When school boards fancy themselves health care providers

When school boards fancy themselves health care providers

I met Madelyn for the first time last month in clinic. Six months prior, she was an otherwise healthy 14-year-old girl. One afternoon, Madelyn’s phys ed teacher led a gym class aimed at completing fitness and health assessments on all of the children in the grade. One at a time, each child was asked to step up and onto a scale to measure weight.  Then height and abdominal girth were measured with a tape measure. Finally, body fat composition was measured using body fat calipers. The gym teacher would do a quick calculation and then state, out loud in front of all the children, each student’s body mass index and body fat composition results. Then, each student was required to perform a number of fitness challenges to assess strength, endurance, flexibility, etc.  At the end of the class, reports were handed out to each student with a list of specific goals for improving overall fitness and health. The children were then dismissed.

The students scrambled out of the gym and then formed a huddle frenetically comparing each others’ results. Madelyn (ordinarily a private and reserved child), caught up in the moment, shared her results and compared with the others. Realizing that her BMI was above average, and noting how many of her peers were thinner than she, Madelyn felt a sudden and overwhelming wave of anxiety, shame, and self-loathing.  She ran to the bathroom, locked herself in a stall and cried as she looked carefully at the information and health recommendations on her card.

Your BMI score puts you in the “overweight” category, approximately 1 kg away from “obese.”  To achieve a healthier weight, it is recommended that you lose at least 6 kilos.  You can achieve this by exercising more each day and choosing lower calorie food options (fruits and vegetables) instead of high calorie options (fatty meats, fried foods, and items with added sugar).

6 months later, I met Madelyn for the first time: severely malnourished, dehydrated, in cardiovascular shock and in need of an emergency hospital admission to save her life.

It turns out that Madelyn took strongly to heart the recommendations she read that day on her fitnessgram. Within a few weeks, Madelyn was skipping breakfast, eating only salad for lunch, and asking her mom to cook carb and fat-free meals for dinner.  Up at 4:30 a.m. every morning, she completed two hours of cardio on the basement treadmill before walking 3 miles to school.  At recess, she got special permission from the gym teacher to work out: 200 sit-ups, 100 push-ups, 200 squats.  She walked home briskly in the hopes of arriving early enough to complete another hour of cardio before dinner. After dinner, she felt overwhelming shame for eating too much and, if no one was around, she’d force herself to vomit whatever dinner remnants might still be in her stomach not yet digested. If she wasn’t able to vomit that night, she counted the calories digested, converted them to minutes of cardio and woke up that much earlier the next morning to make them up.

The weight melted off and the more she lost the more driven she was to lose more. By the time I met her, Madelyn was 25 kilos (55 lbs) and barely alive.

Unfortunately, eating disorders programs across North America regularly care for patients with stories shockingly similar to Madelyn’s.  Often children presenting with eating disorders report life events that trigger their illness.  All too often these triggers turn out to be some form of irresponsible health message coming from school health and fitness program.  Health professionals in the eating disorders community would corroborate this as do some small-scale scientific papers.

Children (along with their parents) should discuss the health implications of parameters like body weight, body height, and body fat composition with credentialed and competent health care practitioners, not with school educators in gymnastics classes.  Sorting out health issues relating to weight and body shape can be complex, challenging and high-risk, especially for young adolescents. Gym teachers, school principles, and class teachers simply do not have the training, experience nor expertise to assess and manage these medical problems.

I am troubled by the growing trend of health and fitness assessment programs, similar to what Madelyn experienced, that are rolling out across the United States.  “Fitnessgrams” are being handed out to children in IowaTexasGeorgiaNew York and many other states. Amazingly, though school boards across America are avidly embracing this Fitnassgram model for health and fitness education in schools, there remains absolutely no evidence, whatsoever, that these programs are doing anything to help improve the health and well being of students.  The real risks, I fear, far outweigh the theoretical benefits.

For Madelyn’s sake, and for the sake of the other vulnerable adolescents like her, let’s leave childhood education to our educators and health care provision to our doctors and nurses.

After 1 month in hospital, Madelyn has gained back 5 kilograms, stabilized her condition and looks forward to discharge from hospital, hopefully in the next 2-3 weeks.  But only then starts what is likely to be a long and tedious battle to overcome her anorexia and earn back the life that she lost.

Dan Flanders is a pediatrician in Toronto, Ontario, Canada, and can be reached on Twitter @drflanders.

Image credit: Shutterstock.com

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  • buzzkillerjsmith

    When a kid gets cachexia, it’s kindasorta time to seek medical care. The kid in the picture is obviously cachectic. A 55 lb wt loss can be caused by cancer. Teachers know this, some guy standing at the bus stop would know this.

  • http://kindercarepediatrics.ca Dr. Daniel Flanders

    Srk –

    That’s a very good question. I have a unique perspective in that I work with both a pediatric obesity and a a pediatric eating disorders population. In the obesity treatment paradigm, we rarely hear of this story. In eating disorders clinic, I’d estimate that inappropriate messaging from schools is (at least a substantial part of) the trigger more than 10% of the time.

    If you speak with professionals who work regularly with children who have eating disorders, you’ll most likely discover that this is a very common story.

    Regarding your second point, there is a difference between health promotion or education and healthcare provision. Measuring bodies and giving child-specific health advice is healthcare provision which should not come from educators.

  • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

    Hmm, childhood obesity is also a massive public problem. It is truly unfortunate that Madalyn in this case developed anorexia nervosa, but I wonder for every Madalyn, how many students took their cards home, and worked with their parents to drop their weight into a healthy range?

    To draw an analogy for lay readers, for every elderly patient we give warfarin on, a certain number will be protected from developing a stroke. On the other hand, a certain number of those patients will experience a fatal GI bleed. A panel of scientific experts assesses the numbers, and determined that it is beneficial in most cases to give warfarin.

    Everything in healthcare has risks and benefits- is there any data on if these Fitnessgrams work to reduce childhood obesity? I wonder if we can do some extrapolation to determine the relative costs and benefits of this program…

    Respectfully,
    Vamsi Aribindi

    • http://kindercarepediatrics.ca Dr. Daniel Flanders

      Unfortunately, there is no evidence, whatsoever, that the fitnessgram programs are doing anything to improve the health or well-being of children. It is a completely non-evidence-based intervention. Your warfarin example works because there is decent quality research behind the recommendations taking into into consideration the risks and benefits. In a situation where the benefits of an intervention, like fitnessgram, are completely unknown (and risks are possible/probable) then, in my opinion, the implementation of said intervention is ethically problematic.

      • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

        Dr. Flanders,

        What are the evidence-based treatments for childhood obesity? You would know better than I, but it is my understanding that the only EBM treatment for obesity is amphetamines (or surgery in extreme cases), neither of which I imagine are appropriate in the peds population. In light of the growing public health crisis of obesity, which clearly is not being adequately addressed by medicine, can we really blame school districts for trying anything they can think of?

        Perhaps the answer here is modification: all results should be given privately, and the info must be accompanied by advice on healthy eating habits.

        Barring that, we should collect evidence of an increased rate of eating disorders at age 18 in these districts compared to districts without. I imagine it wouldn’t be too difficult to run a case control study from your patients alone-

        Respectfully,
        Vamsi Aribindi

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          We should not be experimenting on kids without consent, so your last suggestion is problematic.

          As to the school districts trying anything they can think of, how about quit thinking so much and try the things that used to be the norm before the “obesity epidemic”?
          How about just sticking with healthy foods in the cafeteria, one hour of gym every day, enough recess, properly maintained playgrounds, maybe some nutrition classes, and have a robust offering of after school sports…
          There really is no need for a gym teacher to play doctor and cause utter mortification for this or that individual child, and unless you have experience being a 14 year old girl, you have no idea what this means….

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Ma’am,

            A case control study by definition is a retrospective study- not prospective. You generally don’t need consent for it, since all the data is already collected and treatment has already been done. It does need to go through an IRB, but it would likely fall under exempt or expedited, since there is literally no variation in patient treatment involved. All that needs to be done is correlating the home addresses of the children with a school district, and then determining whether or not that district has a program such as this.

            Ironically, the school district is actually on safer ethical grounds by not running any study at all before they put this program in place. It may go against common sense, but actions taken solely for treatment/the benefit of the patients and not for any scientific reason are given much more latitude. Think about the oncologist who wants to try some crazy new drug as fourth line chemotherapy- if the patient isn’t involved in a trial, that oncologist doesn’t need any go-ahead. It’s only if they’re in a research protocol that the oncologist has to go through IRB procedures. Of course, insurance company payment is another matter.

            I may not have been a 14 year old girl, but I believe I have gone through middle and high school more recently than you. I’m afraid the ideal you describe is not coming back.. School districts have watched as their kids’ weights have ballooned. Many of them are prohibited by federal law from changing what they offer for lunch, courtesy of Food Industry Lobbying. (If you think tomato sauce on pizzas counting as vegetables is bad, just wait till you read the rest of it). An hour for gym is a dream in the era of a teacher’s pay and a school’s survival being determined by standardized test scores. After school sports would be nice if any of the inner-city school districts had any funding to actually keep the building open past 3PM- and participating in sports is contingent upon a high enough GPA- meaning many of the socioeconomically disadvantaged kids who could benefit from the physical activity are ruled ineligible. If we think doctors have it bad these days, we should look at teachers for an example of how much worse it can get. And for that matter, everything done inside a school is useless if the kids are eating McDonald’s for breakfast and dinner.

            The personality traits that underlie anorexia and bulimia are formed before a weight report goes home. Who’s to say that this child would not have been triggered by a magazine, by a friend’s errant comment, by a bully’s sneer in the hallway, or a thousand other things?

            All I’m asking for is some data before we use our public respect and authority as doctors to come out against something. Nutrition and exercise are some of the topics that medicine has incredibly little scientific data on. Dr. Flander’s work with obese children is commendable- but there are clearly not enough of him to go around, and this problem has been getting worse not better.

            There was a time when Doctors with all the power and majesty of medicine and science behind them declared that the best diet is lo-fat. Fast forward a decade or two, and now lo-carb the new watchword. We do not have a good track record of guiding our country’s nutrition and diet policies. Before we knock something someone else is doing, how about we make sure that doing nothing is actually better than what they’re trying?

            Respectfully,
            Vamsi Aribindi

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I seriously doubt that we can discuss treatments and patients and IRBs when we refer to a gym teacher engaging in something that he or she is not even remotely qualified to engage in. If something like this occurred in a school around here, there would have been a dozen irate parents calling the principal within 24 hours, and the teacher would have most likely been fired.

            I also find it strange that we are perfectly content to describe the calamities in our education system and in our communities, and accept them as facts that cannot be changed. Therefore the only solution left is to publicly measure the kids and bully them into some sort of “personal responsibility” thing, which seems to be all the rage now.

            I would also think that one should ask for data before an intervention is undertaken, not after, particularly if incidents like the one described here are already documented. And, by the way, this is not about nutrition and exercise being right or wrong. This is about an adult with no clinical training disregarding the privacy of minors and engaging in activities that have the potential to harm children. And if you are saving your “public respect and authority” for something else, than so be it. I am glad Dr. Flanders is not.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Ma’am,

            I’m not “saving” our public respect and authority for anything. I’m just trying to ensure that we use it in the best manner.

            For that to happen, there is only one question we need to conclusively answer.

            Are these programs actually harmful?

            I’ve brought it up three times now, but you haven’t responded to it. Is there any evidence that if this school program wasn’t there, girls like Madalyn would NOT be triggered by other societal influences?

            If we establish that the answer is yes, these programs independently cause a rise in eating disorders and harm our children’s mental health, then I would be more than willing to protest and advocate against these programs alongside anyone.

            You point out that the gym teacher here publicly bullied the kids. And that’s certainly true in this case. But is that what most schools do? I remember going through something similar- and my numbers of sit-ups and push-ups and mile time were public- but no more so than my performance in any gym activity (which sucked- I’ve always been more on the couch potato side of things).

            But my body-fat percentage and weight were given to me privately behind closed doors- and the results were mailed home if I recall. Just like we shouldn’t judge the benefit of vaccines on the efforts of a worker who re-uses needles, there may be programs who do this with more tact and sensitivity that we ought to consider.

            I am not here to argue for personal responsibility, mental health and happiness be damned. If I was, I would say that we should leave all matters of fitness to parents, and get schools out of the equation entirely. I believe in public health interventions and I believe in giving the benefit of the doubt to the men and women in the arena- trying to do something rather than sit on the sidelines and offering nothing better while we condemn kids to a lifetime of obesity, hypertension, diabetes, and hypercholesterolemia.

            What the school district did in chis case is horrible- but it certainly doesn’t match my experience.

            Respectfully,
            Vamsi Aribindi

          • http://kindercarepediatrics.ca Dr. Daniel Flanders

            2 comments come to mind as I read this:

            1. What about “At first do no harm?”

            2. Imagine a community where suddenly there was big shortage of pilots. Desperate to solve the problem, and with very good intentions, the community leaders decide to mandate plumbers to fly the planes. Every so often, a plumber-pilot screws up and crashes the plane killing a few hundred people. Not a good solution, but at least everyone was trying REALLY hard to solve the problem.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Dr. Flanders,

            I should have clarified earlier- I believe that what the gym teacher did in this case is very wrong. But, I’m judging these programs off of my own experiences 6-10 years ago- where results were not shared publicly but rather mailed home, and no one was humiliated any more than when we all played sports together or went for a run and saw who finished last.

            I have no objection to condemning this particular program. Have you tried contacting Madalyn’s school district, sharing several (anonymized) stories, and asking them to change their policies at least vis-a-vis public reporting of fitnessgram results?

            In terms of “Do No Harm”, Gym teachers may not have much evidence behind these Fitnessgrams. But what I’m hearing you say is that you don’t have too much evidence that what you’re doing is helping either. Obviously, you help kids every day- you see it with your own eyes. But you can’t scientifically take credit for that any more than the gym teacher who says, “I had a chubby kid in 6th grade, and by 8th grade they were athletic. That was us administering the Fitnessgram and showing them they had a problem”. I know the latter is a ridiculous claim, but it’s what the defenders of this program can and will say.

            This may change (and I hope it does), if your CANPWR study bears fruit, but for now these gym teachers, who presumably are experts at fitness and exercise are not provably less qualified than doctors.

            As I said- if you can establish evidence that shows that even those fitnessgram programs that display some basic understanding of 14-year-old psychology and send results home privately are hurting their kids, than I would be more than happy to advocate alongside you.

            Respectfully,
            Vamsi Aribindi

          • http://kindercarepediatrics.ca Dr. Daniel Flanders

            As I mentioned to another commenter, it takes more than just good intentions to provide competent health care.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            In which case, we don’t really have an argument. I am not disagreeing with gym teachers making you do gym stuff, including measuring performance on gym things, giving out trophies for the fastest, the strongest, most improved, or whatever.
            I am uncomfortable with measuring little girls for fatness in public. There may not be any research on the effects of this on obesity, but I am pretty sure there is plenty of research on the effects of labeling, and shaming kids because of physical appearance, and that research is pertinent here.
            If you are saying that the school shouldn’t have done that, then I misunderstood your argument.

          • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

            Ma’am,

            No, I think I’m at fault- I read back and checked, and realized that I never actually stated clearly that what the gym teacher did was wrong. I figured it was assumed but I should have made it clear I consider what he did to be unacceptable; and that I was judging these programs off of my own memories of being the chubby kid in middle school and going through similar, but perhaps more well thought-out programs. My apologies.

            Respectfully,
            Vamsi Aribindi

        • http://kindercarepediatrics.ca Dr. Daniel Flanders

          Best practice guidelines for treatment of pediatric obesity vary tremendously depending on the organization – as you know it takes a long time for research to translate into evidence-based care. We’re in early days. Our group is part of a large-multi-center study (CANPWR) aiming to better understand what works and what doesn’t in pediatric obesity managemen; see http://www.drsharma.ca/canadians-embark-on-landmark-study-on-managing-childhood-obesity.html

          Generally speaking, best care should probably focus on improving (as needed) 4 domains of the child’s life: nutrition, physical fitness, psychological wellness, and medical complications/comorbid conditions. A proper program would be multidisciplinary and include at least one mental health expert, physical fitness expert, nutrition expert, and physician.

      • RuralEMdoc

        “There is no evidence that ……….. improve outcomes” is the biggest cop out I hear on a regular basis.

        Translated: “I don’t like it”

        Kids are fat in this country. Adults are fat. Half of the fat adults are obese. Fat kids become obese adults.

        Any child that develops an eating disorder is a tragedy, but to aimlessly blame a school program that is trying to increase public awareness of our countries horrible lifestyle choices is weak.

        Especially when your main argument is the tried, tested, and overused phrase “There is no evidence to show this works…blah blah blah”

        Yawn

        • http://kindercarepediatrics.ca Dr. Daniel Flanders

          As I’m sure you know, it takes way more than good intentions to deliver proper medical care. Presumably you wouldn’t consider it a good idea to have a carpenter provide emergency care to patients in the ED.

        • JR DNR

          We do have a study that shows that telling girls that they are overweight makes them MORE overweight.

          http://newsroom.ucla.edu/releases/simply-being-called-fat-makes-young-girls-more-likely-to-become-obese

          • chaplaindl

            I had an experience along those lines when I was 10 or 11. My father took me aside after dinner and told me that I needed to be careful because, like him, I was likely to put on weight easily. I wondered what had brought that on (but didn’t ask – military family). I tried to remember what I had eaten for dinner and whether I had asked for seconds. I couldn’t remember. That may have been the last time I could not remember exactly what I had eaten at a meal.

            I was healthy and not overweight when that conversation occurred (I have photos), but I became very self-conscious and conscious of what I ate. I ultimately did become overweight and have struggled throughout my life with obesity. I didn’t attribute any of this to the conversation at the time; I could only remember in hindsight the coincidence between how old I was when that conversation occurred and how old I was when I became weight conscious.

            I imagine there were other things in the background that influenced my sensitivity to that conversation, such as overhearing other conversations among adults about weight and being overweight. That particular conversation directed at me and about my body was the one that tipped the balance toward diminished health.

            During the many periods in my life when I have been overweight, it has never been helpful for someone else to tell me that I was. I already knew, and have regularly gotten good advice and support from healthcare professionals when I could benefit from it. (Fortunately I have a sensitive and diplomatic primary care physician who knows how to begin a conversation about this in a way that elicits partnership rather than shame.)

            I’m grateful that I never had to experience having some random authority figure trying to “help” me in the way some of those who have written comments have. There are enough other mean and judgmental people in the world who do plenty of damage in that way, without a teacher adding public shaming.

    • JR DNR

      Actually – there is a study that shows this method doesn’t work and has the opposite effect. Telling girls that they are overweight makes them MORE overweight.

      http://newsroom.ucla.edu/releases/simply-being-called-fat-makes-young-girls-more-likely-to-become-obese

  • http://kindercarepediatrics.ca Dr. Daniel Flanders

    In the vast majority of cases, the treatment for childhood obesity is not weight-loss; it is lifestyle improvement and normalization of eating. Except for cases of extreme obesity, telling a child to loose weight is inappropriate and, indeed, may be triggering. Most doctors who look after children are sensitive to this. Those docs who are not tuned into this risk can also do harm.

  • http://kindercarepediatrics.ca Dr. Daniel Flanders

    That’s a very good question. I have a unique perspective in that I work with both a pediatric obesity and a a pediatric eating disorders population. In the obesity treatment paradigm, we rarely hear of this story. In eating disorders clinic, I’d estimate that inappropriate messaging from schools is (at least a substantial part of) the trigger more than 10% of the time.

    If you speak with professionals who work regularly with children who have eating disorders, you’ll most likely discover that this is a very common story.

    Regarding your second point, there is a difference between health promotion or education and healthcare provision. Measuring bodies and giving child-specific health advice is healthcare provision which should not come from educators.

  • guest

    This is what happens when the public sector cheaps out and tries to address a public health issue without paying for it. Unfunded mandates are an increasingly popular way for our government to try and get things done.

    Making PE teachers carve time out of their teaching schedule to complete “wellness assessments” that really should be conducted privately by a school nurse (except that schools don’t have those any more due to funding cuts) is just asking for the assessments to be done in an unprofessional manner, since the PE teacher is not a healthcare provider.

    • Ed

      A typical educator and/or medical provider generalization blaming the problem on either the
      student, patient, or taxpayer. As a nation, we spend more on education and healthcare yet we rank well below in virtually all measurable statistics. And your presumption that a “school nurse” would administer “wellness assessments” privately is laughable. Finally, I’m well aware that PE teachers are not providers; my comment was directed to provider remarks.

  • Thomas D Guastavino

    My wife was a part time school nurse for 12 years. Part of her job was to do the heights and weights for the BMI calculations and send out the letters to the caregivers. Here is a percentage breakdown of the reactions:
    1) Number of students that lost weight: 1%
    2) Number of students that gained weight : 8%
    3) Confused caregivers asking why the letters were sent: 25%
    4) Caregivers complaining about wasted taxpayers money: 12%
    5) Returned letters: 5%
    6) Insulted caregivers: 5%
    7) No reaction: about half
    At least my wife got paid for doing this.

    • http://kindercarepediatrics.ca Dr. Daniel Flanders

      interesting. Thanks for sharing!

    • buzzkillerjsmith

      What genius gave her this task? The guy on the school board who owns the local fitness center?

  • LeoHolmMD

    How is trolling child biometrics and releasing them into the hands of minors not a HIPAA violation? Is there parental consent for this?

    • T H

      This was done in Canada: no HIPAA.

      • http://kindercarepediatrics.ca Dr. Daniel Flanders

        Very similar privacy legislation in Canada. I hear this story over and over again in the US as well.

        • T H

          Good to know. Thank you.

  • Wendy Belgard Hanawalt

    So glad you wrote this article. The same thing happened to me 50 years ago in gym class, where my gym teacher read out my weight IN FRONT OF THE ENTIRE GRADE SEVEN SCHOOL and said “Wendy, you need to lose weight.” Most humiliating day of my life up until then and for a good while after. I coped with it by going home and eating everything within a 20 mile radius.

    • http://kindercarepediatrics.ca Dr. Daniel Flanders

      Thank you for sharing this! It is so very important to point out that these fat-shaming policies and practices harm in more ways than one.

      • RenegadeRN

        Yes they do, and I cannot imagine any adult, let alone one involved in child education, thinking public weighing and measuring is ok.

  • RenegadeRN

    Ahh you just hit on a thought I was having reading this whole thread… Weight naturally fluctuates with age in children! Like kids getting a little heavier around 8-10, before the adolescent hormonal shift and attendant growth spurt. I went thru that, so did my daughter. If a child gets caught having a “fitness gram” during one of these it improperly skews their probable trajectory, IMHO.

    And don’t even get me started on the holy grail that is the damned BMI! It makes me furious that it has become THE measurement, used by everyone from HCP to insurance companies (BMI = amt of premium you pay ) and it is NOT a very accurate measure of health! I’m not saying it isn’t a decent marker if used in context with other markers- but those other, more valuable markers are never done. Too much weight (yes, pun intended ) placed on this one number/ marker.

    • querywoman

      Something is rotten in the state of American health care! It’s currently a medicine of numbers!

  • http://kindercarepediatrics.ca Dr. Daniel Flanders

    Thanks for sharing this. Wow! A centrifuge!! That’s really, really sad.

  • http://kindercarepediatrics.ca Dr. Daniel Flanders

    I agree with you. Although it is fairly common for mental and physical health issues to go unnoticed in large schools. Also, sometimes schools do notice and try to help, but they hit a brick well when raising their concern to parents in denial.

  • http://kindercarepediatrics.ca Dr. Daniel Flanders

    Another interesting take on this problem: High School Gym Class Horror Story Demonstrates Risk of “Energy Balance” http://www.weightymatters.ca/2014/07/high-school-gym-class-horror-story.html?m=1

  • querywoman

    Ellen Swallow Richards started the American national school lunch program about a century ago. The routine weighing of school children is associated with that.
    She had to decide what to feed school children and also used height and weight to measure the effectiveness of the program. Of course, this resulted in many children being classified as too thin or too fat.
    Perhaps her program also led to the standardization of American diet, compiling a diet that would be imposed on many people regardless of their cultural and ethnic backgrounds.
    Children who are now in public school would have once worked in the fields, especially after reaching age 13 or 14. Do we want teenagers doing hard, manual labor, or shackled to desks, getting a little rounder, as teenagers?
    Many teenagers don’t like being shackled to school desks, but that’s another problem.
    The public shaming of children should stop. I also saw a scale in the lobby of a public women’s health clinic once.
    As longevity continues to climb in the US, the naysaying about our weight intensifies.
    All weight loss programs fail 97% of the time! Michelle Obama tried to force her ideas of nutrition on our school children, and they wouldn’t eat it.

  • querywoman

    Madelyn is lucky to have survived!

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