Massachusetts Department of Public Health

Massachusetts Department of Public Health
BMI SCREENING PROGRAM FOR SCHOOLS Carol A. Smith MSN, RN School Health Advisor Refresher – everyone needs to attend the “hands-on” training at least once prior to viewing this refresher.

MDPH BMI Screening Programs for Schools
Review of the implementation of the BMI screening initiative has shifted the focus of the goal of this program to support change at the system and environmental level rather than the individual level. The changes in regulations on November 8, 2013 allow schools local control while retaining the core goal of the BMI screening initiative; data collection and systems change by providing data to MDPH The data has already allowed MDPH to focus its obesity prevention efforts and target areas of highest need While BMI screening is important, the focus is no longer on the results but emphasis on healthy diet and active lifestyle not just in the schools but in the community. The aggregate results should be shared with community partners. 2

BMI Screenings Progress is already being made in grades 1, 4, and 7.

Health Consequences of Childhood Obesity
High blood pressure High cholesterol Type 2 diabetes Respiratory problems, including asthma and sleep apnea Joint problems and discomfort Heartburn Behavioral health concerns More likely to become obese adults There are many health consequences of childhood Obesity and they include all of these listed. In the long term, 84%-90% of obese adolescents will become obese adults in contrast 5% of healthy weight adolescents will become obese adults. Adipose tissue acts as an endocrine organ by producing various cytokines which contribute to insulin sensitivity and the development of metabolic syndrome.

Obesity & Household Income
The lower the household income, the higher the rate of obesity

MDPH Mass in Motion Initiatives
Schools Goal: Help children and families achieve wellness by: promoting healthy foods, opportunities for physical activity educational experiences by: Implementing successful school nutrition/physical activity wellness policies Establishing a Body Mass Index (BMI) data collection and reporting system to MDPH Addressing the Public Health Crisis of Overweight and Obesity in Massachusetts There was a call to action in 2008 to address obesity in children. Mass launched Mass in Motion in 2009 which provided grants to 14 cities and towns across the state to build policies and systems to promote wellness. Emphasis on promoting healthy eating and an active lifestyle to promote wellness policies in school and the community. Providing healthy foods and active lifestyle (Removing soda machines and Recess) 6

Health Promotion Influences
As you can see by this diagram, there are many outside influences that affect the ability to change. It takes all of these to be successful.

Massachusetts School-Based Screening Programs
The desired outcome of the Massachusetts Department of Public Health Screening Program is improvement in health and well-being of Massachusetts school aged children so that they are healthy, ready to learn and are able to improve academic achievement. Again, it is important to remember that the purpose of the mandated MDPH school based screening program is to improve the health and well-being of Massachusetts school aged children so that they are healthy and ready to learn and improve academic achievement. 8

Massachusetts DPH and DESE Laws and Regulations
Education Law: Chapter 71: Section 57. Physical examination of pupils; eye examination, written report For your reference the state law and regulations concerning screening programs and in particular, measuring heights and weights, are cited here. 9

MDPH Regulations: Revised October 2013 105 CMR : PHYSICAL EXAMINATION OF SCHOOL CHILDREN : Height and Weight Measurements The BMI regulations that were initially implemented were revised in October of This change focuses on privacy and confidentiality and MDPH no longer mandates schools to report results to parents. This will be reviewed further in upcoming slides

: Height and Weight Measurements Each school committee or board of health shall adopt policies and procedures to ensure that the Body Mass Index (BMI) and corresponding percentile of each student in grades 1, 4, 7, and 10 (or, in the case of ungraded classrooms, by a student’s 7th, 10th, 13th and 16th birthday) is calculated and documented in the health record

Amended Changes to the Regulations
The revised regulations were effective on November 8, Highlights of revisions include: Ensuring privacy during the BMI screening process. Provide increased confidentiality of personal health information and prevent any unintended consequences. Focus for the screening process now is on privacy during screening and confidentiality after screening For example, the gym is not ideal since talking could be overheard and visually the scale could be seen. It is best practice to have a few students wait in the hall and take them in the office and close the door.

(A) Accurate measurement of weight and height and calculation of BMI for students in grades1, 4, 7, and 10 (or by a student’s 7th, 10th, 13th and 16th birthday) shall be done by trained school personnel approved by MDPH It is important to note that when recording the BMI results, the age appropriate tool should be used. Link provided later in presentation

(B) Documentation of the student’s BMI shall be maintained in the student’s school health record.

(C) The school or district shall provide the Department annually with aggregate student BMI data including totals by grade, gender and BMI category, as specified by the School Health Services website reporting tool The reporting tool is discussed later in the slide presentation

(D) Parent(s) and legal guardian(s) shall be provided with an opportunity to request, in writing to the school nurse, that their child not participate in the program The focus has shifted from individuals to healthy eating and active lifestyle for all students and their community

Other Provisions: : Local Authority to Establish Higher Requirements : Religious Objection : Health Record Forms 105 CMR through are minimum regulations for the examination of school children in Massachusetts. The school committee or board of health may provide for more frequent and more specialized examinations or both if it wishes to do so. : Religious Objection In accordance with M.G.L. c. 71, s. 57, a student shall be exempt from physical examinations or screenings on religious grounds, upon written request of the parent or legal guardian, except with respect to communicable diseases. : Health Record Forms Results of required health appraisals shall be recorded in detail on health record forms provided or approved by the Massachusetts Department of Public Health. REGULATORY AUTHORITY: M.G.L. c. 111, § 3 and 5; c. 71, § 57. 17

MDPH BMI Screening Programs
Considerations: Interventions should focus on a healthy lifestyle rather than weight. Weight is NOT a behavior: focus on healthy eating and active living. Schools should direct community efforts toward making the environment healthier for all rather than of personal blame, i.e., not creating special classes or groups that target only those that are under/over weight.

MDPH BMI Screening Programs
Considerations (continued): Screening tests are not diagnostic. They are designed simply to indicate students who may need further evaluation by their primary care provider. Changes in weight are not always a sign of abnormal development; an increase in weight can precede a growth spurt. For BMI results that are of concern, it may be appropriate for the school nurse to contact the parents and/or legal guardians to encourage follow-up with the child’s primary care provider These two reminders are especially important when initiating a comprehensive growth screening program: they are not diagnostic and students’ parents/guardians should be made aware that further testing is needed to confirm a diagnosis. 19

MDPH BMI Screening Program
Pre-screening planning includes: Training personnel to assist with screenings Ensuring proper equipment is well-maintained Providing appropriate space that ensures confidentiality Implementing program with attention to time out of classroom Recording and reporting findings accurately Planning for a comprehensive growth screening program also includes: Training personnel to ensure they are well-prepared to provide the screening in a safe environment for students. Ensuring that the proper equipment for this screening has been well-maintained Providing appropriate space within the school that allows for privacy Implementing program with attention to the time out of the classroom will involve consideration of students classroom schedules Recording findings accurately so that the correct referrals for follow-up can be made 20

Screening Considerations: Rescreening by School Nurse, if necessary Completing follow-up Incorporating content into health education curriculum to promote healthy eating and active living Evaluating results of school-based initiatives Reporting BMI results in aggregate form to MDPH The following should also be included in the planning process As a general rule, the student should be weighed and measured twice as a check, and if you get 2 different results, redo a third time and average it out. Rescreening by the School Nurse should be included in the process if there has been significant changes as recorded by the screeners, to the students growth screening measurements Plan how the aggregate results will be evaluated and who will be included in that process; often the School Health Advisory Council provides consultation to the school nurse concerning this process. Reporting the aggregate results to members of the community should also be part of a comprehensive growth screening program. If the data collected from this screening indicates that there is a problem within the school concerning healthy weight issues, then follow-up would also include a plan to incorporate content into health education curriculum to address both active living and healthy eating. 21

Training for Staff should include: Proper use of equipment for accurate and precise measures The importance of privacy and confidentiality for students The use of sensitive language to communicate results Training other staff such as health educators or physical activity teachers in the school to assist with a comprehensive growth screening program needs to include not only the proper use and maintenance of the equipment, but also the importance of privacy and confidentiality during the screening. While it is important to obtain accurate information when screening for heights and weights, it is equally important that it be done with respect and in a way that will be sensitive and supportive, as well as accurate. It is recommended that at least two staff conduct the growth screening: one to measure the child and one to record the data. Training should also include the review of forms for recording information; Emphasis should also be placed on the importance of privacy and confidentiality for the students before, during and after the screening. Appropriate communication with students regarding height and weight measurement (e.g. saying “Let’s check your weight” instead of. “Let’s see how big you are”, reassuring students that kids’ bodies come in different sizes and shapes, and avoiding labels such as “overweight”, “too thin”, or “too short”) should included in the training for all staff. It is important to remember that the school nurse has the ultimate responsibility for training and monitoring screening activities. 22

Privacy and Confidentiality: Sensitivity to body image and self-esteem; use of language that reflects respect for all shapes and sizes. Height and weight should be measured in a private location, information must be kept confidential. Weight-related stigma and harassment in the school setting should be addressed and not tolerated. Assurance that school health personnel or other school staff with access to student health records not disclose screening results of any student to anyone other than the parent(s)/legal guardian(s) without written consent Privacy is so important. Many screenings are performed in school gyms which is not conducive to privacy if everyone is in the gym. Need sight and sound privacy since students will see and hear the information being recorded. 23

MDPH Screening Program
Privacy and Confidentiality (continued): Every effort shall be made to protect the privacy of the student during the screening. Trained personnel with access to the student’s health record shall not disclose the results either verbally or in written form to anyone other than the parent or legal guardian Students should be informed that the results will be confidential and not shared with anyone else.

Equipment For Measuring Weight Properly calibrated balance beam or strain-gauge floor scale (mechanical or digital) that: can weigh in 0.1 kg or ¼ lb increments has a stable platform has the capacity to be “zeroed” after each weight is taken has the capacity to be calibrated When screening a student’s weight, it is essential that proper equipment be used. A properly calibrated balance beam or strain-gauge floor scale, either mechanical or digital should be used. The scale should be able to weigh in either point one kilograms or one-fourth pound increments; it should have a stable platform and be placed upon a hard surface. Carpeted areas should be avoided in areas used for growth screenings. It is essential that the scale have the capacity to be “zeroed” out after each weight is taken. The scale should have the capacity to be calibrated. It should be calibrated annually or more frequently if transported for use in other schools. Do not use a spring scale – it loses accuracy over time and it cannot be “zero-ed” out after each reading. 25

Equipment For Measuring Height A stadiometer that: is able to read to 0.1 cm or 1/8 inch has a large stable base has a horizontal headpiece that is at least 3 inches wide that can be brought into contact with the most superior part of the head (i.e. the crown) A stadiometer used to measure height should be able to be read to a point one centimeter or one-eighth inch measurement. A stadiometer that is not wall-mounted is preferable. It should have a large stable base and not be used in carpeted areas. It is essential that the horizontal head piece be at least three inches wide so that it can be brought into contact with the most superior part of the head, that is the crown. 26

Check equipment regularly: Scales should be calibrated on a routine annually. If scale has been moved, contact town Department of Weights and Measures to calibrate your scale. Check the stadiometer regularly to be sure the base is stable, the head piece is level. The equipment used to for growth screenings should be checked regularly: Scales should be calibrated on a routine basis. If scale has been moved, contact your town Department of Weights and Measures to calibrate your scale. Be sure to recalibrate the scale after it has been moved to a different location. If used frequently, a scale should be recalibrated on a monthly basis. Check the stadiometer regularly to be sure the base is stable and the head piece is level. When the BMI regulations were first implemented, the Department provided schools with the seca robusta 813 scales in 2011 and They are no longer available thru DPH. The warranty of the product has expired. DPH recommends a balance beam scale or digital scale that can be recalibrated. 27

Procedure for Measuring Height: Student removes shoes, hair ornaments, buns etc Student stands on footplate portion with back against stadiometer rule Bring legs together, contact at some point (whatever touches first) Back of body touches/has contact with stadiometer at some point Body in straight line (mid-axillary line parallel to stadiometer) Head in appropriate position – check Frankfort plane When measuring a student’s height, the student should remove shoes and hair ornaments, buns, or braids to the extent possible. If the student is unable or unwilling to do this be sure to note on the student’s record chart that an accurate measurement was unable to be obtained - don’t ‘guesstimate’ height of hairdo or any thing else that may have them appear taller. Have the student bring their legs together to make contact at some point (whatever body parts touch first). Knees should not be bent, arms should be at the sides, and shoulders relaxed. The student should stand on footplate portion of the stadiometer facing outward, with his or her back against the stadiometer rule. Make sure that the back of the student’s body touches or has contact with stadiometer at some point. Make sure that the body is in a straight line; the student’s mid-axillary line should be parallel to stadiometer. PA Department of Health, 2004) 28

To determine the Frankfort plane: Draw an imaginary straight (perpendicular) line from the back of the board, past the ear opening and the top of the cheek bone. (You can use a pencil or ruler to help check the line). This is called the Frankfort plane. (UCL Institute of Child Health 2008) ( Check to see if the student’s head is in appropriate position. The screener should be able to draw a straight perpendicular line from the back of the board, past the ear opening and the top of the cheek bone. You can use a pencil or ruler to help check the line. This is called the Frankfort plane. It was established in 1884 in Frankfurt, Germany, by the World Congress of Anthropology. The Frankfurt plane became the principal standard of skull measurement because it also identifies the normal plane in which the head is positioned parallel to the ground. 29

Reading Height Measurements: Read at eye level Count visible lines If the arrow points at a line – count that line If the arrow points between lines, read to nearest line Use .5 (1/2) line as guide Read in upward direction (from low to higher number) Repeat measurement and record immediately Repeat measurements should agree within one half centimeter or one fourth inch, if they do not, repeat measurement a third time Lower headpiece snugly to crown of head with sufficient pressure to flatten hair. • Read value at eye level; read in an upward direction (from lowest to higher number). • Measure to nearest point one centimeter or one-eighth of an inch and record value. • The measurement should be repeated, having the child line up again, and the appropriate value recorded immediately on the data form. • Repeat measurements should agree within one half centimeter or one fourth inch, if they do not, repeat measurement a third time and use an average of the three numbers for the height measurement. 30

Procedure for Measuring Weight Child removes shoes, heavy outer clothing, such as sweater, jacket, vest Scale set at zero reading Scale on firm surface, preferably uncarpeted floor Child steps on platform, both feet on platform, stays still Read weight value to nearest ¼ pound or .1 (1/10) kilogram Record weight immediately on form before child gets off scale If using balance beam scale, return weights to zero position The correct procedure for measuring a student’s weight includes making sure that the scale is on a firm surface, preferably an uncarpeted floor. • Set the scale at zero. • Have the student remove his/her shoes. • Have student remove heavy outer clothing, such as sweater, jacket, or vest. The student should also remove an heavy items from his/her pants pockets. • Have the student step on scale platform, facing you, with both feet on platform, and remain still. • Read weight value to nearest one fourth pound or one tenth of a kilogram. • Record weight immediately on the data form before student gets off scale. Check weight 2 times to make sure the result is accurate 31

Balance Beam Scale If using balance beam scale, return weights to zero position. Repeat measurement again. Repeat measurements should agree within one fourth pound or one tenth of a kilogram, if they do not, repeat measurement a third time and average the three numbers to get the final recorded weight. 32

Measurements used for: Determining Body Mass Index (BMI) Clinical assessment for health promotion and disease risk Monitoring growth over time (pattern of growth) and detect growth abnormalities Monitoring nutritional status Establishing outcomes to nutritional and physical activity interventions Accuracy is Important! It is important to remember that screening for height and weights and determining Body Mass Index involves accurate clinical assessment. 33

Anthropometric Measurement Errors Measuring instrument errors Procedures/techniques Reading errors Recording errors There are various types of errors that can occur when doing anthropometric (or height and weight) measurements: these errors include instrument inaccuracies due to poor maintenance or poor functioning. Errors can also occur with the individual screener’s techniques and procedures as well as when reading or recording the screening results. It is recommended that at least two staff members work together to conduct the growth screening so that one person can be dedicated solely to recording the measurements. This greatly reduces recording errors. 34

Recording and Reporting Measurements: Conduct the growth screening using two staff members so that one person can be dedicated solely to recording the measurements. This greatly reduces recording errors. Record the information of student growth screening in an Electronic Health Record. Report aggregate data to MDPH as specified. Gender-appropriate growth charts such as the Stature-for-Age Percentiles & BMI-for-Age Percentiles charts are available on the CDC website · The Stature-for-Age and Weight-for-Age percentiles show how height and weight increase relative to age. · The BMI-for-Age chart shows age-related changes in growth; the weight, height and age of a child are considered in this calculation 35

Checking for quality issues with data before reporting: For all grades, if the average height is more than 3 inches different than the middle height when sorted from highest to lowest. For all grades, if the average weight is more than 5 pounds different than the middle weight when sorted from highest to lowest. Before submitting your data to DPH, check for quality issues

Guidelines for checking for quality issues with data before reporting: For Grade 1 if more than 1% of recorded heights are below 40 inches or over 55 inches. if more than 1% of recorded weights are below 37 pounds or over 110 pounds For Grade 4 if more than 1% of recorded heights are below 48 inches or over 63 inches. if more than 1% of recorded weights are below 51 pounds or over 180 pounds For Grade 7 if more than 1% of recorded heights are below 54 inches or over 71 inches. if more than 1% of recorded weights are below 70 pounds or over 260 pounds For Grade 10 if more than 1% of recorded heights are below 57 inches or over 74 inches. if more than 1% of recorded weights are below 74 pounds or over 275 pounds New

Reporting BMI Screening Results online: For data collection and reporting, please refer to our School Health web page:

For further information on quality checks please contact : MDPH Office of Data Management and Outcomes Assessment Added

Body Mass Index (BMI) Anthropometric index of weight and height BMI = weight (kg)/height (m)2 Commonly accepted index for classifying adiposity in adults – also recommended for use with children Weight category BMI Percentile Range Underweight = < 5th Healthy Weight = >5th to <85th Overweight = >85th to < 95th Obese = or > 95th While it is important to use sensitive language when taking measurements of young people, obese is now a term used in relation to children as well as adults. This terminology is now used to define students who fall in the 95 percentile of BMI or greater. “Fat” is a term used to describe body image and is not a medical term. For children and adolescents, the CDC also uses the term "overweight" and “underweight" to define weight outside of a healthy BMI percentile range for both age and gender. 40

Follow-up: Review screening results – accuracy and effect A referral may be made with permission of the parent/guardian to a student’s primary care provider as needed as determined by the screening results. Per 603 CMR (2), parents can have access to the BMI information upon request. Annual height and weight measurements, including calculating the student’s BMI, provide a simple and effective method of screening for growth abnormalities and identifying students at risk for growth problems. Results of growth screenings should be reviewed on an individual student basis over time, and individual characteristics of each student should be taken into consideration when evaluating the data (for example, an athlete may have a higher than expected BMI for his/her height and weight). 41

Follow-up (continued): Notification of parent or legal guardian with the BMI results is a not required by MDPH, but School Districts may choose to send parent/guardian notification of results This is a local school district decision. Parents and guardians should be encouraged to consult their child’s primary care provider if the school nurse has any concerns. 42

Sharing BMI Data The aggregate BMI measure is one indicator of the health of the school-aged population- and future adults- in the community. This data should be shared with all community members, as healthy eating and active living initiatives are community-wide responsibilities. REVISED-New focus is on healthy eating and active lifestyle rather than on individual weight and BMI results.

105 CMR 215: Standards for School Wellness Advisory Committees
: Standards for School Wellness Committees Committee Functions (3) In setting goals and objectives, the committee shall consider: (d) information about current school and school district programs and practices that might have a bearing on student health, such as: (1) BMI screening data generated in response to the requirements of 105 CMR ; NEW

Sharing BMI Data BMI data results will not be shared without student’s, parents and/or guardians consent Identification of resources that support healthy eating and active living BMI results cannot be shared with anyone without parental consent or the student consent if 18 years or older

Online Resources Massachusetts Comprehensive School Health Manual (2007) BMI Screening Guidelines for Schools (Amended 11/8/13) Children’s BMI Group Calculator for MA Schools Mass in Motion Healthier Schools More information on all population-based screening program guidelines for Massachusetts Schools can be found in the Massachusetts Comprehensive School Health Manual Additional information on the Comprehensive Growth Screening Program for Schools in Massachusetts is available online. 46

MDPH BMI Group Calculator

Resources School Health Services
Topics School Health Record School Health Screening Vision Screening Hearing Screening Physical Examination Body Mass Index (BMI) Screening This Friendly URL will bring you to the School Health Services Main Page. Scroll down to Topics and choose School Health Record- for blank forms. Click on School Health Screening to find the information on these screenings.

MDPH BMI Screening Programs for Schools
Thank You MDPH School Health Unit Thank you for your time and efforts to provide yourself with the skills and knowledge necessary to provide quality screening programs for the children of Massachusetts. 49

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