Thursday, December 16, 2010

A Critique of BMI Health Reports- Caroline Donahue

The health initiative I chose to critique was the Arkansas school system’s use of Body Mass Index (BMI) health report cards. The use of BMI health report cards has been a very controversial issue. Although several states have attempted to use these reports card, I decided to focus on the current Arkansas program. The Arkansas Health report program stems from legislation passed in 2003 called Act 1220. Some of the initiatives this act created were a health advisory committee, more transparency in reporting the funds that schools received from food and beverage contracts, and a BMI reporting requirement to parents. The Act itself states that it will:
Require school to include as part of the student report card to parents an annual body mass index percentile by age for each student: and require schools to annually provide parents with an explanation of the possible health effects of body mass index, nutrition and physical activity(1).

One of the main controversies was that the BMI reports were mandatory. Joy Rockenback, then program director of the Obseity Initiative of the Arkansas Center for Health Improvement described the specifics of the initial mandate:
Rosenback says that in Arkansas there is no opt-out clause. She says, however, that Arkansas will honor any parent who doesn’t want to participate for official medial reasons, whether physical or psychological, but that requests from parents who don’t want to participate simply because they don’t like or are uncomfortable with the program will not be honored (2).

In Rosenback’s definition, having a medical reason was the only justification for not participating in the program. There have been updates to this legislation since its inception in 2003, which was the Arkansas’s Act 201 of 2007. The main change that stemmed from this act was that parents were now permitted to “opt-out” of participating in the BMI report cards if they gave the school their refusal in writing (3). This change made forced participation no longer an issue. While there are many differing opinions on this intervention, I plan to critique it based on social science theories as well as results from other BMI Health report studies.

Use of the Health Belief Model

One of the major flaws of Arkansas use of BMI health report cards is it is applying the Health Belief Model. The National Cancer Institute defines the Health Belief Model (HBM) as follows:
Addresses the individual’s perception of the threat posed by a health problem (susceptibility, severity), the benefits of avoiding the threat, and factors influencing the decisions to act (barriers, cues to action, and self-efficacy) (4).

The Health Belief model is an individual level-based model, which means that it relies on focusing on the individual. The Health Belief Model believes that once someone has rationally thought out their susceptability to a threat, as well as the benefits from not being exposed to said threat and balance it out with factors such as any barriers in their way of obtaining freedom from the threat or the belief in their own success in avoiding the threat, people will make a decision on what they intend to do. HBM then believes that this intention will lead to an action.
Arkansas Center for Health Improvement, which is running the health report initiative in Arkansas, offers a document entitled, Guiding Principles for BMI Reporting in Children & Adolscents When Performed in a School Setting that lists out the premise and intended use of the report cards. The document states:
Confidential Child Health Reports are a health advisory tool for parents- not a grade or report card. They should be sent to parents of all students to advise parents if their child is underweight, health weight, at risk for overweight or overweight and should include: An explanation of BMI and the child’s assessment, Recommendations for a healthy lifestyle, Recommendations to discuss questions or concerns about their child’s health report with the child’s physician (5).

The basic principle these guidelines are based on is giving parents as much information as possible. I would argue this is an example of the use of the HBM, because it is relying on the parents to weigh out the information and to makes changes to help their child, if necessary. The letter is relaying information to parents on what their child’s health status is and the implications (severity) of what being over weight can have a on a child’s health. These letters provide information about a child’s health based on their height, weight and what it normal body mass index should be for a child of such an age of a particular gender. HBM relies on the assumption that people are rational and will weigh the pros and cons when making a decision about their health or the health of their children. The letter do not take the important aspects into consideration like, can a parent afford to make a change? What if a parent intends to make a change in the child’s life, but cannot find the time to get around to it? Intention sadly does not necessarily lead to action. Giving information about a child’s body mass index as well as healthy lifestyle recommendation is not enough. There are a lot of other factors that are not being taken into consideration.
In Linda Thompson’s opinion, one of the major faults with the Health Belief Model is that, “Several assumptions underlie the HBM, including the following: (1) health and health-related behaviors are predicated on an individual’s ability to acclimate to the Eurocentric value system of health (6).” Thompson continues further by stating:
Because the verb “to understand” is not included in the traditional paradigm language from which HBM is derived, imbalanced power relations are embedded in the communication process between the knower and the known. Oftentimes, when nurses implement research from a traditional perspective, they behave in a manner that suggests they are in “authority” or even superior to those they are researching. Furthermore, issues related to class or culture conflict are rarely considered….The lack of personal and historical interpretations result in research being conducted “on” rather than “for and with” a person (Campbell & Bunting, 1991) (6).

This is a very large problem because people are being worked “on” rather than with. The mailings of the BMI health reports are the equivalent of a one-sided conversation because all perspectives, especially in terms of cultures, are not taken into consideration. A sample BMI health report provided by the ACHI website is shown below (7). There are a few variations of the letter, but they are all very similar.

The letter offers advice to parents to talk with their child’s doctor and provides some health guidelines for a heathier lifestyle from the American Academy of Pediatrics. The report that parents receive is purely informational- nothing else. Thompson identifies a major flaw with the HBM, noting that it has an “imbalanced power” relationship between the communicators and their audience with the communicators having an air of authority. Thompson also stipulates that HBM does not take a person’s class or culture into consideration. In a study performed in London schools on the psychological effects of weight-screening programs on parents and children, they reported that:
Participating schools had considerable ethnic and socioeconomic diversity, and this was reduced in the volunteer sample, suggesting that parents of lower socioeconomic status and from ethnic minority backgrounds were more likely to opt out of the measurement and feedback process (8).

This study reported that people were more likely to “opt-out” if they were from a lower socioeconomic background. It is probable that this likelihood to opt out stems from the fact that the demographic they were refering to was wary of the intentions or the people running the study. This could come from not having good communication or cultural compentency. The BMI health report letters do not take the target population’s background or culture into thought.
Lack of Consideration of Reactions of the Parents and Children
Another error of the BMI program is its lack of consideration for the audience receiving the letters. As previously discussed, one major fault of sending the BMI Health report was that it was perceived to have an authoritative, even Eurocentric tone. It is informing parents of the health status of their children, which in itself is a reflection on how good a job they are doing as parents. This can be threatening. For parents of healthy children, the health report would seem to be a non- issue. In fact, the previously-mentioned study conducted in London, cites that:
Interestingly, 30% of parents who continued to describe their child as healthy weight reported making healthy lifestyle changes after feedback, which could indicate a positive reaction to the feedback despite rejection of the weight status label (8).

It seems encouraging that changes can happen when the parents have a positive, even if skewed, view of their child. However, a major factor is being overlooked. What if the parents do not have a good outlook on their child’s health status? What if the parent does not have the time or the capacity to notice that their child has a weight problem? More importantly, what if the parent themselves are overweight? In reviewing a study done on height, weight and BMI screenings in schools conducted in Minnesota, some interesting facts came to light. The study stated, “Many parents of overweight children will be obese themselves, which likely increases parental perception of victim blaming.” (9). Sending home a letter to a parent who themselves may be considered overweight, can elicit a strong reaction. A parent may be trying to deal with their own health and may not have the capacity to help their child as well. It is important to understand the future implications of an obese child with an obese parent as well. One study cited that:

A study from the American Academy of Pediatrics that shows that if one parent is obese, the odds ratio is approximately three times normal risk for that child to become obese in adulthood, if both parents are obese, the risk is 10 times (2).

The increased risk of obesity from having obese parents is devastating. In sending a BMI letter to these families, what kind of a response can we expect? One study reported up to 20% of parents participating in such a program feeling uncomfortable with the letter’s information (9).
A reactance is described as, “When people think that a freedom is threatened they experience reactance, a motivational state aimed at restoring the threatened freedom.” (10). Freedom can be many different things to many different people. One major Arkansas made, most likely in response to the public’s reaction to the BMI health report program, was allowing people to “opt-out” of the program. Forcing parents and children to do something can elicit strong reactions, especially for something as sensitive and personal as one’s body. Sending the health reports home to parents can be seen as incredibly invasive because they not only tell a parent how good a “job” they are doing as a parent, but they give them in Thompson’s words “seemingly Eurocentric guidelines to follow.” Not everyone will have a doctor to consult with. Not every parent or child will feel comfortable talking to the school nurse about their weight. There needs to be resources available for both parents and their children.

Concern over Parents Actions

Another major concern over the use of BMI report cards are the types actions parents take to adress the issues. As cited earlier, the health report includes ideas for a healthier lifestyle and suggests that parents talk to their child’s physician. One study performed in Cambridge, Massachusetts as a pilot on the use of Health reports cited:
Although they had warned parents in the letter not to put their children on diets if they had an overweight status, 19% of parents reported that they had planned diet-related activities for their overweight child. “Parents were too eager to put their children on diets,” says Chomitz. “This is not what we wanted (2).

The Massachusetts study did not find that the health reports warning to not put children on diets or suggestions to follow health guidelines worked. There seems to be a danger of miscommunication. But what about defering to a doctor for advice on what to do? Another study performed in Minnesota reported that, “Among parents who received the BMI letter and expressed a concern for their child, very few plan to seek medical services (8%)”(9).
This is another instance that shows that parents have concerns for their child’s health, yet they are not turning to the suggested resource of a doctor. This is important because these are parents who are concerned about their child’s wellbeing. Parents have a vital role in their child’s life- especially in forming the environment that shapes their child’s health. It makes sense that a parent would need to be notified of their child’s health status, but why aren’t they using these suggested resources or putting their children on diets when they are told this is not suggested?
One reason may be that parents think that they can manage their child’s health status themselves. Some would refer to this phenomenon as optimistic bias. Optimistic bias occurs when you think you are more likely to have something good happen to you (and on the flipside, less likely for something bad to happen to you as well.) In order for optimistic bias to occur the following conditions need to be met:
…an optimistic bias appears to result when two conditions are satisfied. First, the event is perceived to be controllable, so that there are things one can do or contemplate doing to influence the event. Second, people have some degree of commitment or emotional investment in the outcome (11).

The two major aspects for optimistic bias are having an “emotional investment” and a belief that the outcome can be controlled. What is a more emotional investment for a parent than the health of their child? And while there are many ways to control a child’s health, putting a child on a diet is the easiest solution. It is no wonder that almost 20% of parents in the Massachusetts study turned to dieting. It seems like a logical option - control a child’s weight by restricting what goes into the body. With this simple logic in hand, why would a parent refer to a doctor for this advice? Some parents may have the knowledge and resources to address their child’s health issue. However, what about those parents who believe they have their child’s health under control, but in fact don’t? In Neil Weinstein’s study on optimistic bias, he stated that:
People who believe, falsely, that their personal attributes exempt them from risk or that their present actions reduce their risks below those of other people may be inclined to engage in risky behaviors and to ignore precautions (11).

Parents who believe that they are in more control than they really are run the possibility of engaging in behaviors that may be risky to them or even worse to their children. This is dangerous in that not only may it be hard to recognize parents who are overly optimistic, but they themselves will not realize it to the detriment of their child. What can we do to address these problems?

Use of Marketing Theory as a Solution

One thing seems to be clear - these letters are not effective. Melinda Sothern, Director of the Childhood Obseity Laboratory at the Louisanna State University Pennigton Biomedical Research Center, believes that
There is no literature to support the hypothesis that information sent home to parents will result in decreased BMI and reduced childhood obseity…Most parents do not enjoy being confronted with this issue. The place to deal with this is the physician’s office (2).

There is a debate whether it is appropriate for schools to send the health reports and if they are overstepping their bounds by doing so. I believe the proof is in the pudding. The ACHI provides reports on how well their BMI initiative is doing. In assessing ACHI’s seventh year report(12),one of the most startling results from ACHI’s 2009-2010 report was how 56% of sixth grade Hispanic males are considered to be obese and overweight, which is the highest rate for all of the ethnicities, genders and grades. Hispanics have the highest rates for males in all grades in this report. Native Americans followed with their highest numbers for sixth grade males at 48% and 47% for eighth grade males. For females, the highest risk group was sixth grade African Americans with 52% being considered obese or overweight. Close behind were sixth grade females with 49% Hispanics being considered obese and 48% Native Americans. From this data we are able to establish that the sixth grade has the highest percentage of obeseity or overweight at 44%. Yet this data is even more striking because we can see that minorities are more likely to be at risk for higher BMIs. I compiled the data provided by ACHI’s Statewide BMI reports (12-18) on Arkansas’s BMI percents by ethnicity over the course of their health report intervention. The results are shown below.

(*It should be noted that data for Native Americans and Asians were added by ACHI to their Statewide Reports in 2008. Also I was not able to locate data broken down by ethnicity for the year 2007 which is why it is not included.)

In assesing the BMIs over different ethnicities over the duration of the intervention, we can see that there has been little notable change. This chart also reinforces that data from ACHI’s 2009-2010 report of minorities having thehighest BMI rates. Yet, minorites having higher BMI’s is not something new for the years 2009-2010. From looking at the data, we can see that the hispanics and African Americans have had a history of children with the higher percents of being overweight or obese. These letters clearly have not been working, and to the detriment of minority children.
One main issue of the BMI health report is that it is talking at parents. It is an authoritative way to tell them how well they are doing at raising their child. Instead of directing what public health practitioners believe to be right at parents, it may be more effective to evaluate the values and desires of the parents and families. What use is it to send home health reports if a parent does not care, does not have the resources to address the issues, or worse, has a strong negative reaction to them? One of the most critical components in selling a product, such as healthy behaviors, is the reception of the audience. A book on Public Health branding cites some essentials to bear in mind:
Branding provides a mechanism to increase the salience and perceived value of the target behavior in the mind of the consumer….who have to balance numerous competing priorities in a world of limited time and resources. It also reminds us that it we expect our target audience to ‘buy in” to our product, we not only have to effectively promote a desirable package through carefully-selected outlets, we also have to provide it at recognizable and realistic cost that offers a solution to our audience’s needs (19).

We need to identify and address the issue of childhood obseity in a careful way that reaches the values and needs of the target audience. I propose an initiative where pracitioners and researchers go out into the neighborhoods of Arkansas and identify the values and needs that are out there. The focus would be on selling public health in a way that convinces people to “buy-in” to the product of a healthy lifestyle for themselves and for their child. Using this method will help open the doors for parents to receive messages and lower the probability of their reacting negatively. By reaching out to the community, it is possible to identify what is needed to have a healthier community because each community may have different needs and values.

Re-vamp Method of Informing

Another area for improvement is revamping the methods of providing the information. Marilyn Tanner, from the ADA, has a simple solution on how the BMI health reports could be improved upon. She postulates that:
Maybe a parent-teacher conference would be a better place to deliver this kind of sensitive information…I think that a pediatric nutrition specialist should be explaining this information. You don’t want to put them on a restrictive diet, which could stimulate disordered eating patterns and behaviors (2).

The idea of a parent-teacher conference is smart. I would propose that parents meet with a health professional in person to discuss their child’s health, and different ways to maintain a healthy lifestyle. This can be done at the same time as a parent-teacher conference, or scheduled at a separate time that works better for the parents. Such a meeting would be a great resource because it could provide health assessments and advice from professionals to those who may not have access to health services. This program would be completely optional. The health professionals would be able to better assess viable solutions that could be personalized for each family, based upon available resources as well as values and interests held by the family. The in-person meeting would allow for a tailored intervention. This solution could potentially break down the barriers and disconnect a letter can create. By having a health professional to speak to in personal would also hopefully reduce negative interventions, such as dieting, that parents may attempt.
Another important component to the proposed intervention would be to make sure that health professionals on hand speak the languages of the parent population, as well as being culturally competent. This is especially important in Arkansas where some of the higher BMI rates are among minorites.
A last aspect of this parent-health meeting would be the sustainability of the program. The program would need to include contact information where parents can call in or send emails to their contact person if they have any questions or to keep them informed of their child’s progress. This contact would need to be maintained regardless of if school was in session.
Make External School Resources Available
A last component to my intervention would be to couple the in-school meetings with other resources that are available to parents outside of the school. This is one of the most important factors to incorporate, especially if parents are expected to make a change in their families’ lives. The parent community needs to know they have someone working on their side, not having their problems dumped back on them. Marion Nestle, a PhD, professor and Chair of New York University’s Department of Nutrition and Food studies, makes a vital point:
Middle-class parents will get the help they need…but what about families that lack access to such resources? Since obesity is rather strongly linked to poverty, an excess BMI in a child should trigger efforts to link families to social sevices. Otherwise, it won’t help much (2).

Nestle is spot on with her concern for the need for other resources to be available to familes, especially those of lower economic status. To tell someone that their child is overweight, without them having the time, knowledge, or resources to address these issues, is an unfinished- if not seemingly unjust intervention.
I think it would behoove the ACHI to open weekend clinics to parents and children to participate together in physical activites or learn healthy eating habits through cooking lessons. In organizing these activites, it would be important for ACHI to take into consideration the different cultures and languages of the communities they are trying to make a difference in. As mentioned previously, by taking an audience’s interests and values into consideration, it will lead to less resistance and greater acceptance to what is being proposed. That being said, tt would be even better if ACHI could employ members of each community in their programs because of the influence they could have. Sited in a study on reactance:
It seems likely that similarity could moderate resistance to persuasions by affecting other variables, such as perceptions of the communicator’s credibility, the importance of the issue, perceptions of argument quality, and degree of message elaboration (10).

Having something in common with the target audience seems vital to the message acceptance. Having a common bond helps overcome the previously-mentioned problem that Health Belief Model can have an air of authority and Eurocentrism. Members of the community or people who have similar backgrounds to those of the community will be seen as less threatening and authoritative than a BMI health report.


In conclusion, Arkansas has taken the first step. They have acknowledged that childhood obesity is a problem and they are taking action to do something about it. It is important that Arkansas has made controlling childhood obesity a priority and set about an initiave to address it. However, it does not seem that the use of BMI Health reports has been helpful, nor will be helpful in the future. In reviewing the cited data from ACHI’s statewide reports, BMI levels have basically remained the same. On one hand, it is good it has not increased. Yet on the other hand, it is not tackling the issue of childhood obesity either. For a school to identify and label a child as overweight or obese in a report sent home to a parent is not enough. It can even be dangerous. If Arkansas truly wants to make progress in their fight against childhood obseity, they need to change their plan of attack.
First, as previously mentioned it would be a better alternative to elect having an optional conference where a parent could come in to discuss their child’s health status with a qualified health professional. This health professional would be linguistically and culturally competant. They also would be able to help address each family’s situation with the individualized attention that is necessary. Through these individual conferences, the health professionals would be able to help make sure parents take safe measure to work on their child’s health as well as make use of the resources that are available to them. These conferences would also come with the component where a parent or the health professional could keep in touch with one another through out the year via email or telephone. Secondly, the alternative intervetion would need to be coupled with resources provided in the communities. These would include such activities as physical group activites for familes (hikes, bikes, games) to cooking class that showed families how to make foods that they love in a healthier way. It is important to go out into each of the communities and see what their needs and values are, so as to be able to work alongside them for the common goal of healthier children and also hopefully, healthier communities.
1. Arkansas Center for Health Improvement. Combating Childhood Obesity: Act 1220. Little Rock, Arkansas: Arkansas Center for Health Improvement.
2. Scheier, L. School Health Report Cards Attempt to Address the Obseity Epidemic. American Dietetic Association 2004; 104: 341-344.
3. Arkansas Center for Health Improvement. Combating Childhood Obesity: Act 201. Little Rock, Arkansas: Arkansas Center for Health Improvement.
4. Bethesda, MD, “Part 2: The Ecological Perspective: A Multilevel, Interactive Approach,” Theory at a Glance: A Guide for Health Promotion Practice, National Cancer Institute, 2005, Pp 9-21 (NIH Publication No. 05-3896)
5. Arkansas Center for Health Improvement. Combating Childhood Obesity: Act 201. Little Rock, Arkansas: Arkansas Center for Health Improvement.
6. Thompson, L. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice and Education. Journal of Professional Nursing 1995; 11: 246-252.
7. Arkansas Center for Health Improvement. Combating Childhood Obseity: Sample Child Health Report to Parents. Little Rock, Arkansas: Arkansas Center for Health Improvement.
8. Grimmet, C., Crocker,H., Carnell, S. and Wardle, J. Telling Parents Their Child’s Weight Status: Psychological Impact of a Weight-Screening Program. Pediatrics 2008; 122: e682-688.
9. 9-.Kubik, M., Fulkerson, J., Story, M. and Rieland, G. Parents of Elementary School Students Weigh in on Height, Weight, and Body Mass Index Screening at School. Journal of Public Health 2006; 76: 496-501.
10. Silvia, P. Deflection Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005; 27: 277-284.
11. Weinstein, N. Unrealistic Optimism about Future Life Events. Journal of Personality and Social Psychology 1980; 39: 806-820.
12. Arkansas Center for Health Improvement. Assessment of Childhood and Adolescent Obesity in Arkansas: Year Seven (Fall 2009- Spring2010) Little Rock, Arkansas: Arkansas Center for Health Improvement.
13. Arkansas Center for Health Improvement. Assessment of Childhood and Adolescent Obesity in Arkansas: Year Six (Fall 2008- Spring2009) Little Rock, Arkansas: Arkansas Center for Health Improvement.
14. Arkansas Center for Health Improvement. Assessment of Childhood and Adolescent Obesity in Arkansas: Year Five (Fall 2007- Spring2008) Little Rock, Arkansas: Arkansas Center for Health Improvement.
15. Arkansas Center for Health Improvement. Assessment of Childhood and Adolescent Obesity in Arkansas: Year Four (Fall 2006- Spring2007) Little Rock, Arkansas: Arkansas Center for Health Improvement.
16. Arkansas Center for Health Improvement. The Arkansas Assessment of Childhood and Adolescent Obesity – Tracking Progress Online State Report: Year Three (Fall 2005- Spring2006) Little Rock, Arkansas: Arkansas Center for Health Improvement.
17. Arkansas Center for Health Improvement. The 2005 Arkansas Assessment of Chidhood and Adolescent Obseity: Online State Report September 2005. Little Rock, Arkansas: Arkansas Center for Health Improvement.
18. Arkansas Center for Health Improvement. The Arkansas Assessment of Childhood and Adolescent Obesity. Little Rock, Arkansas: Arkansas Center for Health Improvement.
19. Blistein, J. Evans W., and Driscoll D. Chapter 2: What is a Public Health Brand? (pp.25-41) In: Public Health Branding: Applying Marketing for Social Change, Oxford: Oxford University Press, 2008,

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