The Psychological Consequences of “Fat Letters”

Schools in 21 states measure children’s body mass index (BMI) to screen for obesity, and eight states require that reports be sent home to parents to encourage treatment for overweight kids. Proponents acknowledge that there is no evidence that these so-called “fat letters” help children lose weight; they are simply an “awareness tool.” Yet there is substantial evidence that this practice could directly lead to poor self-image and even eating disorders. Massachusetts has wisely ended the practice of sending “fat letters”; the remaining eight states should follow that example as soon as possible.

For obese children, letters home about their BMI are an official judgment that they are inadequate because of their size. “Fat letters” are delivered annually; thus, even when children are trying to make healthy changes, they could continue to receive up to a dozen of these letters throughout their school career.

The spirit of these letters echoes the societal sentiment that obesity is a problem that needs to be fixed. They also insinuate that children are to blame for their condition and that they lack awareness or willpower. And because “fat letters” are a collaboration between the child’s school, parents and doctor, kids are likely to feel that school officials, health care professionals and possibly their own parents are ganging up on them over their weight. This will simply validate their fears that they are somehow bad or subpar because their body is unacceptable. It can also increase cruelty among peers, as obese children are among the most stigmatized, teased and bullied groups of people.

This stigma can result in increased poor self-concept and unhealthy dieting behaviors. The result is a cycle of negative body image, rigid dieting and unhealthy eating that can last a lifetime, with devastating consequences. Adults who binge tend to be obese. Obesity by itself poses a host of health risks; having an eating disorder as well can substantially increase the risk for serious psychological problems—like depression—and health problems like diabetes and cardiovascular disease.

Through health screening and BMI measurement, schools want to motivate children and their families to reduce obesity. But sending regular letters home risks stigmatizing children and can lead kids to be anxious about intervention.

To date, there is a disturbing lack of studies done on schools using this program, and the studies being conducted do not adequately assess the potential risks of BMI screening. This trend reflects a more general problem of eating disorders being under-diagnosed among obese children. Doctors and family members too often view weight loss as a good thing, without assessing whether it’s occurring in a healthy way. This further suggests that any negative consequences of “fat letters” are likely to go ignored and undetected.

It’s unlikely that school officials want to perpetuate eating disorders and body-image issues among children. Fortunately, there are other, more effective ways to help ensure our children are healthy and happy.

• All states should retract the mandate to measure BMI in schools. While BMI is a reliable indicator of other health risks, using BMI alone to gauge children’s health and inform “treatment” plans can have serious negative consequences.

• Schools should focus on fully implementing evidenced-based community nutrition and physical activity programs for all students, regardless of their weight.

• There must be careful studies of “fat letters,” to address possible negative consequences.

• Advocacy groups that specialize in reducing the stigmatization of obesity and eating disorders must be involved.

Policy makers and advocates of BMI screening in schools have the best intentions. However, this policy blatantly overlooks the long-term, potentially devastating consequences of this practice for children. All states must take a step back from this program until we better understand not only its effectiveness, but the very real psychological impact as well.