The
prevalence of overweight and obesity amongst children is climbing nationwide (5,
10). Childhood obesity is problematic from a public health standpoint obesity
in childhood is linked to many adverse
health outcomes later in life, as well as obesity in adulthood (1, 2, 3). In
fact, “for children and adolescents with BMI above the 95th
percentile at any age during childhood, the probability of being obese at age
thirty-five years ranged from 15 to 99 percent (3). Such adverse outcomes
include hypertension, insulin resistance, metabolic syndrome, type 2 diabetes,
asthma, obstructive sleep apnea, nonalcoholic fatty liver disease, and
depression (1, 3).In many states the answer to this epidemic of childhood obesity
is calculating BMI in schools and reporting the information in letters home to
parents. In Massachusetts BMI reporting became a very controversial topic.
BMI
reporting first became mandatory in Massachusetts public schools for 1st,
4th, 7th, and 10th grade students in 2009. The
recording and reporting of individual students’ BMI information was to be
confidential and reported only to their parents or guardians; nurses also
reported aggregate data on all students was to the Massachusetts Department of
Public Health by school nurses. School nurses were also carrying out the BMI
screenings and calculations. Parents received BMI data regarding their
individual children via mail or “secure internet portal” (7). Parents also had
the option of opting out of having their child’s BMI calculated in school at
any point. Healthy weight was defined as BMI from the “5th
percentile to less than the 85th percentile”, underweight as BMI
“[l]ess than the 5th percentile”, overweight as BMI from the “85th
[percentile] to less than the 95th percentile, and obese as BMI
“[e]qual or greater than the 95th percentile” (7). The results of
BMI screenings from the 2010-2011 school year in Massachusetts showed that of
children in grades 1, 4, 7, and 10 (n=205,975) 16.7% of students were
overweight and 15.7% were obese. Prevalence of and obesity was also slightly
higher in males (17.3%) than females (14.0%) (7).
We
can attribute the failure of BMI reporting in large part to its reliance on the
Health Belief Model as a means of effecting change in health behavior. It is
important to note that in the case of BMI reporting—in this context—the actors
are the parents rather than the children. The Health Belief Model operates on
the assumption that people will take “health-related action” because of (a) a
specific health problem or concern that makes taking action important, (b) the
idea of “perceived threat”, and (c) the conviction that adhering to a health
behavior recommendation will reduce said “threat” or have some benefit (6). The
use of the health behavior model as a method of framing BMI reporting proved
deadly for the program and this is why.
Rationalization
of Risk
While
data and literature support the reality that rates of overweight and obesity in
children are on the rise in the United States—and Massachusetts
specifically—this does not guarantee parents’ support for programs such as BMI
reporting. The Health belief model posits that when people realize that their
behavior or actions negatively impacts their health—or in this case the health
of their children—they will cease these deleterious behaviors or actions (6). However,
this assumption is based on the belief that human behavior is rational, a
belief that is inherently flawed. Research demonstrates that parents often
underreport their children’s weight despite the fact that they might be
overweight or obese (9, 10). The reality that parents underreport their
children’s weight points to the irrationality of the human thought process
because despite the fact that they are aware of their children’s appearance
they still do not register their weight as a potential health problem. This
achieved ignorance highlights one reason that intervention based on BMI score
reporting may not be the best option for effecting change in health outcomes.
BMI
reporting seeks to place irrefutable, concrete evidence of possible overweight
or obesity in the hands of parents. However, the argument over the efficacy of
BMI as a screening measure allows parents to rationalize the risk posed by
ignoring BMI reports as the first sign of danger. As BMI reporting became a hot
button issue in the media claims about the unreliability of BMI as a screening
measure amplified parents’ feelings that BMI scores in percentiles denoting
overweight or obese were not as much of a problem as schools and public health
officials were making them out to be (12).
In
only appealing to rational thought processes and rational evaluations of risk,
public health professional made a grave error when rolling out BMI reporting
programs in Massachusetts public schools. The health of their children is very
important to parents and the assertion that they have done something wrong—or
something that impacts their child’s health negatively—in their parenting is
the message that BMI reporting sent as it played out in the media. This message
activates a protective factor in parents—for both themselves and their child. Unfortunately,
the best way to counteract this message that their parenting has fallen short
in some way is to discredit BMI as a means of assessing their children’s
health. Essentially, in the media portrayal of BMI reporting itself became the
threat rather than obesity (6, 12).
The
Danger of Victim Blaming
In
addition to overvaluing the place of rational thought in decision-making, the
health belief model takes dangerous steps into the arena of victim blaming (6).
The risk of overweight and obesity is much higher for children from
socioeconomically disadvantaged backgrounds (1, 11). Because public health as a
discipline has a stake in social justice in relation to health disparities,
addressing health inequity such as disproportionate rates of overweight and
obesity in socioeconomically disadvantaged populations is very important.
Health
belief model on the other hand assumes “that one can successfully execute the
behavior required to produce the outcomes”, in this case referring to achieving
BMI scores between the 5th and 85th percentile (6, 7).
The assumption that everyone has the tools to “successfully execute” behaviors
that will lead to positive health outcomes is erroneous. In the case of
childhood overweight and obesity socioeconomic status is a social determinant,
that has a great deal of influence over the increased vulnerability of a child
to overweight and obesity. Health belief model has no allowances for social
determinants however, which leads to the idea that all parents—regardless of
circumstance—should be able to ensure that their children maintain a healthy
body weight because they know that overweight and obesity increase the
likelihood of negative health outcomes (6, 11).
The
implementation of a standardized measure of BMI reporting also fails to take
into account the impact of social determinants that disparately affect specific
populations more than others. This also has the potential to blame certain
populations for being affected by these risk factors, which is incorrect as
well as counterproductive. The best way to remedy this problematic
standardization of programs is to implement specific, culturally competent interventions
in populations and communities with increased risk for childhood overweight and
obesity due to social determinants such as socioeconomic status (11). These
interventions in high-risk populations should be carried out in addition to or
in place of interventions implemented in populations that are not high risk.
The
Crisis of Core Values
Core values are extremely important in framing the way that
public health interventions are implemented and perceived. In the case of BMI
reporting in Massachusetts public schools public health officials unfortunately
chose to frame this intervention around the core value of health. The
Massachusetts Department of Public Health represented BMI reporting as a way of
protecting the future health of children (7). There are two distinct ways in
which selling the idea of BMI reporting as protective of children’s future
health is flawed. First, people are less interested in modifying health
behaviors when adverse health outcomes relating to their behaviors are years
down the road. Second, this campaign for BMI reporting in public schools is
based around health, which as a core value rarely inspires immediate action;
even less so when the threat of adverse health outcomes is not immediate.
Because
health in this case is refers to the health of children—for whom protection is
a vested interest of parents—this frame of health is stronger than it is
typically. However, the frame of health is still not strong enough. Rather than
choosing health as a core value for BMI reporting as an intervention targeting
reduction in overweight in obesity, public health professionals would have been
much better served by choosing core values such as autonomy or family unity and
basing interventions around these values.
How Can We Create a Culturally
Competent Intervention?
While BMI reporting was not
necessarily a poor intervention in Massachusetts public schools in and of
itself, the way it was carried out—following assumptions made by the health
belief model—predicted its downfall earlier this year. Rather than trying to
tweak BMI reporting, or reframing based in more competent public health
theories I will propose an entirely new intervention.
Historically, many public health
interventions targeting children have been school-based because it allows for a
more equitable and further reaching intervention, under the assumption that the
vast majority of children in the United States are attending public schools.
School based interventions also allow for a more equitable spread of
interventions across populations, demographics, and communities (11). This is
why housing interventions addressing childhood overweight and obesity in public
schools seems the best and most equitable means of reaching the largest amount
of children. School-based interventions are then also the best way of reaching
populations of children in the United States who are at higher risk for
overweight and obesity—such as children from socioeconomically disadvantaged backgrounds
(8).
Keeping all of this in mind, I
propose a two-pronged approach targeting two different populations of children
within and intervention addressing rates of overweight and obesity in
Massachusetts. First a widespread intervention in public schools integrating
health and gym classes with an after school program that focuses on making
physical activity fun (8). Second a program providing realistic nutritional
advice to lower-income families and communities.
In health
and gym classes, a curriculum pertaining to nutrition and healthy eating will
be integrated with the current curriculums in place. Building on this
foundation of nutrition and healthy eating afterschool physical activities will
place emphasis on giving children agency in making decisions about how and in
which kind of activity they would like to participate (11). In making decisions
as a group about what will constitute physical activity that day, children are
empowered to make positive decisions about their health. The nutrition and afterschool
programs focusing on physical activity would have to be both integrative and
interactive to ensure these goals. It is also important to begin these
interventions early on to facilitate the formation of healthy habits among
young children, increasing their likelihood of maintaining healthy habits later
on. I hope that these programs would be at least partially staffed by community
volunteers (both members of the community as well as dedicated community
volunteers such as AmeriCorps service members) as well as college or
professional students studying relevant areas.
This intervention would need to be
available to all children in order to make it effective. It is important to
note however, that for higher-risk populations more focused intervention would
be necessary. Research shows that rates of overweight and obesity
disproportionately affect children from socioeconomically disadvantaged
backgrounds (4). In order to address this dedicated community involvement would
be necessary. An online learning module as well as phone interviews and
training would be cost and time effective in disseminating community and
parental learning curriculums based around what constitutes proper nutrition as
well as ways that proper nutrition can be maintained through economic hardship
(i.e. how to make healthier food choices). These interventions seek to address
both the complicated needs of diverse populations as well as the weaknesses of
the BMI reporting intervention.
Risk Identification
These two interventions mitigate the
miscalculation of the risks of childhood overweight and obesity that plagued
BMI reporting. By dedicating time and resources to provide culturally competent
services and education to parents and communities these interventions do not
leave parents feeling ineffective in the face of hard line statistics--such as
BMI scores—and without realistic options regarding how to improve their
children’s health. The intervention in schools also gives children a sense of
agency and ownership in their own health, making it more likely that they will
maintain healthy behaviors.
Empowering Communities
Rather than blaming communities or
populations for their increased risk of overweight or obesity, these
interventions empower them to change them (1). More importantly, the
interventions also give them tools by
which they can effect this change in the health of their children. Children
learn how to make healthy choices in the context of their circumstances. We
cannot chastise them for not choosing a healthy option, when one is not
realistically available to them. In the same way, parents are empowered to
learn how to make healthier decisions for their family, again within the
context of their circumstances. In fighting childhood overweight and obesity,
it is important to set realistic expectations for populations that are affected
disparately by factors such as finances, access to food, and access to places
where physical activity is safe. This is one reason that schools are an ideal
setting for after school programs dedicated to fun, rather than competitive,
physical activity. For some children schools represent the only space in their
built environment that being physically active is safe.
Enhancing Core Values
While both of these interventions a
based around improving children’s health outcomes and influencing positive
health behavior, health is no longer the core value. Instead of health, we use
empowerment as a way to frame both interventions. In changing the core value
and the framing of the interventions, the interventions challenge parents’
authority roles in their children’s lives less. Rather than telling them that
there is some deficit in their care for their children, because their child has
a BMI score that qualifies them as overweight or obese, we are giving both
parents and children tools to empower them in making healthy decisions and
maintaining healthy physical activity. Rather than passing a mathematical
judgment, we are providing a service.
References
1. Anderson
P., Butcher K. Childhood Obesity: Trends and Potential Causes (pp 19-45). In: The Future of Children. Princeton, NJ:
Princeton University, 2006.
2. Caprio,
S Treating Childhood Obesity and Associated Medical Conditions (pp. 209-224).
In: The Future of Children.
Princeton, NJ: Princeton University, 2006.
3. Daniels
S. The Consequences of Childhood Overweight and Obesity (pp 47-67). In: The Future of Children. Princeton, NJ:
Princeton University, 2006.
4. Economos
C., Hyatt R., Goldberg J., Must A., Naumova E., Collins J., Nelson M. A
Community Intervention Reduces BMI z-score in Children: Shape Up Somerville
First Year Results (pp 47-67). In: Obesity. 2007.
5. Paxson
C., Donahue E., Orleans C., Grisso J. Introducing the Issue (pp 3-17). In: The Future of Children. Princeton, NJ:
Princeton University, 2006.
6.
Rosenstock I., Strecher V., Becker M. Social Learning Theory and the Health
Belief Model. In: Health Education Quarterly. John Wiley & Sons, 1988.
7. School
Health Unit Bureau of Community Health and Prevention, Massachusetts Department
of Public Health. The Status of Childhood Weight in Massachusetts, 2011:
Preliminary Results from Body Mass Index Screening in Massachusetts Public
School Districts, 2009-2011. Massachusetts Department of Public Health, 2012.
8. Story
M., Kaphingst K., French S. The Role of Schools in Obesity Prevention
(pp.109-142) In: The Future of Children.
Princeton, NJ: Princeton University, 2006.
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Childhood Obesity Underreported by Parents (pp 3). In: Journal of Physical Education,
Recreation & Dance. Taylor & Francis Ltd., 2011.
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weight Status: Views of Parents in an Urban Community (pp 470-476). Clin
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C., Hart M., Hodgkins Y., Serrano E., McFerren M., Estabrooks P. Smart Choices
for Health Families: A Pilot Study for the Treatment of Childhood Obesity in
Low-Income Families (pp 433-445). In: Health Education & Behavior. 2012.
12. Miller
T. Massachusetts Mulls Doing Away With “Fat Letters” That Report Schoolkids’
BMI to Parents. In: NY Daily News. 2013.
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