Challenging Dogma - Spring 2008

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

Thursday, May 7, 2009

BMI Reports Card and the Negative Impacts Caused by Traditional Approaches, Labeling and Social Frames - Maura Hackett

The increasing epidemic of childhood obesity has necessitated the creation of solutions to combat this issue. One proposed solution is the Body Mass Index (BMI) Report Card, first passed by the Arkansas State Legislature in 2003 (1). This report calculates a student’s BMI, which is the ratio of weight to height squared, and reports it to the child’s parents. It is considered a simple and effective tool in the correlation of body fat and health. Parents receive report cards based on this information informing them if their child is at risk for obesity. According to the CDC, while the concept of a BMI monitoring program appears to be beneficial there are other issues which must be considered. Currently obesity treatments do not exist, research has not proven the efficacy of this type of initiative, and many communities do not have the available resources to combine the report card with suggestions and health promotion programs for at-risk children (2).
The proposed implementation of these programs is considered controversial by many critics; because of the stigma it attaches to the child and his/her weight. From a social and behavior perspective, the program’s approach and supporting theories are flawed and ineffective. First, it relies on the traditional models of behavior to inform and inspire change in the child. Second, report cards utilize labeling theory apart of the inspiration for change. Society’s labels associated with health and obesity have far reaching consequences with regard to self-esteem and the child’s feelings of self-worth. Third, the ranking and valuation of a child’s weight in the form of a report card employs Framing theory to influence the child’s behavior based on the frame of the social norms and biases concerning health and obesity.
The report cards are intended to inform the parents of the child’s health status and whether s/he is “at risk of becoming overweight or underweight” or is “overweight” (1). It does not provided suggestions and recommendations for a healthy lifestyle or changes to the current diet. The reports cards utilize the ideas of self-efficacy, the weighing of the risks and benefits of obesity, and intention to change for motivation to change the child’s risk of obesity, key components of traditional approaches to health.
Traditional Theories
Traditional behavior theories focus on individual level behavior and the individual’s decision to change a behavior after consideration of social norms, motivation, and consequences. The models are centered on the internal rationalization that an individual has for the costs and benefits of an action and the influences of society have on whether person feels s/he is capable of accomplishing an action. In this case, the parents and child would rationalize the costs and benefits of being obese in America with the social norms of popularity, bullying, the pressure to be thin, and the alienation of morbidly obese individuals, especially in school social cliques.
The Health Belief Model presents decisions as a combination of the rational decision process that involves the consideration of the perceived barriers and the severity of the action, and creates an individual’s intention, which is a direct antecedent of behavior. Susceptibility is the person’s belief that they are vulnerable to the action, and severity refers to the intensity of the possible consequences associated with the action (3).
In comparison, the Theory of Reasoned Action is also based on a personal weighing of the behavior prior to action. However the pre-contemplation is based on the perceived social norms and the intention to carry out the behavior. The decision can be quantified as a cost-benefit analysis of the positive and negative outcomes of the behavior. This theory, unlike the Health Belief Model, draws upon the outside influence of social norms on decisions (4). The social norms in this case are the image of the perfect body and biases against individuals who do not fit this mold.
The Theory of Planned behavior is based on the foundation of the Theory of Reason Action, but also includes the person belief of whether the individual feels that s/he can accomplish the action (5). The feeling of self-efficacy takes the social norms into consideration and translates them into a personal feeling of whether the action can be accomplished. The personal beliefs of efficacy consist of the moral norms and consequences of the premeditated action (3).
The Theory of Reasoned Action focuses on the social stereotypes associated with obese and thin individuals and reinforces this idea by creating a report card system of those who pass i.e. are thin and those who fail are obese. Creating feelings of insecurity and alienation within the child or the parents decreases feeling of self-efficacy, which are components of the larger social norms and attitudes regarding weight loss and the child’s decision to become healthy.
The traditional theories have a similar disadvantage, which is problematic with regard to the BMI Report Card initiative. The theories are based on the individual’s decision to changed and do not consider the larger society or the environment as key components of the decision/ behavior process. As previously stated, communities often do not have the financial resources to implement suggestions and health promotion programs for at-risk children congruent with the report cards. Although, the Theory of Reasoned Action does account for some irrationality, the theories do not recognize the prevalence and frequency of irrationality in everyday behavior, such as the consumption of fast food, even though it is known to be unhealthy. Additionally, they assume that each action is pre-meditated with the costs, benefits and consequences measured prior to action, and spontaneity is not considered. Spontaneity in this case may include drastic measures a child may employ to combat his/her weight such as eating disorders, diet pills and vomiting.
While the theories promote the benefits of a behavior, they do not provide for the possible longevity of a behavior and the difficulty a child or adolescent may encounter in stopping or changing the behavior. The theories discuss the direct link between an individual’s intention and its product or behavior based on a variety of internal and external influences, but they do not the way an individual acts as part of a larger collective.
Labeling Theory
The valuation of weight as part of a report card implies a hierarchy within the children who are analyzed, and defines obesity as deviant from the social norm. The children, who are considered healthy, pass the test while the children who are obese or have the potential for becoming obese fail. The application of labeling theory would explain that the stigmatization of the child’s weight will not inspire the child to lose weight, but perpetuates the trend of obesity within the child. The theory identifies the way society defines and creates deviant behavior. The social groups generate rules for the members to follow and label outsiders who do not conform to the rules and sanctions (6). A report by the US Department of Agriculture stated that 17% of children identified as overweight were in fact healthy and incorrectly labeled. Critics have argued that schools lacking full comprehension of the limitations of the BMI may erroneously identify children as at risk for obesity, causing extra stress and feelings of inadequacy in the children (1).
Whatever initially caused the deviant behavior is not as important as the societal reaction to the behavior and creates a cycle of processes and reactions to the behavior (7). In other words, labeling a child as obese and outside the norm will invariably create a cycle of unhealthy behavior and stigma against the lifestyle, which can perpetuate the obesity throughout childhood and into adulthood. The marginalization of an overweight child triggers a negative self-image, limits feelings of self-efficacy with regard to change, and creates further deviant behavior.
In general, children are not afraid of becoming overweight or obese because of the health implications, rather the negative stigma associated with obesity in society. Studies have shown that children as young as five years old internalize the social stigmas and biases against overweight individuals. Consequently, overweight children have a higher risk of developing depression, low self-esteem, and social isolation. The report cards do not reduce these feelings, but highlight and intensify these thoughts (1). Decreased self-esteem places children at higher risk for alcohol consumption, smoking and feelings of nervousness and loneliness (8).
The risks of decreased self-esteem, depression, and social isolation have direct impacts on the child’s performance in school, motivation, and social relationships. The middle school years are the formative years of self-esteem development and predict the child’s potential interactions in the future (8). Report cards may prove detrimental to the development of a child’s self-esteem at a time when it is critically important. Ignoring a child’s difficulty with weight is not a solution to creating a healthier lifestyle. However, labeling a child at the onset of adolescence without positive, constructive solutions will increase the likelihood of decreased self-esteem and increase the potential of hurtful experiences (1).
The report cards serve only to identify problem of an unhealthy lifestyle and the potential risk of obesity. It is not combined with a solution initiative or prevention program which is applicable to all children as a healthy lifestyle imitative. The reports place the burden for change on the individual child and his/her parents. Although the Arkansas initiative includes provisions for restricted access to vending machines, the development of physical activity standards, and community partnerships, the main onus for change falls to the child and parents (1). This may lead to pressure to succumb to the societal definition of the perfect body and foster disordered eating. Research has shown that adolescents in particular place more importance on body appearance than actual weight. A report card stating that a child is overweight serves as further proof to the child that s/he is imperfect. These feelings increase the body dissatisfaction, the possibility of eating disorders, such as bulimia, anorexia, or compulsive eating, and may increase feelings of suicide. The child may take extreme measures to decrease their body weight rapidly such a purging, diet pills or laxatives (1).
Framing Theory
Utilizing the aforementioned stigmas and pressure to succeed, the BMI report card frame health positively and negatively frame obesity and the health consequences associated with an unhealthy lifestyle. Associating obesity with a failing grade on a report card fames the weight of the child so as to influence the child and his/her parents to choose a healthier lifestyle and decrease the child’s BMI. Framing theory is based on the perceptions of an individual regarding the outcomes of a choice and whether the choice will be profitable (9). The report card frames obesity as a negative option with health and social acceptance as the reward outcomes. Social acceptance and inclusion, especially during adolescent and pre-adolescence is critical in the development of the self-image of a child. Healthy reports on the BMI report card, encourage children who are considered healthy and in the normal range with positive reinforcement and marginalizes children who “fail” attaching a negative stigma to their health and weight.
Although the imitative to decrease childhood obesity rates is important in public health, the BMI report card is understandably controversial. Rather than promoting healthy lifestyles integrated with school curriculums, community outreach and education, the report card places the burden of change on the child and parents. The individual children and his/her parents are expected to change the components of their lifestyle that led to the risk of obesity based on the report card BMI “grade.” The report card marginalizes the child, which can negatively impact self-esteem, social relationships, personal feeling of self-worth and motivation. Without supporting health initiatives, the child is forced to either loser weight or risk becoming labeled as obese and a social deviant. Labels can positively reinforce good behavior, but they can also create a cycle of negative behavior and deviance from the social norms. Children who are not inspired to lose weight or do not have enough knowledge about how to lose weight effectively, will become trapped in the negative spiral of obesity and social stigma.





Alternative Approaches
BMI report cards are intended to inform the parents of their child’s health status and whether s/he is “at risk of becoming overweight or underweight” or is “overweight” (1). The program does not provide suggestions and recommendations for a healthy lifestyle or changes to the current diet, nor does it connect the child’s health to outside factors such as physical activity, school lunch programs, or nutritional education. The reports cards utilize the ideas of self-efficacy, the weighing of the risks and benefits of obesity, and intention to change for motivation to change the child’s risk of obesity, key components of traditional approaches to health. The stigma the report cards attach to a child’s weight reinforces the flawed and ineffective nature of the program. Traditional models of behavior, labels, and the ranking and valuation of a child’s weight dictate the rationale behind the program. Society’s labels associated with health and obesity have far reaching consequences with regard to self-esteem and the child’s feelings of self-worth (7). Framing theory explains the influence over the child’s behavior based on the frame of the social norms and biases concerning health and obesity (9).
The alternative behavior models approach change at the group level with subtle suggestions for change based on aspirations and promises for a healthier life based on core values of beauty, wellness, and overall happiness reinforced with the help of visual images that further inspire a lifestyle. The traditional health behavior models are centered on the internal rationalization that an individual has for the costs and benefits of an action and the influences of society have on whether person feels s/he is capable of accomplishing an action. The Health Belief Model approach presents decisions as a combination of the rational decision process that involves the consideration of the perceived barriers and the severity of the action, and creates an individual’s intention, which is a direct antecedent of behavior. Susceptibility is the person’s belief that they are vulnerable to the action, and severity refers to the intensity of the possible consequences associated with the action (3). A Theory of Reasoned Action would focus on the social stereotypes associated with obesity; focusing on overweight individuals as opponents to the social norms and individuals who fit the BMI healthy rating as part of the larger collective majority (4). In 2003, a lawsuit was filed against McDonald’s accusing the company of making two girls obese. The case was thrown out of court based on a lack of substantial evidence. The judge asked “where should the line be drawn between an individual's own responsibility to take care of herself and society's responsibility to ensure others shield her?” (10) The blame was placed on the girls for becoming fat without regard for the larger social and environmental factors which may have contributed to the girls’ obesity. The logic behind this case and the BMI report cards assigns the blame and responsibility on the individual rather than explaining the obesity epidemic as a condition that must be combated not only on the individual level but at the larger, societal level.
The alternative approach to change would address behavior change at the group level rather than the individual level. This is one of its strengths compared to the traditional models. It also focuses on the multiple forms that influences can be presented to influence changes in behavior. The traditional models only address a few of the factors that influence action and not others such as spontaneity, society as an environmental context, and the frequency of irrationality in individuals, or a group mentality when addressing change. Groups of individuals with the inspiration for changes and images with which to aspire make the behavior appear more approachable so that individuals can overlook some of the hindrances that they may be prone to focus on with the other theories such as pre-meditation, costs, benefits and consequences. The alternative model further improves on the traditional theories through its approach and level of action. It considers the irrationally of individual and groups, by addressing the group mentality through the creation of a visual aspiration of a lifestyle and although the herd mentality can lead to irrational behavior, this attempts to steer the behavior by creating inspiration and promise of a lifestyle visually portrayed by models in commercial and print ads.
A combined approach to the presentation of a health lifestyle and nutritional foods, combined with physical activity would be an affective public health initiative when combating the influence of fast food industry and would lead to changes in school lunch programs and funding for physical education in schools. Therefore the changes will be based on the actions of the larger collective, which represents a distinct improvement on the traditional models of behavior which focus solely on the individual.
New Labels and Frames
The “Truth Campaign” focuses its message toward the youth by creating a rebellion again the large tobacco companies and their operation motives. The goal is to expose “an industry manipulating its products, facts, and advertising to secure replacement for the 1200 customers they ‘lose’ every day…To expose how the tobacco industry has been manipulating our generations and others before it.” (11) The campaign successfully frames the risks of smoking and tobacco so the industry is the guilty party and the American consumer, especially the youth, have the ability to change the way smoking is viewed and regulated. One of the advantages to the “Truth Campaign” is its use of the framing theory to show young consumers that “thinking smoking is rebellious is wrong and cigarettes are systematically marketed and sold a sign of rebellion.”(11) “Truth” illustrates the manipulative, misanthropic acts of the tobacco companies while emphasizing the power individuals and society have to combat tobacco companies’ influences.
A health initiative which framed unhealthy foods and the attempts of food manufactures and lobbyists to manipulate the consumer and appeal to children would change the ideology of weight and health in the US. Fast food, soda and candy companies market to children with colorful advertising and cartoon characters in order to sell their products while making a lasting impression on the children so they will become lifelong consumers. (12) Vending machines sponsored by candy and soda corporations in school combined with the elimination of physical education in schools are contributing to the obesity epidemic. Alternative approaches to behavior would not place the blame on the individual but incorporate weight in the context of the larger unhealthy lifestyle and culture of American society today, creating an effective initiative to combat the obesity epidemic in America. In Appleton, WI, the local school board contracted a natural food company to provide the school lunches and remove vending machine containing candy and soda, with a “a district-wide commitment to healthier eating and lifestyle in general.” (13) The results were healthier, more attentive and academically successful children (13).
Healthy Lifestyle Campaign
The campaign for healthier lifestyle and the fight against obesity is not without its challenges. The fast food industry and food special interest groups including the Corn Refiners Association are spending millions of dollars to convince the American public of the safety of their food while distracting the public form the unhealthy aspects of the foods they produce. The Corn Refiners of America sponsor the “Sweet Surprise” Campaign in which they promote the similar chemical composition to table sugar and state “sweeteners, such as high fructose corn syrup and sugar, make many nutritious foods taste even better, and can be part of a balanced diet.” (14) The manufactures downplay the negative health affects associated with high fructose corn syrup such as “an increased risk of diabetes, especially in children as well as an increased risk of obesity.” (15)
A healthy lifestyle imitative needs to appeal to the American consumer as much as the fast food industry does. Creating a revolution for health in which the fast food companies, lobbyists and manufactures were framed as the villains and deviants from the basic American values of health and happiness, the campaign would create a sensation for change in every generation. Framing the argument is the key to the determination of the perception of problems and will influence the shift in outcomes based on the definition of normal and deviant behavior. (9) An effective way to combat the millions spent in advertising would create a positive label for health and a negative stigma against the industry which bears some responsibility for the epidemic, while including not alienating those who are obese. (7)
The BMI report cards place a numerical value on health without supportive interventions for an overall lifestyle change for not only the child, but his/ her family and American society as a whole. Currently the report card implies a hierarchy within the children who are analyzed, and defines obesity as deviant from the social norm (7). The obsession with success creates a negative stigma in the report cards, children who are considered healthy, pass the test while the children who are obese or have the potential for becoming obese fail. Parents who are not educated about healthy food choices or the overall effects of unhealthy and/or obese lifestyles will not know how to address the BMI report card. Schools and communities need to create interactive programs that combine healthy eating habits, exercise, smart shopping tips, fast and healthy recipes, and an emphasis on physical activity in order to eliminate the stigma of the report cards.






















REFERENCES
(1) Ikeda, Joanne P., Patricia B. Crawford, Gail Woodward-Lopez. 2006. “BMI Screenings in Schools: Helpful or Harmful.” Health Education Research Theory and Practice. 21, 6: 761-769.
(2) Centers for Disease Control and Prevention. “BMI Executive Summary.” Date Retrieved April 3, 2009. (http://www.cdc.gov/HealthyYouth/obesity/BMI/pdf/BMI_execsumm.pdf).
(3) Simsekoglu, Ozlem and Timo Lajunen. 2008 “Social Psychology of Seat belt Use: A Comparison of Planned Behavior and Health Belief Model.” Transportation research 11: 181-191.
(4) Ellis, Shmuel and Shaul Arieli. 1999. “Predicting Intentions to Repot Administrative and Disciplinary Infractions: Applying the Reasoned Action Model.” Human Relations 52: 947-967.
(5) Hagger, Martin S., Nikos L. D. Chatzisarantis, and Jemma Harris. 2006. “The Process By Which Relative Autonomous Motivation Affects Intentional Behavior: Comparing Effects across Dieting and Exercise Behaviors.” Motiv Emot 30: 307-321.
(6) Raybeck, Douglas. “Anthropology and Labeling Theory: A Constructive Critique.” Ethos. 16, 4: 371-397.
(7) Klein, Malcolm W. 1986. “Labeling Theory and Delinquency Policy: An Experimental Test.” Criminal Justice and Behavior. 13, 47: 48-79. Date Retrieve April 3, 2009. (http://www.jstor.org/stable/1685855).
(8) Strauss, Richard S. 2000. “Childhood Obesity and Self-Esteem.” Pediatrics. 105, 15. Date Retrieved April 3, 2009. (http://pediatrics.aappublications.org/cgi/content/full/105/1/e15).
(9) Tversky, Amos and Daniel Kahneman. 1981. “The Framing of Decisions and the Psychology of Choice.” Science, New Series. 211, 4481: 453-458. (http://www.jstor.org/stable/1685855).
(10) Wld, Johnathan. 2003. “McDonald's Obesity Suit Tossed U.S. Judge Says Complaint Fails to Prove Chain is Responsible for Kids' Weight Gain.” CNN. February 17. Retrieved April 24, 2009. (http://money.cnn.com/2003/01/22/news/companies/mcdonalds/).
(11) Truth Campaign. 2009.”About Us.” Retrieved April 24, 2009. (http://www.thetruth.com/aboutUs.cfm)
(12) Public Health Institute. 2006. “Junk Food Marketers Target Children, Survey Says.” Retrieved April 24, 2009. (http://www.phi.org/news_events/news-viewRelease.cfm?pressReleaseID=96&year=2006).
(13) Pure Facts. 2002. “A Different Kind of School Lunch.” Retrieved April 24, 2009. (http://school-lunch.org/wisconsin.html)
(14) Corn Refiners Assocaition.2009 “Sweet Surprise.” Retrieved April 24, 2009. (http://www.sweetsurprise.com/hfcs-and-your-family)
(15) Science Daily. 2007. “Soda Warning? High-fructose Corn Syrup Linked To Diabetes, New Study Suggests.” Retrieved April 24, 2009. (http://www.sciencedaily.com/releases/2007/08/070823094819.htm)

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