“Fat chance” of combating Childhood Obesity with BMI Report Cards: A Critique of an ineffective Public Health Intervention conducted in schools – Do

Introduction

Childhood obesity has single handedly become one of the most serious epidemics facing the United States today. As early as 1999, the Centers for Disease Control (CDC) incorporated obesity and overweight factors in the National Health Examination Surveys (NHANES) (1). NHANES incorporated obesity and overweight as specific conditions, which the program continues to monitor (1). Reports show the prevalence of high weight for length or high body mass index (BMI) among children and teens in the U.S. (i.e., at or above the 95th percentile), ranges from approximately 10 percent in infants and toddlers, to approximately 18 percent in adolescents and teenagers (2).

Theoretically, it is logical for a public health intervention to be conducted at the school given the fact that students from K – 12 typically spend majority of their time at the school. Thus, one of the latest in obesity prevention programs is BMI screening conducted in elementary and middle schools. Although it is not the most comprehensive and efficient method, BMI measurements are the most practical and often-used method to determine overweight and obesity (1). Nationwide, 40% of schools reported that they measure the height and weight or body mass of their students (3). For children and adolescents (aged 2–19 years), the BMI value is plotted on the CDC growth charts to determine the corresponding BMI-for-age percentile (2). Overweight is defined as a BMI at or above the 85th percentile and less than the 95th percentile (1). Screening reports/ results are usually sent to parents and typically include the child’s BMI-for-age percentile, an explanation of the results, recommended follow-up actions, if any, and tips on healthy eating, physical activity, and weight management (3).

More than 13 states have legislation supporting these programs and are actively implementing school-based BMI- measurement (Arkansas, California, Delaware, Florida, Illinois, Louisiana, New York, Pennsylvania, South Carolina, Tennessee, Texas, Vermont, and West Virginia). (3) Arkansas evaluated its statewide program for any negative psychosocial consequences that may have been experienced by the students. “After 4 years of BMI screenings, Arkansas students reported no increases in weight- related teasing, no increases in concerns about weight, and no increases in dieting or use of diet pills (3).” Although conceptually this intervention does provoke greater awareness of the student’s health condition, empirical data indicates that the BMI report has been ineffective in reducing the percentage of overweight persons less than 18 years of age (2). As a childhood obesity prevention program, the BMI report card fails to take into account the following physical and psychological consequences that may arise: children labeled and identifying with the BMI score category, children and parents reacting negatively and going against proposed nutritional guidelines, and the capitation in children’s likelihood of developing a positive level of self-efficacy.

BMI Scores fuel the “Fat Kid” Stereotype – Labeling Theory

The categorization of students as underweight, normal weight, or overweight can induce students to positively or negatively identify with that label, depending on their individual score. The BMI score is effective in taking the initial step of creating awareness about the student’s health condition, but the intervention fails to acknowledge the student’s self-identification and mental association with the “fat label”. According to labeling theory, an individual’s behavior is influenced by how they are judged by society and the ‘label’ they are given (4). Labeling can encourage negative behavior as individuals conform to their label in a self-fulfilling prophecy. Once the students associate themselves with the label, it becomes a challenge for the child to feel motivated and commit to following the nutritional and exercise guidelines listed in the BMI report card. They will begin to believe that they are defined by the label and will take the typical actions associated with being overweight or underweight.

Consider the case of the public health intervention at Campbell County, Washington, where 12-year-old Taylor Barbour, who received a BMI score 7 points over the normal range. The school district sent a letter in the mail inviting Taylor -- and 172 other kids with high BMI scores -- to join an exercise program three times a week and only 7 students accepted the invite. “It's called the Strong Kids Club and came free to his family, with a promise that ‘it will be fun.’ (5)” Because only the overweight children were selected to participate in this exercise program, the children felt labeled as, in colloquial terms, “the fat kids go to fat camp.” In turn, the invitation to the exercise program served as a deterrent to increasing physical activity of these overweight children.

When the student begins to identify with the BMI score, he/she can develop a host of negative health behaviors, such as unhealthy eating and weight-control practices, eating disorders or depression. Of the students deemed “underweight”, they may not feel the need to engage in healthy eating practices to improve their nutritional intake; they may be excessively optimistic about their health condition and dismiss the request to take control of their health. Those students that received a BMI score that qualifies them as “overweight” may feel as though they will always be categorized as overweight children. The negative social and psychological stigma associated with being categorized as an overweight child greatly dissuades the children from engaging in positive health behaviors.

Students refuse to let their BMI score to take away their freedom – Psychological Reactance Theory

The implementation of a successful obesity prevention program requires mutual engagement and consensus from students, parents, and the school faculty to ensure that healthy weight loss can be achieved. When children lose perceived control of their lifestyle and food options, they become threatened by their loss of freedom. According to Brehm, psychological reactance is the "motivational state directed toward the re-establishment of the free behaviors which have been eliminated or threatened with elimination. (6)" By enforcing dietary guidelines and restricting food consumption at the school, children will feel threatened that their freedom has been taken away. The theory also suggests that most people, regardless of whether they actually have independent control, believe that they have a set of "free behaviors" that they can choose from in any situation. Social and environmental factors, including the explicitness of the message, the types of persuasion tactics used in delivering the message, who is doing the persuasion, and the creation of scarcity in a desired object or behavior, may also contribute to the magnitude of arousal (6). Reactance occurs whenever a choice behavior is eliminated or is threatened to be eliminated, and is motivated by the individual's basic need for self-sufficiency, independence, and the need to effect his or her own environment (7). Thus children will take any viable approach to completely go against what is expected of them to improve their health and eating habits.

Psychological reactance theory suggests that coercive attempts of social influence are more likely to result in noncompliance or overt behavioral opposition (7). Research shows that this phenomenon is particularly true with adolescents, who are generally more easily persuaded into a belief or action when the desired behavior is elicited in a warm, embraceable manner (8). Many health campaigns are geared toward adolescents who always seek to be in control of their own behaviors. Not yet adults, but wanting the freedoms enjoyed by adults, adolescents (12- to 19-year-olds) and emerging adults (17- to 25-year-olds) are bombarded with messages prescribing or prohibiting many of their prospective freedoms (8). Thus, they are most susceptible to psychological reactance and may often be motivated to perform the very behaviors proscribed in many of the persuasive messages. When adolescents are faced with a clearly explicit message establishing a feeling of external manipulation, coupled with their previous beliefs and self-assurance surrounding their own dietary behaviors, this can greatly increase the reactance towards the message (9).

Parents’ good intentions do not result in effective Health Promotion - Theory of Planned Behavior/Self-Efficacy

One of the biggest hurdles that the BMI report card intervention needs to overcome is the assurance that parents are compliant with the dietary guidelines and suggestions of how to address obesity outlined in the BMI report card. Theory of Planned Behavior and the concept of self-efficacy can explain the reasoning behind this potential trend. According to the Theory of Planned Behavior, performance of a behavior is a joint function of behavioral intentions and perceived behavioral control (10). When a behavior or situation affords a person complete control over his or her behavioral performance, intentions alone should be sufficient to predict behavior (as specified in the theory of reasoned action). Perceived behavioral control, however, is useful in helping to predict behavior when this is not the case. If a parent or child has low self-efficacy in making healthy food choices, he or she may perceive low behavioral control, which would be a relevant predictor of whether or not the parent or child eats healthy food. Teenagers are apt to view dieting as an effective means of losing weight. But self-reported dieting during adolescence has been found to increase the risk of overweight and obesity in this population (2). Regardless of the amount of anti-diet information included in the education materials, there is still the likelihood that parents will try to control their children’s weight through dieting (10).

According to Albert Bandura’s Social Cognitive Theory, the concept of self-efficacy refers to a persons own belief in that he or she can have control over and success with behavioral change. Children with a sense of high self-efficacy are more likely to engage in behavioral changes and be persistence in sticking to these changes (11). A child without a strong sense of self-efficacy will be less likely to attempt behavioral change because of fear of failure. When a promotion focus is induced, messages that make self-efficacy salient led to greater regulatory fit and thus higher behavioral intentions (13). This is because self-efficacy messages tend to focus on the person’s ability to accomplish a particular action. Because the problem of childhood overweight is typically framed as a matter of prevention (e.g., feed your children fruits and vegetables to prevent them from becoming overweight), response efficacy should create greater regulatory fit and thus higher behavioral intentions (12). This highlights the need for further education for parents on how to appropriately curb and prevent weight gain in their children.

The “Real” Campaign - An alternative Public Health Intervention to fight childhood obesity

As a statewide, comprehensive campaign, the “Real” campaign aims to educate students and parents of all problems with the food industry and improve the overall physical and mental well being of all girls in grades K-12 by promoting healthy eating habits and greater physical activity at school. In this campaign, all students are automatically enrolled into the program at the start of the school year and they are encouraged to engage in group activities to foster a strong sense of community and social support on a weekly basis. Moreover, parents will be required to be actively involved in this campaign to fight childhood obesity by attending in group nutrition education classes held at the school. These classes will provide parents with adequate information to promote healthier eating, how to make educated grocery shopping decisions, and how to make physical activity a priority for the household. This alternative public health intervention program – the “Real” campaign will take a multi-prong approach that will directly address three critical fallacies associated with the BMI report card program: the BMI score labels and isolate the “fat kids”, the school provided healthy behavior guidelines threatens the students’ and parents’ freedom, and the BMI report card does not provide sufficient information to promote self-efficacy amongst children and parents.

Join the “real” campaign – Public health branding

The labeling theory clearly indicates that the BMI score impedes on the effectiveness of the public health campaign; the categorization of children as overweight solely based on BMI score negatively distorts the student’s self-esteem and motivation to engage in healthy behaviors. In the “Real” campaign, we will be using the labeling theory to the benefit of health promotion by first developing a public health brand. Branding can build relationships with audiences to encourage adoption and maintenance of preventative or health-promoting behaviors. “Like commercial brands, they offer a brand promise, and typically ground their brand promotion in a ‘call to action’ that defines what the brand calls upon consumers to do. (13)” Drawing from the strategy used during from Florida’s “Truth” anti-smoking campaign, we realize now that “while youth had varying points of view, there was incredible consensus around their distaste for social marketing and anti-tobacco efforts that pass judgment on tobacco users. (14)” One goal of the “Real” campaign is to uncover and educate students and parents of the hidden aspects of the food industry: the politics behind food labeling, the misleading advertising, the politically biased role of the FDA and other related problems. Contrary to the structure of the BMI report card campaign in which students are grouped by scores and targeted to engage in physical activities, the “Real” campaign places emphasis on creating awareness of the food industry and improving educational materials related to healthy behaviors. Using the labeling theory, we hope to promote the notion that it is simply not cool to let the fast food industry to mislead and persuade children to purchase their food items. “A brand is a promise. It is a social and implicit contract between the promoting agent (i.e. the seller) and the consumer audience. (15)” In this scenario, we are branding a health behavior: make the right food choices, stay physically active to live healthier lives and fight obesity. In order to ensure commitment to the brand, we will mandate all students to sign a declaration that binds them to promise of healthy behavior.

Promote optimism and positivity in students and parents – Self-Efficacy Theory

The BMI report card scores unsuccessfully provide students and parents the appropriate information to instill and sustain healthy eating behavior. While information is provided with regarded suggested dietary guides and the importance of weight loss, students need to be instilled with a sense of high self-efficacy in order to motivate them to engage in healthy behaviors and greater physical activity. Increased self-esteem and higher self-efficacy will be promoted in a group based setting in which their peers will work collaboratively with one another to hands-on projects to improve their health education. Together, the students will develop greater relations with one another and improve their group of social support. The “Real” campaign is designed around the notion that childhood obesity can be explained by social cognitive theory, which states that an ongoing interaction exists among the person, his or her environment and his or her behavior (16). Children will be given responsibility in their own life and health; they will be expected to make realistic goals and held accountable that they will achieve the goals. This philosophy is important for increasing self-esteem and confidence in the children regarding physical activity.

Greater self-esteem and improved overall responsibility in increasing their health can also be supported by promoting advertising with celebrities, sports stars, and other personnel that children from grades K-12 revere and respect their opinion. Using techniques adapted from commercial marketing “such as audience segmentation, have been prominent in public health brands. (15)” Targeting technique is most frequently used to identify specific socio-demographic groups for branded messaging such as by age. “(15) It is instrumental to use techniques derived from commercial branding, particularly from the food industry; students can gain awareness as to how the advertisements from major fast food restaurants are brainwashing student to eat unhealthily. By associating physical activities with fun, entertaining characters students will be likely to become more motivated to maintain a healthy lifestyle.

In addition to improving the student’s level of self-efficacy, it is also crucial to heighten the parent’s confidence to improving his/her health behaviors or appropriately monitor his/her children’s health behaviors. The BMI report card scores simply include education material that explains how the students’ lifestyle can be improved. If schools continue to distribute BMI reports, it has been suggested that parents would like a medical interpretation of whether their child is at healthy weight (18). A more effective way of informing and supporting the families, might be counseling sessions at the schools, which would allow for a more personal setting and may eventually become a better way of helping the parents find tools to offer to their children. Counseling sessions should be held at the school to ensure that parents are accurately utilizing such information.

Improve means of communication - Psychological Reactance Theory

When marketing the “Real” Campaign, school administrators need to be cognizant of how students want to be treated and how they want to be informed about their current health status. The “Real” campaign would be deemed ineffective when “controlling language can be hazardous for promotional health messages and campaigns, particularly those targeting young audiences. (10)” When considering the “Truth” anti-smoking campaign, qualitative research using focus groups were conducted to better assess the means of effective communication to address public health interventions. Across the board “youth told us that they did not want to be told what to do. They wanted ‘the facts’ and then to be left to make their own educated decision. If we were to be successful, ‘truth’ could not preach. “Truth” needed a message other than ‘don’t’. (14)”

Using the lessons learned from the successful “Truth” campaign, it is necessary that the students will not be provoked to react negatively to the public health intervention program. Because this will be an effort to improve health behavior, it is crucial to promote positive behavior. This approach will entail the leaders of the campaign to reassure that the students will have complete control over all activities that they engage within the scope of a healthy lifestyle.

During the group level activities conducted to promote better health behavior, educators will be aware of the tone used, and their approach to influencing students. Research has shown that direct and adverse communication has a cascading effect in which adolescents will react negatively. “Higher levels of controlling language lead to higher levels of psychological reactance and thus higher levels of anger, more negative cognitive evaluations of the message. (10)” When there are less positive assessments of the message given, there will be less intention for the students to behave in the way advocated. Regardless of how persuasive may be, it is ultimately the tone of voice used that will encourage students to partake in the recommended physical activities and improved eating habits.

Conclusion

It is no longer shocking news that childhood obesity is a serious epidemic that is facing our nation today. Multiple public health interventions are currently being conducted at both the federal level and state level to significantly reduce this growing epidemic. One such example of an unsuccessful public health program is the implementation of the BMI report card, in which a student’s weight and height are the sole factors that categorize students as “normal weight, under weight, and over weight”. While it be can be argued that a BMI score would be a practical and simple method of creating a risk assessment of obesity in any given population, the BMI report card fails to consider the psychological repercussions that may severely hinder any student’s ability to engage in a healthier lifestyle. The BMI score provokes social and behavioral consequences that include stigmatization associated with the “fat kid” label; children feeling threatened that their freedom is challenged due to the enforcement of dietary restrictions; and the BMI scores may deter children from engaging in healthy behaviors. In order to ensure that students and parents are receiving the right information and are taking the appropriate steps to combat childhood obesity, there needs to be a complete overhaul of the BMI report card intervention. Developed using the psychological reactance theory, social cognitive theory, and public health branding theory, the “Real” campaign directly counteracts the tribulations associated with the BMI report card obesity prevention program. By addressing the appropriate behaviors that influence both the parents and students in this public health intervention, the “Real” campaign serves to sustainably promote healthy behavior across the lifespan.

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