Friday, May 10, 2013

Are BMI Report Cards The Lightest Way To Break The News?: Weighing In On This Intervention—Stephanie Smith

            For years, public health authorities have been aiming to eliminate childhood obesity without great triumph. This epidemic has continued to impact the lives of millions of children and adolescents across the country as evident by the rising rates of obesity. As of 2010, more than one third of children and adolescents are considered overweight or obese (1). The Center for Disease Control (CDC) defines overweight as having excess body weight and obesity as having excess body fat (1). As the percentage of children and adolescents has more than tripled from 1980 to 2010, interventions are constantly being created to combat this spate of obesity (1-2).
            One of the most common ways to measure if a child is overweight or obese is to determine body mass index, or BMI. BMI is a simple measurement, based solely on a person’s height and weight. The resulting value is compared to average standards to determine whether the person is underweight, “normal,” overweight, or obese. In recent years, BMI has been calculated at schools for surveillance purposes to log trends in the population. Within the last ten years or so, BMI reporting has become popular in the schools. Elementary and middle schools began notifying parents of their child’s BMI on their report card. In addition to getting grades for academics and proficiency, children are now being graded on their BMI. When a child gets a score of “overweight” or “obese” it is the equivalent to receiving a bad grade (3). There is no message accompanying the number about ways to improve health, just an arbitrary score.  
            With over 25 million children in the U.S. overweight and obese, eyebrows continue to raise when wondering where the root of the problem lies (3). In an effort to determine if it is the lack of physical activity, a diet consisting mainly of processed foods, an increase in children’s screen time, public health officials have teamed up with schools to allow for BMI report cards, in an effort to make parents aware of the issue. Proponents of this intervention believe that BMI reporting on the child’s report card will show parents and children that these numbers matter to their health and well-being. Lloyd I. Sederer, M.D. says, “when students and their parents ‘know their numbers’…they are more likely to do something about them (2).” Though receiving a report card with a stamp of physical health failure can be alarming and surprising for many, without proper understanding of what this means, this method of intervention cannot work. There is no explanation as to what the number really means and what can be done to improve it because until this point, childhood obesity has been “under-recognized” (4). Of course, a child’s health is important to consider to avoid obesity later in life, leading to heart disease, diabetes, and certain cancers; but as a child, their health is not solely determined by weight (5). A child’s BMI is not synonymous with their health.
            There are two important points of this intervention that do not allow for its success. BMI, though it is a simple and quick measurement of body mass, is an inaccurate measure of body composition. Since it only uses weight and height in its calculation, a person with a lot of lean muscle can yield a high BMI and be considered obese, when they probably do not have excess body fat. A person could also have a normal BMI, but lack muscle and have more fat, which is unhealthier than the first scenario (3). These inconsistencies can cause potential harm to a child, like the development of an eating disorder that can persist into adolescence and young adulthood, bullying from other students, and pressure from family (6). BMI is an easy way to interpret one’s health, inaccurately.
It is important to instill values of a healthy lifestyle in children, which is not portrayed with this intervention. Since children are constantly going through growth spurts, their weight is constantly fluctuating and should not solely be analyzed by BMI (6). Also, an approach like this is only focusing on the individual level. When BMI is on the report card, parents think that their child is the only one with the problem. Overall, little is known about the effectiveness of BMI reporting on a child’s behavior, attitude, and knowledge, so continuing with this intervention seems unproductive (1,6-7).
            Other than lacking to address the matters previously mentioned, BMI reporting violates several models of behavior change used to create public health interventions. This intervention violates traditional models, as well as alternative models that have transformed over time. The first theory that the intervention defies is the theory of reasoned action. BMI reporting also goes against several elements used to construct the social learning and social cognitive theory. Finally, the intervention produces psychological reactance.

Critique #1: BMI reporting counters the theory of reasoned action
            The theory of reasoned action is based on the concept of attitudes and social norms. It is a function of these two factors that determines a person’s intention to further change one’s behavior (8). The theory claims that attitudes towards a behavior and social norms can be highly predictive of final behavior (11). The theory further states that behavioral intention must precede behavior change in order to be successful. When this theory was developed, the final behavior change did not take into account the involuntary outcomes of the behavior; it simply stated that once a person begins a new behavior, they have succeeded (9). In actuality, many people that are aiming to change their behavior are aiming for a goal that cannot simply be met at the start of change. Usually, for success, follow-up must transpire. It is clear that the intervention is following the same method of this critique; it is looking to change the behavior of a person and not necessarily aid in maintaining suitable outcomes. BMI report cards do not provide parents or children with any further knowledge about how to carry out the implied intentions from this intervention. Parents are given the information that their children are overweight or obese, but are not supported in ways to improve their child’s health. Schools are focusing on improving test scores and grades and less on a child’s health and well-being (10). That is one reason that this intervention was implemented; to remove responsibility of health from the schools and give it back to the parents for their sole concern. Schools are not facilitating parents or children with adequate knowledge of nutritious eating patterns, physical activity, and living a healthy lifestyle.
            Attitudes of those children at risk are not being addressed by the intervention. By sending BMI on a child’s report card, it is likely that the number will not even reach the child. Children do not have any chance to create an attitude towards being overweight if they do not know or understand. This leads to why social norms in this intervention are ineffective. The two questions that one asks when using the theory of reasoned action, pertaining to social norms, are: “what do others around me think?” and “how much do I care what they think? (8).” Neither question is applicable to a child in elementary or middle school. More often than not, report cards are not seen by children at all, so they do not have a chance to imagine “what others think” about being overweight or obese. There is also strong apprehension from parents when they receive a report card that says that their child is overweight and admitting that they need help in creating a healthy lifestyle for their children. A study found that 84% of parents believe their child is of a healthy weight, when in actuality one third of children are overweight or obese (2). Often times, parents are wearing a pair of foggy glasses, hypothetically speaking, when their child is targeted as not being “normal.” It is common for parents to ignore any social norms around them that revolve around their child because they do not want to compare their child to others; a similar philosophy that parents preach to their children. Parents have an internal struggle between admitting that their child needs help to become healthy and ignoring the problem until it is a bigger issue to let their child be himself or herself. The biggest predictor of childhood obesity is an obese mother, so when an attack is made on a child’s weight, it is essentially undermining the rest of the family’s health (10).
            Ultimately, these things do not lead to a child believing that they can become healthy and reach a BMI in the “normal” range. Social norms are shattered by this intervention, mostly because parents become frustrated and offended by the content on the child’s report card. By stamping a child with an arbitrary number that represents their status on a scale of health, there is cause for much embarrassment on the child’s end and harassment from fellow classmates; which can cause much larger issues, like bullying, that can lead to depression or disordered eating (14). 

Critique #2: Several elements of the social learning and social cognitive theory are being ignored 
             More recently referred to as the social cognitive theory, social learning theory was its original moniker. They refer to the same ideals, with certain constructs representing social learning, or social cognition. The individual is not solely involved in this model; behavior and environment are involved in the dynamic process of behavior change. This theory emphasizes the social influence and reinforcement that leads people to make decisions (12). There are six constructs that make up social cognitive theory, three of which are abused by this intervention: reinforcements, modeling, and self-efficacy.
              Reinforcements refer to internal and external factors that affect the likelihood of continuing or discontinuing said behavior (12). Reinforcements can come from the environment or from the person changing their behavior. In this intervention, it is hard to say that there are any reinforcements of any kind. Children are just given a number on their report card. There is not any further information or explanation, just an arbitrary number.
            Modeling, or observational learning, is the social learning aspect of the theory. This construct says that people act by observing the behavior of others around them and acting in accordance with these behaviors, if they feel inclined to do so. BMI reporting does not address modeling in any form. By giving children their BMI on a report card, there is nothing to observe or anyone to learn from. As mentioned earlier, parents’ weight is often indicative of a child’s weight, which means that any prior models that a child might have gotten in the home, would be unworthy in efforts to improve the child’s health (10). Oftentimes, the only model of what children are “supposed” to look like are in fact, models. Children are reading magazines and watching television shows with stick-thin celebrities that pay hundreds of dollars to look a certain way. These kids do not understand that, which could lead to detrimental eating disorders on the other end of the spectrum. There are not any role models in the entertainment industry that truly represents what a child should believe. A child should believe that it is not about what they look like, but about how healthy they are. Children at the elementary or middle school age are very impressionable, so modeling has the potential to play a major factor in changing the behavior of a child if given proper positive reinforcements.
            The third aspect of the social cognitive theory that is not supported by this intervention is the role of self-efficacy in behavior change. Self-efficacy refers to the level of a person’s confidence that they can be successful in behavior change (12). Without adequate self-efficacy, a person is likely to lack incentive to complete a task or perform behavior, finding change too difficult (13). Since this intervention is not addressing the main part of behavior change—the concrete actions necessary to actually change one’s behavior—it is hard to determine if this intervention provides people with any sense of self-efficacy. It is likely that people do not feel confident that they can change their behavior under this intervention because they simply do not know how to change. When parents, and children, receive this report card and see a high number without any further support, they will feel let down and unsure about how to tackle the issue. This is one of the most important aspects of the intervention that needs to be changed because when it comes to losing weight and making healthy lifestyle changes, self-efficacy is the only way that a person will find success.    

Critique #3: Intervention produces psychological reactance
            Psychological reactance theory recognizes the negative response to messages that aim to control one’s freedom and autonomy (15). The actual psychological reactance is an emotional state that comes from lack of control. When a person’s freedom is threatened, it is common for the person to resolve it by completing the task that was prohibited. There are three steps towards generating psychological reactance. It starts with a person perceiving an unfair restriction on their actions, followed by an activated state of reactance, concluding with an act to remove the reactance by the person affected (16). There are several factors that influence whether a message produces psychological reactance. Explicitness, dominance, reason, and similarity determine the height of reactance. BMI report cards violate all of these aspects to instigate psychological reactance.
            Explicitness represents the degree to which the language makes the message plain and clear. Explicitness is context specific, but for the most part, if a message is straightforward, there will be an enhanced sense of reactance (16). BMI report cards teeter on being both straightforward and also quite complicated to interpret and understand. Though parents are given a number that indicates if their child is overweight or obese, which seems straightforward, this message can be complicated. If a child receives an overweight BMI it can be true that they are indeed overweight in the sense that they have too much body fat, but it could also be that they are more muscular. In order for parents to determine if their child needs to lead a healthier lifestyle, parents would have to further analyze their child’s needs.
            Dominance describes the correlation between the source and the person that the message is aimed towards, the recipient. The more dominant a source is over its recipient, the more reactance is produced. In this intervention, the source is the school or government that is mandating BMI report cards. Clearly, the school is dominant over its students and families involved in the system. This dominance makes parent’s question the school’s authority; especially in this case, when their child’s health is involved, most parents believe it is their responsibility, not the school’s.
Another aspect of psychological reactance theory is reason. If there is no reason or support that accompanies the message, it is likely that reactance will increase. With BMI report cards, there is a disconnect between support of the message and what the message is meant to convey. Parents are not given reason or support for what the BMI means for their child. Without any reason, parents become outraged, which is the psychological reactance. The final factor in determining psychological reactance is similarity. If the source of the message is similar to the recipient, reactance will be reduced (15). In the case of this intervention, there is no similarity between the school administrators that are promoting the message and the parents or children that are receiving the information, so there is great psychological reactance invoked.
            In general, psychological reactance theory revolves around the loss of control and how people react to that loss. When the school says that a child is overweight or obese, solely based on height and weight, without taking into consideration that children are growing during these years in elementary and middle school or the child’s body composition, parents become offended. There is a sense of ownership among parents; although obesity is not a healthy lifestyle to lead or to “own”, parents feel that their children are “too good” and that their weight is under their ownership and should not be controlled by the schools administration. There is strong opposition from parents towards about this issue because they believe that schools are meant to teach knowledge and it is up to the parents and family to teach everything else in between (10).     

YOLO Campaign- An alternative public health intervention to reduce childhood obesity 
            The YOLO campaign is based on improving the criticisms previously made against BMI report cards aiming to reduce the rate of childhood obesity. YOLO has become a prevalent term in popular culture after artist, Drake, rapped the lyrics “you only live once, that’s the motto—yolo” in his song The Motto (17). This motto gained much attention causing young people to connect over this term. Though this motto is usually aimed towards a rebellious audience that finds a sense of confirmation with what they are doing, our campaign will aim to use this term in a positive light. Since many children are aware of this term, the campaign will help to reconstruct their view of the motto, while promoting healthy living. YOLO will represent the idea that yes, you only live once, and so why not make it the best life you can live. To do that, you need to lead a healthy lifestyle. This campaign will be focused on a group level, rather than aiming to educate specific individuals. There will not be a focus on the inaccurate measurement of BMI. Children will be targeted, not the parents, so that they see how they can change themselves to become the strongest that they can be. The campaign will be spread throughout communities, aimed towards children, by using #YOLO throughout social media and other aspects of the community, considering that “hashtags” allow the idea to spread to whomever is interested.
            This campaign will not be related to the school day, but rather after-school. Currently, many children go home after school and snack on “junk” food while sitting in front of a screen for hours. So to avoid both of these things, which have been credited to aid in the childhood obesity epidemic, we will take the child out of that situation and keep them active, eating healthy, and learning. High school aged and undergraduate college students will volunteer to lead these groups. There will be focus on physical activity and challenges created to get kids to compete against themselves. There will be healthy snacks supplied there. There will also be cooking lessons, focusing mostly on creating healthy snacks. The kids will also learn the importance of maintaining a healthy diet and how they can eat nutritious foods at every meal. This campaign is focused on reducing childhood obesity, but there will be a similar campaign offered to parents. Parents will stay involved and learn about what their child is learning while also discovering tips to lead the whole family in a direction of healthy living. 

Combating Critique #1: YOLO is about a healthy life, not a healthy weight
            Although weight plays a major role in assessing a person’s health, for a child that is elementary or middle school age, weight fluctuations are normal and crucial. Children are going through growth spurts and puberty—processes that require enough weight to function normally. If interventions harp on the fact that all children need to be in a “normal” weight range and labeling children as being obese, potentially harmful affects are imminent. Children that are obese are often depressed, have low self-esteem, have mental or emotional distress, and can often times end up with an eating disorder (14, 18-19). Many of these conditions persist even after they reach a “normal” weight. It is for these reasons that YOLO would not harp on the child’s weight, but rather on their health. Getting children to believe that they can become strong: that they can run a mile and play sports and that eating healthy will help them accomplish these goals.
            YOLO is about having one life to live, so we want to allow children to see that the one life they get should be the best life, and for that to be possible they need to live a healthy life. One of the other criticisms of the theory of reasoned action with BMI report cards was that social norms were not being addressed. By offering an extension of this program to parents, it becomes the social norm around the house to be active and to eat healthy. By impacting a child with these ideals at a young age, they will be accustomed to living healthy lives. The whole community will be aware of the campaign from #YOLO, so these children will be in a supportive environment, surrounded by a norm of healthy living. Originally, the BMI report cards did not give any information on how to change the intention of becoming healthy into a behavior. YOLO is all about the behavior. Parents and children will not be told their child’s BMI, so there is no intention, in that regard, of participating in the YOLO campaign. They are just participating to be strong and to learn the values of healthful living. They will just be doing it—eating healthy and being active—doing the behaviors that are necessary to combat the childhood obesity epidemic.

Combating Critique #2: Improving self-efficacy and modeling    
             One of the major critiques of the BMI report cards intervention was that there was no sense of self-efficacy among children. They did not know what these numbers meant or what changes needed to be made. YOLO will focus mainly on improving self-efficacy. Not only will the campaign target overweight children, but even “normal” weight children. All of the kids will feel like they are useful and important. Most children experience a sense of low self-esteem that affects anxiety and frustration and has been linked to victimization (20). YOLO will focus on self-efficacy affecting physical activity. For the most part, overweight children feel like they cannot participate in the same physical activity as other students because “they can’t run” or they get too tired. We will instill values revolving around the idea that it does not matter if you cannot run for a long time and it does not matter if you get tired, because you can do it, maybe not right now, but YOLO will get you there. The campaign will aim to prove to kids that practice and participation will allow them to do the same things as everyone else. Self-efficacy is important for anyone that is aiming to lose weight, but since YOLO is not a campaign concentrated on losing weight, but becoming healthy, strong, and the best that the child can be, self-efficacy should be easier to garner.
            The lack of reinforcements in the BMI report cards intervention has proven their importance. The whole campaign is aimed towards children that will participate in events and challenges together. This will bring a sense of unity among the students, so that they act as each other’s reinforcements. Parents and the rest of the community have a responsibility to act as these children’s reinforcements, as well, to encourage them towards becoming healthier and stronger. 
There was also an issue that BMI report cards were not exploring the modeling aspect of social cognitive theory. Modeling is the idea that people’s behaviors are often modeled from observing another person’s behavior. YOLO is going to be lead by students that are willing to take part in all of the activities, and that are eating the healthy snacks to prove to these kids that making these healthy decisions, they too can live that same healthy life. Ideally, many, if not all of the volunteers, will have struggled with their health and weight at one time in their life. That will allow these children to see firsthand what these healthy choices will do for them in the future. Children often look up to teens that they can relate to, as long as they are not feeling inferior. Having real teens and young adults as role models is crucial to getting these children to model their own behavior in a positive and healthy way.

Combating Critique #3: Avoiding psychological reactance
            The main way to avoid psychological reactance is to avoid taking control from a person. The YOLO campaign does the complete opposite. Just by the name of the campaign, people will understand that they only have on life to live and it is their life; they are in complete control over the ability that their body has to become strong, lean, and healthy. Other than losing control, the four factors that lead to reactance will be addressed and reversed.
            As far as explicitness is concerned, there will not be much of a message to convey, as much as there will be actions to perform. The main message of the whole program is to become strong and healthy, but there will not be much more to it than that. The message is not intended to tell people what to do, but instead to tell them what they are capable of doing. To reduce dominance, students are running the campaign. This shows much less dominance than having the schools tell students what to do. Over time, the goal of YOLO is to get young children that have become healthier and stronger, through the efforts of the campaign, to lead the program with the older students. Having peers to prove to the younger students that they can improve their physical abilities and healthy food choices will reduce dominance even more, making kids feel that they can accomplish their goals.
            When there is no reason to support a message, more reactance is invoked. Again, since there is not a straightforward message that is being portrayed, reason can be avoided. That being said, the students that are running the program will share personal accounts of how they have become healthier to the children. For those parents that participate in the parent extension of the campaign, there will be statistics on how leading a healthy lifestyle can benefit a child and a family. There will not be any negative data portrayed, just facts about how making all of these improvements will help them and their family. Since there was not any similarity in the BMI report cards, there would be a great deal of similarity between the leaders and children. They are all young people that want to live healthy lives, which allows them to relate to one another and find common ground.

YOLO is the best solution to combat the criticisms made towards the BMI report cards intervention. By addressing all of the issues that BMI report cards portrayed, YOLO will see great success. YOLO is a program based on doing; not about learning or teaching, but performing to become better. There is no focus on weight, just health through YOLO. Nutrition and eating habits, physical inactivity and sedentary behavior, advertising and marketing, socioeconomic status and race, and genetics are just some of the predicted causes of the childhood obesity epidemic (21). By addressing all of the modifiable changes that children and families can make, progress will be made with the YOLO campaign.

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