The Sandbox Project Growing Healthy Bodies Working Group commends Toronto Public Health on not sending ‘Fat Letters’; warns of negative repercussions of weighing kids

Sandbox letter to Toronto Public Health

Toronto Public Health
277 Victoria Street, 4th Floor
Toronto, ON
M5B 1W2

August 28, 2013

Re: The Sandbox Project Growing Healthy Bodies Working Group commends Toronto Public Health on not sending ‘Fat Letters’; warns of negative repercussions of weighing kids.

To Whom It May Concern,

On behalf of The Sandbox Project charity and our Growing Healthy Bodies Working Group, we would first like to commend you on initiating the Body Mass Index (BMI) Study, to be held in schools next year. As a national child and youth health charity, we are encouraged that you have made this a priority to invest in the health of children as they truly are our future. While this study is a valuable resource that identified one measurement of the status of Toronto children’s health, there are some issues that have been identified by our Growing Healthy Bodies Working Group experts that we would like to bring to your attention.

The Sandbox Project was created in response to the 2008 “Reaching for the Top” report to the Minister of Health for the Government of Canada by Dr. Kellie Leitch, and her finding that Canada is slipping further behind its peer countries when it comes to key health indicators for children and youth.   The Sandbox Project provides leadership to act as a catalyst for change in Canada. It works directly with parents, business, health industry leaders, governments and non-governmental organizations to raise awareness, to pursue research and to collaborate to develop solutions and better public policy.  The Sandbox Project is unique in that we bring together academics, other not for profit organizations, government, parents and corporations to discuss child and youth health issues.

As you know, this study will be valuable resource that identifies the status of Toronto children’s health and we would encourage you to take this opportunity to highlight issues that have been identified in studies measuring BMI.  This study has the potential to be a powerful tool to inform policy and educate Ontarians. Some of the areas for consideration regarding the study include:

  • The BMI is not an accurate reflection of an individual’s (even more so a child’s) health. There is much more to a child’s health than their weight and height. Another important point to consider: “overweight” individuals live longer than their “normal weight” counterparts.
  • We need to remember that even today, about 90% of kids across Canada are not obese. Generally, increased weight does not cause poor health outcomes; rather, it is the environment, genetic and behavioral factors in the context of Canadian culture that lead to poor health. Higher weight is an associated (not causative) finding that occurs alongside poorer health. It is at best an imperfect marker for health.
  • The purpose of categorization is to simplify something complex in an attempt to better understand or view the problem. In the case of BMI classification however, this represents an oversimplification of a very complex issue. While the BMI measurement can be a useful took for classification it also has an inherent bias built into its use. The BMI categories assume homogeneity within groups and exaggerate between group differences. For example, it is assumed that all individuals in the “normal” weight category have similar health outcomes and are significantly different from those in the “overweight” category. However, the variance in the normal weight category could be as much as 20 kg while the between group difference with an individual in the overweight category could be as little as 0.1 kg. We need to consider the effects of classifying individuals, especially children. Further the BMI can be misleading when you take into consideration growth rates, muscle composition, bone density etc. Classification often affects our views of individuals and how we treat them. A focus on BMI classification can be a powerful tool in perpetuating weight-based bias and discrimination.

Recognizing that BMI measurements can be challenging, one of the initiatives coming out of The Sandbox Project is Mitacs partnered research project, The Healthy Scorecard Project. The Sandbox Project in working with the Growing Healthy Bodies Working Group has agreed to sponsor Ian Patton at the University of Toronto to complete his Mitacs (a not for profit research internship program that links researchers with the private sector) Post-Doctoral Research Proposal The Healthy Body Scorecard. The Healthy Body Scorecard project is aimed at developing a tool that will address the limitation of using Body Mass Index as a method of health screening in children. The use of BMI poses many problems based on its limitations when used on an individual level and is inappropriate for health assessment in children.  The Healthy Body Scorecard will be an easy to use health screening tool for health care practitioners that will take into account the various factors that directly affect child health and that might need attention. The Healthy Body Scorecard will help shift the focus off of weight as the key number in regards to child health and place it on the behavioral, environmental and social factors which contribute to healthy body development. The Healthy Body Scorecard will be the result of the input of hundreds of Canadian health care practitioners through survey and focus groups as well as in depth reviews of supporting literature. In the next stages of the project we will be refining and validating the Healthy Body Scorecard as well as developing versions of the Scorecard for different groups or professionals including an “At Home” version for parents and children to complete.

Further, we wanted to support your decision to avoid the use of letters to parents letting them know that their child is overweight.  The “fat shaming” letters have no known positive benefits for children’s health and have possible profound negative mental health implications on a child’s well-being.  We encourage you to rigorously adhere to your voluntary participation in this study and only let students know their BMI if they ask. It would also be a positive asset to the program if you explain the simplistic nature of the BMI measurement, the possibility of measurement error or misclassification (e.g. athletes regularly fall into the “overweight” category), and how it does not necessarily reflect an individual’s health.

We look forward to the outcome of your Body Mass Index Study. Should you wish to discuss this further, we would welcome the opportunity to speak to you about this issue.  Best of luck in the coming year.

Yours sincerely,

Dr. Leora Pinhas
The Hospital for Sick Children
Co-Chair, Growing Healthy Bodies Working Group
The Sandbox Project

Dr. Christine Hampson
President and CEO
The Sandbox Project

Supporting members of The Sandbox Project Growing Healthy Bodies Working Group include:

  • University of Toronto

  • Sick Kids

  • Ronald McDonald House Charity

  • Corus Entertainment

  • Health Canada

  • Breakfast Cereals Canada

  • Concerned Children's Advertisers

  • Anaphylaxis Canada

  • YMCA Canada

For further information about The Sandbox Project, please contact Christine Hampson or visit our website at

CC: The Growing Healthy Bodies Working Group members


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