Thursday, May 6, 2010

BMI Measurements Not the Answer to Preventing Childhood Obesity: A Critique of Arkansas Act 1220 of 2003 – Katie Louer

Introduction

The US is facing a nationwide epidemic. Americans are heavier than ever, and becoming more obese with each day. As the rate of obesity increases in adults, it also rises in children (1). Our nation’s youth are at a higher risk than ever of becoming sick or dying as a result of obesity (1). States have attempted to intervene creating anti-obesity campaigns with little success. In 2003, Arkansas implemented Act 1220 to combat childhood obesity (2). The campaign’s main objective is to report student body mass index, or BMI, to parents. The first year the act was implemented 20.8% of children in Arkansas public schools were overweight and 17.3% of children were at risk of being overweight (3). Six years later 20.4% of Arkansas children in public schools were overweight, and 17.2% were at risk of being overweight (3). Although childhood obesity rates did not increase in the six year period, rates failed to decrease. Arkansas’ attempt to combat childhood obesity continues to be ineffectual. In order for Act 1220 to be successful, the campaign must be revamped. Rather than disempowering the nation’s youth through labels of “overweight” and “obese,” the campaign must promote positive self-identity and esteem, as well as address the social factors contributing to obesity.
Rates of obesity in American adolescents and children have skyrocketed over the last few decades. From 1963 – 1970 four percent of US children ages 6-11 and five percent of teens 12-19 were overweight (4). From 1976-1980, the number of overweight children between 6-11 years increased to 6.5 % and in 2007-2008 this percent rose further to 19.6% (5). The percentage of overweight adolescents (12-19 years) remained at 5% from 1963-1980 (5). However, in the past three decades this rate more than tripled, and 18.1% of teens in this age group were overweight in 2007-2008 (5). What is more, obesity is affecting children early, with the number of overweight 2-5 year olds increasing from 5% in 1976-1980 to 10.4% in 2007-2008 (5).
Overweight children are at a much higher rate for becoming obese adults. According to a study of young adults in Washington born between 1965-1970, obese adolescents aged 10-14 had a 28.3% chance of being obese adults (defined as having a BMI of  27.8 for males and  27.3 for females) (6). Additionally, very obese adolescents (characterized as having a BMI at or above the 95th percentile) in this age group had a 44.3% chance of obesity in adulthood (6). Meanwhile not obese children, aged 10-14, had a 10% chance of being obese as adults, and 9% of not obese teens, 15-17, were obese as adults (1).
As rates of obesity spiral out of control so too do rates and costs of health risks associated with the disease. Obese children and adults are at a higher risk for heart disease, high cholesterol levels, high blood pressure, glucose intolerance, Type 2 diabetes, arthritis-related disabilities, several types of cancer, premature death, and many other diseases (1). In addition to individual health risks, obesity is a strain on the US health care system. In 2000, the total cost of obesity (which included medical costs, and the value of lost wages by employees unable to work) was $117 billion (4).
Similar to other southern states, the people of Arkansas are disproportionately more obese than the rest of the United States. The National Survey of Children’s Health found in 2003 that 32.9% of Arkansas children, aged 10-17, were overweight or obese (7). In 2007, more than 29% of Arkansas adults were identified as obese (1).
With an increasing prevalence of obesity, the need to implement an anti-obesity campaign in Arkansas was glaringly obvious. In 2003, Arkansas’ General Assembly Speaker of the House, Herschel Cleveland introduced a bill to address childhood obesity (8). Governor, Mike Huckabee signed the bill, creating Act 1220 of 2003.
Implementation of Arkansas Act 1220 of 2003 started in the Arkansas school system with a multi-dimensional approach. The act included the following components:
(1) Annual measurement of BMI for all children attending public schools and reporting of BMI to parents
(2) Elimination of access to vending machines in elementary schools
(3) Distribution of funds to hire Community Health Promotion Specialists to work with schools and communities
(4) Establishment of a Child Health Advisory Committee to develop school regulations with regard to nutrition and physical activity
(5) Public reporting of vending contracts
(6) Establishment of school nutrition and physical activity advisory committees (8).

Initially BMI assessments began with BMI report cards and eventually progressed to health reports sent home to parents. Body mass index, which is the ratio of an individual’s weight to height squared, is often used to assess risk for weight-related health problems (8). The report cards created confusion over the reported percentiles (the 99th percentile of BMI indicates highest health risk, while the 99th percentile in a school subject indicates high achievement), and were soon replaced with confidential health reports to parents (1).
Children’s body mass index was measured once a year in grades K-12. Students who were absent on measurement days had to wait until the following year to receive a BMI measurement. Letters sent home to parents described the risks of obesity in a three line paragraph and reported the child’s BMI as one of the following categories: overweight, at risk for overweight, healthy weight, or under-weight (9). Under the section of “What should you do?” parents were advised to show the letter to the student’s doctor, as well as “offer healthy snacks, drink fewer sodas, limit television time, and take family walks or exercise with their child (9).
Health reports made parents more aware of their child’s BMI, but led to few household changes. Before the distribution of health reports, 40% of Arkansas parents accurately classified their child as overweight or at risk for obesity, whereas after the campaign, 53% accurately identified the weight of their children (10). Despite the school’s recommendation, most parents did not talk to school nurses or family doctors about their child’s BMI (10). Furthermore, parents were not more likely to put their child on a diet after receiving the report than they were before the program (10).
Under Arkansas Act 1220 the prevalence of childhood obesity remained the same. According to the 2004 Statewide BMI Report, 21% of Arkansas public school students in grades kindergarten, 2nd, 4th, 6th, 8th, and 10th were overweight and 17% were at risk for overweight (11). There were no changes in 2005 (12) 2006 (13), 2007 (14) or in 2008 (15). Finally, in 2009, six years after the act was implemented, 20.4% of children in these grades were obese and 17.2% were at risk for being overweight (3). In a six year intervention the program failed to accomplish its main objective: combating childhood obesity in Arkansas.

Critique

Unfortunately Arkansas Act 1220 has failed to make any changes in six years of implementation. It continues to be an ineffective approach to battling childhood obesity for three main reasons. Firstly, reporting body mass index to parents can result in children being labeled by their weight and therefore stigmatized by others. Secondly, the program fails to engage parents and the community in the fight against childhood obesity. Lastly, the program does little to address the federally regulated school lunch programs as determined by the United States Department of Agriculture.

Critique Argument 1: BMI Reporting and its Stigma

The reporting of BMI measurements put many Arkansas children at risk of being stigmatized by other children. Act 1220 labeled students as belonging to one of four groups: underweight, healthy, at risk, or overweight (4). Students who were “at risk” or “overweight” were susceptible to the stigma of being called fat. According to the stigma theory, a stigma is defined as “any physical or social attribute or sign that devalues an actor’s social identity as to disqualify him or her from ‘full social acceptance’” (16). Individuals not conforming to the norm (in this case children who are overweight or at risk) are labeled as deviant and subhuman (16). A fear of being labeled so negatively makes children afraid of becoming fat.
Unfortunately, children of all ages are susceptible to the societal stigma against fat people. Over the last 40 years, the stigmatization of obese children has increased by 40% with teasing as the most common result (17). In Arkansas public schools obese children reported significantly higher levels of embarrassment from their BMI, than non-obese children (10). As a result of this embarrassment children are bound to have a lower self-esteem, increased dissatisfaction with their bodies, and may be at risk for eating disorders. Therefore, while Arkansas is attempting to improve the health of children with Act 1220, they are actually damaging students’ self-worth by labeling them as fat.

Critique Argument 2: The Lack of Parental Involvement

In addition to the damaging emotional effects of the campaign, Act 1220 fails to incorporate parents into the intervention. Essentially, parents are engaged with a short and simple letter telling them information they probably around knew about nutrition, exercise, and the importance of seeing a doctor. The only new information they receive pertains to their child’s BMI. Clearly policymakers had the Health Belief Model in mind, assuming that informing parents of the health risks caused by obesity, would be enough to change their child’s eating habits.
Under the framework of the Health Belief Model, behaviors are rationally planned decisions determined by an individual’s weighing of possible outcomes. The perceived benefits to preventive action, and perceived barriers to preventive action are weighed against the perceived susceptibility and severity of the disease (18). While some parents may have found that the severity and susceptibility of obesity was too great, this was not enough for them to make household changes. Parents with overweight children were more likely than parents of non-obese children to be somewhat or very concerned about their child’s weight, but they were not more likely to adopt healthy eating or change exercise behavior (17). Only 20% of families with an overweight child planned “diet-related activities” with their child, and 40% of these families did not plan on having their child see a doctor (17). The lack of medical consultation, and the fact that the prevalence of childhood obesity did not decrease over six years, suggests that parents did not perceive the severity and susceptibility of obesity to be great enough to make any significant behavior changes.

Critique Argument 3: Unhealthy USDA Lunch Guidelines

Finally, while Act 1220 addressed the need for nutritious food in the public school system, it was unable to change federally regulated school lunches, a main source of unhealthy eating. Under Act 1220 elementary schools had no access to vending machines and could not buy foods of minimal nutritional value during the school day (19). Then, in 2005, the Child Health Advisory Committee required that all food and drinks available to elementary, middle, junior high and high schools meet nutrition standards, “except school meals, which are governed by USDA regulations” (19). Sadly, the bulk of foods consumed in schools are school meals.
While the United States Department of Agriculture claims to follow the Food Guide Pyramid for menu planning for school lunches, they still allow many unhealthy options (20). The USDA’s database of allowed foods contains many processed foods as options for school meals (20). In fact, the USDA even consents to schools purchasing processed foods and menu items not listed in the database (20). If the agency responsible for public school lunches throughout the country, permits not only processed food, but processed food chosen by individual schools, it would seem that the nutritional regulations are either not being followed or are simply too lax.

Proposed Intervention

While the design and implementation of Act 1220 seems inherently flawed, there is room for improvement. Arkansas public schools must first stop measuring students’ BMI, and find new ways to label students positively. Instead of labeling students by their body mass index, schools can promote healthy eating. By applying labeling theory they can begin to label students as healthy eaters who are rewarded for their healthy choices. In addition, rather than rely on the Health Belief Model, and assume that parents will make household changes just by learning their child’s BMI, the campaign should incorporate the role of parents into the intervention using the Social Ecological Model. Finally, changes to school meals, either through policy changes in the USDA guidelines or alternative approaches to school lunches, are imperative in the fight against childhood obesity.

Defense of Intervention: Positive Labeling

By applying labeling theory to the intervention, schools can remove the stigma of being labeled as fat and begin labeling children by their positive behaviors. Schools must stop measuring BMI, as it is clearly ineffective and only has detrimental effects on students’ esteem. Teachers should instead promote healthy eating in classes. Students can follow Healthy Eating Reward Charts, and mark the number of healthy choices they’ve made in a week. For instance, students would write the number of fruits or vegetables they ate in a week. At the end of the week, or month, students with the most fruits and vegetables would be rewarded. By making a competition out of eating healthy, the winners begin to be labeled as healthy eaters, and other students will want to follow their lead.
According to labeling theory, labels affect individual’s self-perception (16). They become a self-fulfilling prophecy. Therefore if children are labeled as something positive, according to labeling theory, they will try to live up to this positive label. By labeling students as healthy eaters they will continue making healthy choices, and hopefully inspire other students to do the same.

Defense of Intervention: Social Ecological Model and the Role of Parents

By incorporating the Social Ecological Model into Act 1220, parents can play a greater role in the program. According to the Social Ecological Model there are five levels of social influences: (1) social structure, policy and systems, (2) community (3) institutional/organizational, (4) interpersonal, and (5) individual (21). The broadest level of influence is social structure, policy and systems. Regulations by the USDA and food guide pyramids, for example, are influences, which affect child nutrition at the top level. Community level influences may include social networks, for instance parents of children in Arkansas public schools. Meanwhile organizational and institutional influences refer to the practices of a specific organization, as in a specific Arkansas public school. The level closest to the individual is interpersonal influences, including parents. Ultimately, the individual’s morals and values will determine his or her behaviors.
Because parents are only one sphere away from their child, they have a significant impact on the child’s behavior and decision-making. Parents can instill their own values in their children by promoting healthy eating and exercise. Moreover, parents are the very people buying food for the household. If the parents are not interested in eating healthy, they will continue to buy junk food, giving their kids no other choice but to eat unhealthy. A study by the Department of Human Development and Family Studies revealed that mother’s knowledge of nutrition was positively associated with children eating more vegetables and fruits (22).
Anti-obesity campaigns are beginning to incorporate the Social Ecological Theory into their program design. South Carolina’s Department of Health and Environmental Control has developed an anti-obesity intervention based on the Social Ecological Theory (23). The program promotes organizational changes, such as providing time off or flexible hours to allow employees to exercise during the work day, and getting churches involved in nutrition education (23). Interpersonal influences include support systems for healthy eating and exercise (23). These steps are essential to getting parents interested in exercising and eating right.
South Carolina’s program is a successful example of engaging the community, and particularly parents, in leading healthier, more active lives. If parents can grasp this message and become involved then they can begin to promote nutrition and physical activity to their kids.

Defense of Intervention: Changes in School Lunches

In order for significant changes to be made in Arkansas, changes to school meals must be made at the policy level. Arkansas representatives and senators can put pressure on the United States Department of Agriculture, and advocate for changes in school lunches. Legislators could also give state funding to schools that successfully introduce healthy options into their school menus. By taking advantage of loopholes in USDA guidelines, regarding schools making their own choices and recipes, school kitchens could incorporate more fruits and vegetables, and less processed food into school meals. State funding could then be granted for additional kitchen personnel to help with preparing food.
Aside from policy changes, there are other alternatives to school meals. Programs, like School Food FOCUS, are making changes in schools around the country. School Food FOCUS is a national campaign providing healthier and more sustainable food options to urban school districts (24). Their program includes the Knowledge Café, a social networking site for food service professionals to share ideas and experiences from their school districts (24). The organization also advocates for policy changes, runs the School Food Learning Lab, which helps pilot school districts make changes, and provides education and outreach (24). With their multi-dimensional approach, School Food FOCUS will hopefully transform school meals from unhealthy and unappetizing to nutritious and delicious.

Conclusion

In order for Arkansas to continue Act 1220 it is essential that the campaign be remodeled. With a shift in focus from BMI reporting towards positive labeling of students, parental involvement, and changes in school lunches, Act 1220 will be a success. Without making these changes Arkansas has little hope of combating childhood obesity. Now, more than ever, the state must commit to the fight, and do whatever is necessary to save their children.

REFERENCES:

1. Thompson, J & Card-Higginson, P. Arkansas’ Experience: Statewide Surveillance and Parental Information on the Child Obesity Epidemic. Journal of the American Academy of Pediatrics 2009; 124: S73-S82.
2. Robert Wood Johnson Foundation. Arkansas Act 1220 Evaluation: A Project of Information for Action: School Policies to Prevent Childhood Obesity. Princeton, NJ: Robert Wood Johnson Foundation, 2009. http://www.rwjf.org.
3. Arkansas Center for Health Improvement. Assessment of Childhood and Adolescent Obesity in Arkansas: Year Six (Fall 2008 – Spring 2009). Little Rock, AR: Arkansas Center for Health Improvement, 2009.
4. Wechsler, H., McKenna, M., Lee, S., & Dietz, W.. The Role of Schools in Preventing Childhood Obesity. The State Education Standard 2004: 4-12.
5. Centers for Disease Control and Prevention. Childhood Overweight and Obesity. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/childhood/index.html
6. Whitaker, R., Wright, J., Pepe, M., Seidel, K., & Dietz, W. Predicting Obesity in Young Adulthood from Childhood and Parental Obesity. New England Journal of Medicine 1997; 337(13):869-873.
7. Bethell, C., Read, D.,Goodman, E., Johnson, J., Besl, J, Cooper, J., & Simpson, L.. Consistently Inconsistent: A Snapshot of Across - and Within – State Disparities in the Prevalence of Childhood Overweight and Obesity. Journal of the American Academy of Pediatrics 2009; 123:S277-286.
8. Raczynski, J., Thompson, J., Phillips, M., Ryan, K., & Cleveland, H. Arkansas Act 1220 of 2003 to Reduce Childhood Obesity: Its Implementation and Impact on Child and Adolescent Body Mass Index. Journal of Public Health Policy 2009; 30:S124-140.
9. Arkansas Center for Health Improvement. Combating Childhood Obesity: Sample Child Health Report to Parents. Arkansas Center for Health Improvement. http://www.achi.net/childob.asp
10. Nihiser, A., Lee, S., Wechsler, M., Odom, E., Reinold, C., Thompson, D., & Grummer-Strawn, L. BMI Measurement in Schools. Journal of the American Academy of Pediatrics 2009; 124:S89-S97.
11. Arkansas Center for Health Improvement. The Arkansas Assessment of Childhood and Adolescent Obesity. Little Rock, AR: Arkansas Center for Health Improvement, 2004.
12. Arkansas Center for Health Improvement. The 2005 Arkansas Assessment of Childhood and Adolescent Obesity: Online State Report. Little Rock, AR: Arkansas Center for Health Improvement, 2005.
13. Arkansas Center for Health Improvement. The Arkansas Assessment of Childhood and Adolescent Obesity – Tracking Progress: Online Statewide Report. Year Three (Fall 2005 - Spring 2006). Little Rock, AR: Arkansas Center for Health Improvement, 2006.
14. Arkansas Center for Health Improvement. Assessment of Childhood and Adolescent Obesity in Arkansas Year Four (Fall 2006 - Spring 2007). Little Rock, AR: Arkansas Center for Health Improvement, 2007.
15. Arkansas Center for Health Improvement. Assessment of Childhood and Adolescent Obesity in Arkansas: Year Five (Fall 2007 – Spring 2008). Little Rock. Arkansas Center for Health Improvement, 2008.
16. Slattery, M. Stigma Theory (pp 185-189). In: Key Ideas in Sociology. Cheltenham, UK: Nelson Thornes Ltd., 2003.
17. Ikeda, J., Crawford, P., & Woodward-Lopez, G. BMI Screening in Schools: Helpful or Harmful. Oxford Journal 2006; 21(6 ):761-769.
18. Becker, M., Maiman, L., Kirscht, J., Haefner, D., & Drachman, R. The Health Belief Model and Prediction of Dietary Compliance: A Field Experiment. Journal of Health and Social Behavior 1977; 18(4):348-366.
19. Arkansas Center for Health Improvement. Child Health Advisory Committee Recommendations for Standards to Implement Through Rules & Regulations. Little Rock,AR: Arkansas Center for Health Improvement. http://www.achi.net.
20. United States Department of Agriculture. Part 210: National School Lunch Program. Alexandria, VA: Food & Nutrition Service, 2009.
http://www.fns.usda.gov/cnd/Governance/regulations.htm#REAUTHORIZATION
21. Gregson, J., Foerster, S., Orr, R., Jones, L., Benedict, J., Clarke, B., . . . Zotz, K. System, Environmental, and Policy Changes: Using the Social-Ecological Model as a Framework for Evaluating Nutrition Education and Social Marketing Programs with Low-Income Audiences. Journal of Nutrition Education 2001; 33(1)S4-S15.
22. Davison, K. & Birch, L. Childhood Overweight: A Contextual Model and Recommendations for Future Research. University Park, PA: Department of Human Development and Family Studies at Pennsylvania State University, 2001.
23. South Carolina Department of Health and Environmental Control. Obesity Prevention & Control. Columbia, SC: South Carolina Department of Health and Environmental Control.
http://www.scdhec.gov/health/chcdp/obesity/strategies.htm.
24. School Food Focus. New York, NY. http://www.schoolfoodfocus.org.

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