Obesity and Establishments

This is by no means comprehensive coverage of the law as it pertains to obesity. The object is to look at a few selected moments in history because they are typical, or atypical; and the other object is to grasp the big picture.

A publication from the Social Security Administration in 2019 explained “how we establish that a person has a medically determinable impairment (MDI) of obesity and how we evaluate obesity in disability claims”:

[W]e consider the person’s weight over time. We consider the person to have an MDI of obesity as long as his or her weight, measured waist size, or BMI shows a consistent pattern of obesity.

This seems rather vague, but apparently, variables are very important, and the question of who is legitimately disabled needs to be evaluated case by case. Which is only fair, because all applicants are individuals with their own histories and problems. Returning to the rights and obligations of the education system, in 2019, the Centers for Disease Control said,

Care coordination in schools involves school nurses organizing the care of students by sharing information and maintaining communication among those concerned with the needs and care of students with chronic health conditions (e.g., asthma, diabetes, epilepsy).

Since type 2 diabetes and obesity are very closely related, this would seem to make weight checks necessary, even if not specifically for the purpose of identifying obesity.

Information gathered in the early 1990s was included in a report called “A Closer Look,” which concentrated on the services that school districts nationwide were willing and able to provide. Almost every jurisdiction did First Aid, and administration of prescription meds to students. In the obesity area, “Other commonly provided services include such health screenings as height, weight, vision, and hearing…” Also related to obesity, just slightly more than half of the school districts concerned themselves about nutrition counseling.

Population-based approach versus selective high-risk approach

There are a couple of basic problems. Due to limited resources, school districts often feel they must face the choice between A) offering to everyone services that are so minimal they are almost insignificant; and B) providing more meaningful services to the neediest. As a real-life example…

[…] the National Cholesterol Education program recommends a population-based approach for implementing dietary guidelines for children, combined with a high-risk approach to blood lipid screening targeted only at children considered at risk based on family history.

Another factor is that, because mandatory attendance just makes corralling kids at their schools so easy, administrators sometimes object to being coerced into filling roles they don’t particularly feel it is their job to fill.

(To be continued…)

Your responses and feedback are welcome!

Source: “Policy Interpretation Ruling SSR 19-2p: Titles II and XVI: Evaluating Cases Involving Obesity,” SSA.gov, 05/20/19
Source: “Care Coordination,” CDC.gov, 05/29/19
Source: “Schools & Health: Our Nation’s Investment,” NIH.gov, 1997
Image by Maryland GovPics/CC BY 2.0

Hey Uncle Sam, Mind Your Own Business

Among schools that measure Body Mass Index, it is common to send the child’s parents a letter that states the findings, along with any recommendations for further evaluation and treatment. The previously mentioned “Colorado Healthy Weight Toolkit” includes an example of the opt-out form that parents can sign if they want no part of this. It explains the purpose of the Growth Screening Program and how the screenings take place in privacy, supervised by the school nurse; and why the school wants any additional information it seeks from the family.

Today we look at the kinds of questions that schools have been asking parents. A 2010 publication from the U.S. Department of Education Office for Civil Rights offers a sample questionnaire that includes sensible queries about who is legally responsible for the child, and pre-existing health problems, and medications, known allergies, and so forth. It also asks such questions as…

What does your child do when not in school?
Please describe your child’s behavior at home?
Have there been any important changes within the family during the last 3 years?
What time does your child go to bed at night?
What methods of discipline are used with your child at home?
What is your child’s reaction to discipline?

The aforementioned “Colorado Healthy Weight Toolkit” sample intake form contains places to enter the child’s height, weight, BMI, and blood pressure. Then, a number of boxes are to be checked if there is a history of bullying, low self-esteem, school avoidance, depression, suicidal ideation, or inadequate family resources caused by poverty, homelessness, or crisis.

For girls, there is a checkbox pertinent to heavy or irregular menstrual cycles. Also inquired about is orthopedic pain — strangely, only if it is located below the waist. Back, neck, shoulder and rib pain seems to have no claim on the school’s attention. Parents and educators are also expected to make note of inappropriate sleep patterns, odor complaints, bowel or bladder accidents, skin or wound problems, severe psychological issues, emotional crisis, and acanthosis nigricans. This last item is a skin condition that can indicate diabetes, but which might be difficult to check for, because it tends to show up in the armpits, navel, groin, or under the breasts.

Privacy standards

That some parents regard all this as intrusive, and even abusive, behavior on the part of the authorities, does not come as a total surprise. Meanwhile, one problem that school staff members are supposed to be on the alert for is abusive parents, and reporting suspicious details to law enforcement entities is an official duty.

Certain parents, no matter what their reason — and indeed, one of their talking points is that they do not, as free Americans and taxpayers, need to proffer a reason — do not want the school to give any attention to some of these issues. Even less, do they want the sensitive information entered into any sort of permanent record.

This tension is one of the many factors complicating the effort to lower childhood obesity rates.

Your responses and feedback are welcome!

Source: “Childhood Obesity Legislation — 2013 Update of Policy Options,” NCSL.org, 03/01/14
Source: “Guidelines for Educators and Administrators for Implementing Section 504 of the Rehabilitation Act of 1973,” MemberClicks.net, 2010
Source: “Colorado Healthy Weight Toolkit,” CDE.state.co.us, 12/01/14
Image by Michael B. Smith/CC BY 2.0

Different Strokes for Different States

This blog has been looking at some complications that can stand in the way of the concept of growth measurement, sometimes known as student fitness screening, which is mainly concerned with tracking obesity in school children. We looked extensively at the Body Mass Index measurement process, which establishes the person’s weight in proportion to their height. According to “Childhood Obesity Legislation — 2013 Update of Policy Options,” published by the National Conference of State Legislators, the technique is “widely accepted as a reliable indicator of body fat content.”

Some states mandate the reporting of individual student BMI measurement, while others require the reporting of aggregate BMI data, for various reasons, like identifying which states have the best and worst records of helping children who are headed for obesity or already there.

A few selected states

In 2013, legislators in Massachusetts, New York and Oklahoma left the debate over BMI measurement to wait for their 2014 sessions. Massachusetts carried over a bill that would require BMI measurement in first, fourth, seventh, and 10th grades; and another that would prohibit the health department from collecting height, weight, or BMI data at all. New York had several different bills, all aiming for the collection of the same information.

Oklahoma’s proposed law seemed determined to please everyone, by providing students with the opportunity to attend health and wellness-centered school assemblies, where they could also receive informational material from the Centers for Disease Control and Prevention. Those who wanted their BMI calculated could have that done, and their parents would receive a letter explaining the results.

In that year, Mississippi, Montana and New Jersey looked at legislation that would address BMI measurement but did not pass anything. South Carolina gave schools the authority to do the measurements and collect the data, while Arkansas considered, then rejected, a proposed law that would have ended its BMI measurement program.

Other matters

But obtaining, recording, and reporting BMI stats was not the only thing on the minds of school administrators nationwide. The federal government wanted them to be interested in quite a few health-related areas, including:

• Diabetes Screening and Management at School
• Insurance Coverage for Obesity Prevention and Treatment
• Joint or Cooperative Use Agreements for School Facilities
• Physical Activity or Physical Education in Schools and School Recess Legislation
• Raising Awareness
• School Nutrition Legislation
• School Wellness Policies
• Task Forces, Commissions, Studies, Grants and Other Special Programs
• Taxes, Tax Credits, Tax Exemptions and Other Fiscal Incentives

(To be continued…)

Your responses and feedback are welcome!

Source: “Childhood Obesity Legislation – 2013 Update of Policy Options,” NCSL.org, 03/01/14
Image by Joshua Tree National Park/Public Domain

Schools and Misconceptions

There seems to be an assumption that accurately measuring kids and recording the results are tasks that can be easily performed by just anyone, but that is not the case. To do this science effectively is not easy, and requires the school to buy a certain amount of precision equipment if they don’t have it already. Among the available materials to teach school staff members is the 2007 publication, “Guidelines for Growth Screening in Missouri Schools.”

The instructions are exhaustingly explicit, and important, because if an agency is going to do such a personal and potentially controversial thing to young persons, they had better do it correctly. One sample paragraph is quoted in “Schools Take On the Task,” and here are other excerpts:

A critical element in assessing height correctly is the position of the head. The Frankfort Plane is an imaginary line from the lower margin of the eye socket to the notch above the tragus of the ear (fleshy cartilage partially extending over the opening of the ear). When aligned correctly, the Frankfort Plane is parallel to the horizontal headpiece and perpendicular to the back piece of the stadiometer. When the chin is correctly positioned, the back of the head may not make contact with the vertical surface.

Not every school has a nurse, and not every nurse is trained in these nuances of the art of measurement. The responsible adult needs to know a lot. A few of the major subject headings in this tutorial concern prescreening education; measuring weight; procedure for determining BMI; referral criteria for growth assessments; and considerations for special populations:

All hair ornaments, buns, braids, etc. should be removed to obtain an accurate measurement against the crown of the head.

That is definitely problematic. There have been lawsuits over school staff messing with kids’ hair.

And this is just one state. While the federal government often provides suggestions in the form of guidelines, states can pretty much do as they see fit, and they tend to have philosophical differences that impede the smooth maintenance and consistency of growth measurement programs.

Other angles

The state of Washington offers not only such training modules as “Accurately Weighing and Measuring Infants, Children and Adolescents,” and “Using the CDC Growth Charts for Children with Special Health Care Needs,” but potentially controversial ones like “Adolescent Physical Development” and “Head Circumference.”

The Centers for Disease Control and Prevention offers similar related training. Its topics include “Overweight Children and Adolescents: Recommendations to Screen, Assess and Manage.” There are parents who do not relish the idea of their children being screened or assessed for anything but reading, writing, and arithmetic. There are parents who emphatically do not want their children “managed” by third parties. In America, parents who object to aspects of the school system are in a strong position to resist, and this is one of the stumbling blocks that impede progress toward curbing childhood obesity.

Your responses and feedback are welcome!

Source: “Guidelines for Growth Screening in Missouri Schools,” MO.gov, 2007
Source: “Growth Charts Training,” Washington.edu, undated
Image by GoToVan/CC BY 2.0

Schools and Stumbling Blocks

In the previous post, we mentioned the rationales for why the government takes such an interest in the health of school children. Sadly, while some agree on desirable goals, other constituents are less than enthusiastic. For instance, the authors of the Individuals with Disabilities Education Act mentioned matter-of-factly that during the time period concerned, about 95% of American children attended school.

This is not universally accepted as a good thing. Apparently, lots of people would rather homeschool their children and have more control over the ideologies they might absorb. Others, who don’t even have children, would also be happier if more kids were homeschooled.

We reviewed an article whose authors mentioned that children spend as long as eight hours per day in the school setting, for as many as 180 days per year, also noting,

Schools have as much and probably more continuous and intensive contact with these children and youth during 5 to 18 years of their life except for their parents.

That is exactly what many Americans do not like, the concept that time spent equals brainwashing. They resent the idea that the school curriculum might wield more influence upon a child’s mind than the family’s worldview and opinions. The authors also state that…

Key features of the behavioral and nutrition components of an obesity prevention program must include all individuals in the child’s life who impact the child’s choices: parents and other family members, teachers, school nurse, physicians, physical education instructors, etc.

Many parents have a lot of trouble with what they regard as forced immersion, an unwanted intimacy between their private lives and the government. They do not want to be required to show up at the office and explain why their child is so skinny, or smuggles in a dozen doughnuts to eat during class, or seems unduly fearful, or smells weird.

They prefer a solid barrier between home and outside authority, and have strong opinions about what should or should not be the school’s business. They don’t like the idea of their child being taken into a private space and told to remove part of their clothing so a staff member can accurately measure their weight and height.

Compliance is not automatic

The National Council of State Legislatures published a detailed report on legislation contemplated, considered, adopted, or rejected by the various states during 2013. For instance, in the area of Body Mass Index screening or Student Fitness Screening, the report authors wrote, “The ease of measuring height and weight, without use of expensive equipment, makes BMI screening convenient…” (A glance at the training modules for staff members who are urged to do these measurements with the utmost accuracy gives an impression of the opposite of convenience.)

When people feel strongly about such issues, it might not matter what is mandated by federal, state or local law; it is just not going to happen. In many jurisdictions, local authorities have their ways of foot-dragging or circumvention, or whatever else will keep them from complying with unpopular standards. Parents who do not want to receive letters from the school stating their children’s weight and suggesting that they do something about it can be very powerful on the local level.

Your responses and feedback are welcome!

Source: “Childhood Obesity: Classification as an IDEA Disability,” Sagamorepub.com, 2016
Source: “Childhood Obesity Legislation – 2013 Update of Policy Options,” NCSL.org, 03/01/14
Image by Sodexo USA/CC BY 2.0

Schools Take On the Task

In 2014 the Colorado Department of Education published the Colorado Healthy Weight Toolkit, which is something of a model to which others might aspire. Once again, we look to the very conscientious state for guidance in what they call Growth Screening, defined as “measuring height and weight to calculate Body Mass Index” (BMI). The toolkit includes the messages that parents receive about this process, including a form to be returned if they don’t want their children’s BMI measured.

The literature explains that by state law, schools are required to screen for only two impairments:

While vision and hearing screenings are required, growth screenings are recommended by the Colorado Department of Public Health and Environment as another tool to evaluate the health of each child. Results are confidential. The growth screenings will take place in a private setting, supervised by the school nurse.

On the list of safeguards, the first item is a reminder that parental consent is necessary. Staff should be properly trained to carry out the measurement program and keep appropriate records. Accurate equipment should be obtained, and student privacy assured. The guidebook’s seventh rule reminds the people in charge that they should “regularly evaluate the program and its intended outcomes and unintended consequences,” a precept that is sometimes not followed carefully enough.

Many characteristics are specified for the correct type of scale. It should have no wheels and be otherwise stable. It should be in a private location, and the child’s weight should not be spoken aloud, but only written down. Any “stature device,” ruler, or other height-measuring attachment is not to be used for that purpose. Height is to be measured separately, with a different instrument, the stadiometer. It comes with its own list of procedural requirements, to assure that each individual reading is accurate, and to acquire meaningful statistics.

Another agency weighs in

The Arkansas Center for Health Improvement, like similar departments in other states, presents its measurement protocol in one of its training manuals, which probably all derive from the same sources. The preparation involves such matters as privacy, good equipment, proper form, and not wearing sweaters, jackets, hats or shoes while being weighed or measured.

From another state, Missouri, here is only the first and shortest of a three-paragraph explanation:

The student should stand on the footplate, or at the base of the measuring device, without shoes and positioned with heels close together, legs straight, arms at sides, and shoulders relaxed. The student should be instructed to look straight ahead and stand fully erect without moving their heels. The heels should not rise off the floor. When possible, the head, back, buttocks and heels should touch the wall. All hair ornaments, buns, braids, etc. should be removed to obtain an accurate measurement against the crown of the head.

To make a long story short, the process involved in BMI assessment can be tedious, embarrassing, and even frightening to children. It is a job for trained personnel, and if trained personnel are unavailable for whatever reason, it is a lot of responsibility to put on school employees who might be totally unfamiliar with medical procedures.

Your responses and feedback are welcome!

Source: “Colorado Healthy Weight Toolkit,” CDE.state.co.us, 12/01/14
Source: “BMI Screening Program: Eight & Weight Measurement Training Manual,” Arkansas.gov, 2019
Source: “Guidelines for Growth Screening in Missouri Schools,” MO.gov, 2005
Image by zombieite/CC BY 2.0

Schools and Expectations

The rules for qualification as a disabled person in the education system were laid down by the Individuals with Disabilities Education Act (IDEA) of 2004, which recognized 13 categories of disability, including Other Health Impairment. To come in under the heading of Other Health Impairment, two criteria needed to be met: there had to be “limited strength, vitality, or alertness as related to the educational environment” and “the condition must adversely affect the student’s educational performance.”

What did this document say about obesity? IDEA explained that its list was not all-inclusive, and on some questions did not take a firm stand:

The list does not include or negate the general condition of childhood obesity; however, the conditions of asthma, diabetes, and morbid obesity are explicitly recognized (as of 2009).

Students who are obese whose condition adversely impacts their educational performance, should be eligible for special education services. If a student is obese and has a significant physical fitness or motor skill deficiency, they have the potential to meet the minimum criteria for obesity as a disability…

What kinds of special educations services was the Act talking about? The subject was clarified by the U.S. Department of Education’s Office for Civil Rights (OCR), which was given jurisdiction over Section 504 of the Rehabilitation Act of 1973. In 2010 the agency published guidelines defining the OCR’s main responsibilities as “investigating complaints, conducting compliance reviews, and providing technical assistance.” The intentions were carefully explained:

It is not a plan designed to enhance a student’s performance. It is a plan to provide fairness and equal access to education… A student is entitled to a Section 504 Accommodation Plan if they have been identified and the evaluation shows that the individual has a mental or physical impairment that substantially limits one or more major life activities. This determination is made by a team of knowledgeable individuals, including the parents, who are familiar of the student and his/her disability.

The purpose of Section 504 was to protect individuals with disabilities from being discriminated against. Exceptions might be made for a student whose obesity “substantially impairs the major life activity of mobility.” As examples, the authors suggested seating modifications (including in restrooms), and the opportunity for privacy in restrooms. The student could be allowed extra time to arrive at classrooms, and/or given elevator privileges. The furniture in classrooms could be rearranged. Classes could be moved to different rooms.

There could be dietary modifications or adjusted meal schedules. If the student travels by bus, that situation should be checked for safety. Attendance policies could be more forgiving. The physical education requirements could be relaxed. There might be counseling, or a peer support group. Students with disabilities could be encouraged to take part in clubs and activities.

A certain type of person would perceive all this as shameful coddling of kids who eat too much and play too many video games. But bear in mind, these accommodations are meant to make life bearable not only for a morbidly obese child but for a wheelchair-bound child or a child on crutches. The list of suggested interventions came with a rather significant caveat:

These guidelines might not reflect the opinion of the Office for Civil Rights and/or current court cases. Civil Rights laws and regulations change periodically and will change interpretations of various rules and regulations.

(To be continued… )

Your responses and feedback are welcome!

Source: “Childhood Obesity: Classification as an IDEA Disability,” SagamorePub.com, 2016
Source: “Guidelines for Educators and Administrators for Implementing Section 504 of the Rehabilitation Act of 1973—Subpart D,” MemberClicks.net, 2010
Image by Mr. Thinktank/CC BY 2.0

How Much Should Schools Care?

Several years ago, a major hospital chain conducted an opinion survey in which 90% of the people responded that they wanted schools to play a role in reducing obesity. Regarding what that role should be, how many different pictures were in their minds? More physical education classes? Less junk food in the vending machines? Weigh and measure the students and send alarming letters to their parents? The survey did go further, and learned that 64% of the positive respondents were also in favor of the role being “major.”

In 1997, in a book called Schools & Health: Our Nation’s Investment, the National Center for Biotechnology Information published its viewpoint on the confidentiality of student academic and health records. When speaking of difficulties, they did not beat around the bush:

Providing health care in an educational setting requires consideration of separate and sometimes conflicting standards about clients’ rights to obtain health care and requirements for educators and health care providers to protect the privacy of their clients’ records.

Students are of two important subcategories — legal minors and legal adults — and different procedures are involved in the record-keeping.

Although client health and social service records may belong to the agency where the data are collected, the individual (parent or guardian, in the case of a minor) maintains the right of control over the information in the records.

That is as it should be, but no bureaucracy is error-free. No doubt there are some horror stories of mishandled records. When things go right, the student or parent signs a consent form, so that various agencies can see the records and coordinate their efforts on behalf of the patient. This is desirable for many reasons, like the prevention of medication conflicts. Most clients, or the parents responsible for them, are okay with that provision, but…

[…] this may be problematic when there is an issue related to mental health, drug use, or a sexually related condition. Further, some parents and guardians express concern for the consequences if such information — or information about health problems discovered at the school, such as asthma or seizures — might be obtained by their insurer.

Most people don’t set out to deceive their insurance company, but there is no point in letting them know every detail of a child’s condition before a diagnosis is confirmed or before there is a chance to sanely assess the situation. Obesity is not identical to a mental health or drug use issue, or a sexually related problem, but there might be valid reasons to control the flow of information to other parties. With insurers so eager to find disqualifying “pre-existing conditions,” confidentiality is important.

In the discussion of screening processes, the recommendation is to use “a relatively simple test to identify those who may have a particular problem.” Customary testing methods should be reviewed, and their relevance attested to. Financial resources and other factors will decide how to apportion the attention “between population-based screenings and targeted interventions for high-risk groups.” Here is the crux of the matter:

Unfortunately, screening programs are ineffective unless procedures are in place for ensuring follow-up of identified problems.

(To be continued…)

Your responses and feedback are welcome!

Source: “Schools & Health: Our Nation’s Investment,” NIH.gov, 1997
Image by Thomas/CC BY 2.0