Challenging Dogma - Fall 2009

Thursday, May 20, 2010

BMI Report Cards: Pass or Fail? – Jenna D. Lovaas

I. Introduction
Obesity is a major public health concern and is quickly becoming an epidemic, as evidenced by rapidly increasing prevalence rates (1, 2). Rates of obesity are increasing across all age groups, but the rise in childhood and adolescent obesity is of particular concern. Obesity in youth is defined as greater than the 95th body mass index (BMI) percentile for age- and sex-specific growth charts (3). Between the 1960s and the 1988-1994, the prevalence of obesity among children and adolescents more than doubled, going from 4 percent to 11.3 percent in 6- through 11-year-olds and from 5 percent to 10.5 percent among 12- through 19-year-olds (4). Estimates calculated with measurements obtained through the 1999-2000 NHANES show that the prevalence of obesity is 10.4 percent among 2- through 5-year-olds (up from 7.3 percent in 1988-1994), 15.3 percent among 6- through 11-year-olds, and 15.5 percent among 12- through 19-year-olds (4). More recent estimates show that in 2003-2004, 17.1 percent of U.S. children and adolescents were overweight (5). There is recent research suggesting that the overweight and obesity trends among children and adolescents are leveling off, but the proportion of these populations classified as obese are still high (3, 6). Furthermore, the prevalence of severe obesity in youth, defined as greater than the 97th BMI percentile, continues to rise (7).
This continued trend of obesity and overweight places children and adolescents at risk for developing a number of adverse health conditions that are likely to continue into adulthood, including cardiovascular, gastrointestinal, pulmonary and orthopedic complications (3). Hyperlipidaemia, hypertension and abnormal glucose tolerance are occurring with increasing frequency among obese youth (8). In addition, children are now presenting with type 2 diabetes mellitus, which has previously rarely been seen in children (4, 8). Childhood obesity is also known to be an independent risk factor for adult obesity, and there is evidence of an association between adolescent obesity and increased health risks as adults, independent of adult weight (8). In addition to physiological disorders, overweight and obese youth are at increased risk of developing psychological complications, such as depression, behavioral problems and low self-esteem (9). These psychological disorders can potentially affect a child’s adherence or self-motivation to adopt healthier behaviors (3).
Considering the severe health consequences, both physiological and psychological, effective public health interventions are necessary to address the problem. Schools can have an important role in youth obesity prevention because the majority of young people are enrolled in school; therefore, the CDC has identified a number of strategies that schools can use for obesity prevention (10). Although it is not one of the strategies recommended by the CDC, a number of school districts have begun implementing BMI-screening programs in schools (11). Screening results are often sent to parents and include the child’s BMI-for-age percentile and an explanation of the results. Additional information in the report may be healthy eating and physical activity tips, and any recommended follow-up actions (10). The school health policies and programs study performed by the CDC in 2006 found that 22 percent of states required schools or school districts to measure and assess height and weight or body mass; 73 percent of those states required parent notification of the results (10). As an example, Arkansas, California, Illinois, New York, Pennsylvania, Tennessee and West Virginia use BMI report cards for parent notification (12), while districts in other states have also piloted similar programs.
This paper focuses on school-based BMI measurement and BMI report cards. Section II presents three critiques of this approach to overweight and obesity in youth. Section III then proposes and provides support for an alternative multi-level intervention to address childhood overweight and obesity, taking into consideration the flaws of the BMI report card intervention.
II. A Critique of School-based BMI Measurement and BMI Report Cards
BMI report cards are likely to raise awareness of the importance of childhood overweight and obesity prevention, but the intervention has the potential to do more harm than good. This section presents three arguments for why school-based BMI measurement and report card programs are flawed. First, BMI report cards lack tools to promote self-efficacy; second, this intervention fails to consider the importance of self-esteem in behavior change; and third, BMI report cards neglect to consider the potential for negative labeling.
A. BMI Report Cards Do Not Promote Self-Efficacy
Self-efficacy is one component of Albert Bandura’s Social Cognitive Theory (SCT), which describes dynamic interactions between personal and environmental factors and human behavior. According to Bandura, self-efficacy, goals and outcome expectancies are the three main factors that influence behavior change (13, 14). Self-efficacy, or the belief that one can successfully implement the behavior required to achieve the outcome, can determine whether or not the individual engages in that behavior (13, 15). If individuals have a feeling of self-efficacy, they are capable of behavior change regardless of potential obstacles. On the other hand, if they do not feel like they have any control over their lives or health, individuals are not motivated to work past the challenges (13).
Some BMI report cards simply report the child’s status as underweight, normal weight, at risk for overweight or overweight (16). If parents are expected to help their children deal with the problem of obesity, they need more information and advice than their child’s weight status. A pilot study in Cambridge, MA included suggestions for daily lifestyle changes in their BMI report cards; these suggestions consisted of watching less than two hours of TV, getting one hour of physical activity, and eating five fruits and vegetables (11). While providing this information is certainly a step in the right direction, it is not enough by itself to promote self-efficacy. Both parents and children need to feel that they can be successful at making healthy lifestyle changes.
In the Cambridge study, approximately half of the families who received report cards stating their child was overweight were somewhat or very concerned about their child’s weight status (11). While concerned parents were more likely to plan weight-control strategies, they were not more likely to engage in the suggested preventive measures than less concerned parents. In addition, almost twenty percent of families reported planning diet-related activities to control their child’s weight, regardless of the amount of anti-diet information included in the materials sent home. These results would support the fact that more is needed than reporting a child’s weight status along with suggestions for lifestyle changes. This strategy does not bridge the gap between knowing what to do and actually doing it, a gap that can only be filled by the belief in the ability to perform the behavior (15).
Additional barriers to achieving self-efficacy and behavior change are the schools themselves; the school environment must support the desired behavior in order for the intervention to be successful. Despite state mandates, a recent audit of New York public schools found that few provide the required physical education hours and many violate their own policies by providing vending machines that sell junk food and sugar-sweetened drinks (17). In addition, in a survey of middle school children in two public schools in the Northeast, a study found that competitiveness hampered physical activity, as children who were overweight or not as skilled were less likely to participate during physical education classes and open gym periods. Lack of nutritious food and time to eat prevented healthy nutrition choices (18). School environments with unhealthy food choices and low physical activity do not promote self-efficacy, because overweight children are not able to model the successful, healthy behaviors of their peers, nor are they likely to receive encouragement from teachers and peers to pursue such choices themselves.
B. BMI Report Cards and the Importance of Self-Esteem
BMI report cards fail to take into consideration the importance of self-esteem in motivation and behavior change. Abraham Maslow’s Hierarchy of Needs describes different levels of human needs and how those needs affect motivation and behavior (19). According to Maslow, all needs and drives do not exist in isolation and every drive is related to level of satisfaction or dissatisfaction of other drives. Maslow describes what he calls “deficiency needs”, which include physiological, safety, social and esteem needs, that must be satisfied before a person can beginning achieving the higher-level need of self-actualization (19). Humans have a desire to be accepted and valued by others. Fulfillment of the esteem need leads to feelings of self-confidence, capability, worth, strength and purpose. However, if this need is not met, it produces feelings of helplessness, weakness and inferiority, which can lead to discouragement or compensatory unhealthy behaviors (19).
As evidenced by this theory, children whose self-esteem need is not met are unable to undertake the healthy lifestyle changes necessary to prevent overweight and obesity. Research has shown that young girls who consider themselves overweight are especially vulnerable to low self-esteem (16). Although one study found that many adolescents report using healthy weight control practices, such as decreasing fat intake, they also found a high prevalence of binge eating and unhealthy or extreme weight control behaviors in overweight youth, especially girls; body dissatisfaction, which is closely tied to self-esteem, is a strong predictor of unhealthy weight control practices (20). Regardless of actual BMI, children or adolescents with high levels of body dissatisfaction have lower feelings of self-worth, poorer self-esteem, and more dissatisfaction with other areas of their lives (16, 21). In addition, obese children with low self-esteem are more likely to experience sadness, loneliness and nervousness, as well as more likely to experiment with high-risk behaviors (22).
BMI report cards may actually decrease self-esteem by making children feel they are being judged by their weight. Additionally, the concept of a report card for a health factor such as weight implies that a child can fail (23), which is not the best motivational message. BMI report cards could also increase weight-based teasing in school, further lowering the self-esteem of overweight children and further decreasing their ability to make healthy behavior changes. As Maslow discussed, without self-esteem, people often feel helpless and discouraged. Therefore, to successfully combat childhood obesity, interventions must address the issue of self-esteem.
C. Negative Labeling as a Consequence of BMI Report Cards
Negative labeling is closely tied to self-esteem, as being labeled often leads to teasing and lower self-esteem. The goal of BMI report cards is surveillance and prevention of obesity in children. However, by basing the program in schools and focusing on the individual, this type of intervention not only brings attention to the issue of weight, it also increases the risk that a child will be labeled as fat. Labeling theory was developed in the 1960’s to explain deviance, with Howard Becker’s Outsiders (1963) being the most frequently cited source. According to Becker, one of the most important steps in the development of a deviant career is being labeled as a deviant. Once a person is labeled, he/she is cut off from participation in more conventional groups, leaving the individual no choice but to pursue his/her expected deviant activities (24, 25). This theory has often been applied to mental illness as well. One study of patients discharged from mental hospitals found that stigma was a persistent problem in their lives, and experiences of social rejection were a constant source of stress. The patients’ efforts to cope with the labels resulted in further social isolation and reinforcement of negative self-concepts, and diminished motivation and recurrent psychological problems (26).
These concepts can easily be applied to youth and being labeled as ‘fat’. Overweight girls report experience direct and intentional stigmatization from peers, family members, employers and strangers; the most common place of occurrence for these experiences was school (16). Being labeled increases the risk that youth will be exposed to hurtful experiences, such as teasing or bullying, that have a negative impact on self-esteem. Overweight children have more trouble making friends and are often teased about their appearance (27, 28). Even children as young as five-years-old express a preference for thin figures (29). As Becker discussed, the label of ‘fat’ can result in children conforming to the label in a self-fulfilling prophecy. BMI report cards could, therefore, perpetuate obesity as children who feel they have been labeled as fat resign themselves to the role of the ‘fat kid’ and participate in activities, such as overeating and not exercising, that they feel are expected.
Being labeled can also result in pressure from peers, family and society to engage in harmful weight loss practices that could potentially lead to eating disorders (30). Studies done on the BMI report card program in Arkansas show that dieting and dietary restriction has been increasingly encouraged by parents and practiced by students; this is troubling because research has shown that dieting predicts weight gain in adolescents (31). The 2005 Youth Risk Behavior Survey (YRBS) found that approximately 1 in 6 high school students engaged in unsafe weight loss practices, such as fasting, inducing vomiting, or using diet pills or laxatives (30). However, overweight children are not the only ones at risk for these unhealthy behaviors. The focus on weight created by BMI report cards and the negative attitudes towards overweight children may increase fears that healthy-weight children have about being labeled as fat; this could then push them into adopting unhealthy dieting practices to avoid the socially unacceptable ‘fat’ label.
III. An Alternative Multi-Level Intervention to Address Childhood Obesity
While schools provide an excellent setting to address healthy lifestyle changes since 95 percent of youth are enrolled in school (31), in order for an intervention to be successful, the program also needs to target the community and family levels. Parents are particularly important in any youth obesity intervention because they control much of a child’s food consumption, influence physical activity opportunities (32), and control access to television, computer, and video games. Additionally, there is much evidence suggesting that the eating behaviors of children are shaped by parental feeding behaviors and parental eating behaviors, as well as by parental weight status (33). The nutritional knowledge of mothers and their concern about disease prevention is positively associated with children’s fruit and vegetable consumption and negatively with children’s total fat and energy intake (33). It is therefore important to provide extensive parental education on the importance of providing healthy food choices in the home, especially beginning at an early age since food preferences are learned through repeated exposure to foods. It is also important to educate parents about the importance of eating at home as a family; this has been shown to improve children’s dietary quality, even in adolescence when children tend to make more independent food choices (33).
In terms of physical activity, children with parents who are more physically active are more likely to be physically active themselves (33). Parental encouragement is also related to increased or continued physical activity in youth. However, family resources can also influence physical activity levels; children whose parents transport them to after school activities, or pay fees for lessons or community sports organizations have higher levels of physical activity (33). To remove the disparity in access, schools or community organizations could provide similar activities for free or at reduced costs for families with limited resources.
For the family-based part of the intervention, it is important to emphasize reasonable goals for parents and children to work towards together, as well as to incorporate positive reinforcement. Research has also shown that nutrition education combined with behavior modification results in greater relative weight loss, and increasing problem solving capabilities is also important to successful changes in lifestyle habits (33). A successful intervention would, therefore, include not only nutrition education, but also educate parents about self-monitoring, social reinforcement, modifying their family’s environment for a healthier lifestyle, and problem-solving strategies for themselves and their children.
The school-based part of this intervention would have different levels for the different age groups. Teaching children early about good nutrition choices and the importance of physical activity is key to a healthier lifestyle as they get older. Children at the elementary school level would need fun, entertaining and interactive activities to keep their attention engaged and absorb the information. A pilot program in Missouri is trying such an approach, and something similar would be appropriate for this intervention. The Missouri program works to incorporate brief periods of exercise into the students’ day in addition to regularly scheduled physical education classes and recess (34). The nutrition part of their program teaches students how to read food labels, identify and choose healthy foods and identify deceptive marketing practices. Physical education classes could also incorporate fun games, rather than traditional sporting activities, to engage children who may not be as athletically talented.
At the middle and high school level, nutrition education should continue, along with problem-solving strategies to increase self-efficacy. Children are particularly vulnerable to teasing and bullying at the middle school level, so strategies for dealing with this type of harassment could also be useful; positive reinforcement from teachers, and ideally peers, would also help promote healthy lifestyle habits. Many states have a required number of hours of physical education, but as mentioned previously, not all states fulfill that obligation. It is critical that physical education continue through middle and high school, and it is equally important that these classes incorporate many different types of physical activity to encourage life-long habits. Rather than only incorporating traditional sporting activities, schools should consider adding units on yoga, kickboxing, Pilates, Tai Chi, swimming (if a pool is available), dance, and even walking to name a few. This would allow students to explore more options and potentially find something that suits their needs better.
At all levels of school, there need to be healthy eating options. Lunches provided in cafeterias need to have decreased levels of fat and increased levels of fiber, especially fruits and vegetables. The unhealthy snacks and sugary beverages available in vending machines should be replaced with healthier options. In this way, the school environment will support what the students are learning in class and at home.
The community level of this intervention would be focused more on promoting awareness of the issue of childhood overweight and obesity, as well as awareness of the school and family-based parts of the intervention (35). With community support for the campaign, there is likely to be increased community involvement in schools, increased promotion of healthy behaviors, and development of health and fitness partnerships for schools and families.
A. Tools to Promote Self-Efficacy
The alternative multi-level intervention has numerous ways to promote self-efficacy. One way in which it does this is by approaching behavior change in small steps to ensure the success of those changes (13). Rather than suggesting immediate drastic changes in lifestyle habits, this intervention would promote gradual change through steady modifications in nutrition at home, slow increases in daily physical activity, and promotion of less time spent watching television or playing video games.
In addition, the alternative intervention addresses the four sources of information that provide the basis for expectations of personal self-efficacy (15). The first source is performance accomplishment, or the successful mastery of skills. By teaching skills in problem-solving, self-monitoring, and alternative physical activities, this intervention increases confidence in one’s abilities, thereby increasing self-efficacy. The next source of information is vicarious experiences, which refers to learning from observing others performing difficult activities. Watching parents and other students make healthy food choices and watching their peers successfully involved in daily (fun) physical activity will enhance one’s expectations of mastering those skills.
Verbal persuasion, the third source, will come from both educators and parents as they teach the children about healthy lifestyle choices and encourage their efforts. Finally, emotional/physiological arousal also influences expectations of self-efficacy. People are more likely to expect success when they are not adversely aroused. This alternative intervention would ideally keep emotional stress to a minimum by not focusing solely on weight, as BMI report cards do, and decreasing the amount of potential teasing overweight children may experience. Since the children are then less likely to feel discouraged, they are more likely to expect, and experience, success when they attempt the desired behavior changes.
B. The Importance of Self-Esteem
It is difficult to promote healthy self-esteem in a society that bombards children with images of thin, beautiful people. However, this intervention has the potential to at least give self-esteem a boost for many youth, not just those that are overweight. The education component can not only provide information about healthy nutrition, but can also focus on images and discussions of ‘real’ people and emphasize the importance of healthy rather than thin in an effort to decrease body dissatisfaction. Also, by removing the report card format, the intervention would eliminate those feelings children may have that they are being judged by their size. As mentioned above, the focus on healthy living rather than weight has the potential to decrease teasing and bullying of overweight children, thereby significantly decreasing the feelings of helplessness and discouragement that can interfere with successful behavior change. The self-esteem of individual children is also likely to increase as their feelings of self-efficacy increase, as they successfully work towards the goals that have been established by the program.
C. Removal of Negative Labeling
Negative labeling and self-esteem are, as previously mentioned, closely related. Again, removing the report card-type intervention eliminates the label children may feel they are assigned when their parents receive the report. Removing this label reduces the risk that children will fall into the self-fulfilling prophecy of being ‘fat’, and will instead feel they are capable of eating right and being physically active. Also, the alternative intervention focuses on group activities that engage all children rather than only those with athletic talent, so children will not be excluded and feel isolated. There is much less risk of labeling with this intervention because the issue of weight is rarely, if ever, the focus; instead the focus is on living a healthy lifestyle. Removal of negative labeling also decreases the risk of healthy weight, and overweight, children engaging in harmful weight loss practices by decreasing the level of stigma attached to weight.
IV. Conclusion
While BMI report cards may be successful at bringing attention to the issue of childhood overweight and obesity, they are a number of potential unintended negative consequences. In addition to those outlined in this paper, BMI report cards also fail to identify a large population of children with normal BMIs but unhealthy lifestyle habits (23). The alternative multi-level intervention outlined not only address the negative consequences of BMI report cards, it also promotes healthy lifestyle behavior changes for all children in effort to ensure the children grow up into healthy adults.
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