Massachusetts Department of Public Health

1. Massachusetts Department of Public Health BMI SCREENING PROGRAM FOR SCHOOLS Carol A. Smith MSN, RN School Health Advisor

2. 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

3. BMI Screenings 2011-2014

4. 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

5. Obesity & Household Income

6. 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

7. Health Promotion Influences

8. Massachusetts School-BasedScreening 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.

9. Massachusetts DPH and DESE Laws and Regulations Education Law: Chapter 71: Section 57. Physical examination of pupils; eye examination, written report

10. Massachusetts DPH and DESE Laws and Regulations MDPH Regulations: Revised October 2013 105 CMR 200.000: PHYSICAL EXAMINATION OF SCHOOL CHILDREN 200.500: Height and Weight Measurements

11. Massachusetts DPH and DESE Laws and Regulations 200.500: 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

12. Amended Changes to the Regulations The revised regulations were effective on November 8, 2013.Highlights of revisions include: • Ensuring privacy during the BMI screening process. • Provide increased confidentiality of personal health information and prevent any unintended consequences.

13. (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 Massachusetts DPH and DESE Laws and Regulations

14. Massachusetts DPH and DESE Laws and Regulations (B) Documentation of the student’s BMI shall be maintained in the student’s school health record.

15. Massachusetts DPH and DESE Laws and Regulations (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

16. Massachusetts DPH and DESE Laws and Regulations (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

17. Massachusetts DPH and DESE Laws and Regulations Other Provisions: 200.600: Local Authority to Establish Higher Requirements 200.610: Religious Objection 200.630: Health Record Forms

18. 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.

19. 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

20. 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

21. MDPH BMI Screening Program 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

22. MDPH BMI Screening Program 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

23. MDPH BMI Screening Program 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

24. 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

25. MDPH BMI Screening Program 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

26. MDPH BMI Screening Program 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)

27. MDPH BMI Screening Program 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.

28. MDPH BMI Screening Program 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 PA Department of Health, 2004)

29. MDPH BMI Screening Program 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) (

30. MDPH BMI Screening Program 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

31. MDPH BMI Screening Program 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

32. MDPH BMI Screening Program Balance Beam Scale

33. MDPH BMI Screening Program 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!

34. MDPH BMI Screening Program Anthropometric Measurement Errors Measuring instrument errors Procedures/techniques Reading errors Recording errors

35. MDPH BMI Screening Program 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.

36. MDPH BMI Screening Program 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.

37. MDPH BMI Screening Program 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

38. MDPH BMI Screening Program Reporting BMI Screening Results online: • For data collection and reporting, please refer to our School Health web page: www.mass.gov/dph/fch/schoolhealth

39. MDPH BMI Screening Program For further information on quality checks please contact : MDPH Office of Data Management and Outcomes Assessment

40. MDPH BMI Screening Program 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 categoryBMI Percentile Range Underweight = < 5th Healthy Weight = >5th to <85th Overweight = >85th to < 95th Obese = or > 95th

41. MDPH BMI Screening Program 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 23.07 (2), parents can have access to the BMI information upon request.

42. MDPH BMI Screening Program 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.

43. 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.

44. 105 CMR 215: Standards for School Wellness Advisory Committees 215.100: 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 200.500;

45. 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

46. MDPH BMI Screening Program Online Resources Massachusetts Comprehensive School Health Manual (2007) www.mass.gov/dph/fch/schoolhealth BMI Screening Guidelines for Schools (Amended 11/8/13) www.mass.gov/dph/fch/schoolhealth Children’s BMI Group Calculator for MA Schools www.mass.gov/dph/fch/schoolhealth Mass in Motion Healthier Schools http://www.mass.gov/eohhs/gov/departments/dph/programs/community-health/mass-in-motion//

47. MDPH BMI Group Calculator

48. Resources School Health Services http://www.mass.gov/dph/fch/schoolhealth Topics School Health Record School Health Screening Vision Screening Hearing Screening Physical Examination Body Mass Index (BMI) Screening

49. MDPH BMI Screening Programs for Schools Thank You MDPH School Health Unit 617-624-5447