Sunday, January 5, 2014

A Review of Body Mass Index Screening and Reporting in Schools, and a Proposed Alternative Intervention to Promote Healthier Lifestyles Among School Children and Adolescents—Sarah Tadiri

The worsening obesity epidemic in America has urged public health officials to find an answer to this problem, and stop the population’s growing susceptibility to obesity-related illnesses. In 2003, three school districts implemented health report card programs to target rising obesity among children and adolescents (5).  The program involves calculating student’s body mass index (BMI) from measured height and weight and using that information to classify their risk for obesity.  A health and fitness report is then sent home to each parent along with educational material about promoting healthy eating and activity. If the child is classified as overweight or at risk, the report advises to consult with the primary care physician for a comprehensive evaluation (5). Among the goals of the program are to, “Identify students who are underweight, overweight or obese or at risk of becoming overweight or underweight….encourage discussions between families and health care providers about their child’s growth and development...[and] promote healthy eating and active living in the school community” (3). Although the pilot program involved just three school districts, the campaign has gained popularity over the past ten years. As of April 2013, it has been adopted state-wide, by 9 states (1). However, even as early as the pilot study, concerns about bullying, victimizing and eating disorders in adolescents have created controversy surrounding this program. This past October, the Massachusetts Public Health Council voted to cease the practice of sending home health reports which has been implemented in Massachusetts public schools since 2009 (1). Opponents of the program argue that it attracts negative attention to those children categorized as overweight or at risk, and fosters stigmatization of those children. Supporters maintain that “BMI screening letters are an additional awareness tool to promote conversations about healthy eating habits, exercise, and weight in the safety and confidential environment of the child’s home” (2). However, regardless of the potential negative side effects, the question that should be asked is how effective this intervention actually is at effecting changes that lead to healthier lifestyles. Does it target the correct aspect of the problem? Is provision of information alone enough to change behavior? Does the method of delivery make the message likely to be well-received?
Body Mass Index screening and reporting in schools is not an effective public health intervention against childhood obesity. The focus of this program is too narrow. Identifying children who are at risk for obesity-related health issues creates an intervention aimed at individuals.  Instead, the intervention should widen the target, and take advantage of the community aspect of schools. Furthermore, this intervention oversimplifies the causes of and factors that contribute to the increases in obesity among children and adolescents. If fails to consider the factors, other knowledge of the long-term consequences, that influence health choices.  A more effective intervention would be to directly target behavior at the group level in order to encourage healthier choices about diet and exercise.

Critique 1:
One of the main issues with Body Mass Index (BMI) screening intervention in schools is that it is aimed at the individual level. Although it uses an institution (the school) as a vehicle to deliver the intervention, it leaves the responsibility of finding a solution up to the parents and children. This method is inefficient for a number of reasons, including its lack of follow-through. While those parents might be concerned about their child’s weight, they might not be equipped to make the necessary lifestyle changes. The intended solution for parents of overweight children is to follow up with a family physician or school nurse to decide what the best actions would be moving forward, however, “an evaluation of the program found that parents neither consulted school nurses about their children’s BMIs, nor contacted family doctors for follow up care in significant numbers” (6). If the intervention relies on action of parents, but doesn’t have a mechanism of follow up built in, then there is no guarantee that the intervention is even completed. This could also lead to unintended methods of weight loss that are not safe or healthy.  If parents are given information that says their children are overweight, but do not follow up with a doctor, they might accidentally put them on diets that are unsafe. Or, the children themselves could self-impose unsafe dieting methods. In the test-study for this intervention, results showed that, “although they had warned parents in the letter not to put their children on diets if they had an overweight status, 19% of parents reported that they had planned diet-related activities for their overweight child” (5).  This intervention places too much responsibility on individuals that do not necessarily have the capacity or knowledge necessary for safe and effective management of the issue.
Furthermore, families might have difficulty making the recommended changes, due to financial reasons or lack of access. For example, a family might not have a good grocery store near their neighborhood, or they might not be able to afford to shop at it. In this case they fast food and cheaper options might be the only practical option. Similarly, there might not be a safe place to play or exercise within a reasonable distance of their home. Targeting individuals with this sort of campaign is inconsiderate of lower socio-economic levels, and an incomplete consideration of the context of the issue..
The individual focus of this intervention also lends itself to victim blaming and bullying.   In this case, children who are categorized as overweight or obese are vulnerable to stigmatization and bullying by peers.  An evaluation of the program from 2010 reported that even after being in place for 6 years, 6% of adolescents reported “being victims of weight-based teasing” and 3% reported taking diet pills (4).  While this might be a small percentage of participants, it is still a negative effect, and needs to be considered as an unintended consequence of the intervention. Again, this method is unfair and insufficient, as it tells certain children that they are fat, without really providing any solution. It also could make parents of those children feel responsible for their children being overweight. The individual focus of this campaign actually hinders progress towards its goal.

Critique 2:
A second issue with BMI reporting in schools, is that they failed to take psychological reactance into consideration when designing this intervention. In this particular case, the insult that parents  might feel as a result of schools telling them that their children are overweight or obese could overshadow concern for the child’s health. In this case, the way the message is delivered could contribute to psychological reactance. Schools can generally be associated with grades, lessons, teachers and instruction. Because of these universal associations with school, information about a child’s weight might make the parents of overweight children feel as if they are being reprimanded, or even judged. Particularly, including the BMI categorization with the child’s report card creates the idea that this is another grade given to the child (and the parent). This transforms a high BMI from simple information about a child’s health, to a bad grade—something at which they are failing.  Dr. Melinda Southern, Director of the Prevention of Childhood Obesity Laboratory at Lousiana State University provides further insight into this particular aspect of the issue, by analyzing the framing of the information provided to parents. She argues that, “‘When they use the words ‘at risk’ or ‘overweight’ in the letter, then they have diagnosed,’” says Sothern. “‘If you just give the percentile then it is screening. Once you label what that number means, then you are diagnosing’” (5). The diagnosis part of this is key, because it increases the dominance of the message being imposed on parents. Instead of simply stating facts about a child, this campaign goes a step further to place the child into weight categories, thereby clearly presenting it as a problem if the child is deemed overweight.
Another factor of this intervention that could increase psychological reactance is the perceived threat it poses to values and freedom.  This campaign not only tells parents that their children are overweight, but also sends home “resources that will help students and parents or guardians practice healthy lifestyle habits to avoid future health problems” (3). What children eat, and how much time they spend sedentary are factors that generally depend on parenting. Therefore, this campaign identifies a problem, and then asserts that the causes of that problem are things that the parents are doing incorrectly, or poorly. While it is well known that diet and lifestyle habits are contributing factors to one’s weight, the way this information is presented in this campaign is confrontational. No parent wants to be told that they are making their kids fat, even if they are. As Sothern continues, “Most parents do not enjoy being confronted with this issue. The place to deal with this is the physician’s office” (5). While this campaign tries to promote and encourage good habits and healthy behavior, the way it’s framed creates a perceived threat to the freedom to choose one’s own lifestyle, and make one’s own decisions about diet and exercise.

Critique 3:
            Perhaps the greatest design flaw of the BMI reporting intervention is that it is built almost solely around the health belief model. According to this model, choices about one’s health depend on the weight of perceived severity of the health threat, and the perceived benefits of changing one’s behavior. In the context of this campaign, this would mean that simply making someone aware of the consequences of being overweight, they will make the necessary lifestyle changes to become healthier. This ideology is clearly reflected in this intervention, as the design simply provides people with information about their health status (BMI) and advice about how to improve. This program assumes that providing a parent with their child’s BMI will act as “an alarm, an alert, a much-needed red flag…to awake the parent” (5).  While this program might succeed in spreading awareness of obesity-related health risks, it falls short of its goal to reduce those risks because it fails to consider contextual factors that lead to health decisions.
The greatest issue with applying the health belief model to this scenario is that it assumes long term health is everyone’s first priority. This is an example of fundamental attribution error, because it fails to consider the context in which people make decisions about eating and exercising. By providing information as an intervention, this model suggests that unhealthy behaviors are due to character rather than context. The program is basically assumes that the only reason a child is overweight is because of a lack of knowledge or understanding about the severity of the issue. According to Maslow’s hierarchy of needs, long term health is a higher order need, so someone who is worried about more basic things like food and safety probably won’t care as much about their BMI. As discussed briefly in Critique 1, not everyone is financially capable of making the recommended changes. Additionally, even if there aren’t financial barriers, there can still be physical and circumstantial barriers. For example, if someone lives in an urban environment, on a busy street, the safety of their children would take priority over the importance of playing outdoors and physical activity. Even without these barriers to a healthy lifestyle, there are other factors in this equation that this model fails to take into consideration.
This model’s assumption that people make rational decisions regarding health also contributes to its insufficiency as a solution to childhood obesity. The eating and exercise habits that people adopt are not necessarily reasoned or planned decisions, but rather the result of a complex combination of events and choices over the long term. Furthermore, according to the theory of optimistic bias, people tend to underestimate personal risk, even if they overestimate the risk to a general population. Therefore, merely providing parents with information about the possible health risks of having a high BMI, no matter how severe, won’t necessarily convince them that their children are at risk. Simplifying the situation to this extent impairs our ability to effectively intervene.

Proposed Intervention:
            The goal of this intervention is to use schools to promote healthy eating and behavior in children, in order to reduce childhood obesity and obesity-related health disorders. Because children spend such a high percentage of their time in school, the school is in a unique position to implement interventions aimed at creating healthy habits in children. However, in order to maximize effectiveness, and minimize psychological reactance, the intervention should be aimed not at the individual level, but at the institutional level. Furthermore, since the school represents a social network, the intervention should take advantage of the principles of social network theory in order to spread its message as quickly as possible. Since people tend to adopt behaviors as a group or network, assessing the relationships of that group can help determine the best target for intervention.  I propose transforming the eating and exercise habits of the entire school by directly targeting the children’s behavior, rather than their parents’ values. First, remove unhealthy foods and sugary drinks from vending machines. Second, incorporate more physical activity into the daily schedule, by increasing recess time for elementary school, and increasing frequency and efficiency physical education programs in adolescents. Third, reformat the lunch plan to include healthier options, emphasizing fresh foods, fruits and vegetables and whole grains, and exclude fattening and fried foods from the menu. By changing the food options and building in exercise to the daily routine, it is possible to create an environment where the default decisions about health are the correct decisions. In this way, we can bypass confronting values and wasting time trying to individually change the lifestyle of every family in the school. Furthermore, by intervening at a group level, this intervention can avoid some of the negative consequences cause by BMI reports such as bullying and eating disorders.

Defense 1:
There are many factors and circumstances that contribute to the lifestyle choices that families make about diet and exercise. As discussed above, many of the factors that lead to unhealthy habits are out of the control of the individual. Therefore it makes more sense to change the overall context of the issue, rather than the individual. The fact that children and adolescents spend so much of their day at school can be used to the advantage of the intervention because it creates a context that is then amenable to intervention. It is more effective to influence a whole group (in this case the school) at once, instead of individually trying to change each family’s attitude towards health. By changing everyone’s eating exercise habits, at least while they are at school, this intervention effects the whole school at the same time, instead of targeting each parent individually and scaring them into changing their children’s lifestyle. Changing the food options available, instead of trying to make people choose the healthy option, simplifies the equation. Another advantage of considering a whole group rather than each child is that it eliminates the cause of stigmatization. Since everyone is subjected to the same diet and exercise modifications, no one is isolated and labeled as different. It also creates a more positive association with health, by taking the blame away from the individual, and focusing on what the school, as an institution, can do to improve childhood obesity trends. By intervening at the group level rather than the individual, this intervention is more effective at altering behavior, and more considerate of personal values and the circumstances that shape diet and exercise habits.

Defense 2:
Screening and reporting BMI’s in schools fosters psychological reactance because of the confrontational situation that it creates. This proposed intervention avoids psychological reactance because it doesn’t isolate any individual by associating them with a negative trait. Furthermore, instead of confronting personal values about lifestyle, it targets the institution (school) and behaviors directly. In this way, the intervention avoids creating the sense of blame for the parents that the BMI report cards can cause. Accordingly, since parents aren’t felt blamed for their children being overweight, there is no reason for anyone to become defensive, and reject the overall message. There is no “finger pointing” involved in this intervention. Psychological reactance can also result from perceived manipulation and dominance. This intervention avoids both of those conflicts because it doesn’t attempt to control people’s choices, but rather it changes the context in which those choices are made. The one potential opening for psychological reactance is the changes made to diet options. The removal of unhealthy foods from vending machines and lunch menus could potentially be perceived as a threat to freedom since it would mean eliminating some of the current options. However this can be minimized using framing techniques. If the changes to the lunch program are simply framed as “new options” instead of replacement options, the intervention can minimize the threat to freedom by creating the feeling of adding options instead of losing them. This intervention focuses on positive aspects, by promoting exercise and healthy food without using scare tactics, or negative labels. It also creates less risk for psychological reactance because it doesn’t isolate anyone. Instead of recommending behavioral changes based on weight category, this program encourages healthy behavior in the entire community within the school. It places the emphasis of the intervention on health instead of weight, which can be a sensitive subject.

Defense 3:
Instead of relying on the health belief model, this intervention incorporates ideas of group-level models such as the social network model. The social network model is based on the idea that health behavior can only be understood by examining entire communities, or social networks. It considers the relationships between a person and the important people in their life, and how those relationships can influence that person’s health behavior and lifestyle. By understanding the connections between individuals in a social network, one can decide where to aim an intervention to create the most effective outcomes. In the context of obesity and health habits, the students of each school represent a complex network of relationships. In this case, this intervention identifies the common factors between all of the individuals, and aims to change those. Since all children within a given school district attend the same school, they participate in the same curriculum, choose lunch options from the same menu, and have access to the same snacks in the vending machines. Therefore, in order to have the greatest impact on a widespread network, these are the factors that should be targeted. By increasing time spent in physical education, and removing sugary drinks and unhealthy snack from vending machines, this intervention automatically cuts down on unhealthy habits during the school day. If unhealthy foods aren’t an option, then it isn’t necessary to convince anyone to choose healthy options. Basing the program on changing behavior instead of health belief model allows adoption of healthy behaviors immediately and then gradually will allow for change in attitudes. This intervention targets specific communities, defined by school, instead of each individual in the state.

Obesity, particularly among children and adolescents, is a growing epidemic in America that deserves attention. Schools provide a unique opportunity when planning interventions aimed at childhood obesity because of the central role they play in the lives of children. The BMI screening and reporting campaign attempted to take advantage of the school system to promote obesity awareness and healthy diet and exercise. However it is an unsuccessful campaign, due to the flawed assumptions it makes about the causes of obesity, the narrow scope of factors that it considers, and the level of society at which it makes the intervention. It is designed to intervene at the individual level, which completely discounts the social network and relationships within the school. Since children spend the majority of their day at school, it is possible to target interventions at the institutional level, and make changes to the policies of the school, such as school lunches, physical education, and vending machines. These changes then diffuse through the entire population of the school at once, and lead to behavior adaptations of a large group much more quickly that interventions aimed at individuals. Once these behavioral changes become habit, they can evolve to influence values and attitudes towards health. In this way, schools can be utilized to effect entire transformations of health behaviors that lead to obesity and related illnesses.

1.Bidwell, Allie. Massachusetts schools to stop sending ‘Fat Letters’. US. News and World Report 2013;
2.Flaherty, Michael R. “Fat Letters” in public schools: public health versus pride. Pediatrics Perspectives 2013; 131:403-405.
3.Massachusetts Department of Public Health. BMI Screening Guidelines for Schools. MA: Massachusetts Department of Public Health, 2009.

4.Philips, Martha M. et al. The evaluation of Arkansas Act 1220 of 2003 to reduce childhood obesity: conceptualization, design, and special challenges. American Journal of Community Psychology 2012; 51:289-298.

5.Scheier, Lee M. School health report cards attempt to address the obesity  epidemic. Journal of the American Dietetic Association 2004; 104:341-344.
6.Vogel, Lauren. The skinny of BMI report cards. CMAJ 2011; 183:E787-788.

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