Challenging Dogma

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

Wednesday, May 2, 2007

Agenda-Setting in Childhood Obesity Battle Falls Short: A Critique of BMI Report Cards in Schools – Elizabeth Roller

Childhood overweight and obesity is a growing public health problem. Recent analysis of the National Health and Nutrition Examination Survey (NHANES) estimated 17.1% of US children (aged 2-19 years) were overweight in 2003-2004 (1). This figure represents a significant trend of increasing prevalence in overweight children from previous surveys since NHANES began in 1971 (1-2). The increase in prevalence from NHANES 1971-74 to NHANES 2003-04 is dramatic across all age groups: 5.0% to 13.9% for children aged 2-5 years, 4.0% to 18.8% for children aged 6-11 years and 6.1% to 17.4% for children aged 12-19 years (1-2). Childhood overweight and obesity is a major public health problem with overweight children and adolescents facing both direct health problems and increased risk of health problems later in life (3). Overweight children and adolescents have increased risk factors for cardiovascular disease such as high blood pressure and elevated cholesterol, triglyceride and fasting insulin levels (4). Childhood overweight is also associated with Type 2 diabetes, sleep apnea (3, 5), liver degeneration (3) and asthma (6). Being overweight as a child or adolescent also greatly increases the risk of becoming obese in adulthood (7-8).

Given the severity of childhood overweight and obesity consequences, public health interventions are necessary to address this growing problem. One recent intervention informs parents of potential weight problems by sending Body Mass Index (BMI) report cards home from school. Arkansas was the first state to require school BMI report cards in 2003. California, Illinois, New York, Pennsylvania, Tennessee and West Virginia now also require school BMI report cards (9). The effect of this intervention is similar to agenda-setting in mass media where the extent to which the media covers a certain topic influences how important the public views the topic, with more media coverage inspiring greater public importance (10). Recipients of BMI report cards are likely to regard BMI and childhood obesity as an important topic, but may differ in their opinion and response to it. In this manner, BMI report cards may be a successful agenda-setting tactic in the childhood obesity battle, but without considering tools that promote self-efficacy, the potential for negative labeling, the relevance of BMI to healthy behaviors or the key role self-esteem plays in children’s hierarchy of needs, this intervention falls short and could do more harm than good.

BMI Report Cards Lack Tools to Promote Self-Efficacy

Though just one factor in the complex system that influences behavior, self-efficacy provides a useful framework in which to evaluate some of the shortcomings of the BMI report card. Albert Bandura’s social cognitive theory and concept of self-efficacy posits that a person’s decision to engage in a particular behavior and his or her persistence in obtaining a goal is influenced by the person’s perception that he or she can successfully complete the behavior and achieve the desired outcome – that is, his or her level of self-efficacy (11-12). People with high levels of self-efficacy are more likely to try new behaviors and persist in their completion (12). Self-efficacy is further influenced by the person’s mastery experience (success in performance), vicarious experience (modeling from others), social persuasions (encouragement or discouragement from others) and physiological factors (response to stress) (11-12).

The BMI report card simply provides parents with a number categorizing their child as underweight, normal weight, at risk for overweight or overweight. This information by itself does not provide parents with any tools to address the problem and promote self-efficacy. Some BMI report cards include suggestions of daily lifestyle changes such as watching less than 2 hours watching television, getting 1 hour physical activity and eating 5 servings of fruits and vegetables (13). Communicating this knowledge is important, but with an emotionally charged issue such as weight this may not be an effective method to connect with parents. Many parents receiving BMI report cards for the first time were angry and responded by throwing them away (14-15). A more personal approach, such as a counseling session, would be a more effective way to get the message across. Recipients of BMI report cards lacking such examples of healthful behaviors are without any tools or suggestions to address the problem.

Additionally, providing examples of healthful behaviors is not enough to promote self-efficacy. Parents and children need to feel as though they can be successful engaging in these behaviors. This intervention will not succeed unless the environment at school supports the desired behaviors. Providing healthful foods and encouraging physical activity at school would promote self-efficacy by providing the opportunity for modeling from other students and encouragement from teachers and students. Environments where unhealthy food and low physical activity is the norm do not promote self-efficacy. Unfortunately, this is the typical situation in many schools. Despite adhering to the state-mandated BMI report cards, one rural school district in New York does not provide all children year-round physical education and serves pizza and funnel cake for breakfast (15). Without properly providing parents and children tools to promote self-efficacy, those receiving a BMI report card may feel helpless and unable to do anything to improve the situation.

BMI Report Cards Risk Negative Labeling

BMI report cards seek to identify at risk or overweight children to intervene and improve their health. Unfortunately, by using the “report card” format and focusing on the individual, this intervention increases the risk of labeling a child as ‘fat.’ The negative impact of labeling in this situation is two-pronged: it renders the intervention ineffective in the overweight population and it encourages unintended negative health consequences in the healthy weight population. According to labeling theory, an individual’s behavior is influenced by how they are judged by society and the ‘label’ they are given. Labeling can encourage negative behavior as individuals conform to their label in a self-fulfilling prophecy (16). In this manner, BMI report cards could perpetuate obesity as children who feel they are labeled as fat may begin to see that as their social role and resign to being ‘fat’ in a self-fulfilling prophecy. Some children may overeat and shy away from physical activity because they feel that is what is expected of them as ‘fat’ children.

Labeling can also act in the opposite direction by making non-overweight children feel as though they are being judged by their weight and fear being labeled as fat. In response to this fear, healthy-weight children may engage in unhealthy dieting to avoid a ‘fat’ label which they recognize as socially undesirable. Children adopt society’s social bias against fat people at young ages. Children as young as 5 rate thin figures more favorably than heavy ones and are more likely to choose thin figures as their friends (17). Overweight children are less likely to receive friendship nominations from their peers (18) and are often teased about their appearance (19-20). Given teasing and negative attitudes towards fat children, it is possible that some normal weight children and adolescents may respond to BMI report cards with unhealthy weight control practices to avoid this undesired label.

It is not difficult to see a potential link between BMI report cards and unhealthy weight control practices. Unhealthy weight-related behaviors such as dieting, fasting, binging and purging are alarmingly prevalent in US adolescents (21-22). In a recent study among adolescents, 57% girls and 33% boys reported unhealthy weight control behaviors while 12% girls and 5% boys reported extreme weight control behaviors (21). Moreover, current research suggests that it is adolescents’ perception of their weight, not their actual weight that puts them risk for body image and weight-related disordered behaviors. Adolescents teased about their weight were more likely to have unhealthy weight control behaviors (binging, frequent dieting) five years later, after controlling for their actual BMI (19). Additionally, adolescents teased about their weight have a greater risk of low body satisfaction, low self-esteem, high depressive symptoms and suicide ideation or attempt after controlling for their actual BMI (23). BMI report cards have the potential to make some children feel as though they are being graded on their appearance and consequently alter their perception of their body. It is this altered perception that puts them at risk for the behaviors described above. Additionally, BMI report cards are likely to make weight a popular topic among schoolchildren. This could increase weight-based teasing, which puts both overweight and normal weight children at greater risk for negative health behaviors and outcomes (19, 23).

BMI Report Cards do not Emphasize Healthy Behaviors

By focusing on a number, BMI report cards do not address the unhealthy behaviors that lead to obesity such as an unhealthful diet and lack of exercise. Though lack of physical activity and poor diet are considered important contributors to obesity (24-25) these behaviors extend beyond children and adolescents with BMIs considered overweight. In the 2005 Youth Behavior Risk Survey (YBRS) only 20.1% of high school students reported eating 5 or more servings of fruits and vegetables daily in the week preceding the survey and only 33% reported attending daily physical education classes (26). Both low consumption of fruits and vegetables and physical inactivity are linked to increased risk of cardiovascular disease and some cancers (27-29). Many children may have normal BMIs, but have unhealthy diet and exercise behaviors that could lead to health problems later in life. With a report card format, parents and children who receive a ‘normal’ score may interpret that as validation of their current lifestyle and consequently not be encouraged to consider healthful lifestyle changes. By focusing on BMI, this intervention neglects a large population of at risk children.

BMI Report Cards Fail to Recognize Importance of Self-Esteem

BMI report cards fail to recognize the key role self-esteem plays in school children’s hierarchy of needs. Abraham Maslow’s Hierarchy of Needs puts forth different stages of human needs and how they affect motivation and behavior. As described by Maslow, deficiency needs including physiological, safety, social, and esteem must be satisfied before a person is able to tackle higher-level growth needs of self-actualization (30). According to this theory, children and adolescents will not be able to adequately address healthful diet and exercise behaviors if their basic need for self-esteem is unmet. Being overweight is associated with low self-esteem (31-32) particularly among adolescents teased about their weight (23). Without addressing the problem of low self-esteem in this population, interventions to combat childhood obesity will not be successful. Rather than considering ways to improve self-esteem, BMI report cards are more likely to decrease self-esteem by making children feel as though they are being judged on their weight. BMI report cards could also promote weight-based teasing in school, further decreasing self-esteem in the target population. Lacking self-esteem, overweight children and adolescents are ill equipped to tackle healthful behavioral changes.


BMI report cards may be a successful agenda-setting tactic in the fight against childhood obesity, but this intervention is unlikely to be effective and could have unintended negative consequences. This intervention lacks tools to promote self-efficacy, leaving parents and children feeling helpless and unable to adopt a healthful lifestyle. The ‘report card’ format presents the risk of negatively labeling children as ‘fat,’ perpetuating unhealthful behavior as children begin to see this as their social role and resign to this label in a self-fulfilling prophecy. BMI report cards could also promote unhealthful weight control behavior in healthy children who fear the ‘fat’ label. Additionally, by focusing on BMI rather than promoting healthful diet and exercise behavior, this intervention neglects a large population of children who have normal BMIs but unhealthful diet and exercise behaviors. Finally, this intervention neglects the important role self-esteem plays in school children’s abilities to modify behavior.

A more appropriate intervention would focus on positively promoting healthy eating and exercise habits for all children. Focusing on behavior rather than BMI targets the health of all children while removing the report card judgment with risk of negative labeling and decreased self-esteem. Promoting healthful behaviors will also improve self-efficacy by demonstrating what children and parents can do to have healthy bodies. The intervention would also be more successful if it focused on the school system, rather than individual parents and children. Healthy behaviors need to be supported in a school environment when children are surrounded by their peers. Making physical activity and healthful food choices the norm in a typical school day is an important step towards overcoming childhood obesity.


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