ABSRACT

This is a descriptive study carried out to determine the nutritional status of primary school

children ages five(5) to eleven(11) years using body their mass index(BMI). Body mass index is

a statistical parameter used to determine the nutritional status/body weight efficiency of

individuals, and it has been used in many countries for assessment of underweight, healthy

weight, overweight, and obesity in children and adults. The prevalence of obesity in children is

increasing and is recognized as a risk indicator of cardiovascular disease in adulthood. The

sampled children were measured and their BMI was calculatedas weight (kg)/ height^2

(m^2).Underweight , healthyweight, and obese children were identified using charts from pooled

internationally accepted data age and sex specific cut-off points for BMI. The BMI ranges from

09.25kg/m^2 to 28.20kg/m^2 with a mean BMI of 15.02kg/m^2. The prevalence of Under

weight , healthy weight , over weight and obesity were 16.33%, 64.34%, 12%, and 7.33%

respectively. More Nigerian children had BMI within the normal range. The prevalence of

malnourishment among children though predominantly low should be taken seriously, especially

as it appears to be associated with improving socioeconomic status . School health education

(physical activity and nutritional education ) is recommended as preventive measures.

KEYWORDS: Nutritional status, Body Mass Index, Weight, Height , Obesity

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF STUDY

Nutritional Status is an important indicator enabling diagnosis . Nutritional status is

assessed using anthropometric and biochemical tests, among others. Anthropometric

measurements used to determine nutritional status include assessment of the physiological status

of the body based on its height and weight.

Body Mass Index (BMI) is the most popular and commom method for nutritional status

assessment. Body Mass Index is a measure of the ratio of one’s body mass to the square of his/

her height,and it has been in use in many countries for assessment of overweight, obesity ,

together with nutritional status determination.Theimcreasing prevalence of overweight and

obesity in both children and adults is associated with many diet-related chronic diseases

includind diabetes mellitus, cardiovascular diseases, stoke, hypertensions and certain cancers. In

order to maintain a regular and constant body weight standard, the knowledge of body mass

index was introduced by the World Health Organisation to enable the entire public have an

insight into proper diet regulation.WHO, 2019. Due to the purpose of this study emphasis will be

laid only on the body mass index of primary school children in Owo within the ages of five to

eleven years old.

 Body Mass Index is a number calcualated from one’s weight and height ,it is a reliable

indicator of body fatness for most children and teens . It does not measure body fat directly,but

research has shown that BMI correlates to direct measures of body fat , such as energy x-ray

absorptiometry (DXA). BMI can be considered an alternative for direct measures of body fat and

nutritional status determination. For adults it is usually age independent and may not absolutely

depend on sex of the individual , but for children and teens . BMI is age and sex-specific and

often referred to as BMI-for-age. The World Health Organisation (WHO) has released several

recent reports on the body mass index (BMI) and its relationship to health.

In a 2019 report, the WHO found that while BMI is an imperfect measure of health, it

remains an important tool for assessing population-level trends in obesity and overweight.

According to WHO over 390 million children and adolescent were overweight in 2022 ,

including 160 million who were living with obesity. In 2021, UNICEF released a report titled

“Childhood and Obesity and Overweight : A global challenge and solutions to protect children’s

health,” which focuses on the global trends in childhood obesity and overweight , as well as

potential solutions to address the issue. This report highlights the importance of BMI as a

measure of childhood obesity and overweight , but also notes the limitation of BMI ,particularly

in low and middle-income countries. The report also discusses the need for a holistic approach of

addressing childhood obesity , including social and environmental factors that may contribute to

the problem.

The Center for Diseases Control and Prevention (CDC) defines body mass index (BMI) as “a

persons weight in kilograms divided by the square of his or her height in meters.” The CDC

notes that this is an indirect measure of body fatness, and that it has limitations. The CDC

recommends using other measurements in addition to BMI to assess health risks related to body
fatness, including waist circumference , body fat percentage , and measures of blood pressure ,

glucose and cholesterol. The CDC also emphasizes that BMI is not an appropriate measure of

body fat for children, pregnant women or people with certain medical conditions.

BMI is age-specific and sex-specific and is often referred to as BMI-for-age. After BMI is

calculated for children and teens, the BMI number is plotted on the CDC BMI-for-age growth

charts ( for either girls or boys ) to obtain a percentile ranking .

The CDC’s growth charts provide a recent definition of BMI for children and teens, based on age

and gender. The charts show the average BMI for healthy children and teens , at specific ages,

based on information collected from the National Health and Nutrition Examination Survey

( NHANES) . The CDC recommends using these charts to track a child’s BMI over time , to see

if they are growing at a healthy rate . Children whose BMI falls above 85th percentile on the

CDC growth charts are considered to be overweight , and those above 95thpercentile are

considered obese. Percentiles are the most commonly used indicator to assess the size and

growth patterns of individual children in most countries of the world. The percentile indicates the

relative position of the child’s BMI number among children of the same sex and age. The growth

charts show the weight status categories used with children and teens (underweight, healthy

weight , overweight , and obese . CDC 2020.

The International Association for the Study of Obesity (IASO) is another organization

that has published recent reports on BMI and health. In 2019, IASO released a statement on the

World Health Organization’s classification of BMI and it’s implication for global health . The

statement highlights the challenges of using BMI as a global standard , given the large variations

in body composition across different populations . The different also notes the need for more

research to understand the relationship between BMI and health outcomes . IASO has also
published reports on the prevalence of overweight and obesity in different regions of the world.

The 2022 CDC Extended BMI-for-age Growth Charts include four additional percentile above

the 95th percentile (the 98 th, 99.9 th and 99.99 thpercentiles) and can plot BMI up to 60

kg/m^2.

This research work was carried in other to ascertain the degree of precision in using

the analysis of body mass index the determining the nutritional status of children within the age

of five (5) to eleven (11). Secondly, to assemble information of sufficient quality and quantity

which will help in the provision of basis for making accurate analysis and sound decision on the

health of children within the age five years to eleven years old using their body mass index. This

research comprises of the principles which accomplishes the processes of determining the

nutritional status of children within the ages of five to eleven years using their body mass index,

it also covers the exploitations of some statistical models which helps in proper estimations of

child’s nutritional condition , using a world known standard for health status determination.

1.2 STATEMENT OF PROBLEM

The problem of this research work is to ascertain the degree of precision in using analysis

of body mass index in determining the nutritional status of children within the ages of

five to eleven years.

 Secondly, to assemble information of sufficient quality and quantity which will

help in the provision of basis for making accurate analysis and sound decision on the

health of children within the age of five years to eleven years old using their body mass

index.

1.3 OBJECTIVES OF THE STUDY

The Objectives of the study are to:

1. Investigate the prevalence of nutritional problems such as Underweight, Overweight

and Obesity among children ages five to eleven using BMI.

2. Investigate the factors that can affect the assessment of nutritional status of children

3. Compare BMI measurements in different age groups, gender, or socioeconomic

group.

4. Investigate the relationship between BMI and other health indicators .

5. Provide information that can be used to improve the assessment of nutritional status

in children, and to inform future research.

6. Analyze the health importance of continually measuring the BMI of children.

7. Reach and maintain a healthy weight which is important for overall health and can

help you prevent and control many diseases and conditions such as heart diseases,

type 2 diabetes , gallstones, breathing problems, and certain cancers.

8. Identify the risk of children that are at risk of malnutrition or obesity , based on their

BMI measurements.
1.4 RESEARCH QUESTIONS

1. What is the nutritional status of primary school children using BMI in selected

schools in Owo?

2. Does gender and age play a role on the nutritional status of children?

3. What is the influence on socio-economic status on nutritional status of children?

4. What is the relationship between BMI and other health indicators such as blood

pressure or cholesterol level?

5. How does the assessment of nutritional status usingBMI differ from other methods,

such as skinfold measurements or dual-energy X-ray absorptiometry?

6. What are the implications to assess BMI to assess nutritional status in children?

1.5 HYPOTHESIS

\ One possible hypothesis for the study on the assessment of nutritional status in children

is : “ BMI is an accurate and reliable measure of nutritional status in children, and it is associated

with other health indicators.”

1.6 SIGNIFICANCE OF THE STUDY

A study of the assessment of nutritional status in children using BMI could have

several important implications on profession(nursing ) , health providers and the society.

Firstly,for nurses it could help increase opportunities to provide evidence-based care for

children with nutritional needs. It could also provide greater understanding of the link

between nutrition and health, which coud lead to improved nursing education and
 practice. Furthermore, it enhances collaboration between nurses and other healthcare

professionals , such as dieticians and pediatricians , to improve the care of children with

nutritional needs and also for more recognition of the role of nurses in addressing

childhood Obesity and promoting healthy lifestyle.

The assessment of nutritional status in primary school children using BMI also

have several significances to health providers. The number one point is to help health

providers on better identification of children who are at risk of malnutrition and obesity

so that they can receive appropriate care and support. The second point is to improve

understanding of the importance of the link between nutritional status and health , which

inform evidence based – practice and policy decisions . Also to improve ability to track

and monitor progress in improving nutritional status in children.

In the society, nutritional status in children using BMI helps in reduction in the

burden of childhood obesity and related health problems, such has type 2 diabetes and

cardiovascular diseases . It also include an improvement in children’s physical and

mental health, which could lead to improved educational outcomes, productivity , and

quality of life . Ultimately , a more sustainable future as improving nutritional status in

childhood can have a long -term impact on the health of future generations.

1.7 SCOPE OF THE STUDY

The study will be deliminated to children within the ages of five (5 ) to eleven ( 11 )

schooling at selected schools at Owo L.G.A. The study will cover the use of BMI as a measure of
nutritional status in children, the various factors that can affect the assessment of nutritional

status of children and a discussion of the advantages and disadvantages of each methods, a

discussion of the challenges faced in assessing nutritional status in children, a review of the

methods used to assess nutritional status in children including anthropometric measurements snd

biochemical assessment , a comparison of different methods used to assess nutritional status in

children, and a discussion of the advantages and disadvantages of each method.

1.8 OPERATIONAL DEFINITION

1. NUTRITIONAL STATUS :This is defined as the degree to which a child’s

nutritional needs are being met, based on the child’s height and weight , and taking

into account factors such as age and gender.

2. BMI : This is defined as the body mass index , calculated by dividing a child’s

weight in kilograms by their height in meters squared.

3. CHILDREN: This is defined as individuals aged 2-18 years old.

4. ASSESSMENT : This is defined as the process of measuring and evaluating a child.

5. DATA COLLECTION METHOD : This include the methods used to collect data on

nutritional status such as surveys or interviews.

CHAPTER TWO

LITERATURE REVIEW

This chapter presents related materials reviewed from books and journals such as

published and unpublished articles from University libraries and internet materials.

This presentation will be done under the following headlines : Conceptual Review;

Concept of BMI, Classification of BMI, the biological and p physiological basis of

BMI, social and cultural factors that influence the accuracy of BMI, ethical and legal

issues associated with using BMI, implications of using BMI to assess nutritional

status of children, different methods used to collect and analyze data on BMI in

children, other measures that correlates with BMI. Theorectical Review; Ecological

Systems theory , Social cognitive theory and Health belief model theory. Emperical

Review of related studies and summary of literature review.

2.0 CONCEPTUAL REVIEW

2.1 Concept of BMI

The concept of BMI was first introduced in the early 1800s by Belgian

statistician Adolphe Quetelet, who was interested in the relationship between height

and weight . However, it wasn’t until the 1950s that the term “body mass index” was

first used , by Ancel Keys and colleagues . Since then, BMI has become a widely used
measure of body fat and health. Many different organizations and researchers have

contributed to the research and understanding of BMI, including the World Health

Organization, the National Institutes of Health , and the Centers for Diseases Control

and Prevention.

BMI or body mass index , is a measure of body fat based on height and weight . it is

calculated by dividing a person’s weight in kilograms by dividing by the square of

their height in meters. In a adult BMI between 18.5 and 25 is considered to be within

the healthy range, while a BMI of 25 or above is considered overweight, and a BMI OF

30 above is considered obese . It is based on the idea that excess body fat is associated

with an increased risk of health problems such as diabetes , heart diseases , and some

types of cancer . The concept of BMI in children is similar to the concept of adults.

However, there are some important differences.

In children , the references ranges for BMI are based on sex and age specific

growth charts . This means that a child’s BMI compared to other children of the same

age and sex , rather than to a single standard for adults. While BMI is a useful measure

of health in adults, it’s not always a reliable indicator of health in children. This is

because children can have excess fat without being overweight , and they can be at a

healthy weight but have other health risks. For example, a child may have a high BMI

but be a very physically active and have strong muscles. Or, a child may have a healthy

BMI but have a poor diet and low levels of physical activity. These children may be at

risk for health problems even though their BMI is within the normal range.

In the review of Obesity,Dr Vijayakumar’s , (2019) shows the implications for health

and wellbeing of children. His findings suggest that children who are obese are at risk
for a range of negative outcomes, including cognitive and academic difficulties. This is

especially concerning given that childhood obesity is a growing problem in many parts

of the world. To address this issue, Dr Vijayakumar has suggested that interventions to

promote healthy eating and physical activity should be a priority . He has also called

for increased research into the mechanisms linking childhood obesity and cognitive and

academics outcomes, so that we can better understand how to prevent these negative

outcomes.

Dr Richard Rosenkranz and his colleagues analyzed data from the avon Longitudinal

study of Parents and Children , a longitudinal study of over 14,000 children in the

United Kingdom. They found that children who were obese at age 7 were more likely

to have poorer cognitive and academic outcomes at age 11. ( Rosenkranz et al., 2019 ).

Dr Deborah Frank and her colleagues analyzed data from the Fragile Infant Feeding

Study, a longitudinal study of premature infants in the United States. They found that

infants who were born premature and had a low birth weight were more likely to have a

lower BMI in childhood, and that this was associated with lower cognitive and

behavioral outcomes. This study adds to the growing body of evidence linking to early

childhood obesity to long term health and development outcomes. ( Frank et al.,

2019 ).

Silverman and Trevor C.Lipscrombe derive the mathematically exact BMI

probability density function (PDF), as well as the exact bivariate PDF for human

weight and height are shown to be correlated bivariate lognirmal variables whose

marginal distributions are each lognormal in form. (Silverman and Lipscrombe, 2022).

J. Thavamani has tried to create awareness and preventive health measures among
students on Body Mass Index, and preventive measure for obesity through counselling

students on healthy nutrition and the importance of physical activities (Thavamani ,

2019).

Apart from obesity among children, there are also children who are

underweight. According to the latest available data from the World Health Organization

, about 11 percent of children in Nigeria between the ages of 5 and 11 are underweight .

This is significantly higher than the global average of about 7 percent. Underweight is

most common in the rural areas of Nigeria, where poverty and food insecurity are more

common. It’s important to note that this is only an estimate , and the true number of

underweight children may be even higher. This is because not all children are weight

and measured as part of routine checks, and many children may not be able to assess

health care services . Underweight generally can cause malnutrition and also be a sign,

but it’s not the only sign. Infact , some children may appear to be at a healthy weight or

even overweight but still be malnourished. This is because malnutrition can be caused

by a variety of factors , including lack of access to healthy foods, poor diet quality , and

underlying health conditions. In 2019, UNICEF published a report titled “ Children in

the Middle : The Double Burden of Malnutrition Among School- Aged Children,”,

which focused on children between the ages of five and eleven . The report found that

while the undernutrition problem among children in this age group has improved in

recent years, overweight and obesity is becoming increasingly common.

For healthy weight children , based on the data that is available , it is

estimated that around 30% of children in Nigeria are of healthy weight. This number

may vary by region and socioeconomic status .

2.2 CLASSIFICATION OF BMI ( BODY MASS INDEX )

The World Health Organization (WHO) classifies BMI for children into five

categories : underweight, healthy weight, overweight, moderate obesity , and severe

obesity . These categories are based on the child’s BMI relative to other children of the

same age and sex. The WHO also uses these categories to determine whether a child is

at risk for developing chronic diseases later in life.

The WHO classification of BMI for children is as follows :

1. Underweight : A child is considered underweight if their BMI is less than the 5th

percentile for their age and sex. Underweight can be caused by a variety of factors

including inadequate nutrition , frequent illness, and lack of access to health care. It

can have serious consequences including delayed growth and development ,

increased risk of illness and death , and increased risk of chronic diseases later in

life.

2. Healthy Weight : WHO defines healthy weight for children as a BMI between the 5

th and 85 th percentiles for their age and sex. This means that a child is considered
 to have a healthy weight if their BMI falls within this range. Children who fall

outside of this range may be at risk for health problems.

3. Overweight : WHO defines overweight for children as a body mass index greater

than or equal to the 85 th percentile but less than the 95 th percentile for their age

and sex. This means that a child is classified overweight if their BMI IS higher than

85 percent of children their age and sex. The 85 th percentile is used as a cut- off

because it is a common point where health risks begin to increase.

4. Moderate obesity : A child is considered to have moderate obesity of their BMI is at

or above the 95 th percentile for their age and sex. This means that their BMI is

significantly higher than that of the average child their age and sex. Moderate

obesity can lead to a number of health problems, including type 2 diabetes, high

blood pressure, amd joint problems .

5. Severe obesity : WHO defines severe obesity for children as a body mass index

greater than or equal to the 99 th percentile for their age and sex. This means that a

child is considered obese if their BMI is higher than 99 percent of children age and

sex. Severe obesity can have serious health consequences , including type 2

diabetes, high blood pressure , sleep apnea , and joint problems . it can also lead to

meantal health problems such has depression and anxiety.

2.3 THE BIOLOGICAL AND PHYSIOLOGICAL BASIS OF BMI

BMI is a widely used measurements for assessing weight status, but it has its

limitations . Here’s an overview of the biological and physiological basis of BMI.

1. Weight and Height : BMI is calculated by dividing weight ( in kg ) by height

( in meters ) squared ( kg/ m^2 ) . This simple formula doesn’t account for

muscle mass, bone density , or body composition.

2. Body composition : BMI doesn’t distinguish between lean body mass ( muscles,

organs, bones ) and body fat. Athletes or individuals with a muscular build may

have a high BMI without being overweight .

3. Fat distribution : BMI doesn’t account for fat distribution , which is important

for health risks. Central obesity ( visceral fat around the waist ) is associated

with a higher risk of chronic diseases with peripheral fat ( fat around the hips

and thighs ).

4. Body water composition : BMI doesn’t account for variations in body water

content, which can affect weight . For example, athlethes may have a higher

chances due to increased muscle mass.

5. Bone density : BMI doesn’t account for variations in bone density , which can

affect weight. For example, individuals with osteoporosis may have a lower

bone density , leading to a lower weight.

6. Hormonal influences : Hormones like testosterone , estrogen , and cortisol can

affect body composition and fat distribution , leading to variations in BMI.

7. Genetic factor: Genetic variations can influence body weight , body

composition , and fat distribution , making BMI less accurate for some

individuals.

8. Age- related changes : BMI doesn’t account for age-related changes in body

composition , such as the loss of muscle mass and bone density with aging .

9. Sex differences : BMI doesn’t account for sex differences in body fat

distribution and muscle mass.

10. Ethnicity and population-specific variations : BMI may not be suitable for all

ethnic groups or populations , as body composition and fat distribution can vary.

According to Journal Nature Medicine published a study in 2023

titled , “ Multiomic signatures of body mass index identify heterogenous health

phenotypes and responses to a lifestyle intervention” . The study found that blood

omic profiles can provide information on several health conditions, and that a

machine learning model trained to predict BMI through blood metabolites was able

to provide better clinical measurements than genetic predisposition or observed

BMI. Another study published in Nature found that BMI is flawed and needs to be

redefined . The study argued that BMI does not distinguish between lean body mass

and body fat and does not account for fat distribution , which is important for health

risks. A third study published in springer found that while BMI is an empirical and

objective measure of health, it is also an arbitrary and subjective label for

categorizing the population. The study argued that researchers should be aware of

the definitional ambiguity of BMI across different research methods and contexts.
 It’s important to recognize that BMI is a roughestimate and should be used

in conjunction with other measurements ,such as waist circumference , skinfold

measurements ,or more advanced body composition assessments , to get a more

accurate picture of health.

2.3 SOCIAL AND CULTURAL FACTOR THAT INFLUENCES THE

ACCURACY OF BMI

In the accuracy of BMI, social and cultural factors can

definitely play a role. For example, different cultures may have different

perceptions of body image and what is considered “ideal” or “healthy”. This can

impact how people view and interpret their BMI results. Additionally, social

pressures and norms around body size and weight can influence how individuals

perceive and respond to their BMI. It’s important to remember that BMI is just one

measure of health and doesn’t take into account factors like muscle mass or body

complications . So, it’s also good to consider other indicators of health as well. The

Body Mass Index (BMI) of children is influenced by a variety of social and cultural

factors that play a significant role in shaping their lifestyle choices, dietary habits,

and physical activity levels. These factors can vary across different socioeconomic

groups, ethnicities, and cultural backgrounds, impacting the prevalence and severity

of childhood obesity.
Some of the social and cultural factors that influences the accuracy of BMI in children include:

1. Cultural norms and beauty standards : Different cultures have varying ideals of beauty

and body shape, which can influence perceptions of weight and body compositions . In

many western countries such as United states , United kingdom, and many European

countries , has a strong emphasis on being slim and having a lower BMI as a standard of

beauty. This perception is often perpetrated by media, fashion , industry and societal

expectations. While in some other cultures, such as certain parts of Africa , the pacific

islands , and some Native American communities , there is a cultural preference of larger

body size and a higher BMI. Thes cultures view a higher BMI as a symbol of beauty,

fertility , and good health. This can really affect the BMI of children.

2. Food habit and dietary practices : Dietary habits and food choices can impact weight and

body composition , and may not be accurately reflected in BMI of children. However , a

study conducted by BMC Public Health (2020) in the united states found that lower-

uncome households purchased foods of lower nutritional quality compared to higher-

income households . This suggests that socioeconomic factors may influence dietary

choices by parents towards their children and potentially impact BMI.

3. Physical activity level :Cultural and social factors can influence physical activity levels,

which can affect weight and body composition.Physical activity level has a significant

impact on the Body Mass Index (BMI) of children. Increased physical activity is

associated with lower BMI values and a reduced risk of obesity in children. Studies have

shown that engaging in regular physical activity helps to maintain a healthy weight,
 improve overall fitness, and reduce the likelihood of developing obesity-related health

issues.

Regular physical activity contributes to energy expenditure, which can help prevent excess

weight gain and promote weight loss when combined with a balanced diet. Physical activity also

plays a crucial role in improving metabolic health, enhancing cardiovascular fitness, and

supporting overall well-being in children.

Incorporating structured physical activity programs, such as school-based interventions that

include additional extracurricular activities or increased daily exercise time, has been shown to

be effective in reducing BMI and preventing obesity in school-aged children. These interventions

often lead to improvements in body composition, waist circumference, waist-to-height ratio, and

overall physical fitness levels among participants compared to control groups.

4. Age and general differences : Age and generational differences have a substantial impact

on the BMI of children. Research indicates that younger generations are being exposed to

an obesogenic environment from an earlier age compared to older generations. This early

exposure to factors contributing to obesity can lead to higher levels of obesity prevalence

at a younger age for children in these newer generations. However, despite this higher

and earlier exposure to obesity, studies have shown that younger generations do not

necessarily reach higher levels of BMI and obesity prevalence at midlife and beyond

compared to older generations.

The Doetinchem Cohort Study highlighted that while younger generations may experience

obesity at an earlier age, their BMI levels tend to plateau by midlife, showing convergence with
older generations. This unexpected observation suggests that there might be a population-specific

energy balance reached at this stage, influencing the BMI trends across different generations.

5. Ethnicity and race :BMI may not be suitable for all ethnic groups or races , as body

composition and fat distribution can vary. The disparities in obesity prevalence between

racial and ethnic groups can be partially explained by a number of behavioral and

socioeconomic risk factors. Studies have indicated that Asian children typically display

lower prevalence rates of obesity-related risk factors than African American children,

who typically have greater prevalence rates relative to other populations. The pace of

baby weight increase during the first nine months of life is a significant factor in the

discrepancy in BMI scores between white children and their minority counterparts. It has

been determined that this early weight increase is a strong predictor of BMI scores at

later times.

6. Gender roles and expectations :Gender norms play a significant role in shaping body

image ideals for children. Societal expectations regarding body size and appearance differ

based on gender. For instance, girls are often encouraged to strive for a thin body ideal,

while boys may face pressure to achieve a muscular or larger physique. These gender-

specific ideals can influence how children perceive their bodies and may impact their

attitudes towards weight management.

Gender norms can influence weight control behaviors in children. Research suggests that

adherence to traditional gender norms may lead to different approaches to weight management.

Girls who conform more closely to feminine norms, which may include the pursuit of thinness,

are more likely to engage in weight loss behaviors such as dieting or skipping meals. On the

other hand, boys who conform to masculine norms emphasizing size and strength may be
inclined towards weight gain strategies like consuming supplements or increasing food intake.

This behaviours affects the BMI accuracy of children.

7. Stigma and discrimination: Research has indicated that children and teenagers who

encounter stigma related to their weight frequently have negative mental health

outcomes, such as signs of anxiety, despair, and low self-worth. These unfavorable

feelings can trigger unhealthy coping strategies, including eating out of emotion, which

can add to weight gain and feed the cycle of discrimination and stigma.

Furthermore, the stigma associated with being overweight can make people less inclined

to adopt healthy habits and seek out the right medical care. Children who experience

weight stigma in medical settings, for example, may refuse treatment or show mistrust of

medical personnel, which can have a negative impact on their health. Weight-related

stigma and discrimination can impact mental and physical health, and may not be

8. accurately reflected in BMI.

2.4 ETHICAL AND LEGAL ISSUES ASSOCIATED WITH USING BMI

Ethical and Legal Issues Associated with Using BMI for Children

Body Mass Index (BMI) is a commonly used tool to assess weight status in both adults and

children. However, when it comes to using BMI specifically for children, there are several

ethical and legal considerations that need to be taken into account.

Ethical Concerns:
1.Stigmatization: One of the primary ethical concerns associated with using BMI for children is

the potential for stigmatization. Labeling a child as overweight or obese based solely on their

BMI score can have negative psychological effects on the child, leading to issues such as low

self-esteem and body image problems.

2.Inaccuracy: BMI does not differentiate between muscle mass and fat mass, which can lead to

misclassification of children who may be muscular but not necessarily overweight or obese. This

inaccuracy raises ethical questions about the validity of using BMI as the sole measure of a

child’s weight status.

3.Parental Pressure: Utilizing BMI to categorize children’s weight can also put undue pressure on

parents to take drastic measures to address their child’s weight, potentially leading to unhealthy

behaviors such as extreme dieting or excessive exercise.

4.Legal Considerations:

Privacy Concerns: In some cases, using BMI measurements in schools or healthcare settings may

raise privacy concerns regarding the collection and storage of sensitive health data about children

without proper consent or safeguards.

5.Discrimination: There is a risk of discrimination based on a child’s BMI status,

especially in educational settings where decisions about participation in physical

activities or access to certain programs may be influenced by a child’s weight

classification.

6.Parental Rights: Legal issues can arise when schools or healthcare providers use BMI

measurements without parental consent or fail to involve parents in discussions about their

child’s weight status and potential interventions.

(AMA J Ethics. 2023;25(7):E514-516.)

Physicians’ Ethical Responsibilities

American Medical Association (AMA) Code of Medical Ethics talked about Physicians Ethical

responsibilities, this association does not directly address the use of BMI, 4 opinions are

particularly relevant to considering the use of BMI in clinical encounters. Opinion 1, “Quality,”

states that physicians have an obligation “to ensure that the care patients receive is safe,

effective, patient centered, timely, efficient, and equitable” and that “physicians should actively

engage in efforts to improve the quality of health care” by, among other things, monitoring the

use of “quality improvement tools.”While this opinion does not bar the use of BMI, it does

suggest that physicians have a responsibility to ensure that its use is patient centered and

equitable and that its effectiveness as a quality improvement tool should be monitored.

Opinion 2, “Disparities in Health Care,” dictates that, beyond monitoring quality improvement

tools, physicians have a professional obligation to support “the development of quality measures

and resources to help reduce disparities.” This obligation has important bearings on the use of

BMI as a diagnostic tool , as it has become increasingly clear that the current general cut point of

30 to diagnose obesity should be personalized to account for differences in sex and

race/ethnicity. As Stanford et al note in their research aimed at redefining BMI risk thresholds for

metabolic disease: “When obesity is defined by a correlation with the presence of metabolic risk

factors, the BMI cutoffs to define oesity would change for specific race/ethnicity and sex

subgroups instead of [there being] a single BMI threshold.”

Opinion 3, “Physician Responsibilities to Colleagues With Illness, Disability or Impairment,”

states: “In carrying out their responsibilities to colleagues, patients, and the public, physicians

should strive to … eliminat[e] stigma within the profession regarding illness and

disability.”11 Because BMI is often treated as measurably bjective despite being a cultural

construct, and thus can unintentionally dehumanize patients,4 physicians have a responsibility to

minimize and try to eliminate the stigma of obesity that can be exacerbated by the use of BMI as

a diagnostic tool. Similarly, Opinion 4, “Patient Rights,” articulates that the patient-physician

relationship should be a collaborative and mutually respectful alliance that upholds the patient’s

right to “courtesy, respect, dignity, and timely, responsive attention to his or her

needs.” Physicians’ awareness of the ways that implicit bias and physician stigma against

patients withoverweight or obesity can impact patient outcomes is critical to ensuring a

respectful and dignified clinical encounter.( AMA J Ethics. 2023;25(7):E514-516.).

Apart from physicians responsibilities, parents also have their responsibilities which includes

their ;

1.Legal Responsibilities:

Parents have a legal responsibility to ensure the well-being and health of their children. When it

comes to using BMI (Body Mass Index) as a tool to assess a child’s weight status, parents should

be aware of the legal implications associated with this practice. In many jurisdictions, parents are

legally required to provide their children with proper nutrition, healthcare, and overall support

for their physical and mental development. Failing to address concerns related to a child’s weight

and health could potentially lead to legal consequences such as charges of neglect or

endangerment.
In some cases, schools may also play a role in monitoring students’ BMI as part of their wellness

programs. Parents should familiarize themselves with the laws and regulations in their region

regarding the collection and use of BMI .data in educational settings. It is essential for parents to

understand their rights in terms of consent and access to this information, as well as how it is

being utilized by schools or healthcare providers

2 .Ethical Responsibilities:

Beyond the legal obligations, parents also have ethical responsibilities when it comes to using

BMI for children. It is crucial for parents to approach discussions about weight and body image

with sensitivity and empathy. Using BMI as a sole indicator of health can be problematic, as it

does not account for factors like muscle mass, bone density, or overall fitness level.

Parents should focus on promoting healthy habits rather than solely focusing on weight numbers.

Encouraging balanced nutrition, regular physical activity, and positive body image can contribute

significantly to a child’s overall well-being. It is important for parents to avoid stigmatizing

language or behaviors that may negatively impact a child’s self-esteem or relationship with food

and exercise.

Additionally, respecting a child’s privacy and autonomy is essential when discussing sensitive

topics like weight. Parents should involve children in decision-making processes regarding their

health and well-being, fostering open communication and mutual respect.

In conclusion, while parents have legal obligations to ensure the health of their children, they

also bear ethical responsibilities when using BMI as a tool for assessing weight status. By

approaching this topic with care, understanding, and a focus on holistic well-being, parents can

support their children in developing healthy habits and positive self-image.( AAP, 2023 ).
2.5 IMPLICATIONS OF USING BMI TO ASSESS NUTRITIONAL STATUS OF CHILDREN.

Healtheffectsofoverweightandobesity.CentersforDiseaseC
ontrolandPrevention.ReviewedSeptember24,2022.Accesse
dNovember8,2022.
https://www.cdc.gov/healthyweight/effects/index.html

PhelanSM,BurgessDJ,YeazelMW,HellerstedtWL,GriffinJM,v
anRynM.
Impactofweightbiasandstigmaonqualityofcareandoutcome
sforpatientswithobesity. ObesRev. 2015;16(4):319-326.

ViewArticlePubMedGoogleScholar

FruhSM,NadglowskiJ,HallHR,DavisSL,CrookED,ZlomkeK.
Obesitystigmaandbias. JNursePract. 2016;12(7):425-432.

ViewArticlePubMedGoogleScholar

GutinI.
InBMIwetrust:reframingthebodymassindexasameasureofh
ealth. SocTheoryHealth. 2018;16(3):256-271.

ViewArticlePubMedGoogleScholar

NuttallFQ.
Bodymassindex:obesity,BMI,andhealth:acriticalreview.
NutrToday. 2015;50(3):117-128.

ViewArticlePubMedGoogleScholar
HumphreysS.
TheunethicaluseofBMIincontemporarygeneralpractice.
BrJGenPract. 2010;60(578):696-697.

ViewArticlePubMedGoogleScholar

Romero-CorralA,SomersVK,Sierra-JohnsonJ,etal.
Accuracyofbodymassindexindiagnosingobesityintheadultg
eneralpopulation. IntJObes(Lond). 2008;32(6):959-966.

ViewArticlePubMedGoogleScholar

StanfordFC,LeeM,HurC.Race,ethnicity,sexandobesity:isitti
metopersonalizethescale? MayoClinProc.2019;94(2):362-
369.

ViewArticlePubMedGoogleScholar
AmericanMedicalAssociation.Opinion1.1.6Quality.
CodeofMedicalEthics.AccessedJuly21,2022.
https://www.ama-assn.org/delivering-care/ethics/quality
AmericanMedicalAssociation.Opinion8.5Disparitiesinhealt
hcare. CodeofMedicalEthics.AccessedJuly21,2022.
https://www.ama-assn.org/delivering-care/ethics/disparitie
s-health-care
AmericanMedicalAssociation.Opinion9.3.2Physicianrespon
sibilitiestocolleagueswithillness,disabilityorimpairment.
CodeofMedicalEthics.AccessedJuly21,2022.
https://www.ama-assn.org/delivering-care/ethics/physician-
responsibilities-colleagues-illness-disability-or-impairment
AmericanMedicalAssociation.Opinion1.1.3Patientrights.
CodeofMedicalEthics.AccessedJuly25,2022.
https://www.ama-assn.org/delivering-care/ethics/patient-
rights
AmericanMedicalAssociation.Opinion11.2.1Professionalis
minhealthcaresystems.
CodeofMedicalEthics.AccessedJuly21,2022.
https://www.ama-assn.org/delivering-care/ethics/professio
nalism-health-care-systems
CITATION
AMAJEthics. 2023;25(7):E514-516.
DOI
10.1001/amajethics.2023.514.
CONFLICTOFINTERESTDISCLOSURE
Theauthor(s)hadnoconflictsofinteresttodisclose.
Theviewpointsexpressedinthisarticlearethoseoftheauthor(s)anddonotnecessarilyreflecttheviewsandpoliciesoftheAMA
.