Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Critique of the BMI Report Card – Jenna Tonet

Obesity has been a continued concern in the United States, especially as it has risen dramatically in a relatively short period of time. One age group that is of great concern is children. Public health practitioners and health care professionals have worked to decrease obesity rates among adolescent using school-based interventions. One example of a public health intervention at the school level is the Body Mass Index (BMI) report card. Teachers issue students this card if the child is found to be at risk for becoming obese. This intervention is not effective for reasons that include labeling the child as overweight, framing the issue in a negative way, and preventing the child from believing they can change their behavior.
The intention of the BMI report card is to prevent obesity early enough in an individual’s life to make a difference. However, the approach is highly problematic because of its affect on an individual. Adolescence is a time in when children are very impressionable. Even though the intervention’s focus is to target the problem before it starts, the report card has more repercussions than good outcomes. The aim to prevent obesity becomes overshadowed by the harm caused to the child for a number of reasons. O’Dea (9) and Garner (4) both discuss the areas of concern regarding obesity prevention programs that are school-based, such as “stigmatization of pupils whose body weight are outside the “normal” range,” and “labeling of pupils as “overweight,” “obese,” “lazy” (1).
Stigmata Theory
The first and foremost reason is that the report card places a label on the child. This derives from the social science theory called the stigmata theory. When an individual is labeled a certain way, they develop a self-fulfilling prophecy (3). When the teacher gives the child this report card, they will often believe that they are and always will be overweight. Since the adolescent has this label, they will assume that this label is true. Therefore, they will not take understand how to interpret the original goal of the report card. The purpose of the card will not matter because the child and the parents will only focus on the label. According to the self-fulfilling prophecy, rather than trying to change the behavior, the child will assume the identity.
Since only the children who are found to be at risk for obesity receives this report card, they are singled out from the rest of the students. The stigma from this card affects how the individual views themselves and how they feel the other children look at them. If the report card has a negative connotation, the child will feel stigmatized. Also, they will feel isolated from the other children. When an individual is still developing their identity, they are vulnerable to impression, including what others think about them.
In a study of boys’ and girls’ perceptions of “fatness, thinness, social pressures and health” using focus groups, one of the conclusions was that the children believed that while being fat should not matter, they really did believe it does matter because those children were teased, bullied and had few friends (2). One such comment in the boys’ focus group was that “…people would be laughing at him, saying, “Ha ha, you’re fat, we’re strong” (2). With this label, the child’s stigmatization shows if other children tease them about the report card. The other children look at them differently because of the label given to the particular child with the report card.
Since not all children receive the report card, it is considered out of the social norm and not acceptable. The child can become victimized; and they suffer from being treated and viewed differently. In the focus group study, one of the boys accused the others of hypocrisy because they believed that the boys would single out the overweight child – “They say that now but in real life they’ll make fun of you if you’re different” (2). He had been an example of why that was true because he had been made fun of by boys in the group for that reason (2). Since adolescents do not know how to handle and understand differences, the child who is singled out is subject to their ridicule.
Social Cognitive Theory
Furthermore, the social cognitive theory illustrates more of the social factors addressed above. While this theory used to be known as the social learning theory, it moved from behaviorist roots to a theory that addresses individuals consciously operating within an environment (3). According to social cognitive theory, changing behavior is a function of individual characteristics, external factors, and an interactive process (3). However, the BMI report card directly contradicts this approach to changing a behavior. The self-fulfilling prophecy that results from the card’s issue prevents the first function of social cognitive theory.
This function, the individual’s characteristics, begins with the concept of self-efficacy, which is when a person has a sense about the new behavior, their confidence that they can do it and overcome obstacles (3). However, these components become questioned if the child does not believe that they can do it. The presentation of the report card can be viewed in a negative light. This does not allow the child to view a change in behavior as positive. Therefore, they will not want to change their behavior due to lack of confidence.
The child’s behavioral capability depends on their belief that they can make the behavioral change (3). Nonetheless, the report card is simply a piece of paper that warns the child and their parents that the child is at risk for becoming obese. In elementary school, an individual is still developing psychologically, so they will not completely understand the purpose of the card. Since they are singled out, the child only sees that and not the signal to make behavioral change. They also pick up cues from their classmates who bully them about their weight. In the focus group study, the boys felt pressure to tease others, and one comment in the focus group was “They’ll be miserable for the rest of their lives because they’ll get picked on” (2).
While it should be the parent’s role to deal with the card, they might see it as a problem and not accept it. For example, a teacher may notice a learning disability. In a number of cases, the parents do not want to believe that their child is “different.” The report card acts the same way because the parents may take it as a sign that their child is different from the other children. They do not want to see them as different or others to view them as different.
This leads to another component of the social cognitive theory, which is emotional coping (3). How the child and the parents handle the report card plays a significant part in the process. The child feels bad for getting the card and the parents do not like the label placed on their child. If no one can handle the situation in a beneficial way, then the intervention is ineffective. This result prevents the ability to handle change on a mental and emotional level (3).
The last two concepts within the first function of changing behavior, self-control and expectations, do not directly apply to this public health intervention. The report card deals more with the initiation of changing behavior and not the actual behavioral change. Self-control relates to the ability to carry out and change without returning to the original behavior. The fact that there the report card does not address these two factors contributes to the intervention’s ineffectiveness. The card just tells that there is a problem and does not provide information about what to do in the long term. In order to be effective, an intervention needs to follow through the progress of the behavioral change.
The next function of the social cognitive theory incorporates environmental factors. As stated before, the BMI report card does not address the environment. The external factors are the social and physical environment that surrounds individuals (3). Clearly, this intervention does not address the child’s peers – no one wants to be singled out of a group for something viewed as “bad.” It negatively influences the child’s social environment because they become susceptible to being teased by the other children in their class (2). Their self-esteem is lowered and they feel forced to make a change, which is not a healthy approach. For example, one girl in a focus group said: “When I was really chubby they all used to call me ‘fatty,’ so I had to stop tennis and so I went on a diet and nobody has called me ‘fatty’ since” (2).
The last function of the social cognitive theory is the “interactive process of reciprocal determinism, where a person acts based on individual factors and social/environmental cues, receives a response from that environment, adjusts behavior, acts again, and so on” (3). Again, due to its faults, the BMI report card does not even effectively achieve this function because the cues and individual factors do not produce positive results. If the child adjusts that behavior based on the social environment, it would not fit the intervention’s goals. Rather than change in order to lose weight, the child might hide from the children and focus on the embarrassment of the card. The problem shifts from obesity to avoidance. The intervention introduces another issue into the equation rather than dealing with the original issue.

Framing Theory
The last overarching reason for why the BMI report card is an ineffective public health intervention stems from the framing theory. The way an issue is framed significantly determines how people will react to it. The real battle is to change people’s behaviors by framing the issue accordingly. People do not respond to the facts but how the issue is framed (7). When facts do not fit a person’s frame, then the fact is not internalized (7). However, if the fact does fit the frame, then it is internalized (Lakoff).
The BMI report card is an example of how a public health issue is framed. The frame acts as a way to prevent the problem of obesity before it happens. However, this frame shows that the child has a problem and portrays it in a negative way. It is beyond the child’s comprehension and not within their frame of thinking. Also, the parents will not fit into the frame correctly either because they will see that their child has a weight “problem” that requires behavioral change, which is a result of how the issue is framed. Frames lead to either more or less effective ways of addressing an issue, and in this case, the frame is less effective.
The development of the interpretative framework is to understand why people come to be exposed to certain risk or protective factors (8). This is an example of contextualizing risk factors, which the BMI report card fails to do. This intervention develops the card based on limited screening. Like many public health interventions, the report card assumes an individualistic approach to behavioral change rather than accounting for the whole picture. It fails to incorporate factors that include socio-economic status, access to healthy foods and safe parks, and cultural values.
Another component of the framing theory is Lakoff’s Levels of Analysis, which utilizes frames to achieve social change (7). The BMI report card applies to the third level; the card falls into the program category in this level and addresses the issue of health care. However, even though it incorporates this level, it is not a successful frame. While obesity is a health care concern, this particular intervention has an overly broad approach. The generalization indicates that the frame needs to be more specific. The card should be framed at level one, which involves values and principles, such as personal health value (12). While this is at a more individual level, the card should also include social factors. That is where contextualizing social factors play a role. The card should not tell the child and the parents that the child is at risk for becoming obese. Rather, it should frame the issue as valuing health overall – physical, emotional, and mental. The card should be directed toward the individual child’s situation, which depends on their risk or protective factors such as cultural/ethnic background.
The facts do not change at this point because the wording only shifts when framed toward a specific situation. The parents will be less hostile toward the card if the facts are presented differently. If the facts are presented in a way that the parents can understand, then they internalize the frame – it is a fact of how humans think (12). Parents are often sensitive when it comes to their children because they do not like to be told that they are not properly raising their children. The report card does not explicitly say this, but that is how parents internalize feedback that they view negatively. That is why the intervention should be more positive.
Although children may be too young to make health based decisions by themselves, it should not just come from the teacher issuing a piece of paper. There should be more health based education tailored to the child’s level of comprehension. While some might argue that the school system can only do so much and that is more of a responsibility of the parents, schools should still do something because they cannot control the parents. However, the intervention should consider the issues of labeling, framing, and environmental influence as more significant than the report card demonstrates in order to be more effective.
Counter-Proposal Intervention to the BMI Report Card – Jenna Tonet
The problem of childhood obesity has been on the rise in the United States for some time now. While public health practitioners and health care professionals have worked to decrease obesity rates among adolescents using school-based interventions, the example of the BMI report card poses more harm than good. It is ineffective for reasons that include stigmatizing the child, framing the issue negatively, and lowering the child’s self-esteem. The school is a good place to have a community level intervention, but the intervention might not be successful. More effective interventions at the school level require community involvement, including parents, teachers, and health educators. Also, the approach should be a positive view of the child’s overall well-being and health. There should be no card, which acts as a label and singles the child out from their peers.
The intervention should be portrayed positively so that the teacher, child, and their parents view the situation in a more positive light. One type of intervention could take an existing component of the school system – parent-teacher conferences – and integrate feedback on the child’s overall well-being as observed in the classroom. The purpose of parent-teacher conferences is for the teacher to let the parents know how the child is doing in the classroom; this should be an overall and comprehensive evaluation. However, the teacher alone cannot evaluate all the health factors of the child. This is where health educators would come in to help assess the child’s health. The conference would address flaws of the BMI report card, including labeling, framing, and environmental influence, as will be shown in this paper.
To get rid of the BMI report card entirely would be better for the child, parents, and the teacher. Due to its limited individualistic development, the BMI report card fails to show that many factors contribute to an individual’s health and well-being. Also, without the BMI report card, the child does not receive a “label” with the actual card, they are not singled out from their peers, and the parents would not look at the situation as negatively. All of these factors imply that there is a need for a new paradigm. In other words, the issue requires a new frame.
Framing Theory—Positive Paradigm
Reframing the issue would provide a better way for everyone to comprehend the issue and internalize the facts. For example, O’Dea (10) mentions the need for a new paradigm: one example cited was the ‘health at any size’ movement, which has been successful in part due to the focus on health improvement instead of weight status. O’Dea (10) argues that this broad focus, which incorporates and highlights several components of health, can result in positive outcomes in child obesity prevention. These factors include the physical, psychological, social, and spiritual (10). This frame is better to suit everyone involved so that no one thinks negatively of the situation.
The parents could better comprehend the issue at hand because their ultimate concern is their child’s well-being. The point of the conference is to communicate with the teacher and to receive feedback from the teacher about their child. However, they will not internalize facts that are considered negative because the parents want what is best for their child since they believe that their child is perfect. If the teacher’s feedback tells them otherwise, or that they are not as ‘good’ as the other children in the classroom, then the parents will not think favorably of the situation. Rather than framing it as a “problem,” the teacher could address it as overall health well-being. The use of positive language makes a significant difference.
The way to develop a frame is to understand why people become exposed to certain risk or protective factors (8). This is an example of contextualizing risk factors. An intervention should incorporate factors that go beyond the individual level. Many current public health interventions assume an individualistic approach to behavioral change rather than accounting for the whole picture. Instead, the focus should be to encourage children to engage in a healthy lifestyle (11). While it is difficult to find or develop an intervention that draws upon several factors, the parent-teacher conference brings in the family and community levels.
Additionally, this approach addresses the best level from Lakoff’s Level of Analyses, which is level one (7). This level involves values and principles, such as personal health care (7). Even though this seems to be more individualistically based, the parent-teacher conference incorporates social factors by the involvement of the family and school community. Both the parents and the teacher are significant to a child’s well-being and overall development due to their roles and relationship with the child. The social network theory exemplifies this because the theory highlights the importance of relationships between and among individuals, and the nature of these relationships influence beliefs and behavior (3). If they can work together, they can help the child together through a network; they can help the child to act in ways that is good for their health (3).

Stigmata Theory—Labeling the Child
Reframing the issue also helps to deal with the issue of stigmatization. One example that the child already faces in regard to social stigmatization is: “Prejudiced attitudes from other children and resulting peer rejection is one of the most common sources of stigmatization of obese children” (11). This shows that the child already deals with negative peer influence. The parent-teacher conference replaces the BMI report card and takes away some stigma by taking away the physical label. While it is still an issue, the child is not subject to teasing from being singled out in another way.
The teacher is also influential in how the children interact. If begun as early as preschool, the teacher could teach and encourage the children how to accept each other. However, this would need to continue throughout the child’s development because their psychological development continues throughout elementary and middle school. Peer influence continues through adolescence because social networks develop and continually change through a person’s life. These relationships have a nature that can influence beliefs and behaviors (3). The relationships between the child and the teacher and between the child and their parents are opportunity to encourage health promotion. Their relationships are vital to help the child since they are a significant part of the child’s life.
As long as they maintain an active role in the child’s life, their influence is greater. One example of influence is that parental behavior could influence their child by encouraging better nutritional habits and self-regulation. “One study demonstrates that young children are more willing to taste novel foods if their mother models tasting the food first compared to a condition in which children are offered food with no adult model” (5, 11). This also demonstrates that environmental and individual factors contribute to the child’s overall health, which is part of the social cognitive theory.
Social Cognitive Theory—Environmental Influence
A significant part of the social cognitive theory brings the individual characteristics and environmental factors together, whether it comes from the parents, teachers, or peers (3). The parent-teacher conference addresses the environmental role by introducing the teacher and parental influence into the situation. With parental support, the child has a better chance of changing the behavior. A good support system builds upon the child’s self-esteem and self-efficacy. If they believe that they can make the change, the child has a greater opportunity to actually go through with the change.
Additionally, environmental factors also show how children can learn from others through the situation and by reinforcement (3). The school acts as one venue where teachers influence children through role modeling. “In several related quasi-experimental studies, silent teacher modelling was found to be ineffective in encouraging food acceptance among pre-schoolers, but ‘enthusiastic’ verbal teacher modelling was found to increase food acceptance” (6, 11). While more studies need to be conducted in order to best utilize teacher role modeling to best suite the children in the classroom, such studies are a great starting point for this intervention.
Lastly, the social cognitive theory puts together the individual and external factors through an “interactive process of reciprocal determinism, where a person acts based on individual factors and social/environmental cues, receives a response from that environment, adjusts behavior, acts again, and so on” (3). The child acts upon environmental influence and their attitudes and beliefs about the behavior. If they receive community and social support, i.e., from their parents and the teacher, they are likely to change their behavior as long as their environment allows them to do so.
While the BMI report card poses more harm than good, parent-teacher conferences could take advantage of the fact that the child should not be singled out in their classroom environment. This exchange occurs outside the child’s environment where they are vulnerable to judgment. The frame and context of the situation should be positive so that everyone involved internalizes the issue. The parents and the teacher take the time to talk about and address the child’s overall well-being, both academic wise and health wise. Also, they provide support for the child so that the child believes that they can make the behavioral change and be less subjected to harassment from the other children.
1. Davidson, Fiona. Childhood obesity prevention and physical activity in schools. Health Education 2007; 107(4): 377-395.
2. Dixey, Rachael, Pinki Sahota, Serbjit Atwal, and Alex Turner. A qualitative study
of boys' and girls' perceptions of fatness. Health Education 2001; 101(5): 206-216.
3. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
4. Garner, D.M. (1985), “Iatrogenesis in anorexia nervosa and bulimia nervosa”,
International Journal of Eating Disorders, Vol. 4, pp. 348-63 in Davidson, Fiona. Childhood obesity prevention and physical activity in schools. Health Education 2007; 107(4): 377-395.
5. Harper KU, Sanders KM. The effect of adult’s eating on young children’s acceptance of unfamiliar foods. Journal of Experimental Child Psychology 1975; 20: 206–214, in Schwartz, M.B. and Puhl, R. (2003). “Childhood obesity: a societal problem to solve”, Obesity Reviews, Vol. 4, pp. 57-71.
6. Hendy HM, Raudenbush B. Effectiveness of teacher modeling to encourage food acceptance in preschool children. Appetite 2000; 34: 61–76.
7. Lakoff, G. “Simple Framing.” Available online at, accessed
November 2008.
8. Link, BG and Phelan, J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35(extra issue): 80-94.
9. O’Dea, J.A. (2003), “Suggested activities to address body image issues, eating problems and Child obesity prevention in school environments”, Journal of the Home Economics Institute of Australia, Vol. 10 No. 3, pp. 2-12 in Davidson, Fiona. Childhood obesity prevention and physical activity in schools. Health Education 2007; 107(4): 377-395.
10. O’Dea, Jennifer A. Prevention of child obesity: ‘First, do no harm.’ Health Education Research 2005; 20(2): 259-265.
11. Schwartz, M.B. and Puhl, R. (2003). “Childhood obesity: a societal problem to solve”, Obesity Reviews, Vol. 4, pp. 57-71.
12. Wallack, Lawrence. “Framing: More Than a Message.” Available online at, accessed November

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