Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Sunday, April 20, 2008

BMI Report Cards In The United States- How Fat Are You? – Albert Do

The social and health consequences of obesity have burgeoned to staggering proportions in the United States. Almost half of all adults and nearly 20% of children can be considered overweight or obese in the United States, according to the National Institutes of Health, and the trend is only becoming more extreme in the past decade (1). Obesity is responsible for over 300,000 premature deaths per year in the United States, and is a leading cause of hypertension, heart attacks, and diabetes in people of all ages, races, and socioeconomic backgrounds (2).
The challenge against obesity mounted by various organizations as well as the government has made little headway in curtailing this alarming trend, which explains the nearly three-fold increase in prevalence of obesity during the past two decades (3). New interventions are implemented every month, targeting numerous facets of food production, delivery, availability, and consumption. However, most programs have been relatively unsuccessful in changing behavior to reduce obesity and the current obesity trend shows little indication of reversing (4).
Increasing concern over children’s nutritional and physical health has fueled the development of programs regulating school cafeteria food and vending machine sales. One particular program, implemented in Arkansas and Pennsylvania as well as being considered in several other states, seeks to report a child’s body mass index (BMI) on their academic report cards (5). BMI is calculated using an individual’s height and weight, and obtaining a number indicating his or her level of obesity. A BMI value between 18 and 25 signifies the normal healthy range. Values above and below signify over- and underweight categories, respectively. These cutoffs correspond to being outside the 95% range for age, according to the Center for Disease Control (CDC) (6).
Advocates of the BMI report card believe that parents need this information in order to help their child achieve healthy eating habits and physical health. Studies suggest that parents might unconsciously turn a blind eye to the onset of obesity in their own children, and so informing parents of their child’s health might be a useful way of promoting more healthy behaviors (7). Proponents also argue that reporting BMI information will help motivate children to make better health decisions for themselves.
However, although reporting BMI information may be useful for informing parents of their child’s health, mandating it in report cards is fundamentally limited in several aspects, predisposing it to fail like many previous interventions. A focus on proximal, rather than ultimate causes means that this program does not directly address the risk factors and causes for one to first develop unhealthy eating behaviors. In addition, utilizing BMI to categorize students as overweight is neglectful of the myriad psychological outcomes associated with labeling and stigmatization. Finally, the scope of this program does not extend beyond providing information, and a strict adherence to the health belief model has set this program up for failure (8). Addressing these issues is essential in the development of an effective intervention, and will be important in managing the obesity epidemic.

From Parental to Proximal to Ultimate Influences
A BMI value provides information about a child’s weight relative to his or her height. It does not provide insight as to why an individual would overeat or have low physical activity. Although BMI information could potentially motivate parents to modify some facets of a child’s life, it does address any these underlying factors. In fact, it does not directly tackle any risk factors for obesity, rather shifting the responsibility to the child’s caregiver.
In particular, social factors play an important role in the shaping of child behavior (9). BMI reports inform parents about their child’s health so they can take appropriate steps to remediate unhealthy behaviors, yet parents are somewhat limited in their influence. Youth behavior is shaped by other things, including teachers, role models, and particularly their peers, who researchers believe play a larger role than parents (10). Research also suggests that social conditions are a major contributor to a child’s nutrition behavior, which extends beyond the realm of parental influence (11). Simply reporting BMI to parents would play little role in influencing child behavior, and for that reason it will be unlikely to curtail obesity.
It is more important to address the risk factors that cause obesity, rather than simply telling someone that they are unhealthy. Numerous sources affect the development of obesity, including low socioeconomic status, race, accessibility to television, vicinity from parks, and even eating speed (12,13). Many of these extend beyond the realm of the individual, and are actually social factors that need to be looked at in a different way rather than a constant fixation on individual actions. By perseverating on the individual level, the BMI report card intervention focuses on the very proximal concern that an individual is overweight, while overlooking the many, distal factors that contributed to that individual’s condition in the first place. Without addressing these deeper issues, this intervention will be unsuccessful in dealing with obesity in anyone, especially in children.
From Labels to Stigmatization to Perpetuation
BMI report cards aim to change health behaviors through letting parents know that their child is heavier than their height indicates they should be. This way, parents will know that their child falls outside the range of normal weights for children of his or her age. But what is normal? As previously stated, normal is defined as falling within the 95% range of weights for one’s age. In addition, being outside “normalcy” confers upon a child one of several labels: “underweight,” “healthy weight,” “overweight,” or “obese.” Because making fun of others and being teased is an unavoidable social consequence for children, labeling a child as “abnormal” will fuel the stigmatization of obesity and perpetuate children into the social periphery (14). Even without BMI labels, research suggests that children who are considered different already tend to be socially stigmatized and be on the periphery of their circle (15). It is unnecessary to further instigate these situations, yet the BMI report card program facilitates its occurrence.
In addition to lowering self-efficacy, predisposing obese children to not change, social stigmatization had been show to be associated with emotional problems, such as depression, low self-esteem, and social isolation (16). Because these emotional issues have been implicated as risk factors in the development of eating disorders, the unwanted consequence of the BMI report card program will be exactly the opposite of the intervention’s original intent. Research suggests that children eat to cope with problems, irrespective of whether or not they are overweight (17).
In addition to emotional negative consequences, labeling theory posits that when affixed with a label (in this case, underweight, overweight, or obese), an individual will tend to self-identify and internalize the values of that label. Some have said that in order to prevent obesity, there needs to be more focus on individual health, rather than one’s weight (18). However, reporting BMI information on a child does exactly the opposite, and will ultimately be counterproductive in controlling unhealthy eating.

From rigidity to inaction to ineffectiveness
As previously stated, the BMI report cards initiative does not incorporate social cognitive theory or self-efficacy. In fact, it relies on a strict adherence to the health belief model. By providing parents with their child’s BMI information, this program’s hopes to produce healthier lifestyles by focusing on perceived susceptibility and seriousness of obesity (19), as well as making children aware of their own weight (20). However, the health belief model, though important in the development of public health interventions, is not the only framework that should be considered.
It also fails to actively direct children and parents towards better health behaviors, since it simply provides information and incorporates no actions to remediate the issue. Taken by itself, information can be useful in helping one change his or her health behaviors, but without guidance many people cannot take appropriate steps in order to address their concerns about obesity, even if they wanted to. It might not be a simple matter of eating healthier or being more physically active, but this program does not consider that possibility. BMI information may be useful in determining who is overweight and who is not, but without knowing the appropriate steps to take afterwards, nothing is likely to change, other than people knowing that they have been categorized as overweight.
Ultimately, this intervention will likely be ineffective, and its implementation will be ceased. In fact, some are already calling it a failure and are calling for its repeal (21). Its failure will not signify any new trend in the fight against obesity, and will only perpetuate the trend that the United States has followed in the past: a lack of thoughtfulness in the design and conduct of its public health interventions. Epidemiologic research has shed much light on the mechanisms and etiologic nature of eating disorders, yet few programs utilize this information in order to develop an effective means of improving public health.
It must be said, however, that there have been successful programs that were effective in their goal to increase healthy eating. For example, school education programs that target children directly have been shown to be potentially effective. In particular, an pilot after-school nutrition program has demonstrated that self-efficacy might be a useful point of intervention (22). Also, some alternatives to BMI report cards allow schools to play a direct role in changing eating behavior, such as modification of cafeteria offerings and vending machine options.
BMI should take a backseat in the dialogue of public health intervention. It was conceived as simply an indicator for one’s weight relative to his or her height, and should remain that way. Intuitively-speaking, it makes sense that calling someone fat would not usually motivate individuals to change their deep-rooted habits. Developers might want to consider the wide range of potential areas to target their programs, as well as the many theoretical frameworks that dictate health behavior. In addition, being mindful of the social factors that play a role in the onset of obesity will go a long way in the development of successful public health interventions and the battle against obesity.

(1) U.S Department of Health and Human Services. National Center for Health Statistics. Health, United States, 2006. Center for Disease Control and Prevention (2006). Table 73-74.
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(6) U.S. Department of Health and Human Services. Defining Overweight and Obesity Centers for Disease Control and Prevention:
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(9) Link B, Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior, 1995; 80-94.
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(14) Hayden-Wade HA, Stein RI, Ghaderi A, Saelens BE, Zabinski MF, Wilfley DE. Prevalence, Characteristics, and Correlates of Teasing Experiences among Overweight Children versus Non-Overweight Peers. The North American Association for the Study of Obesity, 2005; 13:1381-92.
(15) Lather JD, Stunkard AJ. Getting Worse: the Stigmatization of Obese Children. Obes Reg, 2003; 11:452-6
(16) Raine A. Biosocial Studies of Antisocial and Violent Behavior in Children and Adults: A Review. Journal of Abnormal Child Psychology, 2002; 30;4:311-26.
(17) Roemmich JN, Wright SM, Epstein LH. Dietary Restraint and Stress-Induced Snacking in Youth. Obesity Research, 2002; 11:1120-6.
(18) Bjorvell H, Rossner S, Stunkard A. Obesity, Weight Loss, and Dietary Restraint. International Journal of Eating Disorders, 2006; 4: 727-34.
(19) Sapp SG, Weng C. Examination of the Health Belief Model to Predict the Dietary Quality and Body Mass of Adults. International Journal of Consumer Studies 2007; 3:189-94.
(20) Briefing: Body Mass Report Card. Public Broadcasting Service: Journal Editorial Report:
(21) MSNBC. Arkansas’ Obesity Report Cards get Failing Grade:
(22) Rinderknecht K, Smith C. Social Cognitive Theory in an After-School Nutrition Intervention for Urban Native American Youth. Journal of Nutrition Education and Behavior, 2004; 36:298-304.

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