Challenging Dogma - Fall 2007

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

Saturday, December 8, 2007

Are You Getting an “A” on Your BMI Report Card: Are BMI Report Cards Aimed at Reducing Obesity or Increasing Eating Disorders- Elizabeth Kadernauth

Obesity vs. Overweight

Obesity is quickly becoming the leading prevalent public health problem in the United States, having among the highest rates of obesity among developed countries (1). However, there is a difference between the definitions of obesity vs. overweight. In general, both expressions indicate that an individual’s weight is greater that what is considered healthy based on height standards. Obesity refers to having too much body fat, whereas overweight indicates weighing too much (2). The Centers for Disease Control and Prevention defines overweight in the pediatric population of having a Body Mass Index (BMI) of greater than 95% for age (9). The statistics regarding the United States obesity issue are outstanding. The National Center for Health has tracked the issue over four decades and has found that the number of obese Americans has increased from 13% to 31% of the population. 63% of Americans are overweight with a BMI above 25, and 31% are obese with a BMI in excess of 30 (3). As alarming as those statistics are the most frightening statistics are that childhood obesity in the United States has more than tripled in the past two decades and overall is responsible for 300,000 deaths every year (3).

In order to curb the growing rates of obesity, public health programs have created interventions that are being aimed at creating healthy lifestyle changes at an early age. One such public health intervention is measuring a child’s height and weight in order to identify his or her BMI. The original intervention was that a letter would be sent home indicating whether a child’s BMI showed that his/her weight was normal or posed a health risk (8). However, there has been an increased rally for the direct placing of a child’s BMI on his or her report card. Among the states leading this crusade has been New York, Pennsylvania and Texas (8). School systems following this approach believe that it is their duty to teach students about obesity as well as promote future healthy choices by changing unhealthy habits. Advocates also believe that parents should be informed about their children’s current BMI in order for there to be any chance of overturning the epidemic. Since it is often difficult for parents to recognize a problem they may delay getting help because they are typically a poor judge of their child’s weight (10- 12). Even though BMI report cards may initially be a useful tool to inform parents of their child’s health, the public health intervention of mandating BMI report cards in school systems is setting itself up for potential failure. BMI report cards do not account for the social and psychological factors such as peer pressure, teasing that can lead to low self esteem, and the progressive or regressive attitudes pertaining to weight that can be associated with labeling children at an early age. Similarly, BMI Report Cards do not take into account Social Learning Theory in providing a positive model for healthy behavior change among children. And finally BMI report cards prove based on Agenda Setting Theory that public health interventions tend to fail because it only takes into consideration what is on the current public agenda rather than an integrated long term coordination among other weight related issues and interventions.

Remaining Obese After Being Labeled

The public health intervention of placing a child’s BMI on report cards may label kids from early on in development. The labeling theory suggest that when an individual is labeled as part of a group (in this case as overweight or obese) that individual will tend to internalize and self identify with that label. A study conducted on the population-based longitudinal study of 2,500 teens on issues pertaining to eating disorders, including obesity concluded that in order to prevent both obesity and eating disorder there needs to be a larger focus on health rather than weight. Focusing on weight alone is depreciatory and counterproductive (4).

The words obese and overweight tend to carry a heavy stigma in American society associated with increased discrimination. By labeling a child as obese, we are enforcing this stigmatism because we are subconsciously separating obese and overweight children from their other peers, thus creating anxiety about body image (5). Research has found that obesity defined by BMI was linked to a 25% increase in the odds of anxiety (6). In attempts to diminish anxiety we tend to overindulge in food to reduce stress. The idea of placing a child’s BMI in report cards not only creates a label, but can be part of a continuous snowball effect that can end with overindulgence in food. Instead of making important strides towards a healthy weight, some children may be more likely to continue the lifestyle they have been practicing previously and continue to remain obese.

A New Eating Disorder

On another level, even though BMI report cards may help determine which children are overweight and obese, it does not provide a positive model for which children can change their lifestyle and behaviors pertaining to weight. In not providing a positive model towards a healthy lifestyle, the public health intervention of sending home BMI report cards also fails to take into account the Social Learning Theory. Social learning theory provides that learning is done by observation. The intervention does not account for social learning theory because is does not provide an appropriate model for which a child can effectively change their behaviors about their weight. Without an positive model, sending children home with BMI Report Cards stating that they are obese could lead to a self obsession with weight.

In Arkansas, after implementing BMI report cards, the biggest fear among children and parents has been that the intervention has lead to a 13% increase in teasing among peers (13). In response to the teasing, parents are concerned that labeling a child as obese may cause them to model their lifestyle behavior on what they see and what is most accessible in their surrounding environments. For children, what is most accessible and influential is the media. In a society where the media constantly focuses on the shrinking frame of Hollywood actresses and fad diets; children are more likely to shape their behaviors based on what they learn by modeling other people; using the media as a standard for beauty and acceptance.

No one can deny that the life of a Hollywood actor is glamorous. Their lives are surrounded by fame, adoration, money, success, and constant media attention. However, beneath the glare of the spotlight is the constant struggle to remain beautiful, to remain youthful, and to remain thin; an increased scrutiny to remain flawless. Most fad diets, from Atkins to the South Beach diets are credited if not endorsed by actors, musicians, and models in the entertainment industry for their slim figures. Almost monthly is there some new exercise regime or diet supplement that can help aid in creating svelte bodies that we as individuals could only aim and wish for. What are astonishing about these particular weight transformations is that an actor or actress can go from having a healthy BMI to a less than normal BMI in a mere matter of time. Tabloids neighboring the cashiers at local stores all seem to be giving praise to those that were able to tone their bodies in a matter of weeks. It is these unrealistic standards that serve as the models for those trying to work towards a healthy weight and lifestyle changes.

Many claim that BMI reports cards may be an important starting point for making children aware of their weight (14), but the model for which children are proceeding with weight loss is unhealthy. Not only is it promoting drastic weight loss, but it is giving the false perception that it can be accomplished in a fairly short time span. Instead of becoming a healthy weight, children might go to the extreme and develop an eating disorder, such as bulimia or anorexia because they are so focused on their weight and trying to resemble the figures that have the media attention (15). Previously, the study of 2,500 teens stated that it is often counterproductive to label someone as obese, but that we should rather focus on lifestyle over weight loss; concluding that it underscores that the more weight per se is talked about the more likely teens are to adopt dangerous dieting habits (4). In order to make effective strides toward a healthy weight and lifestyle, we need not focus on the issue of weight, but on the environment and culture for which children develop their poor lifestyle choices. The BMI report card intervention does not take into account the Social Learning Theory in providing a suitable model for which one can appropriately change his/her behavior, nor does it account for the environment for which one grows up in.

The New Public Health Intervention Fad

A few years ago the media and public health programs held great focus on the issue of eating disorders in the form of anorexia and bulimia. Fast forward a couple of years and the main issue is not the high percentage of teen agers and adults suffering from anorexia and bulimia, but rather the high percentage of Americans that are becoming more obese. Public health interventions are like fads that almost seem to change when the media focus changes. The public health intervention of BMI report cards falls into that stereotype because it only accounts for what is currently on the public agenda.

The Agenda Setting Theory suggests that the mass media has the ability to transfer the importance of objects on the mass agenda to the public. Right now obesity is on the agenda and is more focused on. Issues of obesity and negative publicity has caused fast food companies to work overtime to reformat their menus to include healthier low fat options, while sports wear companies are working to get children from in front of the television and outside. Even with all the healthier options to promote healthy lifestyle behaviors, eating disorders are still an issue that plagues a large percent of all Americans.

Instead of shifting interventions based on what is on the agenda at the moment, public health interventions need to be reworked in order to take care of both extremes at the same time if it wants to promote healthy living and lifestyle choices to the public. Although BMI report cards are also sent home to children that have a less than average BMI, the goal aims to notify whether a child is inherently overweight or obese (2, 5). Over 8 million people in the US suffer from an eating disorder and have the highest mortality rate out of any mental illness (7). With statistics like these, public health programs need to focus on creating an intervention that focuses on the overall problem of eating disorders rather than subcategorize their programs to address what is on the public agenda at the moment. By only concentrating on what is on the agenda at the moment and not what has been on the agenda in the past, interventions will never fully serve as a continuous stride at protecting the public. There must also be more concentration on the overall outcome of their interventions. In order to promote healthy behaviors, public health interventions need to create and have long term perspectives rather than short term goals.


For the public health intervention of sending home BMI report cards to work more effectively many factors need to be taken into account: Labeling theory, Social Learning theory and Agenda Setting theory. BMI report cards need to be careful not to uphold the stigmatization of obesity and weight. Rather than putting BMI on report cards, there need to be a method of reporting a child’s BMI with regard that that information stays within the confidential school to parent relationship. Once this form of confidential notification has been established, the school needs to provide some sort of model in order for there to be effective outcomes to the intervention. Whether the model be suggestions of exercise routines or how to eat healthy, the intervention needs to promote these suggestions as a lifestyle change that should encourage all members of children’s immediate families to participate. If there is full participation from the family under an appropriate model, children will be more likely to change their behavior because they aren’t being singled out but rather encouraged. To make public health intervention pertaining to body image, weight and healthy lifestyle effective we need to continuously focus on both extremes of eating disorders. What is necessary is a public health intervention that tackles anorexia, bulimia and obesity on a long term basis so that there isn’t a cycle of progression and regression in statistics pertaining to these issues. It is still early to predict the long term success of the BMI report card intervention. However, until the intervention addresses labeling, social learning theory and agenda setting theory the program will only see limited success and results.


1. U.S. Dept. of Health and Human Services, National Institutes of Health. "Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report" (2000). NHLBI document 98-4083

2. Medicine, U. N. (2007). Obesity. Retrieved October 2007, from MedlinePlus: Trusted Health Information for You:

3. Medicine, U. N. (2007). Obesity. Retrieved October 2007, from MedlinePlus: Trusted Health Information for You:

4. Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: How do dieters fair 5 years later? Journal of the American Dietetic Association. 2006;106(4):559-568.

5. Labeling Children Obese When They Enter School Is A Flawed Approach To Dealing With Obesity Epidemic. (2007, April 13). Retrieved from Medical News Today:

6. Insight. (2007, February 14). Researchers look into obesity’s links to anxiety and mood disorders. Retrieved from Insight Journal:

7. DMH. (2006). Eating Disorder Statistics. Retrieved from South Carolina Department of Mental Health:

8. Kantor, J. (2007, January 8). As Obesity Fight Hits Cafeteria, Many Fear a Note From School. New York Times.

9. Kuczmarski RJ, Fleagal KM. Criteria for definition of overweight in transition: background and recommendations for the United States. Am J Clin Nutr. 2000;72: 1074–1081.

10. Eckstein KC, Mikahil LM, Ariza AJ, Thomson JS, Millard SC, Binns HJ. Parents' perceptions of their child's weight and height. Pediatrics. 2006;117:681–690.

11. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood obesity: do parents recognize this health risk? Obesity Res. 2003;11:1362–1368.


13. BMI Report Cards: The 'F' Is For 'Futility'. (2006, February 28). Retrieved from The Center for Consumer Freedom:

14. Body Mass Report Card. (2005, April 20). Retrieved November 2007, from The Journal Editorial Report:

15. Jade, D. (2002, April). Eating Disorder and the Media. Retrieved from The British Medical Association, Eating Disorders Body Image and The Media:

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  • At December 10, 2007 at 7:17 PM , Blogger Read said...

    Elizabeth- Great topic choice! And you did a great job showing how this public health measure would be ineffective. I do feel that at one point the focus of you the argument shifted too far away from the BMI report cards on to the glamorous actors and actresses. And there were some inconstancies in the capitalizing of Social learning Theory.

    Also, I learned what the word svelte means--good word. I'll be using it.

  • At December 14, 2007 at 10:03 AM , Anonymous Deinera said...

    I agree that this public health intervention is particularly misguided...I can only imagine what it would be like to not hide a bad grade on a report card from your peers, but a BMI you were embarassed about. Your arguments about how the current focus neglects anorexia and bulimia were also very interesting.


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