Challenging Dogma - Fall 2008

Thursday, December 18, 2008

BMI Report Cards in Schools, Critique of a Current Public Health Intervention – Vibe Andersen

Introduction to a Public Health Problem

Public Health professionals need to focus immediate attention on a rapidly growing public health problem encompassing the United States. The prevalence of obese children ages 6-11 has doubled in the past 20 years from 6.5% in 1980 to 17% in 2006, and has tripled in adolescents ages 12-19 from 5% to 17.6% (1). The increasing numbers of obese and overweight children in the U.S. is due to complex interactions of social/environmental/cultural and political/economic factors, that influences the level of physical activity and eating habits of children in the U.S. (2). At least 61% of obese young people have at least one additional risk factor for heart disease, such as high blood pressure or high cholesterol levels. Children who are overweight or obese are more likely to become obese as adults and are therefore at greater risk of heart disease, type 2 diabetes, stroke and several types of cancer (1,3). Obese children also deal with social and psychological problems such as stigmatization, labeling and poor self-esteem (4). Considering the severe consequences of this growing problem, public health interventions must be considered a crucial necessity.

According to the Centers for Disease Control and Prevention (CDC), a child is defined as being obese when his or her Body Mass Index (BMI) is equal to or greater than the 95th percentile of the age-and-gender-specific BMI charts, and termed overweight or at risk when at or above the 85th percentile (5). In recent years, much attention has been focused on BMI measurements programs by schools as an intervention in the battle against childhood obesity. In 2003, the state of Arkansas initiated and implemented a statewide BMI screening and surveillance program (Act 1220 of 2003) and other states have since followed, (Illinois, Maine, New York, Pennsylvania, Tennessee and West Virginia) (6,7). Under the program, schools inform parents of students they have determined either have or are at risk of developing weight problems, by sending home BMI report cards stating the students BMI. All students receive BMI report cards, not just children in the risk group.

The following will be a criticism of why I believe, that the use of BMI report cards in schools can be considered a flawed intervention in the battle against childhood obesity. I will argue, that this intervention does not provide tools for parents to help boost self efficacy in their children. Another argument will be, that the use of BMI report cards includes a high risk of negative labeling and social marginalization of children. Finally, I will make an argument, that using BMI report cards puts too much focus on weight and not enough emphasis on healthy behavior and living, and on that account risks loosing the focus of promoting a healthy lifestyle in families at risk and most importantly in children.

BMI report cards fails to recognize the importance of self-efficacy

An individual’s decision to engage in a behavior, and his or her persistence to stay with the behavior change, is influenced by the individual’s perception as to whether he or she can be successful. According to Albert Banduras social cognitive theory, the concept of self-efficacy, refers to a persons own belief in that he or she can have control over and success with behavioral change. Children with a sense of high self-efficacy are more likely to engage in behavioral changes and be persistence in sticking to these changes (8,9). A child without a strong sense of self-efficacy will be less likely to attempt behavioural change because of fear of failure. In supporting and boosting self-efficacy you can, according to Banduras, support the child’s beliefs that he or she can succeed in changing their behavior (10).

Giving parents of children with an obesity or weight problem a BMI report card does not provide any tools for the parents in order to help and support their child’s sense of self-efficacy. The BMI report cards provide a number to the parents, that places their child on a scale of being either under, normal or overweight or obese. Some states do also include some information and guidelines for a healthier diet from the American Academy of Pediatrics suggestions for healthy lifestyle, but do not offer counselling or follow-up to the parents (6). Parents are left to make sense of a number on a report card, and just information on healthy lifestyle provided to them by the schools, is not enough to make anyone change behavior and does not boost self-efficacy. Self-efficacy plays a key role, and ways of boosting children’s belief in that they can succeed in changing diet and exercise regime, and in that way influence their BMI, is crucial for the rate of success in any intervention battling obesity. Quite a few parents receiving the BMI report cards for the first time reacted with anger and disregard (11). A qualitative study in the U.K. showed, that parents would like a medical interpretation of whether their child is at healthy weight and also that parents found BMI a difficult concept to understand (12). A more effective way of informing and supporting the families, might be counseling sessions at the schools, which is a more personal setting and may turn out to be a better way of helping the parents find tools to offer to their child.

One could also argue, that without true support within the school environment such as increasing the amount of physical activity scheduled into the school day, and serving a healthier diet in the school cafeteria, the intervention does not have much chance of success (7). Parents and children need to feel that their choice of a healthier lifestyle is being supported in schools where children spend a good part of their week. Schools have a huge responsibility to promote self-efficacy, by providing an environment where modeling from other students and encouragements from teachers and peers is encouraged.

BMI report cards and the risk of negative labeling

By using the term “report card” in the intervention some children could feel as if they are getting graded on the way they look. The risk of children feeling as if they have been officially labeled as “fat” is very high. According to labeling theory, behavior by the individual is influenced by the way the individual is judged by society, and the label he or she thereby gets (13). Labeling theory has roots in sociology and according to social psychologist George Herbert Mead, as an individual you are aware of how you are judged by others from your perception of the role you play in social interactions. There are different rules in different social settings, and varying social and moral norms plays a role in behavior and labeling of individuals (13). The use of BMI report cards focus on the individual, and poses a significant risk of labeling overweight children as being “fat” in the eyes of their peers. Labeling can directly lead to negative behavior in the way that individuals can be seen to accept to the label they are given, in that way enabling the label to work in a self-fulfilling way. The group of children being branded as “fat”, may resign themselves to this being their social role, and may loose any motivation they had to strive for healthier behavior. Some children may start overeating and avoid physical activity because they feel that is what is expected from being “fat” (13,14).

Another negative outcome of BMI report cards could be an increase in taunting and bullying of overweight children, a problem already reported as existing (15). Overweight children are more likely to be teased about their weight and less likely to form friendships than their non-overweight peers (16). Studies conducted on adolescents being teased about their weight showing that they are at high risk for low self-esteem, depression and suicidal attempts (17,18).

Also labeling can have a significant effect on the group of children not characterized as overweight. The fear of being labeled as “fat”, a label this group sees as socially less accepted, can be so severe in this group that unhealthy dieting could become a big problem, resulting in eating disorders and serious body image issues (11,16). So the use of BMI report cards in schools could have negative consequences in both the groups of overweight children and in the group of children being at healthy weight (19).

BMI report cards: too much emphasis on weight not enough emphasis on healthy behavior

The use of BMI report cards risks putting too much emphasis on children’s weight and not enough on healthy behavior and lifestyle. Focusing only on body size, without looking at the big picture, puts the health of children at normal weight at high risk of being neglected. They may have a normal BMI, but eat an unhealthy diet and have sedentary behavior that could lead to health problems later on in life (20). Many problems associated with weight are consequences of poor diet, genetic factors, ethnicity, level of physical activity and spending too much time engaged in sedentary activities, such as watching TV and playing videogames. Parents inactivity and high consumption of energy dense food are also risk factors associated with childhood obesity (12).

The National Health and Nutrition Examination Surveys (NHANES) 1999-2004 found that 23.5% of normal-weight adults were cardiometabolically abnormal, while 51.3% of overweight adults and 31.7% of obese adults were cardiometabolically healthy (17). The long-term health risk might in fact be higher for some of the children defined as normal-weight, and BMI measurement might not be accurate predictor of unhealthy behavior (21). One could argue, that the intervention using BMI report cards does not focus at all on promoting a healthy behavioral change. With BMI report cards, children and parents in the group of “normal” children may be lulled into thinking that they do not need to consider healthier alternatives to change their habits.

BMI is practical, easy to obtain and reliable, but arguments are, that entire states are adopting a policy that has not yet been tested (22). Little is known about the outcome of BMI measurement programs, including effect on weight-related knowledge, attitudes and behavior of children and their families. Kipping in a clinical review of obesity in children, argue that as long as we do not have an effective intervention available to follow up on the population that gets a high BMI score, screening school children for weight problems is hard to justify (11,23).


The problem of the increasing numbers of obese and overweight children in the U.S. is, as mentioned in the introduction, a diverse and complex social and environmental problem and it is a collective responsibility that requires individual, family, community, corporate and governmental commitments. Using BMI report cards in schools is one amongst many interventions designed to try to address the growing problem. I would, with my arguments state, that the use of BMI report cards in schools, as an intervention addressing childhood obesity, is flawed in its lack of including important factors, such as self-efficacy, risk of negative labelling of children and lack of emphasis on healthy behavior and living. The effectiveness of this intervention is highly questionable and may actually have directly negative consequences, as the outcome of the intervention has yet to be evaluated. It leaves parents with a number on a report card and no tools to promote self-efficacy, and offers no solution to reverse the course. The significant risk of negative labelling children as being “fat” and in that way directly increasing the risk of further unhealthy behavior in obese and overweight children, as they see the label as their social role, must be seen as another flaw in the intervention. BMI report cards could also promote unhealthy weight behavior in the group of “normal” children, as they fear of being labelled “fat” could lead this group in the direction of eating disorders and serious body image issues. The intervention does not emphasize healthy lifestyle. By this focus on body size (BMI) rather than healthy diet, a positive exercise regime and healthy life style, the intervention overlooks a large group of children who have a normal BMI but might lead a very unhealthy life. BMI levels within the normal range may as a consequence lure families into staying with an unhealthy lifestyle. To date the effect of the BMI screening program on childhood obesity has yet to be scientifically evaluated.

Counter-Proposal to a Current Public Health Intervention

Obesity is a consequence of choices and lifestyle. These lifestyle issues need to be addressed individually and collectively as a society in order to change the path of the rising numbers of overweight and obese children in the U.S. The focus need to be moved away from body size and towards behavior and environmental factors. Instead of using BMI report cards in schools, that indeed focus on body size, I will argue that a focus on healthier lifestyle for all children, no matter what BMI level they are at, is a better approach in order to avoid the flaws pointed out in assignment #3, and also why I find this proposal superior to the original intervention on the specific flaws that I articulated in assignment #3.

Self-efficacy, a key component in behavioral change

Ways of boosting children’s belief in that they can succeed in changing diet and exercise regime is crucial for the rate of success in any intervention battling childhood obesity in the U.S. Children with a sense of high self-efficacy are more likely to engage in behavioral changes, and be persistence in sticking to these changes (8,9). The use of social cognitive theory as part of a frame for an intervention would be a good approach, as a key element in this theory is self-efficacy, social modelling and learning by observing. According to social cognitive theory, children model what they see, and learn from what others do, so if the social norm is healthy lifestyle with healthy food and exercise, there is a good chance that children will model that (10,25). Also studies have shown, that peers and siblings attitude towards eating and food consumption significantly influences children’s behavior (26,27).

Ways of boosting self-efficacy would be to give the children responsibility in their own life and health, make realistic goals for and with the children. In praxis introducing cooking classes in schools, where children get hands on experience in preparing healthy meals, would be one way of boosting the children’s belief in possible behavioral change, and at the same time teach nutrition. Another way of boosting self-efficacy in children, would be focusing more on including or building in physical activity into everyday life for children; walk/bicycle to school, make class projects exploring new ways of exercising daily in a new and fun way. Making the children feel, that they are a part of a group with a common mission. Make children feel they belong and in achieving their goals, boosting their feeling of success.

Changing the social norm is hard and very challenging, families need more practical advise in being able to choose a healthier lifestyle and finding tools to boost self-efficacy (25). Counseling sessions at the school would be a more personal setting than merely a report card sent home. In this way, by giving parents tools to boost children’s self-efficacy through counseling, you move away from the flawed approach by BMI report cards only stating a number. Schools have a huge responsibility in promoting self-efficacy, by providing an environment where modeling from other students and encouragements from teachers and peers is encouraged (7). But not only schools have responsibility, the whole community needs to come together in a multilevel approach where different sections work together to find a solution (home, schools, physicians, state, government).

Reducing the risk of negative labeling

Schools should be a safe and supportive environment for students of all sizes, and implement strategies to promote physical activity and healthy eating. The risk of children feeling as if they have been officially labeled as “fat” is very high by using the term “report cards”, as the BMI report card intervention does. To decrease the risk of negative labeling, you would have to address the way society judge individuals (13). A significant flaw by using BMI report cards in schools, is the risk of self-fulfilling behavior in children with high BMI score. The risk of acceptance and resigning to a social role and the de-motivation this could course for these children, leading to lack of interests in physical activity sometimes combined with overeating (13,14). The question is what type of health related communication, instead of sending home a “report card” from the school to the family, is most likely to bring positive results, and at the same time dismiss the chance of labeling some children. One different approach in schools could be making an assessment of quality of diet, eating habits, physical activity and time spent in sedentary behavior. On top of this you would make an assessment of the child’s body image and relationship with food, and making this assessment part of every child’s school year, the risk of just pointing out some children and hereby risk negative labeling is decreased (7,28).

In addressing the negative effect BMI report cards have on the risk of increasing weight teasing and bullying, schools have a serious responsibility in boosting children’s self-esteem. Working away from a school system with report cards on weight will also be beneficial for the likelihood of overweight and obese children’s risk of teasing and bullying (14,16). The fear of being labeled fat that can lead some children within the normal range of weight to unhealthy dieting and other eating disorders needs to also be addressed (18). Eating and exercise habits are shaped by social and cultural structures and norms, and building an approach that includes these elements would stand a better chance of successfully taking up the battle against childhood obesity (25,93-111).

Emphasis on healthy behavior, environment and lifestyle -not body size

The focus on body size by stating children’s BMI score on report cards puts the health of children of normal weight at risk. BMI report cards focus mainly on overweight and obese children, hereby totally overlooking the risks involved in leading an unhealthy lifestyle but still being within the normal BMI range (17,20,21). A more appropriate approach would focus on positively promoting healthy living, healthy eating habits, exercise for all children, not only for those that, by using BMI report cards, are being labelled obese.

In today’s society and eating environment, good nutrition is something that sadly must be learned. We need to ensure, that the school policies and the whole school environment encourage physical activity, and ensure students meals in pleasant sociable environments as well as providing psychosocial support (23). In my opinion, by making unhealthy food less accessible in schools cafeterias by simply taking it off the menu, not only adding healthier choices, but removing unhealthy choices, you would be able to influence healthier eating behavior. True support within the school environment such as increasing the amount of physical activity scheduled into the school day, and serving a healthier diet in the school cafeteria is needed now (19,23). Parents and children have to feel that their choice of a healthier lifestyle is being supported in schools, where children spend a good part of their childhood hours. Parents need to understand, that they are teachers too, children models what they see, not what they are told and the society needs to build support and awareness for parents (28).

There will always be a political/economic context that will affect what people do, and especially what they can or cannot do (25). The food environment we live in is toxic, the influences of the food industry is massive in the obesity epidemic that is currently a reality in the U.S. (24). One of the problems public health advocates faces in the U.S. is the highly individualistic mentality in the society, and as a result of that, individuals are assumed to have sole responsibility for their choices. The level of individualism is why so many people object to proposals to changes in the food environment, i.e cafeteria lunches, and children’s access to unhealthy food in vending machines, they do not like to be told what they can or cannot eat (24,27). But changes in the food environment are necessary to influence lifestyle changes.


There is very modest effectiveness of programs aimed at individual behavioral change to prevent childhood obesity, which is why a paradigm shift at societal and political/governmental level is needed, in order to see any significant changes towards lifestyle changes. On governmental level politicians needs to realize that changes in the food environment is necessary. Public health workers have to be realistic in their planning of interventions and create a realistic frame for the work. Select from different factors and decide what to focus on in the light of resources, as public health does not have unlimited resources or time, so you have to pick your battles. The battle against childhood obesity is a complicated multi factual battle that will need a multilevel approach. Not only schools have responsibility, but parents, family physicians, community and government all have to contribute. Intervention using BMI report cards in schools is flawed in different ways. An approach focusing on providing tools to help boosting children’s self-efficacy, decrease the risk of negative labeling, and support healthy lifestyle by moving focus away from body size, is in my opinion a superior approach. By the use of social cognitive theory as part of a frame of an approach, you would be able to focus on self-efficacy as a key component, and reduce the risk of leaving parents without tools to support their children. By focusing on a healthier life style for all, you would reduce the risk of labelling some children as fat. By assessing all children, and meet with all families to offer counselling in healthy lifestyle and possible behavioral changes, you would create a possibility not only for overweight children at risk, but all children equally. It is my strong belief that the mindset of thinking convenient, easy, automatic, effortless and free “the American way of life” needs to be challenged and changed if any intervention shall stand any chance in the battle against childhood obesity in the U.S.


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