No. 4, October 2006
Body Mass Index and Blood Pressure Screening in a Rural Public School
System: the Healthy Kids Project
William E. Moore, PhD, Aietah Stephens, MS, Terry Wilson, MHR, Wesley
Wilson, MHR, June E. Eichner, PhD
Suggested citation for this article: Moore WE, Stephens A,
Wilson T, Wilson W, Eichner JE. Body mass index and blood pressure screening in a rural public
school system: the Healthy Kids Project. Prev Chronic Dis [serial online] 2006
Oct [date cited]. Available from: http://www.cdc.gov/pcd/issues/2006/
All students (N = 2053) in Anadarko public schools, grades kindergarten through 12, were invited to be screened for height, weight, and blood pressure to assess the health status of this multiracial, multiethnic (American Indian, white, African American, and Hispanic) population in southwestern Oklahoma.
Centers for Disease Control and Prevention’s 2000 growth charts were used to determine body mass index (BMI) percentiles, and standards from the National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents were used to assess blood pressure.
Seven hundred sixty-nine students with active consent participated in the
screening. Of these, approximately 28% were overweight. American Indians were
at significantly greater risk of being overweight or at risk for overweight
than whites (relative risk [RR], 1.4; 95% confidence interval [CI], 1.1–1.7) as
were African Americans (RR, 1.5; 95% CI, 1.1–2.0), whereas Hispanics (RR,
1.3; 95% CI, 0.9–2.0) did not have a statistically significant increased
risk compared with whites. BMI at or above the 95th percentile was strongly associated with
elevated blood pressure (≥90th percentile) (RR, 3.8; 95% CI, 2.6–5.4).
Students who participated in this BMI screening in the Anadarko public
school system evidenced high rates of excess weight, with American Indians and
African Americans at greatest risk. Elevated BMI was strongly
associated with elevated blood pressure.
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The Healthy Kids Project is an ongoing height, weight, and blood pressure
screening project in the Anadarko, Okla, public school system. The project
originated from discussions about health issues at a quarterly meeting of the
University of Oklahoma Prevention Research Center’s (OUPRC’s) Community
Advisory Board (CAB). A member of the CAB commented that while examining
children in her role as a nurse for the public schools, she noticed many
overweight children with acanthosis nigricans, defined in The Merck
Manual of Diagnosis and Therapy as “a velvety hyperpigmentation on the
neck, axillae, and groin” that “is probably the skin manifestation of
severe and chronic hyperinsulinemia” (1). She also suspected that many
children might be hypertensive based on blood pressure readings of children
she examined for routine health problems. A collaboration
among the CAB, OUPRC, and the Anadarko public schools was established to
investigate these observations. A plan was implemented to offer screening to
all children in the Anadarko public schools to determine the prevalence of
overweight and elevated blood pressure. The group decided that the
results of this screening should be presented to the administration of the
school system to be used in policy decisions related to children’s health in
the district and that individual results would be given to parents of students who participated in the screening.
The United States has experienced an epidemic increase in the prevalence of
adult obesity in the past decade (2-4). The 1999–2000 National Health and Nutrition
Examination Survey estimates that approximately 64.5% of adults are overweight
(body mass index [BMI] ≥25 kg/m2) and that approximately
30.5% are obese (BMI ≥30 kg/m2) (5). Children and adolescents
have not been spared; the survey indicates that approximately 15.3% of
children and 15.5% of adolescents are
overweight (BMI ≥95th percentile for age and sex) (5). Analysis of data
from the National Longitudinal Survey of Youth shows that some racial groups
and geographic areas have even higher prevalence rates of overweight.
Hispanic (21.8%) and African American (21.5%) youths had appreciably higher
rates than non-Hispanic white (12.3%) youths, and the southern states had the
highest prevalence (17.1%) among geographic regions (6). Recent results of the
screening of all public school children in Arkansas (21% overweight) and
surveys in Texas (20%–21% overweight) also indicate a higher prevalence of
overweight in these states (7-9). Although there are many studies from
different geographic areas indicating that American Indian children have a
greater prevalence of obesity than white children, national data with an
appropriate sample do not exist (4,10).
Given the increases in weight for height and age, accompanying blood
pressure elevations may be expected. A recent investigation of public school
students aged 10 to 19 years in Houston, Tex, demonstrated that hypertension is
associated with excess weight and that the prevalence of hypertension may be
increasing. However, this study did not include children aged 5 to 9 years or
American Indians (8).
Recent increases in childhood and adolescent obesity have paralleled
large increases in childhood and adolescent type 2 diabetes (11-13). This
increase portends possible increases in other chronic conditions associated
with childhood and adolescent obesity, such as asthma, sleep apnea, and
gallbladder disease (11). The importance of stopping the epidemic of childhood
obesity also stems from the association of obesity with adult cardiovascular
disease (CVD) and type 2 diabetes. Obesity is a risk factor for both diseases.
There is evidence that overweight children become overweight
adults, and this association becomes stronger the longer obesity persists
during childhood. This association suggests that obesity among children is a long-term risk factor
and may indicate earlier onset
of adult disease (14-17). Being overweight as an adult is also associated with
elevated blood pressure, and there are several reports that hypertension is
increasing among American Indian adults in the Southwest (18-23).
Other CVD risk factors also cluster with obesity in children. The Bogalusa
Heart Study showed strong positive associations between BMI, blood pressure,
and low-density lipoprotein cholesterol (LDL-C) and showed a negative association
between BMI and high-density lipoprotein cholesterol (HDL-C) (24).
The Anadarko School District provides an exceptional opportunity to examine
the relationship between
weight and blood pressure status among American Indian, white, Hispanic, and
African American students living in the same rural community. This
investigation can generate data of broad scientific interest while also
providing much needed information for the school district, students, and
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The Anadarko School District, in southwestern Oklahoma, has a total population of
9370. The 2000 U.S. Census, using mutually exclusive racial and ethnic
categories, indicates that 41.9% percent of respondents identified
themselves as white, 37.9% as American Indian, 5.3% as African American, 0.2%
as Asian, 6.3% as multiracial, and 8.4% as Hispanic or Latino. The school-aged
population (5–19 years) represented 40.3% of the American Indian population
and 19.3% of the white population (25). The median 1999 household income in
the school district was $26,540, approximately 79% of the Oklahoma median and
63% of the U.S. median (26). American Indian, African American, and
Hispanic households had 83%, 86%, and 74%, respectively, of the income of
white households (25).
The Anadarko public school system
The public school system consists of six schools: three elementary schools
(one for kindergarten and first grade, one for second and third grades, and one
for fourth and fifth grades), one middle school (sixth through eighth grades),
one high school (ninth through twelfth grades), and one alternative high
school. Approximately 2053 students were enrolled during the 2001 to 2002
school year. The racial and ethnic composition of the student body was 60.5%
American Indian, 28.8% white, 4.8% African American, and 5.8% Hispanic or
Latino. Girls comprised 49.4% of the student body and boys 50.6%.
Seventy-seven percent of the students were eligible for free or reduced-price
lunches in 2001, 1.58 times the Oklahoma average (27).
We recruited participants from the Anadarko student population during the annual
enrollment day for the 2001 to 2002 school year. A
recruitment letter and consent/assent form were included in the enrollment
package that each parent or guardian is required to pick up and complete
before the start of each school year. Students were also recruited through
distribution of the letter and form at each school while screening was
being conducted. We returned to each school until all those with
consent/assent forms were screened or we were notified that they had moved.
Active parental or guardian consent and child assent were obtained in accordance with the project protocol
approved by the University of Oklahoma’s Health Sciences Center
Institutional Review Board. Data were collected on 769 students.
Height was measured to the nearest 0.1 centimeter using a SECA Road Rod
stadiometer, and weight was measured to the nearest 0.1 kilogram using a SECA
770 digital scale (SECA Corp, Hanover, Md). Both height and weight were
measured with shoes, coats, and other heavy outerwear removed.
BMI was calculated as weight in kilograms divided by height in meters squared.
One investigator measured the height and weight of approximately 85% of the
participants, and all field measurements were obtained by individuals trained
and supervised by this investigator. BMI and sex- and age-specific BMI
percentiles were calculated using the Centers for Disease Control and
Prevention’s (CDC’s) Epi Info software and its 2000 growth chart
database (28). The BMI percentiles were stratified into sex- and age-specific
classifications based on CDC’s 2000 growth charts as follows: underweight
(<5th percentile), normal weight (≥5th percentile but <85th percentile), at risk of
overweight (≥85th percentile but <95th percentile), and overweight (≥95th
Blood pressure was categorized according to the classifications described
by the 1996 National High Blood Pressure Education Program Working Group on
Hypertension Control in Children and Adolescents Report (29). The
classifications are defined according to the following age, sex, and height
specific blood pressure percentiles from normative tables based on one blood
pressure measurement: normal (systolic and diastolic blood pressure <90th
percentile), high normal (systolic or diastolic ≥90th percentile but
<95th percentile), and hypertensive (systolic or diastolic ≥95th
percentile). Classification is based on the highest categorization of
either systolic or diastolic blood pressure. The report also states that a
diagnosis of hypertension should be based on the average of at least two
measurements per measurement occasion on at least three separate occasions
over weeks or months and that a mercury sphygmomanometer should be used. It is
inferred that an assessment of normal blood pressure requires only one
Blood pressure was measured using an Omron HEM-907 IntelliSense (Omron
Healthcare, Inc, Vernon Hills, Ill) electronic digital blood pressure monitor
with appropriately sized cuff. Blood pressure measurement began after the
student sat quietly for 3 minutes. This measurement was recorded. For
participants younger than 18 years, age-, sex-, and height-specific tables for
the 90th (high normal) and 95th (hypertensive) percentile systolic and
diastolic blood pressures were consulted to determine blood pressure
classification (29). Students were considered to have elevated blood pressure
if their systolic or diastolic blood pressure was in at least the 90th
percentile. If the student’s systolic and diastolic blood pressure were
normal, blood pressure was recorded, and the student’s blood pressure
measurement was concluded. However, the blood pressure was retaken after 1
minute if the first measurement was elevated. The process was repeated one
more time if the blood pressure remained elevated. Some elevated blood
pressures were missed during the process of examining blood pressure tables in
a field setting; however, these individuals were retested in a subsequent
session. If the blood pressure was elevated for consecutive
measurements, the student’s blood pressure was remeasured at least 2 weeks
later. If this measurement also revealed consecutive elevated blood pressure,
the student was scheduled for a third and final blood pressure assessment. The
names of students whose blood pressure remained elevated on three
separate measurement occasions were given to school nurses for follow-up. Blood pressure
for these students was measured in the privacy of the nurse’s office using a mercury
This blood pressure screening protocol was designed to
increase test specificity by reducing false positives while maintaining
sensitivity for referral. It was also designed to allow a practical and
sustainable workload that could be continued annually with limited resources.
The protocol was designed to investigate the relationship between
weight status and blood pressure, not to determine the prevalence of
hypertension. Racial and ethnic classification and date of birth were based on
self-report and verified with school records for all elementary school
Stata version 8.2 (StataCorp LP, College Station, Tex) was used to perform
descriptive and inferential statistical analyses. Binomial regression models
were generated to explore the associations between weight status and racial
and ethnic classification and the relationship between weight status and blood
pressure. To ensure that minimal residual confounding existed, we adjusted
these models for age and sex. Ninety-five percent confidence intervals (CIs)
were generated for all risk ratio estimates. Because of the difficulty in
reconciling the child and adolescent blood pressure classification standards
with those for adults (18 years and older), blood pressure analyses were
performed only on students younger than 18 years (n = 745). Blood pressure
classification for each measurement occasion was based on the last blood
pressure measurement taken.
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We screened 769 (37.5%) of 2053 students in the school system for height
and weight. All but two students were also screened for blood pressure. The
elementary school response rate was 50.8% (517/1017), the middle school
response rate was 28.3% (140/494), and the high school response rate was 20.7%
(112/542). There was a significant linear trend of decreasing
participation with increasing grade level (Cochran-Armitage trend test, P
< .001). Of the participants, 62.4% were American Indian, 27.3% were white,
6.0% were African American, and 4.3% were Hispanic. One Asian student also
participated but was excluded from further analyses. The overall response rate
by racial and ethnic classification did not differ significantly from the
expected distribution (χ2 goodness-of-fit test,
χ23 = 6.3,
P = .10). This lack of racial or ethnic bias held when the data were
stratified by school status (elementary, χ2 goodness-of-fit
1.8, P = .61; middle school, χ23 = 5.6, P = .13; high school, χ23 = 2.8, P = .42). Neither was an
overall sex bias in response rates noted (χ2 goodness-of-fit
test, χ21 = .09, P = .92). This lack of sex bias also held when the
data were stratified by school status (elementary, χ2 goodness-of-fit
test, χ21 = 0.0, P = .86; middle school, χ21 = 0.6, P = .43; high school, χ21
= 0.4, P = .54).
Table 1 provides BMI categories by grade level
and sex; Table 2 provides BMI
categories by race and ethnicity. Binomial regression models to examine the
relationship between weight status and race were adjusted for age and sex
(Table 3). Overall, 27.9%
of the students screened were overweight. American Indians had a higher
prevalence of overweight (32.2%) than any other racial or ethnic group. This
prevalence was significantly greater than the prevalence for white students
when students who were overweight were compared with those of normal or
underweight status in a binomial regression model (Table 3). No
statistically significant racial or ethnic differences were found for risk
of overweight status, but the point estimates for American Indian, African
American, and Hispanic students were greater than for white students. A
binomial regression model comparing those at risk for overweight or
overweight with those of normal or underweight status provides evidence that
American Indian and African American students are at significantly greater risk of
being more than normal weight than white students (Table 3). Although
Hispanic students tended to be heavier than white students, this result was
not statistically significant. This comparison is important because risk of becoming
overweight and being overweight track with similar strength into adult obesity
(15,17). No statistically significant sex differences in weight status were
evident; 28.0% of males and 27.8% of females were classified as overweight
(Pearson χ23= 2.98, P = .40). We found a
hint of an increasing linear trend for overweight as grade level increases
(Table 1). However, this trend is mitigated by the decrease in overweight seen
among high school students when compared with middle school students
(Cochran-Armitage trend test, P = .11). When the
high school results are excluded, there is a statistically significant
increasing trend for overweight as grade level increases (Cochran-Armitage
trend test, P = .003).
Blood pressure categories
From the total sample of 747 students aged less than 18 years, 745 had
their blood pressure measured. Two students were not measured for blood
pressure because their clothing interfered with the measurement. No student
with elevated blood pressure was lost to follow-up. Only data from the 745
students younger than 18 years were examined further because of the difficulty
reconciling adult blood pressure standards with those for children and
adolescents. At the first screening session, 18.4% (137/745) of the students
had blood pressure at or above the 90th percentile for their age, sex, and
height. After the second measurement occasion, this percentage was reduced to
5.1% (38/745), and only 2.8% (21/745) had blood pressure at or above the 90th
percentile that persisted for three measurement occasions (i.e., three to nine
Association of overweight status and elevated blood pressure
A strong association was seen between students with a BMI at or above the
85th percentile and blood pressure at or above the 90th percentile on
the first measurement occasion (Table 4). This association gained strength as
elevated blood pressure persisted with repeated blood pressure measurements,
with the second measurement occasion providing a crude relative risk (RR) of 5.95 (95% CI,
2.52–14.07) and the third a crude RR of 6.70 (95% CI, 1.99–22.55) (data not
numbers of students with elevated blood pressure prevented regression modeling
for these subsequent measurements.
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The response rates were reasonable but far from ideal. Volunteer bias may
have substantially skewed the observed prevalence rates for overweight. It is
possible that this was the case for older students in middle school and
high school. A result of this bias might be an underestimation of the
prevalence rates for underweight, risk of overweight, and overweight. Weight
consciousness and autonomy from parental influence arguably increase with
age, and therefore older overweight students may have been less
likely to participate in the screening than normal weight students. The
cross-sectional decline in overweight prevalence between the middle and high
school cohorts also indicates that there was an underrepresentation of overweight students among those screened and that this
underrepresentation may have increased with age. The apparent decline could
also be a cohort effect; however, anecdotal evidence from school personnel
indicates that many overweight students in high school and middle school
did not participate in the screening. Recent statewide results from Arkansas
may indicate that a reduction in overweight among high school students is a
real phenomenon, but the decline is not discussed (7).
Low to moderate response rates could lead to biased prevalence rates for
elevated blood pressure. An underrepresentation of overweight students
could definitely have this effect, but despite low response rates, the
association between elevated blood pressure and elevated weight should remain
The results of the weight status screening provide important information
for the participants, parents, and school district. The prevalence of
overweight among the participants is nearly twice that of recent national
rates, rates already considered epidemic (5). The prevalence of overweight
among the American Indian participants is more than twice the national
prevalence estimates for the general school-aged population. Even among white
participants, usually seen as at less risk for overweight than American
Indians, African Americans, or Hispanics, the prevalence of overweight was
greater than national rates for children and adolescents. The overweight
prevalence rate for white participants (18.1%) was the lowest by racial and
ethnic classification but was still substantially greater than recent national
prevalence estimates of approximately 15.4% for children and adolescents and
much greater than the Healthy People 2010 objective of less than or
equal to 5% (5,30).
A unique aspect of the overweight prevalence data for the Anadarko public
schools is that it provides an opportunity to compare the overweight status of
American Indian and white students living in the same integrated
community. Although many potential confounders exist, it is notable that
American Indian students had a significantly increased risk of being
overweight compared with their white peers (Table 3). Explanations for
this difference are yet to be determined. Biological and cultural differences
are strong possibilities (4). Economic factors may also play a role; whereas
54% of white students were eligible for free or reduced-price lunches, 85% of
American Indian, 85% of African American, and 90% of Hispanic students were
eligible. However, a recent large-scale investigation has shown that food
insecurity, a corollary of poverty, is associated with lower BMIs in children
(31). Another recent investigation has provided evidence that community
availability of fitness facilities and other venues for activity is positively
associated with healthy weight (32). However, the fact that the students all
live in the same community diminishes the possibility that access to
sidewalks, parks, playgrounds, fast-food outlets, or grocery stores is an
Blood pressure status
Only 2.8% of the students had elevated blood pressure (≥90th
percentile) that persisted over three measurement sessions and multiple blood
pressure readings. However, the National High Blood Pressure Education Program
Working Group on Hypertension Control in Children and Adolescents stated that
it should be expected that less than 1% of children and adolescents will be
diagnosed as hypertensive when multiple measurements are taken over weeks or
months. Doubling this expected percentage to extrapolate to the 90th
percentile indicates that there may be an excess prevalence of elevated blood
pressure among these students. However, the unique protocol and electronic
blood pressure monitors used for this screening may underestimate the
prevalence of elevated blood pressure compared to using averaged measurements
with a mercury sphygmomanometer.
Because of the low yield from screening children for hypertension,
recommendations against universal screening have been made (33,34). However,
these recommendations were based on the need for highly trained personnel
using mercury sphygmomanometers. The advent of high-quality electronic blood
pressure monitors, combined with the epidemic of obesity, may have changed the
cost–benefit equation for blood pressure screening. In fact, recent research
supports the premise that rates of hypertension may be increasing among
children but that normative data based on electronic oscillometric blood
pressure measurement are needed for future screening efforts (8).
Association of overweight status and elevated blood pressure
Although the prevalence of elevated blood pressure in the Anadarko public
schools is difficult to interpret, the consistent and strong association of
high BMI with elevated blood pressure may presage future increases in
child, adolescent, and adult hypertension if the prevalence of obesity is
sustained or increases (20,35).
We presented the data in this paper to the principals, superintendent, and
other interested school personnel of the Anadarko public school system. Their
response has been positive and demonstrative of the often-forgotten altruism inherent in America’s public schools. The middle school
implemented a school-based walking program for sixth graders in the 2002 to 2003 school year. The high school implemented and evaluated a
school-based student walking program during the second half of the 2002 to
2003 school year. Lastly, the district has decided to commit resources to
perform weight and blood pressure screening annually as part of
usual student health activities and to examine cost vs benefits and effectiveness of this activity.
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The authors thank the students, parents, staff, faculty, and administration
of the Anadarko public schools for their cooperation, collaboration, and
support. This journal article and the research it describes were funded
through the CDC Prevention Research Centers’ cooperative agreements with
University of Oklahoma Prevention Research Center, no. U48/CCU610817 and no.
1-U48-DP-000026. The contents are solely the responsibility of the authors and
do not necessarily represent the official views of CDC, the Anadarko School
District, or the Anadarko community.
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Corresponding Author: William E. Moore, University of Oklahoma Prevention
Research Center, 800 NE 15th St, Room 532, Oklahoma City, OK 73104. Telephone:
405-271-2330, ext 46718. E-mail: William-Moore@ouhsc.edu.
Author Affiliations: Aietah Stephens, Terry Wilson, Wesley Wilson, June E.
Eichner, University of Oklahoma Prevention Research Center, Oklahoma City,
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