Challenging Dogma - Fall 2008

Tuesday, December 16, 2008

Why the BMI Report Card is not an effective intervention for the childhood obesity epidemic and an alternative intervention- Emma Wicker


Childhood obesity is at epidemic levels and is a major public health concern(1). Results from the 1999-2002 National Health and Nutrition Examination Survey (NHANES), indicate that an estimated 16% of children and adolescents between the ages of 6 and 19 are overweight. What is even more troubling is the fact that this represents a 45% increase from the 1988-1994 NHANES which estimated that 11% of children were overweight. In real numbers this means that approximately nine million children over the age of 6 years are obese(2). This is of major concern because overweight children face a variety of health risks both while they are children and later when they become adults. Children that are overweight are at risk for developing Type II diabetes, sleep apnea, and asthma(3-5). Overweight children are much more prone to becoming overweight adults and as obese adults their health problems are likely to become exacerbated(6). On top of the health issues previously mentioned, overweight adults battle health problems such as cardiovascular disease, cancer and stroke(7-8).

Given that childhood obesity is a major health concern, several public health interventions have been attempted to address this issue. This paper will examine one such intervention, a Body Mass Index (BMI) report card for children that is sent home from school(9). The idea behind the BMI report card is if parents know that their child’s BMI is too high they will be motivated to initiate steps to address the issue. The report card is designed to focus parent’s attention on the issue of childhood obesity. The first school district to role out this program was Arkansas in 2003 and later California, Illinois, New York, Pennsylvania, Tennessee and West Virginia all sent home BMI report cards(10-11). While the BMI report card was designed with the best of intentions, it has several failings. These failings include the fact that the BMI report cards fail to promote self-efficacy, it does not recognize that behaviors occur in a social context and finally it has the potential for negative labeling.


The first step in evaluating the effectiveness of the BMI report card is to evaluate its ability to promote children’s self efficacy. The social cognitive theory developed by Albert Bandura lays out the concept of self efficacy(12). According to this model, perceived self-efficacy plays a very influential role in personal motivation. People who harbor doubts about their capabilities to perform a healthy behavior are easily dissuaded by failure. In contrast, people who have a strong sense of self efficacy intensify their efforts when they fail to achieve their goals. People with strong self efficacy will persist in the behavior until they succeed in achieving their goals. If self efficacy is important for a child to be able to successfully undertake a healthy behavior that will address their obesity, then the BMI report will not be a successful intervention.

The BMI report card is a very simple tool. All it has on it is the child’s BMI and what weight category the child falls into based on their BMI. The categories are ‘underweight’, ‘normal weight’, ‘at risk for becoming overweight’ and ‘overweight’. There is no information provided on the report card on how to promote the child’s self efficacy in the home setting. If the child does not believe that they will be successful in executing healthy behaviors, simply knowing that they are overweight will not solve the problem. The best way to promote self efficacy is through mastery of experiences. What this means is if a person is successful in performing a behavior, then those successes will build a strong belief in one's personal efficacy(13).

To effectively promote a child’s self efficacy there needs to be many avenues where the child can be successful in performing healthy behaviors both at home and at school. If the school sends home a report card that says that the child’s BMI is too high, they also need provide opportunities for the child to eat healthy foods at school or to exercise. Unfortunately, not only do the schools not provide information on how self efficacy can be promoted at home, but they also do not provide avenues in which to promote a child’s self efficacy at school.

According to a study published in 2003 by the National Institute of Child Health and Human Development, children may not be getting enough exercise through their schools' physical education programs. The study specifically looked at third grade children and found that these children only received an average of twenty five minutes per week in school of moderate to vigorous activity(14). In contrast, the recommended amount of exercise that children should get is thirty to sixty minutes of moderate to vigorous activity every day.

The school can also impact childhood obesity with the food that they serve to the children. There have also been some studies that suggest that children who eat the school lunches are in fact more likely to be obese than those who eat food prepared from home(15). If the school is not going to provide an avenue for children to perform healthy behaviors, the children will not end up with a strong sense of self efficacy and therefore their ability to be successful in performing healthy behaviors will be substantially diminished.

Social Context

Many public health interventions are individual level models. The Health Belief Model and the Theory of Reasoned Action are just two of the many models used by public health professionals that focus on behavior at an individual level and do not take into account the social context that the person lives in(16-17). These models do not recognize that healthy behaviors do not occur in a vacuum. There are many issues that may arise if the context of childhood obesity is ignored. One way this is evidenced is by the fact that children with obese parents are more than twice as likely to be obese themselves(18). This is consistent with the ideas put forth by the Social Network Theory which posits that what determines an individual’s behavior is the behavior of other people in their social network(19). The Social Network Theory indicated that it is not individual characteristics, but the relationship between individuals that is important in influencing health beliefs and behaviors. Research shows that network phenomena are very important to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties(20).

If a child’s social network is a powerful influencer on their behavior, then the BMI is not a successful tool in addressing the problem. Some of the report cards offer no suggestions at all on how a child or the family can do something to address the BMI. A few of the BMI report cards offer a few simple suggestions such as watching less than 2 hours of TV, getting 1 hour physical activity and eating 5 servings of fruits and vegetables(21). However, none of these suggestions offer tools on how the entire family can participate in healthy behaviors.

Getting an entire group of people to change a behavior can be seen in the Diffusion of Innovation Theory(22). The Diffusion of Innovation Theory has its roots in sociology and it is concerned with the mechanism by which an innovation makes its way through certain channels until it is communicated to all the members of a social system. If the social network is important, than any intervention to combat childhood obesity needs to be designed to effectively diffuse the innovation through the social network. The way the BMI report card is set up offers no way to diffuse healthy behavior through the child’s social network.

The other problem is that the report card does not recognize that the healthy behavior happens in context of many other behaviors. Parents have many concerns to worry themselves with and health may not be at the top of the list. According to Maslow's Hierarchy of Needs, basic needs such as food and shelter much be met before one can worry about a chronic illness such as obesity(23). If the parent is concerned about paying the rent or just getting some kind of food on the table they are not going to be worried about providing their children with 5 fruits and vegetables a day or giving them ample opportunity to exercise.

This intervention assumes that once the parents are informed about their child’s obesity, first, they will decide to do something about it and second, that they will have the resources to undertake the desired action. As mentioned earlier in terms of Maslow’s Hierarch of Needs, just because the parents have the information does not mean that they will chose to act on it. The second issue is that just because someone may have the intention to undertake an action does not mean that they will have the resources available to undertake those actions.

Research has shown that there is a significant relationship between socioeconomic status, race, and geographic location with childhood obesity(24-26). Some studies suggest that certain populations such as children in low socioeconomic status families and children in the country's southern region tend to have higher rates of obesity than the rest of the population. The increased risk of obesity is especially evident among African-American and Hispanic children(27). These two minority groups have upwards of 24% of their children above the 95th percentile in terms of weight. If the two genders are separated it can be seen that among males, the highest prevalence of obesity is observed in Hispanics and among females, the highest prevalence of obesity is observed in African Americans(28). The BMI report card does not offer any suggestions for healthy behavior that recognize ethnic and SES differences. If parents are not provided with the appropriate tools to help their children, then they will not be able to provide the children with the opportunity to engage in healthy behavior.

Children also have many worries that may prevent them from participating in healthy behaviors. One of the steps on Maslow’s Hierarchy of Needs is self esteem and the respect that children are receiving from others. Children who are overweight struggle with their self esteem and may find themselves marginalized by their peers(29). If children are struggling with these issues they may not be able to implement the healthy behaviors necessary to address their obesity. The BMI report card offers no skills to help the child feel better about themselves. In fact, the report card may have the opposite effect and lower the child’s self esteem as they feel they are being labeled as ‘fat’.


The BMI report card has one final flaw which is the fact that the BMI report card puts the children into one of four categories which could cause a problem no matter what category the child falls into. Labeling Theory postulates that the labels that are applied to people influence their behavior, particularly the application of negative or stigmatizing labels. This can then become a self fulfilling prophecy as the person believes that they have no choice but to conform to the label(30). If a child falls into the ‘overweight’ BMI category or even the ‘at risk for becoming overweight’ category the child may feel that they have been labeled as ‘fat’. This label may leave them feeling powerless to do anything about the issue. This may mean that children would ignore any possible opportunities to engage in healthy behavior that are presented to them. Being labeled as fat also may have a deleterious effect on the child’s self esteem and may encourage them to engage in unhealthy behaviors. Children who are already overweight and suffer from low self esteem are more likely to over-eat which will further exacerbate their obesity(31).

Children may also not fully understand what the BMI index means. Children as young as six are receiving these BMI report cards, and the BMI report card does not offer an explanation of what a high BMI means in terms that a six year old could understand. Children who do not understand whet the BMI index really is may feel that they are being chastised for being overweight as the BMI report comes home in the form of a report card. This may lead the children to drastically and dangerously cut down on their caloric intake or to stop eating all together(32).

The BMI index may also cause children who are categorized as ‘normal weight’ or ‘underweight’ to engage in unhealthy behaviors. Children are aware that there is a social bias against ‘fat’ people and they may do whatever they think is necessary to avoid being labeled as ‘fat’(33). This may encourage children who are not overweight to engage in unhealthy weight control behavior in order to avoid a ‘bad’ report card.

Summary of BMI Report Card Failures

While the BMI Report card was designed with the best of intentions, it does not provide tools for the child to address their weight issues. In 2007 Arkansas released its fourth annual report that discussed its program to address childhood obesity which included the BMI report card. This report showed that since 2003, the program has had no effect on reducing childhood obesity as there has been no change in the percentage of children whose BMIs fell into the ‘overweight’ or ‘at-risk-for-overweight’(34). In 2003 when the program began, about 20% of Arkansas children were classified as ‘overweight’ and 17% as ‘at-risk-for-overweight’, and those percentages remained the same in 2007. By not providing tools that promote self efficacy or address the social context that the child is in, the BMI report card will not be able to successfully address childhood obesity. In fact, by sending home the report card, the intervention may have a negative impact on the health of both normal weight and overweight children as the fat label is not conducive to performing the desired healthy behaviors. For the BMI report card to be successful it will need to address these issues.

Alternate Intervention

The BMI report card has many issues that makes it ineffective at addressing the childhood obesity epidemic. For an alternate intervention to be effective it will need to address all of the failings of the BMI report card. When developing an effective intervention it will need to address self efficacy, the social environment of the child and labeling in order for the intervention reach its intended goal of having children engage in healthy behaviors.

Since a child spends time both at school and at home, both of these environments need to support the child in their healthy behaviors. If the school were to offer a program that both the children and the parents attended then the parents would be involved in the behavior which is important for the child’s success in executing the behaviors. Schools have parent teacher conferences, usually during the fall and spring semester, and during that time the school should also have a panel of health professionals available to speak with both the children and the parents. The professionals should include a nutritionist, an exercise professional, a psychiatrist and a public health professional available who can tell the families what support program there are in their local community, such as programs that will help them get healthy food, where they can exercise and other publicly funded programs that will help them lead healthy lives. Each family will sit down with the panel on a one on one basis so that the panel can address the specific needs of each family. The family will also be provided with information that they can take home with them. Given that many parents work, the conference needs to take place not only during the day, but there needs to be an evening and weekend option as well. Each panel will also need to be trained so as to be able to appropriately address the needs of the different communities that each school is located in. The children who go to schools in upper class neighborhoods will have different experiences than the children who live in inner city neighborhoods and each panel needs to be trained as to recognize and work with those differences. With the wealth of information both the parents and the children will be able to work together to support the child’s healthy habits.

This information will also allow the child to make healthy decisions when not at home, like how to choose healthy food at school. As part of this intervention the school needs to provide the children with avenues in which they can use their new knowledge to generate positive results. As part of this program the school should design its school lunch menu and physical education so that healthy food options are offered at lunch and so that the children have multiple opportunities to exercise.

How The Alternate Intervention Addresses Self -Efficacy

According to the Social Cognitive theory, perceived self-efficacy plays a very influential role in personal motivation (12). People who believe that can execute a behavior are more likely to be successful in doing so. This belief is strengthened when the child is given the opportunity to gain mastery of experience. The reason that the alternate intervention is an improvement is that it offers the child tools so that they can execute healthy behaviors and gain mastery of experience. After attending the panel the child will know how to make the right food choices and how to find ways to exercise based on their own individual experiences. When they are able to make those decisions they will feel empowered and then will be more likely to make those decisions again in the future.

The new intervention also will provide the parents will the tools to help support the child’s self efficacy. If the parents are able to support the child’s healthy decisions the child will be more likely to be successful which, again, will support the child’s self efficacy. The school will also provide avenue that will promote the child’s self efficacy as by having healthy food to choose from and effective physical education programs the child will be successful in executing the healthy behavior at school which will also boost their mastery of experience and therefore their self efficacy. With both the home environment and the school environment supporting the child’s self efficacy the child is much more likely to be successful.

How The Alternate Intervention Addresses The Social Level Issues

Another problem with the BMI report card is that it is an individual level model and does not take into consideration the child’s environment. The alternate model is an improvement as it incorporates the child’s family in the intervention. As indicated by the Social Network theory, what determines an individual’s behavior is the behavior of other people in their social network (19). What this means is, that if the parents are acting in a healthy manner, it is more likely the child will do the same. If the family is involved in the intervention and given the tools to engage in healthy behaviors then it is much more likely that the child will do the same. This intervention provides the family with the tools to engage in healthy behaviors which will have a positive influence on the child’s behavior.

One of the main problems with the BMI report card is that it does not recognize that healthy behaviors happen in the context of many other behaviors. On Maslow's Hierarchy of Needs health is a higher level need than other needs such as shelter (23). If the lower level needs are not met then it will not be possible to meet the higher level needs. As the panel will include a public health professional to assist the family with finding programs that will help them address the lower level needs it will be a more successful intervention than the BMI report card. This professional can help the family find inexpensive housing and other public assistance program that may be available to them. With this information it will be easier to meet the needs lower on the hierarchy and when those needs are met they will be able to address higher needs on the hierarchy, such as health.

Children also have many worries that may prevent them from participating in healthy behaviors. One of the steps on Maslow’s Hierarchy of Needs is self esteem and overweight children can struggle with their self esteem which would make it harder for them to attend to higher level needs such health. The problem with the BMI report card is that it offers no skills to help the child feel better about themselves, which is one of the reasons that it is not a successful intervention. The school based health panel will have a psychiatrist on it that will help the child address any self esteem issue that they may have. If the child feels better about themselves they will be more likely to engage in healthy behaviors which will also help to boost their self esteem.

Another problem with the BMI report card is that it does not recognize ethnic and SES differences. Children may face unique challenges based on their SES or ethnic profile and the BMI report card does not offer any tools to address these challenges. The advantage if this alternate intervention will try to address theses challenges. The health panel will be trained to help families navigate their SES environment and be trained to be culturally sensitive. As each family will meet with the panel one on one, the family can be given tools that specifically address their SES and ethnic needs.

How The Alternate Intervention Addresses Labeling

According to Labeling theory the labels that are applied to people influence their behavior, in particular the application of negative or stigmatizing labels (30). The problem with the BMI report card is that it gives a label to each child. If the child believes that there is nothing they can do after they have been labeled ‘fat’ then they will not engage in healthy behaviors which may help address the problem. On the other end of the scale, a child who has not been labeled as ‘fat’ could be so worried about being labeled ‘fat’ that they engage in unhealthy behaviors to avoid becoming labeled ‘fat’. The alternate intervention is an improvement because when the family meets with the panel they will not be labeling the child, just offering tools to live a healthy life style. All children will meet with the panel no matter what their weight so there will not be a negative stigma associated with going to the panel. If the child is not labeled then it can not negatively influence the child’s behavior.


The BMI report card is not sufficient for addressing the growing epidemic of childhood obesity. This alternate intervention does not have the failing of the BMI report card and therefore would likely realize greater success. This new model addresses self efficacy, the social environment and labeling theory and by doing so will help the child execute healthy behaviors so the child can live a healthier life.


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