Monday, December 13, 2010

BMI Report Cards: Can Increasing Awareness Actually be a Negative Thing? – Britni-Lynne Brierly

Obesity is one of the most pressing health problems affecting children in the United States today. Recent studies have shown that levels of childhood obesity are currently over 30% in the United States (1). Obesity has been linked to asthma, type 2 diabetes, cardiovascular risk, sleep apnea, and elevated blood pressure (2-3). Although symptoms of some of these diseases will not show up until adulthood, childhood health greatly affects health in adulthood, suggesting that if obesity is not dealt with in childhood, a person is at a higher risk for a great number of diseases when they get older. In fact, 50% of overweight children are likely to become overweight adults (5). Therefore, it is necessary to combat obesity during childhood in hopes that being healthy as a child will positively affect a person’s health in the future.
Schools in several states, including Arkansas, California, Delaware, Massachusetts, Oklahoma, Pennsylvania, and Tennessee, have tried to combat the childhood obesity epidemic by issuing BMI report cards to their students along with their regular report cards (1). These ‘report cards’ tell a student’s body mass index as well as their BMI percentile (where they fit in relation to other students) (4). Supporters of BMI report cards argue that alerting parents that their children are at an unhealthy weight is the first step in getting a child’s weight under control. They point to statistics that show that parents are likely to underestimate their child’s weight status and therefore not realize that their child has a weight issue (6). Therefore, supporters argue, by sending these reports home to parents they are raising awareness about a child’s actual weight and encouraging parents to make the recommended lifestyle changes that will help their child lose weight (1).
However, research on the actual effectiveness of BMI report cards has proved that this intervention does not work as well as supporters had hoped. While the report cards may increase awareness of obesity, studies show that they do not lead to any significant change in health behavior that serves to decrease obesity levels (6). In fact, there may actually be negative consequences, such as negative labeling and stigmatization, associated with BMI report cards. These negative consequences could lead to obesity becoming a self-fulfilling prophecy in overweight children (7). Overall, the BMI report card public health intervention to attack childhood obesity is flawed because of its reliance on the Health Belief Model, the labeling of children as “overweight” and “obese,” and the lack of interventions targeting obesity at a school level.
BMI Report Cards Rely on the (Flawed) Health Belief Model
The Health Belief Model says that health-related behaviors depend on a number of factors occurring simultaneously in a person’s mind (8). By rationally weighing the perceived benefits and barriers of doing a certain behavior, a person will then form an intention to complete a behavior and subsequently engage in said behavior. A combination of two factors determines the perceived benefits of completing a behavior. These factors are the perceived severity of disease (in this case, obesity) and the perceived susceptibility to disease.
The idea behind BMI report cards is rooted heavily in the Health Belief Model for predicting changes in behavior. Supporters of BMI report cards say that when a parent is made aware that their child is at or above the 85th percentile in weight, they will use this information to make changes in their child’s health behaviors (4). Parents are now informed about the severity of the disease (their child is above the 85th percentile, so they are much higher than normal weight students) and the susceptibility to further complications because of the severity of their weight problems. Based on the Health Belief Model then, parents are able to make informed decisions about the benefits of changing health behaviors (their child will lose weight and thus become healthier) and weigh these benefits against potential barriers to changing behavior. The outcome should then be a desire to help their child make lifestyle changes and eventually lose weight. In an ideal, rational world, this model would accurately predict behavior intentions.
However, the Health Belief Model has a number of flaws that make it an ineffective model to base an intervention on. First, people may have the best of intentions, but simply having an intention to do something does not guarantee that a behavior will be done. A study done by Chomitz et al. in Cambridge, Massachusetts focused on BMI report cards and used quasi-experimental methods to evaluate the effectiveness of the BMI report card intervention. Students from four elementary schools were assigned to one of three conditions: (1) a personalized weight and fitness health report card intervention, (2) a general-information intervention, and (3) a control group. While the results of this study showed that the intervention groups did increase parents’ awareness of their child’s weight status, there was no significant difference in the actual health behavior of children in either of the intervention groups as compared to the control group (8). This data proves that although parents may be informed about their child’s health and have the intention to do the behaviors, there is not a significant link between the intention and the actual behavior. This suggests that simply telling people they need to change their behaviors will not lead to actual change.
A second flaw of the Health Belief Model is that it does not take social factors into consideration when trying to predict behavior (9). This model assumes that people make decisions based only on their thoughts and do not take peer influence and other social factors into consideration when making decisions. Research shows that this is not how behavior operates in everyday life. In fact, obesity seems to be related to social factors in the fact that it is “contagious” and that a child is more likely to become obese if they have a friend who is obese (10). The Health Belief Model does not take these social factors into consideration when predicting decisions that will be made and therefore it is flawed in accurately predicting behavior. Just because a parent has been informed that their child is obese does not mean that the parent’s knowledge about the child’s obesity will change the social factors that may, in fact, be contributing to the obesity. Also, research shows that having friends who are obese makes a person less likely to be unhappy about being obese (10). If a child who is obese has made friends over the years with other people “like him/her” he/she might be less likely to want to lose weight if it means risking losing a fellow obese friend. Since the Health Belief Model does not take these social factors into account when attempting to predict behavior, it is flawed at actually predicting the behavior.
BMI Report Cards Run the Risk of Negative Labeling
Labeling theory, developed by Howard Becker to describe the behaviors of criminals, posits that people are labeled when they deviate from the social norm (11). These labels are often negative and may lead to stigmatization which in turn leads to negative consequences for the labeled individual (12).
Link and Phelan describe the five components of stigma that develop from labeling in their article, “Stigma and its Public Health Interventions” (13). First, people identify and label human differences. With BMI report cards and obesity, overweight children have been identified and labeled as ‘different’ than their normal weight peers because of their weight. Second, the person’s ‘label’ must be linked to undesirable characteristics. People see obesity as an undesirable condition because of the negative health effects associated with being overweight. The third component of stigma involves the labeled group to be understood as ‘them’ while the rest of people are known as ‘us.’ Now, children who have been labeled as overweight by the BMI report cards are considered outcasts among their classmates simply because they have been given the label of being overweight. Next, people who have been labeled and subsequently stigmatized experience a loss of power and discrimination from those in the ‘us’ group. Not only are children who have been labeled overweight now part of an out-group, they are now being discriminated against because their ‘label’ goes against the social norms of not being overweight. Finally, the lack of power of the stigmatized group causes intense discrimination and social outcasting (13).
When children are given BMI report cards that report their body size in relation to their peers, these children may feel as though they are being labeled. Once a child has been labeled as ‘overweight’ or ‘obese,’ there are a number of negative consequences that can occur as a result. Attribution theory, a theory that says people search for the causes of any event or occurrence, may be present in labeling and be one of the reasons that labeling leads to negative outcomes (14). When people come across a certain event, especially one that does not fit into their ideas about social norms, they make either a situational or dispositional judgment about the reasons the event occurred. The reason this is problematic in the case of a child’s weight is because people are more likely to make dispositional attributions than situational attributions about the reasons the child is overweight. The fact that a person is overweight is blamed on internal, controllable reasons rather than situations in the environment when the latter might actually be the case (15). If a child is lead to believe that their weight is in their control and yet they still feel unable to do anything about it, this may lead to negative cognitions, low self-esteem, and other negative effects.
There are many other negative effects that stem from labeling a child as overweight. Once a child has this label and feels discriminated against, this lowering of their self-esteem may lead to eating disorders and other negative mental health issues (16). Children may have been labeled based on the number they were given on their BMI report card, but still, they may not even fully understand the number. This lack of insight that many people say they have about what the number on the BMI report card actually means can lead to feelings of helplessness in children and eventually negative feelings about themselves as a person.
The procedures for screening BMI in school may lead to lower self-esteem in adolescents. In a study examining the comfort level of school weight screening, more than 50% of overweight girls screened reported that they were uncomfortable with the screening procedures (17). This statistic shows that it is not only the issuing of the BMI report cards, but also the procedures used to measure BMI in schools, that lead to children’s negative feelings about themselves. Therefore, issuing these BMI report cards only serves to label children with a number that they might not fully understand and may eventually lead to discrimination by other children based on the label.
BMI Report Cards may be the only Attempt in Some Schools to Raise Awareness of Obesity
Many schools have begun to issue BMI report cards in the hope that parents will realize their child is overweight and make changes to fix this problem. However, as previous research has shown, this is not the case; even though BMI report cards may raise awareness of obesity, they have not been proven to change unhealthy behavior in any way (6). Schools may be trying to raise awareness of childhood obesity, but if they are not doing anything to combat the problem during school hours, the issuing of BMI report cards will not make a difference in the rates of obesity.
According to the Department of Health and Human Services, only 69.3% of elementary schools require some form of physical education during school hours. Only 13.7% of elementary schools provide physical education more than three days a week and only 3.8% provide daily physical education (18). However, the Center for Disease Control states that children should be getting at least an hour of physical activity per day (19). These statistics show that America’s elementary schools are clearly lacking sufficient levels of physical education for their students. What is the point, then, of issuing report cards that list a child as overweight if schools are not going to contribute to fixing that problem by setting time aside for children to be active and participate in group physical activity?
Another major factor that contributes to children being overweight is poor nutrition. Simply exercising is not enough to maintain a normal weight for some kids, and a healthy diet must be incorporated for the student to lose weight. Foods in school cafeterias do not usually meet healthy standards. Vending machines contain soda, candy, and chips, and ‘hot lunches’ are often fatty and cheaply made. If schools do not work to change the types of food they are exposing children to during the day, they are being hypocritical in sending BMI report cards home to parents. Even if a school gets through to a parent with the BMI report card and the parent changes the child’s health behaviors at home, if they are still exposed to unhealthy foods at school, the intervention cannot be completely effective. Schools must work to change their lunch menus and stock vending machines with healthier options.
Schools rely on district funds to issue the BMI report cards. Perhaps this money could be better spent on improving school lunches, expanding physical activity programs, or increasing availability of afterschool activities (2). The following interventions attempt to change curriculum at schools in order to promote healthy behaviors without hurting overweight children’s self-esteem.
There are many ways that schools could work to try and battle the childhood obesity epidemic that do not include labeling children with BMI report cards. If schools worked to make the educational environment a healthier place for children, hopefully children would extend the healthy behaviors they engage in at school to their home life as well. Issuing the BMI report cards takes money from school budgets that could be better spent on other programs (2). If BMI report cards were eliminated, districts could use the money saved to implement other, more effective interventions. Schools should work to increase the frequency of physical education classes, provide healthier food choices, and incorporate nutrition and health classes into the curriculum. If schools still decide it is necessary to issue BMI report cards to their students, there are many ways these reports can be improved to eliminate the risk of negative labeling and stigmatization.
Schools need to work to improve the amount of physical activity that students engage in during school hours. They could require students to participate at least three times a week in physical education during school hours. In addition, schools could expand their afterschool programs to include more physical activity that is interesting to students and would make them want to participate. This combination of in-school and after school exposure to physical activity would hopefully encourage students to become more active. However, schools should not require students to engage in afterschool activities because this requirement may have negative consequences. According to psychological reactance theory, when people feel told to do something, they may perceive this as a threat to their freedom and in response refuse to participate in the required act (20). Therefore, according to this theory, schools should encourage children to participate in after school physical activities by showing them that their peers are participating and giving them positive incentives to do so, but they should not strictly require children to participate.
Schools should develop nutrition and health classes to teach children about healthy behaviors. Children would work together in these classes to teach each other about living healthier lives and eating better. This portion of the new intervention would address one of the limitations of the Health Belief Model that the BMI report cards do not consider – social influence. By working together, kids increase their awareness about their peers and see them as a person rather than just an ‘overweight’ kid. Schools could use the jigsaw classroom to increase students’ awareness of each other. The jigsaw classroom theory, developed by Elliot Aronson, increases children’s empathy towards their peers by encouraging them to work together to complete classroom goals (21). The technique works to increase empathy because each student’s knowledge about the subject depends on the other students in the class. Each student researches a certain portion of a topic and then the students come together to share what they have learned. Because each student’s performance in the class is dependent on their peers, students are likely to encourage their classmates to interact with everyone to share what they have learned. This works especially well for students who feel that they are outcasts – in this case, students who may have been negatively labeled because they are overweight – because they are incorporated into discussions with the rest of their class and made to feel that their opinion matters. Labels die away when students unite for the common goal of succeeding in class.
Congress should legislate to improve healthy choices in school lunch. Instead of removing favorite dishes from the menu completely, schools could make subtle changes in the ingredients, such as substituting low-fat cheese for regular cheese on pizza and making pizza with whole-wheat crusts (22). That way, kids do not feel that their freedom to chose their favorite foods has been taken away from them, and by choosing their usually favorites, they will be inadvertently eating healthier. However, research shows that simply providing children with healthy food does not guarantee that they will actually eat healthily (23). Therefore, schools should use marketing theory to promote the healthier lunch choices. By presenting healthy foods in a way that is more appealing to children, schools could increase the amount of healthy foods that children eat(). Priming children with the idea that these healthy foods are actually ‘cool’ to eat may make kids more likely to eat them because they now associate positive things with these healthy foods.
Finally, if schools do insist on issuing BMI report cards, there are many ways that they could administer them in a way that is more beneficial to the children they are trying to help. Instead of simply sending home a BMI number and a percentile spot on the BMI report card, administrators could add information that would help families make changes in their lifestyles at home. Many of the complaints that parents have about the BMI report cards are that, while they do contain the number that alerts parents that their child is overweight, the reports do not give parents sufficient information about that the number means (4). Many parents, and especially the children who the reports are about, are confused about the meaning of the BMI number. Therefore, it would be beneficial to parents to receive additional information about BMI and how they can help their children live healthier lives. Exercise and eating tips could help parents make small changes in their children’s lives that would promote healthier living and encourage overweight children to become healthier.
The improved BMI report cards would not contain numbers and therefore would not label children. Instead, these reports would contain information about interventions for children of all weight statuses and the BMIs would not be explicitly stated on the card. This lack of a ‘label’ would allow parents to find out more information about the health risks to overweight children without exposing children to the negative stereotype. Primary care physicians should also make more of an effort to inform parents about the risks their children are at. This would be more beneficial than school screening, which often happens with other peers in the room. This exposure is what makes children embarrassed about their weight and leads to labeling.
Issue 1: BMI Report Cards Rely on the (flawed) Health Belief Model
The proposed interventions address the limitations of the Health Belief Model - the model that BMI report cards are based on. As stated before, one of the main flaws of the Health Belief Model is that it fails to incorporate social factors into decision making. The style of the proposed nutrition classes allow social factors to come into play. Students are working together in these classes and developing social ties that will ultimately influence their behavior in the future. This may include health behavior. If these classes encourage the cooperation of overweight individuals with their normal weight peers, the overweight students could potentially adopt healthy behaviors that their peers practice in order to fit in with them, such as joining an afterschool activity or sports team to spend more time with their friends. Therefore, the social influences from working together with children different than they are could positively influence overweight student’s behaviors.
While the Health Belief Model is an individual model that focuses on affecting only one person at a time, the proposed intervention focuses on affecting groups of people instead of individuals. Group models are more effective than models implemented at the individual level and are more likely to change the behaviors of the people they are trying to affect. Since these interventions focus on influencing many people at once by increasing their awareness of healthy behaviors and their actual participation in healthy behaviors, they are more likely to actually have an effect on behaviors than attempting to affect individual’s behaviors through an approach like the BMI report card.
Issue 2: BMI Report Cards run the Risk of Negative Labeling
The proposed interventions minimize the risks of negative labeling. By not issuing BMI numbers to individual students, they are not at as great of a risk as being labeled as ‘overweight’ or ‘obese.’ This lack of labeling also leads to less discrimination and stigmatization about being overweight. In fact, the proposed interventions actually increase awareness of individuality as opposed to group labeling of ‘us’ and ‘them.’ The jigsaw classroom encourages students to work together despite their differences toward a common goal. Once students work together with people they may have initially made judgments about, they are able to see them as more than the negative label. This cooperation allows students to prove that negative stereotypes about them are wrong and show that they are more than just the label they are given. This may lead to acceptance by other students and a subsequent increase in self-esteem of children who used to feel discriminated against.
Issue 3: BMI Report Cards may be the only Strategy Increasing Awareness of Obesity in Some Schools
The proposed interventions clearly address the limitation of the BMI report card being the only strategy that schools use to combat childhood obesity. By increasing exposure to healthy foods and encouraging children to be more active during school hours, schools would be combating obesity during school hours without labeling children. As previously stated, schools that issue BMI report cards without making any changes in health behaviors during school hours are being hypocritical. Therefore, it is important that schools increase the number of strategies combating obesity during school hours. Once again, since these interventions are based on groups and not individuals, it is likely that the interventions will be more successful than those attempting to change the behaviors of one person at a time.
Overall, in order to make a change in childhood obesity levels, it is important that schools work with parents to help children change their health behaviors. It is not enough for a school to simply tell a parent that their child is overweight; school administrators must make changes in their curriculums that promote physical activity and nutrition. They must also offer healthier food choices for students during school hours. If schools and parents work together to fight the obesity epidemic in a positive way, it is likely that there will be a greater overall effect than just telling parents that their children are overweight through BMI report cards and expecting this to make a difference in obesity rates.
1. Evans, E. W. & Sonneville, K. R. BMI report cards: will they pass or fail in the fight
against pediatric obesity? Current Opinion in Pediatrics 2009; 21: 431-436.
2. Forman, S. F. & Woods, E. R. BMI report cards: do they make the grade? Current
Opinion in Pediatrics 2009; 21: 429-430.
3. The Center for Health and Health Care in Schools (CHHCS). (2005). Childhood
obesity: what the research tells us. /Files/obesityfs.ashx.
4. Kantor, J. (2007, January 8th). As obesity fight hits cafeteria, many fear a note from
school. The New York Times. Retrieved from /fullpage.html?res= 9801E4DA1530 F93BA35752C0A9619C8B63&page wanted=1.
5. Denehy, J. Health report cards: an idea whose time has come? The Journal of School
Nursing 2004; 20(3): 125-126.
6. Chomitz, V. R., Collins, J., Kim, J., Kramer, E. & McGowan, R. Promoting healthy
weight among elementary school children via a health report care approach. Archives of Pediatrics & Adolescent Medicine 2003; 157: 765-772.
7. Merton, R. K. The Self-Fulfilling Prophecy. The Antioch Review, 1948.
8. Rosenstock, I. M., Strecher, V. J., & Becker, M. H. Social learning theory and the
health belief model. Health Education Quarterly 1988; 15 (2): 175-183.
9. Behavior change – a summary of four major theories. (2002). Family Health
International. Retrieved from mahhxc332vwo3g233xsqw22er3vofqvrfjvubwyzclvqjcbdgexyzl3msu4mn6xv5j/bccsummaryfourmajortheories.pdf.
10. Graham, C., Young, H. P., & Hammond, R. A. (2007, August 21st). Obesity and the
influence of others. The Washington Post. Retrieved from http://www.brookings. edu/opinions/2007/0821 technology_ graham.aspx.
11. Becker, H. S. Outsiders: Studies in the Sociology of Deviance. New York: The
Free Press, 1963.
12. Puhl, R. M. & Brownell, K. D. Psychosocial origins of obesity stigma: toward
changing a powerful and pervasive bias. Obesity Reviews 2003; 4: 213-227.
13. Link, B. G. & Phelan, J. C. Stigma and its public health implications. Lancet 2006;
367: 528-529.
14. Weiner, B. Reflections on the history of attribution theory and research: people,
personalities, publications, problems. Social Psychology 2008; 39(3): 151-156.
15. Crandall CS, Schiffhauer KL. Anti-fat prejudice: beliefs, values, and American
culture. Obesity Research 1998; 6: 458–460.
16. Granato, S. (2007, January 15th). Schools fight childhood obesity with BMI report
cards. Associated Content. Retrieved from http://www.associatedcontent. com/article / 125169/schools_ fight_childhood_obesity_with.html?cat=51.
17. Kalich, K. A., Chomitz, V., Peterson, K. E., McGowan, R., Houser, R. F., & Must, A.
Comfort and utility of school-based weight screening: the student perspective. BMC Pediatrics 2008; 8:9.
18. Physical Education. (2006). School Health Policies and Program Study. Retrieved
from pdf/FS_
19. How much physical activity do children need? (2010). Center for Disease Control
and Prevention. Retrieved from /guidelines/children.html.
20. Brehn, J. W. A Theory of Psychological Reactance (pp. 377-390). In: Burke, W. W.,
Lake, D. G, & Paine, J. W. Organizational Change – A Comprehensive Reader. San Francisco, CA: Jossey-Bass, 2009.
21. Jigsaw Classroom. Social Psychology Network.
22. Jalonick, M. C. (2010, March 24th). Congress takes aim at unhealthy school lunches.
Associated Press. Retrieved from /ns/health-diet_and_nutrition/.
23. Croll, J. K., Neumark-Sztainer, D., & Story, M. Healthy eating: what does it mean to adolescents? Journal of Nutrition Education 2001; 33(4): 193-198.

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