [to] raise awareness among parents about their children being obese, and thus instilling motivation for behavioural changes or lifestyle modifications, this is unlikely to have effects in and of itself," Dunkin said.
To bring about change, notifications should include referrals to programmes that could help parents make lifestyle modifications for their children, he added.
But Dunkin would prefer to see weight issues addressed by a family's paediatrician.
"I think it is the primary responsibility of the paediatrician to discuss obesity on a case-by-case basis with the child and the family, and try to help them with life changes," he said. "As a paediatrician I often speak to the family about this, and can assist them with advice on what to do to improve their child's health."
While Flaherty agrees that paediatricians should measure a child's BMI at every child's well-care visit, he said these check-ups are only performed annually.
"Paediatricians have 15 to 20 minutes per year to deal not only with BMI, but a variety of other preventive health issues," Flaherty said. "The public school system is a universal organisation that has been used as a forum to reach children and parents for a variety of other issues: vaccinations, dental exams, and hearing and vision screening."
For more on childhood obesity, visit the U.S. National Library of Medicine.