Challenging Dogma

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

Friday, April 20, 2007

BMI: Body Mass Index or Bad Mental Image? A Critique of Public School BMI Tracking - Crysta Caprio

Overview of the program
Some schools in the United States, including Pennsylvania and Arkansas public schools have administered a plan to expand annual growth screening, which consists of measuring each child’s height and weight, to include: a) calculating individual BMI (Body Mass Index) for each child, b) determining each child’s BMI percentile for gender and age, c) reporting the screening to each child’s parents via a letter mailed home. The purpose of this program is to raise concern and awareness of the child’s weight status, as well as encourage plans for weight control, and preventive behaviors (1). Studies of the program have shown increased parental awareness of their child's weight status. There has been no evidence, however, of the decline of overweight and obesity rates as a result of this program (2). Furthermore, no studies have been performed to assess the impact this program has on children’s self-esteem and on the family of an overweight child.

The mandatory tracking of the BMI of every public elementary and high school student is not a step in the right direction to solve the obesity epidemic. BMI is not an accurate reflection of a child’s health status. The BMI report sent home also can set the grounds for poor self-esteem leading to disordered eating, decreased social acceptance, and decreased self-efficacy (1-18).

Childhood and adolescence are times of tremendous biological, cognitive, and psychosocial growth and development (4). It is clear that this program has not considered the multiple systems of influence or the complexity of their effects on behavior change in children and adolescents.

Inaccuracy of BMI
BMI is a measure of body composition and is calculated by taking a person’s weight and dividing it by their height squared. BMI proves to be unreliable scientifically because it does not distinguish between fat mass and lean body mass (muscle, tissue, bone). The measure is not accurate in differentiating who is overfat from who has a big stature or a great deal of muscle. Researchers have stated that, because muscle weighs more than fat, many physically fit people are classified as overweight (4-5).

Another study concluded that the height-weight relationship differs between adults and children 15 years or younger. BMI was designed to assess the body composition and weight status of adults. It does not prove the most reliable tool for determining the weight status of children (5). BMI used in public schools therefore is an inadequate method of assessing the health status of children.

Making children aware of their own BMI creates problems
The idea of informing parents of their child’s health status may not be a terrible one. A problem arises, however, when children read their own report card. In fact, they will not only read their own, but they may compare their report card to their peers. A report card always has been composed of grades along with a behavior evaluation that children are supposed to view as very important. Including BMI on the child’s report card or creating a separate “health report card” accentuates the idea that weight is of extreme importance (6). This makes weight status more of a contest, which contributes to a poor body image, and to the weight obsession in America (7).

Imagine a girl in high school who already has a distorted body image. She has the rest of her life to deal with the pressures existing in our culture that imply the importance of the shape of her body (8). Now her school is bringing to her attention a number that is supposed to be representative of her weight. This presents her with one more way to compare herself to her girlfriends. The idea that “the lower the BMI, the better” may begin to get into vulnerable minds. The “underweight” BMI category then becomes desirable. This may raise the risks for children to develop anxiety over physical appearance, fear of eating, obsession with food and weight, and, in extreme cases, eating disorder symptoms (7-9).

Perceptions of physical appearance often develop during adolescence. Feelings such as body dissatisfaction and a drive for thinness come to exist in the adolescent mind and lead to positive or negative self esteem (10). In addition, self-perceptions have shown to be highly related to health status. Positive physical self perceptions prove to be important predictors for physical activity and healthy dietary intake (9). Children who are overweight or who have negative self perceptions are less likely to participate in activities and more likely to “give up” leading to increases in weight gain (11). BMI reporting places a child into a category, which if is not ideal, can lead the child to feel like an outcast and to adapt an overall poor mental image of him/herself. This decrease in self-esteem, in turn, can lead to further unhealthy habits. During this fragile time of life, anything that can help to raise a child’s self-esteem and prevent them from developing diseases and disorders should be done.

In addition, an obsession with dieting easily becomes an obsession with overeating. Any type of program that tells children that they are not in the “ideal” range regarding weight easily pushes them into disordered eating, whether it be starving, binging, or a combination of the two (9). Encouraging children to diet forces them to see certain foods as “bad” and “good”(7). This has shown to lead to guilt-ridden binge eating. Of particular concern are children who are only slightly overweight. This program treats cosmetic weight loss as if it was a medical issue and has shown to make people worry more about weight as they grow up. A boy who may not be heavy at all but who has a great deal of lean body mass can be told that they he is overweight and that he needs to lose weight for his health. He may then begin to start dieting and obsessing over food. If he is not successful at proper weight loss, this often can lead to a struggle with weight throughout life, and the psychological effects of the struggle has shown to make people considerably overweight. (8).

Improper framing of the child obesity epidemic
This program assumes that children are capable of making rational decisions for their future health. The idea of BMI report cards implies that if children are told the health risks of having a high BMI, then these facts will be enough for them to change their behaviors, even when they are away from their parents.

The program does not take into consideration the social surroundings or the decision making process of school-aged children and adolescents. Children possess the need for social acceptance (12). Eating is a very social activity and a way for children to connect and feel accepted by peers. Children that participate in after schools activities often eat fast food and as they age, tend to eat out more with friends. Also, junk food is commonly eaten at social gatherings amongst children. Informing a child of their overweight status on the BMI scale is not going to convince children to disregard these social eating activities and instead, start making healthy food choices on their own (6-9).

According to Erikson’s eight stages of development, one of the three skills that the school aged child masters is relating with peers according to the rules. Furthermore, during adolescence, feelings of self-consciousness and self doubt can be avoided by feelings of acceptance. During this stage, the adolescent develops social relations, adopting constructive and leadership roles. The content of these two stages are imperative in the development of personality. They both focus on social ties and while conformity is not always the best choice, it plays a big role in the maturation of children (13-14). It is therefore important for children to take part in these social eating activities. BMI tracking focuses on individual change, which is not only unrealistic, but can setback the maturation of a child because it encourages children to steer away from social norms.

Another factor that is disregarded by this program is children’s inability to truly understand the nature of risk. Based on evidence observing the attitudes and intentions of young children and adolescents, it becomes obvious that children will not make decisions based on the risk factors for a disease. Humans in general, and especially children, tend to live for the “now” and into the limited future; not the long term (15). Research of the adolescent brain has found that brains under 18 years are not yet capable of avoiding risky behavior. Simple factors like the presence of peers are much more likely to effect teens’ behavior than logic and reasoning(16). This notion explains why adolescents are more susceptible to using cigarettes and engaging in any risky behavior in general. It also explains why educating children on the consequences of their weight status or bad eating habits, which BMI tracking tries to encourage, is not likely to influence them to make a behavioral change.

Your child is overweight. What now?
Through implementing this program, public health practitioners are making what really is a complex problem seem like something very simple (8). Children and parents are simply presented with a problem that they are responsible for changing. However, they are not given any tools to do so. This program as it exists now does not contribute to raising self-efficacy. It makes weight loss an unrealistic goal and confuses parents in deciding what is best for their kids.

Our country has been struggling with weight for some time now. If losing weight was as easy as noticing that you have to, there would be no problem! Losing weight, especially for children, requires lifestyle changes on the part of the entire family. (17-18) Parental involvement in the effort for a child to lose weight is important, but simply throwing a number on a report card is not the way to encourage it. Studies have shown that parents’ readiness to make lifestyle changes for their overweight or at risk for overweight children is dependent on many factors such as socioeconomic status, place of residence, and stress levels, which are three barriers that BMI tracking fails to acknowledge. If a family cannot afford and/or does not have the time to buy and cook food, it is often easier to get convenience foods or stop at fast food restaurants. Urban residences can also effect the child’s ability to engage in physical activity because it if often dangerous to play outside. (17). A study was performed in which nurse practitioners counseled families in order to prevent and treat childhood obesity, and succeeded in doing so. Not one nurse consistently used BMI in order to assess or treat the problem. Instead, the nurses dealt with preventative techniques such as parental attitudes, the American lifestyle, and lack of resources for the family (19). BMI tracking does not take into account that implementing a healthy weight loss plan for a child may involve battling much more complex issues.

Daunted by what is required to make a lifestyle change, parents may not attempt a healthy weight loss plan for their child at all. Furthermore, they may feel that this is just an extra factor to worry about (17). For instance, if a child is not excelling in school and the parent receives a report card full of Cs along with a BMI of 30(obese), the parent may feel overwhelmed and not know which problem to address first. A common reaction to feeling overwhelmed or stressed is decreased self-esteem and/or self-efficacy (20). The parent may then choose to push the entire issue aside and not approach the child’s health or grades. When the child sees that the parent has neglected the issue, he/she also may feel as though the feat to achieve weight loss is impossible. The approach that this program takes, in presenting parents with a number, and expecting them to make positive changes is an unfair expectation that can lead to further problems with a family. Instead, the program should focus on the how to lead a healthy lifestyle with the resources that are available to families.

A look into the future
Childhood obesity is on the rise and while public health practitioners are trying to help the problem through several recent campaigns, they have failed to make any noticeable difference in this epidemic. As this paper solely critiques BMI public school tracking, we come to see many important concepts that are overlooked in trying to prevent obesity. Perhaps public health practitioners should focus more on promoting a healthy, active lifestyle for children. One way to do this is by helping children link a healthy diet to positive immediate outcomes, such as feeling and looking their best, and improving athletic performance. The message that a child needs to change his or her eating habits is not going to make the biggest difference coming from a school or even a parent, but can be quite influential coming from peer role modeling(13-14). Through advertisements, children can see people just like them eating and enjoying healthy foods as well as having fun being physically active. In addition, empowering children and allowing them feel beautiful inside and out can be the best way to ensure a bright future. Children will then grow into people who love and respect themselves and thus, will always want to take care of themselves (9). Public school BMI tracking has failed to focus on the tendencies, surroundings, and self-worth of children. It therefore cannot make a significant change in the health status of children and should be abandoned so that further efforts to encourage the vibrant lives of children can be made.

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