Why BMI Report Cards Fail To Curb Childhood Obesity In Schools: Criticisms Centered On Biopsychosocial Theory – Tom Eliopoulos
Introduction
Obesity has been a growing concern in America for over 20 years, as evidenced by the fact that forty-nine states had an obesity prevalence factor of over 20% in 2007 (1). These figures beg the question of what should be done to address this growing trend. Is anyone actually responsible for curbing childhood obesity in America? And if so how far should they go? A conclusion has yet to be reached, but in the mean time a number of people seem to think that middle schools and high schools offer a good forum to address the nation’s problem. A recent approach that schools in over seven are using is Body Mass Index report cards (2, 3). These are special reports sent home regularly or along with a child’s grades that alert them and parents of a child’s seeming health status. This approach is quite flawed when considered in light of the prominent Biopsychosocial model for health and illness set forth throughout the social sciences. This model purports that biological, psychological, and social factors all play a part in determining the outcome of an illness or disease (4). In scrutinizing the flaws of this intervention, I will consider arguments involving each of the three components of this theory.
Biological Misconceptions
From a biological perspective, this approach makes little sense because adolescents have not yet stopped growing, and assessing them by their body mass index is an inappropriate assessment of health status. Further, studies which have explored the variability of body mass index in children have found that this measurement actually suggests that the BMI measure used to assess fatness in children may be under-estimating the true prevalence of the problem (5). This is because the same BMI measure of fat index can reflect a wide range of different values of body fat and fat free mass. In addition, according to Shape Up America! even small errors in measuring height or weight can significantly affect the BMI index, and can easily reflect inaccurate standings as overweight or non-overweight (6). Under this doctrine, then, a perfectly active and in-shape person would be considered to have a high BMI if their height and weight don’t fit properly into the charts.
Continuing with this issue, in 2005 a Fox News special report aired to investigate the use of BMI index as an accurate indicator of health. Their study found that using this index as a reference, nearly 200 of the 426 basketball players in the National Basketball Association (NBA) would be approaching overweight status and a good number would be considered overweight (14). This highlights the fact that BMI does not account for weight due to muscle gains. In fact, this report clearly illustrates the extent to which BMI is inaccurate as a biological indicator of health.
There is also evidence to suggest that onset of puberty can affect weight, and such gains are healthy or normal. In this respect, issuing BMI score reports would not only reflect a flawed strategy but also one that is not even appropriate to apply for many adolescents, especially girls. One study found that even cross-culturally weight gain is a normal derivative effect of puberty for young girls and there is much individual variability based on when these biological developments occur (13).
Psychological Issues
In terms of the psychological approach found in this intervention, there are several reasons why it is flawed. This is the case first in terms of the child’s conception of themselves as overweight individuals. Sending home reports to families that a child has a weight problem sets a tone within their family and educational setting that facilitates harboring negative perceptions about themselves. What is more, is that these reports are sent home even where a child may seem to be approaching a weight spike or a slight weight gain which unduly causes alarm for all parties concerned. A recent study examined this phenomenon in 16,314 individuals and found that the perception that one was overweight in itself presented a significant barrier to engaging in exercise and physical activity in overweight people (7). Further, these reports effectively cause these children to consistently evaluate themselves in terms of their weight status in reference to their community. A study of overweight adolescents found that those who were surrounded by a daily environment with obese people would start to develop inaccurate perceptions of what it is to actually be overweight (8). In other words, they begin their psychological baseline data changes about what obese people actually look like. As a logical extension of this reasoning, standard BMI reports inaccurately labeling children as overweight or on the verge of obesity—when really they are not— will serve a similar function. Where this practice causes children to believe that they have a serious weight problem and improperly incorporate normal-weight peers into their internal reference model for obesity is cause for great alarm.
Additionally, the psychological effect of a child perceiving themselves as overweight or inadequate in some way will inevitably affect their self-esteem in a very negative way. It is quite reasonable to presume that a young child receiving a report from school that they are obese fits these criteria. A study of adolescents showed that they associated weight gain, as defined by BMI, with perceptions of being overweight which in turn resulted in depression and lowered self-esteem (9). Another study surveyed 80 twelve-year-old girls and found that those with higher BMI indexes had significantly lower measures of self-esteem and self-concept as compared to girls with lower BMIs (16). Adolescence is riddled with emotional milestones and awkward developments enough to foster many opportunities for lowered self-esteem and depression, and there is no reason that schools should introduce another variable into the mix by instituting BMI report cards as an attempt at intervention with data so evidencing the practice as psychologically counter-productive in children.
Social Problems
Social factors are grounds for another crucial set of reasons why BMI report cards represent a flawed intervention strategy. One of the biggest obstacles adolescents face in middle and high schools is trying to fit in. This is universal. Part of this challenge emanates from ridicule by peers. Implementing BMI report cards merely provides another way for children to ridicule one another and sets up a forum for further social detriment within the educational setting. One author documents this phenomenon, explaining how bullying and harassment are directly linked to reduced self-esteem in children (10). The article correctly describes how practices, such as this, inevitably lead to a hostile school environment and one in which these overweight children become the product of discrimination. Issuing BMI reports will serve only to strengthen and highlight the differences between adolescents and create dangerous settings in which obesity may no longer be the biggest risk that these children face. Still another study investigated the stigmatization of overweight and non-overweight Mexican children by their mothers and peers, finding that those mothers who were normal weight tended to choose a picture of the non-obese person as the preferred friend for their child over an overweight person in a significant way (15). The results of this study illustrate the extent to which mothers’ negative attitudes towards obesity are projected onto their children and is an important consideration here where BMI is used as the measure for social norms.
Furthermore, such stigmatizations by peers are likely to lead to a preoccupation with being thin and significant social pressures as well (11). By dramatically emphasizing weight status through BMI reports, as opposed to fitness or leading a healthy lifestyle, this strategy puts adolescents at a higher risk for developing eating disorders such as anorexia or bulimia.
Another problem with schools pre-occupying themselves with weight is that it will also serve to propagate a divide among students with respect to SES. By this I would suggest that lower SES families have less money to spend on healthy diets for their children and so are more likely to choose unhealthy option like fast food more often than a student from a higher SES family who can afford meals from Whole Foods. A related study, which examined the association between frequency of family meals and weight status in 4-9 year olds, found that those who ate very few family meals had a significantly greater risk for being overweight during middle childhood (12). These differences are brought to light more readily via this intervention, where these low SES children who consequently must each more such convenience foods are systematically labeled and discriminated against by their peers and school officials because of their weight.
Remarks
An approach conforming to Biopsychosocial theory is by far the most comprehensive method for tackling the growing problem of childhood obesity in our country’s elementary education institutions. The “BMI Report Card” intervention strategy is flawed in a number of important ways that ignore biological underpinnings and psychological implications as they relate to children and their weight or perceived body image and self-esteem. This tactic is most fundamentally flawed in that BMI is not an appropriate measure of fitness or health status in the least, and even neglects consideration of muscle gains in its analyses. Most striking though was the intervention’s complete disregard for the destructive social norms and environment that these institutions were fostering among student-peers by placing such importance on weight—as opposed to fitness or health. Before any future strategy is implemented to address the concern of the rising number of overweight children in American schools, it must make doubly certain that; the biology behind it is correct, the intervention does not cause unnecessary psychological stress, and that it can be achieved in a way that does not exacerbate social injustices and discrimination.
REFERENCES
1. Department of Health and Human Services. U.S. Obesity Trends 1985-2007. Atlanta, Georgia: Centers for Disease Control and Prevention. http://www.cdc.gov
2. ABC News. The Battle of the Bulge at Schools. Drexel Hill, PA; ABC News. http://abcnews.go.com/Nightline/Story?id=2889317&page=1
3. The New York Times. As Obesity Fight Hits Cafeteria, Many Fear a Note from School. New York, NY: NYTimes.com. http://www.nytimes.com/2007/01/08/health/08obesity.html
4. ConneXions. The Biopsychosocial Model of Health and Illness. http://cnx.org/content/m13589/1.2/
5. Wells J. The Contribution of Fat and Fat-free Tissue to Body mass Index in Contemporary Children and the Reference Child. International Journal of Obesity 2002; 10: 1323-1328.
6. Shape Up America!. Childhood Obesity Assessment Calculator. http://www.shapeup.org
7. Atlantis E. Weight status and perception barriers to healthy physical activity and diet behavior. International Journal of Obesity 2008; 32: 343-352.
8. Maximova A. Do you see what I see? Weight status misperception and exposure to obesity among children and adolescents. International Journal of Obesity 2008; 32: 1008-1015.
9. Xiaojia G. Pubertal Transitions, Perceptions of Being Overweight, and Adolescents' Psychological Maladjustment: Gender and Ethnic Differences. Social Psychology Quarterly 2001; 64: 363-375.
10. Meyer J. Obesity Harassment in School: Simply 'Teasing' Our Way to Unfettered Obesity Discrimination and Stripping Away the Right to Education. Law & Inequality 2005; 23: 429-454.
11. Agras S. Childhood Risk Factors for Thin Body Preoccupation and Social Pressure to Be Thin. American Academy of Child and Adolescent Psychiatry 2007; 2: 171-178.
12. Rollins B. Family Meal Frequency and Weight Status in Young Children. Annals of Epidemiology 2007; 9: 745-745.
13. Britton J. Characteristics of pubertal development in a multi-ethnic population of nine-year-old girls. Annals of Epidemiology 2004; 3: 179-179.
14. Fox News. Athlete Study Exposes Flaw of BMI Obesity Measure. FoxNews.com. http://www.foxnews.com/story/0,2933,149807,00.html.
15. Bacardi-Gascón M. Stigmatization of Overweight Mexican Children. Child Psychiatry and Human Development 2007; 2: 99-105.
16. O’Dea J. Self-concept, Self-esteem and Body Weight in Adolescent Females. Journal of Health Psychology.
Campaign For A Healthier Tomorrow: A Better Intervention For Getting America’s Schoolchildren Back In Shape – Tom Eliopoulos
Introduction
The Biosychosocial model, originally posited by psychiatrist George Engel in 1977, presents a comprehensive approach for tacking issues of health and illness by considering the role biological, psychological, and social factors play in the condition (4). Having established that the ‘BMI report card intervention’ offers a flawed approach with regard to this popular social science model, the next step is to suggest a better program for schools to deal with their concern over students’ risk for childhood and adolescent obesity. The following approach addresses some of the flaws of the current intervention and lays out a three-fold plan for encouraging adolescents to start leading healthier lifestyles. By encouraging proper assessment techniques, individuality, and a culture of exercise within school settings this approach offers a comprehensive program to help today’s youth circumvent some of the negative health outcomes associated with obesity and inactivity.
Rethinking Biological Indicators
BMI is already been established as an incomplete assessment for risk of obesity in children and adolescents (5, 6, 13, 14). It cannot account for muscle mass, and is based solely on height and weight measurements. A more accurate indicator for monitoring this problem is waistline measures or waist-to-hip ratio (17). Studies at Harvard and Tufts Universities both issued reports confirming studies that showed that the size of one’s waist was a better predictor of heart disease and diabetes than BMI (18, 19). This is important because obesity is not what schools are worried about—it is the detrimental health effects of this condition like diabetes and cardiovascular strain that are the matters of concern. Thus, as a better way to monitor these health risks, a better intervention would use waistline measurements rather than BMI as its assessment method and my improved approach proposes just that.
Besides these indicators, an essential part of the biology of healthy living involves the food that people consume. Despite school concern over keeping adolescents from becoming overweight— the ‘BMI report card intervention’ did nothing productive to advance the cause, and served only to monitor it. Numerous studies and articles have detailed the significant role that healthier and more frequent eating behaviors play in maintaining a healthy body and self (24). A better intervention would have schools take a more proactive approach to address their concerns, and re-work school menus to include healthier foods or even replace the three-meal system with one where small snacks are served several times throughout the day.
Controlling for Adolescent Self-Deprecation
Another major flaw of the ‘BMI report card intervention’ was that issuing such reports placed weight-status at the forefront of these children’s consciousness, and as such caused psychological stress and feelings of inferiority from quantitatively comparing themselves to their peers (7, 8, 9, 16). A better intervention would address this problem directly by using a system that emphasizes individuality and goal-setting in its approach. Research has shown that where adolescents believe that they can accomplish the goals set before them, such as ones they set for themselves, that they are more likely to actually achieve them (23). Thus an improved approach would enlist adolescents to meet with a nutritionist hired by their school to develop some realistic fitness goals, a timeframe, and a plan for working towards those goals. Such an approach would instead focus adolescents’ attentions upon their own progress and cause them to evaluate themselves based on their own criteria—de-polarizing the importance of peer-to-peer comparisons and associated psychological stresses.
Further, another concern was that labeling a child as overweight could cause them to misinterpret their weight status compared to their community and put them at risk for eating disorders like anorexia. For an improved intervention strategy, I would suggest incorporating the method of bibliotherapy. Bibliotherapy refers to the use of books to help people understand and solve their problems – weight loss in this case (21). In combining these personalized fitness plans with bibliotherapy, this approach offers a superior intervention with regard to psychological matters. Further, studies have shown that where bibliotherapy is introduced into a bold weight loss program, these people experienced enhanced weight loss results (20). Other research has shown that bibliotherapy is particularly useful for developing an individual's self-concept, fostering an individual's honest self-appraisal, and helping an individual plan a constructive course of action to solve their problems (22). This combined approach offers an all around better alternative to the current intervention in a way that is more sensitive to the psychological well-being of adolescents—one where they learn the facts about leading a healthy lifestyle, set realistic goals as individuals, and work towards them at a self-defined pace.
Bridging Social Divides and Championing Stigmatization
A third major flaw of these schools’ method was that broadcasting BMI scores to parents and adolescents creates an environment that enables harmful social stigmatizations involving weight, SES, and even peer associations (10, 11, 12, 15). Therefore, the third component of my improved approach calls for schools to develop an culture where general healthfulness is encouraged, rather than weight loss, and infuse that mentality into the school’s day-to-day operations. This shift in thought will create a world of difference and will be less taxing on children’s self-esteem because health is a long term goal, and not a number that fluctuates daily (27). This can be accomplished by offering a multitude of opportunities for physical activity throughout the day during study halls, lunch breaks, and before and after school. For example, a teacher may lead a fun-run during a free period or yoga during lunchtime as they do in the BU School of Public Health. It is also important that some non-demanding physical opportunities are offered so that anyone, regardless of weight status, could find an activity that they can enjoy as exercise and that speaks to their particular level of fitness. One study involving HIV-positive Latino men addressed this same approach to stigmatization. The study found that community involvement seems to compensate for the associations between stigma and depression (25). In other words, creating a culture where individuals were more involved in an issue, such as health and exercise culture in schools, seems to have the effect of reducing stigmatizations. Another study found that social support and cohesion, attitude, and perceived behavioral control all influenced the extent to which individuals adhered to exercise plans (26). By designing their own fitness plan and setting realistic goals with the school nutritionist, it is likely that adolescents will perceive themselves as having more control over their behavior. However, with faculty and students coming together to create a network of support and excitement around fitness it is much more likely that these children will stick with their individual fitness plans and accomplish their health goals.
Concluding Remarks
This intervention is superior in that it assesses health using a more appropriate technique focusing on fitness, not weight, and allows adolescents to set their own fitness goals and learn the truth about nutrition to avoid stressful peer-to-self comparisons. It is also superior to the ‘BMI Report Card’ intervention because it attempts to foster a supportive school environment where there are physical activities for students at all fitness levels and the faculty partner with students in these fitness efforts. This comprehensive approach, founded on the social science’s popular Biopsychosocial model for health would be a firm step in the right direction. By keeping our children healthy now and teaching them the skills they need to continue living healthy in the future, Americans may have a fighting chance at curbing the obesity epidemic that has swept our nation by storm.
REFERENCES
1. Department of Health and Human Services. U.S. Obesity Trends 1985-2007. Atlanta, Georgia: Centers for Disease Control and Prevention. http://www.cdc.gov
2. ABC News. The Battle of the Bulge at Schools. Drexel Hill, PA; ABC News. http://abcnews.go.com/Nightline/Story?id=2889317&page=1
3. The New York Times. As Obesity Fight Hits Cafeteria, Many Fear a Note from School. New York, NY: NYTimes.com. http://www.nytimes.com/2007/01/08/health/08obesity.html
4. ConneXions. The Biopsychosocial Model of Health and Illness. http://cnx.org/content/m13589/1.2/
5. Wells J. The Contribution of Fat and Fat-free Tissue to Body mass Index in Contemporary Children and the Reference Child. International Journal of Obesity 2002; 10: 1323-1328.
6. Shape Up America!. Childhood Obesity Assessment Calculator. http://www.shapeup.org
7. Atlantis E. Weight status and perception barriers to healthy physical activity and diet behavior. International Journal of Obesity 2008; 32: 343-352.
8. Maximova A. Do you see what I see? Weight status misperception and exposure to obesity among children and adolescents. International Journal of Obesity 2008; 32: 1008-1015.
9. Xiaojia G. Pubertal Transitions, Perceptions of Being Overweight, and Adolescents' Psychological Maladjustment: Gender and Ethnic Differences. Social Psychology Quarterly 2001; 64: 363-375.
10. Meyer J. Obesity Harassment in School: Simply 'Teasing' Our Way to Unfettered Obesity Discrimination and Stripping Away the Right to Education. Law & Inequality 2005; 23: 429-454.
11. Agras S. Childhood Risk Factors for Thin Body Preoccupation and Social Pressure to Be Thin. American Academy of Child and Adolescent Psychiatry 2007; 2: 171-178.
12. Rollins B. Family Meal Frequency and Weight Status in Young Children. Annals of Epidemiology 2007; 9: 745-745.
13. Britton J. Characteristics of pubertal development in a multi-ethnic population of nine-year-old girls. Annals of Epidemiology 2004; 3: 179-179.
14. Fox News. Athlete Study Exposes Flaw of BMI Obesity Measure. FoxNews.com. http://www.foxnews.com/story/0,2933,149807,00.html
15. Bacardi-Gascón M. Stigmatization of Overweight Mexican Children. Child Psychiatry and Human Development 2007; 2: 99-105.
16. O’Dea J. Self-concept, Self-esteem and Body Weight in Adolescent Females. Journal of Health Psychology 2006; 4: 599-611.
17. Barclay L. Waist Girth Predicts Cardiovascular Risk Better than BMI. MedScape Medical News 2002. http://www.medscape.com/viewarticle/441804
18. Waist better than weight as measure of health risk. Harvard Women’s Health Watch 2003; 5: 1.
19. Waist-to-Hip Ratio Predicts Heart Risk Better than BMI. Tufts University Health & Nutrition Letter 2006; 11: 1-2.
20. Klem M. Competition in a minimal-contact weight-loss program. Journal of Consulting and Clinical Psychology 1988; 1: 142-144.
21. Holistic Online. Depression: Bibliotherapy. HolisticOnline.com. http://www.holisticonline.com/remedies/Depression/dep_bibliotherapy.htm
22. Aiex N. Bibliotherapy. ERIC Clearinghouse on Reading, English, and Communication Digest 2003; 83.
23. Lambert M. Positive psychology and the humanistic tradition. Journal of Psychotherapy Integration 2008; 18: 222-232.
24. Neumann K. Reach your Feel Great Weight!. Health 2008; 4: 108-115.
25. Valles J. Confronting Stigma: Community Involvement and Psychological Well-Being Among HIV-Positive Latino Gay Men. Hispanic Journal of Behavioral Sciences 2005; 1: 101-109.
26. Courneya K. Cognitive mediators of the social influence-exercise adherence relationship: A test of the theory of planned behavior. Journal of Behavioral Medicine 1995; 5: 499-515.
27. Tiggemann M. The Effect of Exercise on Body Satisfaction and Self-Esteem as a Function of Gender and Age. Sex Roles 2000; 1-2: 119-127.
Obesity has been a growing concern in America for over 20 years, as evidenced by the fact that forty-nine states had an obesity prevalence factor of over 20% in 2007 (1). These figures beg the question of what should be done to address this growing trend. Is anyone actually responsible for curbing childhood obesity in America? And if so how far should they go? A conclusion has yet to be reached, but in the mean time a number of people seem to think that middle schools and high schools offer a good forum to address the nation’s problem. A recent approach that schools in over seven are using is Body Mass Index report cards (2, 3). These are special reports sent home regularly or along with a child’s grades that alert them and parents of a child’s seeming health status. This approach is quite flawed when considered in light of the prominent Biopsychosocial model for health and illness set forth throughout the social sciences. This model purports that biological, psychological, and social factors all play a part in determining the outcome of an illness or disease (4). In scrutinizing the flaws of this intervention, I will consider arguments involving each of the three components of this theory.
Biological Misconceptions
From a biological perspective, this approach makes little sense because adolescents have not yet stopped growing, and assessing them by their body mass index is an inappropriate assessment of health status. Further, studies which have explored the variability of body mass index in children have found that this measurement actually suggests that the BMI measure used to assess fatness in children may be under-estimating the true prevalence of the problem (5). This is because the same BMI measure of fat index can reflect a wide range of different values of body fat and fat free mass. In addition, according to Shape Up America! even small errors in measuring height or weight can significantly affect the BMI index, and can easily reflect inaccurate standings as overweight or non-overweight (6). Under this doctrine, then, a perfectly active and in-shape person would be considered to have a high BMI if their height and weight don’t fit properly into the charts.
Continuing with this issue, in 2005 a Fox News special report aired to investigate the use of BMI index as an accurate indicator of health. Their study found that using this index as a reference, nearly 200 of the 426 basketball players in the National Basketball Association (NBA) would be approaching overweight status and a good number would be considered overweight (14). This highlights the fact that BMI does not account for weight due to muscle gains. In fact, this report clearly illustrates the extent to which BMI is inaccurate as a biological indicator of health.
There is also evidence to suggest that onset of puberty can affect weight, and such gains are healthy or normal. In this respect, issuing BMI score reports would not only reflect a flawed strategy but also one that is not even appropriate to apply for many adolescents, especially girls. One study found that even cross-culturally weight gain is a normal derivative effect of puberty for young girls and there is much individual variability based on when these biological developments occur (13).
Psychological Issues
In terms of the psychological approach found in this intervention, there are several reasons why it is flawed. This is the case first in terms of the child’s conception of themselves as overweight individuals. Sending home reports to families that a child has a weight problem sets a tone within their family and educational setting that facilitates harboring negative perceptions about themselves. What is more, is that these reports are sent home even where a child may seem to be approaching a weight spike or a slight weight gain which unduly causes alarm for all parties concerned. A recent study examined this phenomenon in 16,314 individuals and found that the perception that one was overweight in itself presented a significant barrier to engaging in exercise and physical activity in overweight people (7). Further, these reports effectively cause these children to consistently evaluate themselves in terms of their weight status in reference to their community. A study of overweight adolescents found that those who were surrounded by a daily environment with obese people would start to develop inaccurate perceptions of what it is to actually be overweight (8). In other words, they begin their psychological baseline data changes about what obese people actually look like. As a logical extension of this reasoning, standard BMI reports inaccurately labeling children as overweight or on the verge of obesity—when really they are not— will serve a similar function. Where this practice causes children to believe that they have a serious weight problem and improperly incorporate normal-weight peers into their internal reference model for obesity is cause for great alarm.
Additionally, the psychological effect of a child perceiving themselves as overweight or inadequate in some way will inevitably affect their self-esteem in a very negative way. It is quite reasonable to presume that a young child receiving a report from school that they are obese fits these criteria. A study of adolescents showed that they associated weight gain, as defined by BMI, with perceptions of being overweight which in turn resulted in depression and lowered self-esteem (9). Another study surveyed 80 twelve-year-old girls and found that those with higher BMI indexes had significantly lower measures of self-esteem and self-concept as compared to girls with lower BMIs (16). Adolescence is riddled with emotional milestones and awkward developments enough to foster many opportunities for lowered self-esteem and depression, and there is no reason that schools should introduce another variable into the mix by instituting BMI report cards as an attempt at intervention with data so evidencing the practice as psychologically counter-productive in children.
Social Problems
Social factors are grounds for another crucial set of reasons why BMI report cards represent a flawed intervention strategy. One of the biggest obstacles adolescents face in middle and high schools is trying to fit in. This is universal. Part of this challenge emanates from ridicule by peers. Implementing BMI report cards merely provides another way for children to ridicule one another and sets up a forum for further social detriment within the educational setting. One author documents this phenomenon, explaining how bullying and harassment are directly linked to reduced self-esteem in children (10). The article correctly describes how practices, such as this, inevitably lead to a hostile school environment and one in which these overweight children become the product of discrimination. Issuing BMI reports will serve only to strengthen and highlight the differences between adolescents and create dangerous settings in which obesity may no longer be the biggest risk that these children face. Still another study investigated the stigmatization of overweight and non-overweight Mexican children by their mothers and peers, finding that those mothers who were normal weight tended to choose a picture of the non-obese person as the preferred friend for their child over an overweight person in a significant way (15). The results of this study illustrate the extent to which mothers’ negative attitudes towards obesity are projected onto their children and is an important consideration here where BMI is used as the measure for social norms.
Furthermore, such stigmatizations by peers are likely to lead to a preoccupation with being thin and significant social pressures as well (11). By dramatically emphasizing weight status through BMI reports, as opposed to fitness or leading a healthy lifestyle, this strategy puts adolescents at a higher risk for developing eating disorders such as anorexia or bulimia.
Another problem with schools pre-occupying themselves with weight is that it will also serve to propagate a divide among students with respect to SES. By this I would suggest that lower SES families have less money to spend on healthy diets for their children and so are more likely to choose unhealthy option like fast food more often than a student from a higher SES family who can afford meals from Whole Foods. A related study, which examined the association between frequency of family meals and weight status in 4-9 year olds, found that those who ate very few family meals had a significantly greater risk for being overweight during middle childhood (12). These differences are brought to light more readily via this intervention, where these low SES children who consequently must each more such convenience foods are systematically labeled and discriminated against by their peers and school officials because of their weight.
Remarks
An approach conforming to Biopsychosocial theory is by far the most comprehensive method for tackling the growing problem of childhood obesity in our country’s elementary education institutions. The “BMI Report Card” intervention strategy is flawed in a number of important ways that ignore biological underpinnings and psychological implications as they relate to children and their weight or perceived body image and self-esteem. This tactic is most fundamentally flawed in that BMI is not an appropriate measure of fitness or health status in the least, and even neglects consideration of muscle gains in its analyses. Most striking though was the intervention’s complete disregard for the destructive social norms and environment that these institutions were fostering among student-peers by placing such importance on weight—as opposed to fitness or health. Before any future strategy is implemented to address the concern of the rising number of overweight children in American schools, it must make doubly certain that; the biology behind it is correct, the intervention does not cause unnecessary psychological stress, and that it can be achieved in a way that does not exacerbate social injustices and discrimination.
REFERENCES
1. Department of Health and Human Services. U.S. Obesity Trends 1985-2007. Atlanta, Georgia: Centers for Disease Control and Prevention. http://www.cdc.gov
2. ABC News. The Battle of the Bulge at Schools. Drexel Hill, PA; ABC News. http://abcnews.go.com/Nightline/Story?id=2889317&page=1
3. The New York Times. As Obesity Fight Hits Cafeteria, Many Fear a Note from School. New York, NY: NYTimes.com. http://www.nytimes.com/2007/01/08/health/08obesity.html
4. ConneXions. The Biopsychosocial Model of Health and Illness. http://cnx.org/content/m13589/1.2/
5. Wells J. The Contribution of Fat and Fat-free Tissue to Body mass Index in Contemporary Children and the Reference Child. International Journal of Obesity 2002; 10: 1323-1328.
6. Shape Up America!. Childhood Obesity Assessment Calculator. http://www.shapeup.org
7. Atlantis E. Weight status and perception barriers to healthy physical activity and diet behavior. International Journal of Obesity 2008; 32: 343-352.
8. Maximova A. Do you see what I see? Weight status misperception and exposure to obesity among children and adolescents. International Journal of Obesity 2008; 32: 1008-1015.
9. Xiaojia G. Pubertal Transitions, Perceptions of Being Overweight, and Adolescents' Psychological Maladjustment: Gender and Ethnic Differences. Social Psychology Quarterly 2001; 64: 363-375.
10. Meyer J. Obesity Harassment in School: Simply 'Teasing' Our Way to Unfettered Obesity Discrimination and Stripping Away the Right to Education. Law & Inequality 2005; 23: 429-454.
11. Agras S. Childhood Risk Factors for Thin Body Preoccupation and Social Pressure to Be Thin. American Academy of Child and Adolescent Psychiatry 2007; 2: 171-178.
12. Rollins B. Family Meal Frequency and Weight Status in Young Children. Annals of Epidemiology 2007; 9: 745-745.
13. Britton J. Characteristics of pubertal development in a multi-ethnic population of nine-year-old girls. Annals of Epidemiology 2004; 3: 179-179.
14. Fox News. Athlete Study Exposes Flaw of BMI Obesity Measure. FoxNews.com. http://www.foxnews.com/story/0,2933,149807,00.html.
15. Bacardi-Gascón M. Stigmatization of Overweight Mexican Children. Child Psychiatry and Human Development 2007; 2: 99-105.
16. O’Dea J. Self-concept, Self-esteem and Body Weight in Adolescent Females. Journal of Health Psychology.
Campaign For A Healthier Tomorrow: A Better Intervention For Getting America’s Schoolchildren Back In Shape – Tom Eliopoulos
Introduction
The Biosychosocial model, originally posited by psychiatrist George Engel in 1977, presents a comprehensive approach for tacking issues of health and illness by considering the role biological, psychological, and social factors play in the condition (4). Having established that the ‘BMI report card intervention’ offers a flawed approach with regard to this popular social science model, the next step is to suggest a better program for schools to deal with their concern over students’ risk for childhood and adolescent obesity. The following approach addresses some of the flaws of the current intervention and lays out a three-fold plan for encouraging adolescents to start leading healthier lifestyles. By encouraging proper assessment techniques, individuality, and a culture of exercise within school settings this approach offers a comprehensive program to help today’s youth circumvent some of the negative health outcomes associated with obesity and inactivity.
Rethinking Biological Indicators
BMI is already been established as an incomplete assessment for risk of obesity in children and adolescents (5, 6, 13, 14). It cannot account for muscle mass, and is based solely on height and weight measurements. A more accurate indicator for monitoring this problem is waistline measures or waist-to-hip ratio (17). Studies at Harvard and Tufts Universities both issued reports confirming studies that showed that the size of one’s waist was a better predictor of heart disease and diabetes than BMI (18, 19). This is important because obesity is not what schools are worried about—it is the detrimental health effects of this condition like diabetes and cardiovascular strain that are the matters of concern. Thus, as a better way to monitor these health risks, a better intervention would use waistline measurements rather than BMI as its assessment method and my improved approach proposes just that.
Besides these indicators, an essential part of the biology of healthy living involves the food that people consume. Despite school concern over keeping adolescents from becoming overweight— the ‘BMI report card intervention’ did nothing productive to advance the cause, and served only to monitor it. Numerous studies and articles have detailed the significant role that healthier and more frequent eating behaviors play in maintaining a healthy body and self (24). A better intervention would have schools take a more proactive approach to address their concerns, and re-work school menus to include healthier foods or even replace the three-meal system with one where small snacks are served several times throughout the day.
Controlling for Adolescent Self-Deprecation
Another major flaw of the ‘BMI report card intervention’ was that issuing such reports placed weight-status at the forefront of these children’s consciousness, and as such caused psychological stress and feelings of inferiority from quantitatively comparing themselves to their peers (7, 8, 9, 16). A better intervention would address this problem directly by using a system that emphasizes individuality and goal-setting in its approach. Research has shown that where adolescents believe that they can accomplish the goals set before them, such as ones they set for themselves, that they are more likely to actually achieve them (23). Thus an improved approach would enlist adolescents to meet with a nutritionist hired by their school to develop some realistic fitness goals, a timeframe, and a plan for working towards those goals. Such an approach would instead focus adolescents’ attentions upon their own progress and cause them to evaluate themselves based on their own criteria—de-polarizing the importance of peer-to-peer comparisons and associated psychological stresses.
Further, another concern was that labeling a child as overweight could cause them to misinterpret their weight status compared to their community and put them at risk for eating disorders like anorexia. For an improved intervention strategy, I would suggest incorporating the method of bibliotherapy. Bibliotherapy refers to the use of books to help people understand and solve their problems – weight loss in this case (21). In combining these personalized fitness plans with bibliotherapy, this approach offers a superior intervention with regard to psychological matters. Further, studies have shown that where bibliotherapy is introduced into a bold weight loss program, these people experienced enhanced weight loss results (20). Other research has shown that bibliotherapy is particularly useful for developing an individual's self-concept, fostering an individual's honest self-appraisal, and helping an individual plan a constructive course of action to solve their problems (22). This combined approach offers an all around better alternative to the current intervention in a way that is more sensitive to the psychological well-being of adolescents—one where they learn the facts about leading a healthy lifestyle, set realistic goals as individuals, and work towards them at a self-defined pace.
Bridging Social Divides and Championing Stigmatization
A third major flaw of these schools’ method was that broadcasting BMI scores to parents and adolescents creates an environment that enables harmful social stigmatizations involving weight, SES, and even peer associations (10, 11, 12, 15). Therefore, the third component of my improved approach calls for schools to develop an culture where general healthfulness is encouraged, rather than weight loss, and infuse that mentality into the school’s day-to-day operations. This shift in thought will create a world of difference and will be less taxing on children’s self-esteem because health is a long term goal, and not a number that fluctuates daily (27). This can be accomplished by offering a multitude of opportunities for physical activity throughout the day during study halls, lunch breaks, and before and after school. For example, a teacher may lead a fun-run during a free period or yoga during lunchtime as they do in the BU School of Public Health. It is also important that some non-demanding physical opportunities are offered so that anyone, regardless of weight status, could find an activity that they can enjoy as exercise and that speaks to their particular level of fitness. One study involving HIV-positive Latino men addressed this same approach to stigmatization. The study found that community involvement seems to compensate for the associations between stigma and depression (25). In other words, creating a culture where individuals were more involved in an issue, such as health and exercise culture in schools, seems to have the effect of reducing stigmatizations. Another study found that social support and cohesion, attitude, and perceived behavioral control all influenced the extent to which individuals adhered to exercise plans (26). By designing their own fitness plan and setting realistic goals with the school nutritionist, it is likely that adolescents will perceive themselves as having more control over their behavior. However, with faculty and students coming together to create a network of support and excitement around fitness it is much more likely that these children will stick with their individual fitness plans and accomplish their health goals.
Concluding Remarks
This intervention is superior in that it assesses health using a more appropriate technique focusing on fitness, not weight, and allows adolescents to set their own fitness goals and learn the truth about nutrition to avoid stressful peer-to-self comparisons. It is also superior to the ‘BMI Report Card’ intervention because it attempts to foster a supportive school environment where there are physical activities for students at all fitness levels and the faculty partner with students in these fitness efforts. This comprehensive approach, founded on the social science’s popular Biopsychosocial model for health would be a firm step in the right direction. By keeping our children healthy now and teaching them the skills they need to continue living healthy in the future, Americans may have a fighting chance at curbing the obesity epidemic that has swept our nation by storm.
REFERENCES
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Labels: Adolescent Health, Maternal and Child Health, Obesity, Orange
posted by Danielle Lawrence @ 6:29 PM
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