Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Failing Grade: The Ineffectiveness of BMI Report Cards--Kaitie Feloney

Over the past decade it has become painfully clear that childhood obesity is an epidemic within the United States. Once only a condition for the few, obesity is now the status quo for the majority of American children. Whereas only 6.5% of children ages 6-11 were classified as obese in 1980, that figure has climbed to 17.0% in 2006 (1). Defined by a child being at or above the 95th percentile of the body mass index (BMI) scale, obesity has recently become a main focus of public health advocacy groups. One recent public health intervention that is designed to fight childhood obesity is displaying a child’s BMI on her report card so that her parents know if the child’s weight is getting too high. While this intervention was designed with good intentions, its lack of several key features caused it to be destined for failure. The BMI-report card program did not provide perceived benefits of weight loss, and did not address the self-efficacy, or social norms associated with childhood obesity.

Childhood obesity has negative consequences for nearly every system in the human body, including joint problems, and higher rates of reactive airway disease and insulin resistance (2). In addition to clinical problems, obese children often face taunting and bullying from their peers, actions that can cause psychological damage over time. Obese children are more likely to be the target for relational (withdrawing friendship or spreading lies) and overt (kicking or pushing) victimization as well, which means that obesity can negatively affect a child’s life in more than one way (3). Many factors can contribute to childhood obesity and it is not the exact same mix that causes the condition in every child, but generally genetics, level of physical activity, diet and familiar factors are all contributors (4). Of note is the fact that most of these factors exist outside of normal school hours, with the exception of lunch and gym class.

BMI Report Cards Do Not Illustrate the Benefits of a Healthy Weight

There are currently seven states that require that a child’s BMI be reported on his or her report card: Arkansas, California, Illinois, New York, Pennsylvania, Tennessee and West Virginia (5). While the specific layout of each report card is different, all list the child’s BMI as well as a classification of normal, overweight, or obese. One problem with these report cards, though, is that not every state uses a format that clearly explains what the number means. In addition, there are not always tips listed for how to encourage physical activity or healthier eating, so parents can be left with a bad grade in their child’s weight and no suggestions as to how they should fix it. Another key piece of information that these report cards lack is an explanation of the benefits of staying at a healthy weight, getting physical activity and eating nutritiously. Children (and parents) often know that overweight and obesity are not healthy, but they may not know specific reasons why it is healthier to be within the normal weight range. Providing the potential health benefits, such as sleeping better and being able to run faster in gym, could give the children and parents tangible reasons why they want to improve, versus not knowing why their lifestyle should change. This is especially significant for parents to see, as they are usually the ones directing the child’s diet and level of physical activity.

While the lack of an explanation of how to reach or sustain a healthy weight is problematic for overweight or obese children, the lack of attention to an overall healthy lifestyle also negatively affects children at a healthy weight. Some children may lead an extremely unhealthy lifestyle, with little to no physical activity, a lack of nutritious foods and no parental guidance on healthy life choices, yet these children might still have a BMI within the normal guidelines. Research studies have shown that there is a positive link between the hours of television viewed per week and fatness in children, so while a child might not be overweight at the point the report card is issued, he or she might already have established unhealthy behaviors that could lead to health problems (6). In this case, it is important to list ways to lead a healthier lifestyle so as to prevent the child from becoming overweight or obese in the future. Focusing solely upon the BMI number prevents a large number of children from receiving information about a healthy lifestyle.

BMI Report Cards Do Not Address Self-Efficacy

The concept of self-efficacy is central to social cognitive theory, and it is the idea that an individual’s belief in their own ability to complete an action and meet a set goal shapes the decision of whether or not to engage in the action, as well as their perseverance in completing the action (7). While self-efficacy is a measure of a person’s confidence in her ability to complete an action, self-efficacy is also influenced by other aspects, namely that individual’s physiological factors, vicarious experience, social persuasions, and mastery experience. A person’s physiological factors are defined as her response to stress, and vicarious experience is how an individual interprets other people’s responses and models her own behavior accordingly. Social persuasions are whether the people surrounding an individual encourage or discourage a particular behavior, and mastery experience is how successful the individual has been at performing historically (8). In regards to an emotionally-charged subject like weight, self-efficacy is extremely important to address. If a child and her parents know that she is overweight but feel that they cannot complete the necessary steps to bring her to a healthy weight, it is much less likely that they will even attempt to make changes in the first place. The mix of factors that can lead to a child becoming overweight is especially linked to self-efficacy, because feeling that one is able to eat a few more fruits and vegetables, cut down on soda, or get a little more physical activity can all have a significant impact upon health. Studies have found that only slightly decreasing the amount of time that children are sedentary can greatly decrease their chance of becoming overweight (9). When only a small modification in behavior is necessary to create a significant change, a person’s conception of self-efficacy is vital to success. BMI report cards fail at encouraging self-efficacy because they do not suggest healthful behaviors or provide encouragement to the child. As a result, many recipients of the report cards who have a classification of overweight may feel that they do not know how to confront this problem, may lose confidence in their ability to resolve the situation, and in the end will not make any lifestyle changes.

BMI Report Cards Do Not Address Subjective Norms

One of the key features of the theory of reasoned action is that an individual takes subjective norms into account before making a health behavior decision. Ajzen and Fishbein state that subjective norms stem from a person’s beliefs about how others in their social group will react to a behavior, and their personal motivation to conform to these social norms (10). This means that if an individual is greatly affected by subjective norms, they might not undertake a health behavior for fear that their peers will disapprove of the behavior. The United States has a very conflicted culture regarding body weight, as the majority of Americans are overweight or obese, and yet television and marketing almost exclusively portray very thin women and very muscular men. This trend has led to women having many insecurities about weight, which trickles down to young girls. Several studies have found that the weight-control practices utilized by girls in a social group can affect how the other girls view body image and their own risk of practicing unhealthy weight-loss behaviors (11).

Since BMI report cards are handed out to children (who are supposed to give them to parents but will inevitably read them first), it is extremely important to take subjective norms into account when designing an intervention that targets school-age children. There is a great deal of pressure upon girls especially to remain thin, and a BMI rating of “overweight” could result in teasing, bullying and a great deal of stress for the student. Sending home a document that has such socially-significant phrases on it is a failure on the part of the designers of the BMI report card. A better approach would have been to schedule a parent-school nurse conference, either in person or over the phone, to help avoid embarrassment in front of their peers for overweight children.

Another way to improve subjective norms is to change the culture of the school so that the culture of individual social groups might also change. The physical education and nutrition teachers at schools could plan school-wide initiatives to help children believe that healthy eating and physical activity are fun and enjoyable. In addition, it should be taught that all children should adhere to these behaviors, not just children with weight problems. It has been found that physical activity helps to stave off cardiovascular disease amongst all children, normal and underweight included, so these behaviors should be touted for all (12). These actions could help to make behaviors like healthy eating and increased physical activity more accepted within all social groups, so that overweight children will not be the only individuals subjected to these behaviors.

Additionally, the promotion of the health benefits of a healthy weight could help to convince children that if unhealthy behaviors are the norm, conforming to that norm might not be the best decision. In this sense explaining the health benefits of weight loss could work together with establishing positive subjective norms to help increase the chance that children and parents will be successful. The lack of attention that BMI report cards give to the potential health benefits of weight loss and addressing subjective norms is ineffective separately, but the combination of these two blunders can result in an even lower chance of children undertaking more healthful behaviors. There are many flawed parts to the planning and design of BMI report cards, but this combination in particular can result in little to no change.


BMI report cards have a number of shortcomings, but the intention behind the intervention was good. It is true that the problem of childhood obesity is a pressing issue in the United States, and public health interventions need to be designed and implemented as soon as possible to prevent this epidemic from affecting even more children. That being said, this intervention was flawed for a number of reasons, which is a common occurrence when a new public health problem is identified and the first interventions are set into action. The lack of information about the potential health benefits of maintaining a normal weight, the failure to address or promote self-efficacy and the lack of attention given to subjective norms are all aspects of this intervention that are poorly designed and cause BMI report cards to be ineffective.

While there are many problems with the current design of the BMI report card intervention, certain changes could be made that would result in the program being more effective. Restructuring the report cards to provide a detailed explanation of each classification, i.e. normal, overweight, etc., would help parents and children to better understand the significance of a BMI. In addition, suggesting healthy behaviors such as consuming more fruits and vegetables and increasing physical activity will help parents and children improve their sense of self-efficacy, as well as remind normal weight children how to maintain a healthy weight. Finally, promoting healthy behaviors for all children within the school will help to create a culture of positive subjective norms towards healthful behaviors. In doing so, the school will help take attention away from overweight children trying to make better health behavior decisions and instead focus upon the overall health of the school community. BMI report cards have the potential to help stabilize the number of children who become classified as overweight every year, and then potentially reduce that number by alerting parents to children who are at risk of becoming overweight, but this will only happen if several changes are made to the program. In its current state, though, the intervention of BMI report cards is lacking in several key areas and is ineffective as a public health intervention.

Health Reporting—A Fresh Approach in the Fight Against Childhood Obesity-Kaitie Feloney

The BMI report card has recently become the focus of a great deal of media attention. Some news coverage points to the report cards as an innovative approach to fighting obesity in the United States, while other news reports vilify the schools for possibly hurting the feelings of overweight children. While neither assessment is accurate, it is certain that BMI report cards in their current format represent an ineffective public health intervention. In order to become an effective and worthwhile tool, the report cards must explain the perceived benefits of a healthy weight, address self-efficacy as related to weight loss, and take into account the social norms associated with childhood obesity.

BMI report cards are an intervention that has been attempted in seven states (13). Under the current framework, a child’s body mass index (BMI) is included on the normal report card with a designation of underweight, normal, overweight, or obese. The idea behind the report cards is that parents who might otherwise be unaware of a child’s weight problem can be made aware of the situation, and that the parent will then take steps to address the issue. This methodology has several problems, namely that the report cards do not explain the perceived benefits of a healthy weight, address self-efficacy or the social norms of childhood obesity. With a few minor changes, however, an overall health reporting system could become an effective tool to help fight childhood obesity in the United States. A more effective intervention would be to link BMI reporting to parent-teacher conferences. Instead of receiving a piece of paper with a number and little to no explanation, parents could receive a print-out explaining the BMI and the child’s classification, as well as direct counseling from the school nurse or health teacher. In addition, the print-out could address several aspects of health, such as days absent from school due to illness, performance in gym class, and performance in health class. Doing so would take the focus off weight and place more emphasis on a healthy lifestyle, so that all children could have a goal to work towards instead of singling out overweight or obese children.

Health Reporting Will Explain the Perceived Benefits of a Healthy Weight

The health belief model operates under a number of assumptions, one of which is that an individual weighs the perceived benefits of a health behavior before undertaking it (14). With the old approach of BMI report cards the perceived benefits of a healthy weight were not explained. Under this new intervention, the benefits of a healthy weight will be explained directly to parents at the conferences, as well as to children during health education class. Doing so will help to convince parents that measures should be taken to help their children maintain a healthy weight, as well as explain to children why these behaviors are important. The theory of reasoned behavior also addresses the idea that a person’s belief about what will happen if they undertake a particular behavior affects his attitude towards that behavior (15). Research has found that maintaining a normal weight and the behaviors that lead to this (such as regular physical activity and nutritious meals) can help prevent chronic diseases later in life, such as type II diabetes and cardiovascular disease, as well as joint problems, sleep apnea, and hypertension (16). Explaining these potential benefits to parents will help educate them as to which behaviors lead to a healthy weight, as well as help minimize any defensive feelings the parent may have. Telling a parent that her beloved child is overweight can easily result in anger, but framing the conversation as one about overall health, of which weight is only one part, may help to lessen angry feelings.

Health reporting will address self-efficacy as related to weight loss

As noted previously, social cognitive theory explains the concept of self-efficacy as the idea that an individual’s belief in her ability to complete an action affects the decision of whether or not to engage in the action and the perseverance in completing the action (17). A person’s concept of self-efficacy is also affected by other aspects, like that individual’s psychological factors, social persuasions, mastery experience and vicarious experience. One of the main failings of BMI report cards is that they did not address self-efficacy as it relates to weight loss, leaving children and parents feeling helpless. The ability to complete physical activity and eat nutritiously is greatly impacted by a person’s self-efficacy, so in order to ensure that health reporting will be effective, self-efficacy will be buoyed on a regular basis.

One way that health reporting will promote improved feelings of self-efficacy is through the print-outs given to parents as part of parent-teacher conferences. The informational sheets can suggest ways to add physical activity into daily life, as well as examples of nutritious meals and snacks. Parents and children can read through the sheets and get ideas for how to move towards a healthier lifestyle, and these tips can be helpful for normal weight children as well. For example, the informational sheet could use uplifting language and images to help children feel confident about their ability to maintain a healthy lifestyle. The nutritional section could note that drinking soda instead of water or milk is a good choice, and that drinking less soda is linked to a lower average caloric intake (18). Health and physical education teachers should also put forth a positive attitude in class, and running a school-wide challenge to improve one’s health could result in improved feelings of self-efficacy school-wide.

Health reporting will take into account the social norms related to childhood obesity

While the lack of focus upon self-efficacy was a serious shortcoming of BMI report cards, a more severe failure of the program was its inadequacy in addressing the social norms associated with childhood obesity. The theory of reasoned action states that an individual considers the subjective norms of a health behavior before choosing to engage in it. These subjective norms emerge from an individual’s belief of how others in his social group will react to a particular behavior, as well as the individual’s desire to conform to these social norms (19). For a topic as emotionally-charged as childhood obesity addressing social norms can greatly impact the success of a program. Overweight and obese children are more likely to endure bullying from classmates, as well as experience feelings of shame and depression, and it is clear that various social stigmas of being overweight have developed among school-age children (20). Delivering health information about the child at parent-teacher conferences avoids the potentially embarrassing situation of being handed a BMI report card that reads “overweight,” which other children could see and taunt. In addition, the health and physical education teachers should try to cultivate an environment of respect and acceptance so that children of all sizes will feel comfortable in gym class and ultimately in all settings. Creating this open culture will help to shift the social norms of the school towards an environment in which healthy behaviors are looked upon favorably, and where children who are trying to improve their health status are celebrated.


The BMI report card program that was initialized in several states earlier this year was designed with good intentions, but it ultimately fell short in its accomplishments due to several glaring omissions. The program as designed did not provide children and parents with the perceived health benefits of a healthy weight, and did not address self-efficacy or social norms as they relate to childhood obesity. A health reporting intervention that focuses upon communicating information directly to parents alongside a health print-out would provide more information, and a school-wide health improvement initiative would help to increase a child’s sense of self-efficacy as well as improve the social norms associated with childhood obesity, and this program could potentially help to fight the ongoing epidemic of childhood obesity in the United States.



2.) A. Must and R.S. Strauss. “Risks and consequences of childhood and adolescent obesity.” International Journal of Obesity (1999), 23, Suppl. 2.

3.) I. Janssen, W. Craig, W. Boyce, W. Pickett. “Associations between overweight and obesity with bullying behaviors in school-aged children,” Pediatrics (2004), Vol. 113 No. 5, pp. 1187-1194.

4.) C. Ebbeling, D. Pawlak, D. Ludwug. “”Childhood obesity: public-health crisis, common sense cure,” The Lancet (2002), Vol. 360 No. 9331, pp. 473-82.


6.) A. Grund, H. Krause, M. Siewers, H. Rieckert, MJ Muller. “Is TV viewing an index of physical activity and fitness in overweight and normal weight children?,” Public Health Nutrition (2001), Vol. 4, pp. 1245-51.

7.) MK Salazar. “Comparison of four behavioural models,” AAOHN (1991), Vol. 39, pp. 128-135.

8.) Ibid.

9.) LH Epstein, AM Valoski, LS Vara. “Effects of decreasing sedentary behavior and increasing activity on weight chance in obese children,” Health Psychology (1995), Vol. 14, Issue 2, pp. 109-15.

10.) I. Azjen, M. Fishbein. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall; 1980.

11.) M. Eisenberg, D. Neumark-Sztainer, M. Story, C. Perry. “The role of social norms and friends’ influences on unhealthy weight-control behaviors among adolescent girls,” Social Science and Medicine (2005), Vol. 60 Issue 6, pp. 1165-1173.

12.) O. Raitakan, K. Porkka, S. Taimela, R. Telama. “ Effects of persistent physical activity and inactivity on coronary risk factors in children and young adults,” American Journal of Epidemiology (1994), Vol. 140, No. 3, pp. 195-205.


14.) Becker MH, ed. “The health belief model and personal health behavior.” Health Educ Monogr. 1974;2:Entire issue.

15.) Azjen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall; 1980.

16.) Sothern MS, Loftin M. “The health benefits of physical activity in children and adolescents: implications for chronic disease prevention.” European Journal of Pediatrics (1999), Vol. 158 No. 4, 271-74.

17.) MK Salazar. “Comparison of four behavioural models,” AAOHN (1991), Vol. 39, 128-136.

18.) Harnack L, Stang. “Soft Drink Consumption Among US Children and Adolescents Nutritional Consequences,” Journal of the American Dietetic Association (1999), Vol. 99 No. 4, 436-41.

19.) Azjen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall; 1980.

20.) Sjoberg R, Nilsson K, Leppert J. “Obesity, Shame and Depression in School-aged Children: A population based study,” Pediatrics (2005), Vol. 116 No. 3, e389-92.

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