Weight Bias in Schools

In the medical field, as well as in life, things are not always either black or white, but rather various shades of gray. In the past, providers have used growth charts, family history, and pubertal status to review development, growth spurts, pubertal status. In the early 1990’s Body Mass Index (BMI) became a new determinant of health yet BMI alone, without looking at growth patterns and growth spurts are not indicative of health: just as weight alone does not indicate or refute evidence of an eating disorder.

This use of BMI as the sole measure of health gave way to quick calculations, rather than using traditional methods that encompassed more of a global picture of health status.

What began as a medical practice has led some schools to also measure BMI in an attempt to assist with health.

Many school districts, including many in North Carolina, have implemented school measurements and potential diagnoses solely based on BMI and weight indicators in order to identify children at risk for poor health outcomes. Unfortunately, measurement by inadequately trained school staff, often taking place in an open setting, can be deeply shaming and have a lasting impact on children and adolescents.

Studies by the Centers for Disease Control (CDC) have shown little to no evidence supporting this practice, yet it continues to take place in schools across the country with little thought into the negative impacts this process could have on young children and adolescents. The documentary “The Student Body” (2016) chronicles a student asking apparently well-meaning legislators who implemented school-based weight measuring to weigh themselves in public. Almost all declined.

Despite the statements made by the CDC regarding the use of BMI measurements in schools, this practice remains up to individual school districts to decide on the method and setting in which a student’s weight is obtained and discussed.

Changing the Narrative

It is important to understand that BMI alone to make determinations on a patient’s health is not accurate, and can be harming. When counseling a child or adolescent about their weight, approach them in a non-shaming manner, with consideration of the many factors that affect an individual’s weight, eating habits, and overall health. Consider the following:

Not everyone who is larger than average becomes “ill.” There are nuances in risk and health outcomes that are multifactorial.

Mandated weight-loss counseling has not always been shown to be effective. Some individuals will resort to unhealthy means of weight loss, interpreting their healthcare provider’s advice as a mandate for extreme changes.

Shared decision making with families is much more effective than an (unintentional) blaming based counseling. How does a parent feel when they are told they are harming their child? Are they likely to feel empowered or that they have a trusting relationship with a provider?

Shame is not an effective motivator.

One of the initial conversations we have with our patients is the importance of moderation. Moderation is an important concept in eating disorder treatment. There are no simple black and white reasons or answers around this disorder, and there are many nuances to be found in the gray zones. While having this conversation with a young patient, she told us that she preferred red and white as the example, versus black and white, because she wanted to “live in the pink.” And that is the exact mindset we have to take when approaching health and weight. We need to think in the “pink.”

We need to shift the focus and encourage long-term changes, acknowledging the individual’s wonderfully made body, teaching gratitude for their body’s capabilities, and keeping it safe for the future. We should teach moderation, provide holistic guidelines, discuss long-term goals, and consider making thoughtful changes when appropriate. We need to look in the gray area at all the nuances in each individual, and not make snap judgments based on one quick calculation that doesn’t take anything else into consideration. We can do better for our children.

About the Author

Preeti Matkins, MD, FAAP, FSAHM is a board-certified pediatrician with 25 years of experience, eight of which have been spent providing care for children and young adults impacted by eating disorders. Dr. Matkins is the Executive Director at our Child, Adolescent & Young Adult Center in Charlotte, NC. She is a member of the Academic Pediatric Association and a fellow of the Society of Adolescent Health and Medicine and the American Academy of Pediatrics and was recently contributed to the seventh edition of Blueprints Pediatrics, a review book for medical students.