Amy Oztan is one of thousands of parents who got a letter from school bluntly pointing out that her son is fat. She promptly threw the letter away.
"My son, who is very tall for his age and is a little husky, but fit, brought home a piece of paper from his school listing his BMI and stating that he was obese," said Oztan, a New York City mother of two.
"I ignored it, because anyone looking at him would laugh at that assessment," said the 37-year-old who writes for NYC Mom Blog. "But when my husband saw it he freaked out a little bit."
Soon, many more children might be routinely subjected to the fat police and a one-size-fits-all measurement of health -- the body mass index or BMI -- as health experts and politicians attempt to deal with the childhood obesity crisis.
BMI, a simple formula that compares a person's weight and height, is the most widely used tool to screen for weight-related health problems and is recommended by the American Academy of Pediatrics for all children and adolescents.
Though some individuals are exceptions, the BMI can prompt doctors for further test for an absolute diagnosis of obesity.
The report is part of the Altarum Institute Obesity Prevention Mission Project, which has responded to first lady Michelle Obama's "Let's Move" campaign to promote regular screening of all children's BMI.
Researchers say public health surveillance through immunization registries -- a model being implemented in Michigan and in San Diego County, Calif. -- could be a cost-effective way to provide needed data and help determine how resources are allocated.
Oztan insists the BMI is a "minefield" when it comes to evaluating health and state surveillance would be a "dumb idea."
"I see thin kids walking to my kids' school eating Cheetos for breakfast, and those kids wouldn't get targeted by this program," she said. "My son takes tae kwon do four days a week and can run faster than any kid in his class, but he would be targeted."
And doctors, who are on the front lines, say that the BMI battle alone may not be enough.
"My admonition is not to lull ourselves selves into thinking just BMI gives us a solution," said Dr. George Flores, senior program officers of The California Endowment, a community-based health foundation.
"Environment and behavior are the things we need to pay most attention to," he said. "If you just look at weight, you miss the more important issues of what need to be measured tracked and corrected -- the things that lead to being overweight."
Doctors say the problem is that children watch too much TV and play video games instead of going outside. Parents don't model good eating habits and schools are cutting back on physical education programs and recess.
Childhood obesity has more than tripled in the past 30 years, according to the Centers for Disease Control and Prevention. The prevalence among children aged 6 to 11 years increased from 6.5 percent in 1980 to 19.6 percent in 2008. Among teens it jumped from 5 percent to 18 percent.
But Altarum researchers say data on children ages 5-14 are scarce and among children under 5, only those enrolled in public assistance programs are counted.
"The advantage of the registry-based clinical model is that it focuses on the youngest children -- where we have the best chance of preventing obesity from developing in the first place," said co-author and Altarum fellow Matt Longjohn.
"The clinical model also reminds providers to screen children and how to counsel them and their families according to established standards."
Bills in Congress to Enable BMI Surveillance
Two bills in Congress have been introduced that would provide grants through the Department of Health and Human Services to help states develop and expand their immunization registries.
Some studies estimate that the epidemic costs the nation $1,000 per person, per year in health care costs -- about $150 billion or 10 percent of overall health care expenditures.
"And the end is not in sight," said Longjohn. "We are developing a generation of kids with adult risks before they leave adolescence."
About 30 states have implemented or considered BMI surveillance programs, most of them school-based, like the one in Arkansas that was launched in 2003.
"In an ideal world, the doctor has a list of who is coming in that day and the immunization registry tells him they need this shot, this lead test follow-up and height and weight assessed and the BMI checked to see if they are overweight and if they are, kick in with other screening tests," said co-author and senior policy analyst Amy Sheon.
With the registry-based model, personally identifiable information never leaves the doctor's office and the only data shared is aggregate information on rates of obesity.
But some parents object to surveillance as an "intrusion by well-meaning adults."
"I have no problems with government publishing information regarding the effects of obesity and educating the public on this issue," said Scott Hipsak of Anchorage, Alaska.
"Further rules and regulations will not address this issue," he said. "People will eat what they want when they want it and you cannot change that."
He insists advertising, like anti-smoking campaigns would be more effective.
"I have one skinny to medium child and one child who has always, always been off-the-charts for weight since she entered the world at 9 1/2 pounds," she said of her adopted 5-year-old. "It's how she's built. It's how her family's built."
"She is also very active, eats a wide variety of healthy foods and is sick the least of us so to take her weight as a measure of her entire health would be a huge mistake," said Friedman, 40.
She is also frustrated by efforts to "shame" children and parents, rather than providing healthier school lunches, and making good food more affordable in neighborhoods where shopping is a challenge.
Parent, Teacher Say State Should Get Involved
But other parents agree that the state should take on a larger role.
"If I had failed at being a good parent by letting my child get fat in the first place, yes, I would welcome help from a doctor," said Ann Joyce of Liberty, N.C. "Health trumps privacy when you have failed as a parent. Parents need to wake up to what they are doing to their kids."
Ignoring a child's growing waistline can also be tantamount to child abuse, according to Emily Abbott, who teaches high school in Tacoma, Wash.
"Though I am not a mother, I would expect someone to step in and help if I was doing an ill job raising my child," she said. "Accepting and allowing obesity in children is slowing killing them and setting them up for an early grave."
New York nutritionist Keith Ayoob agrees that collecting BMI data is a "starting point" for addressing the obesity epidemic.
"You want to find out what the contributing factors are -- 9 times out of 10, it's not in school but the other 18 hours of the day," said Ayoob, director of the Nutrition Clinic at the Rose F. Kennedy Center at Albert Einstein College of Medicine. "We worry about what's going on at home."
Often parents seeking help walk into his Bronx office for a half-hour visit with a shopping bag full of chips and soda. Others say they have never offered their child fruits or vegetables.
"We owe kids better than that," said Ayoob, "Parents need to learn to be parents and set healthy limits and let you know they are in charge and this is not a democracy."
"When parents give kids food, they are training them, not just feeding them," he said. "Parents sometimes have to deal with their own eating issues."
Such was the case with his patient, Karen Butler-Brock, whose son Andrew is overweight and has a family history of diabetes and heart disease.
"He had insatiable appetite and the pounds were packing on," she said. "This kid is genetically coded for disaster and has to remain a healthy weight."
By the age of 7, she started to notice Andrew's weight gain. "He's a kitchen raider and a food hoarder," said Butler-Brock, who works for New York City's United Federation of Teachers.
But with the help of Ayoob, she made dietary changes: introducing green vegetables, measuring starches, eliminating snack foods and changing from whole to skim milk.
Today, at 13, Andrew is "still fighting the battle," but has made improvement, according to his mother.
Now, she is an advocate for BMI surveillance, hoping it will also help low-income communities like the Bronx, where childhood obesity is rampant, to generate more health programs.
Ayoob agrees that BMI testing ultimately belongs in the hands of professionals and not gym teachers.
"Doctors are the gatekeepers," he said. "And parents trust doctors."