by Michael D. Anestis, M.S.
The other day, I came across an article on CNN.com that was posted on Facebook by "A Voice in Recovery" (follow @VoiceinRecovery on Twitter) detailing a controversial policy at Lincoln University in Pennsylvania. Apparently, beginning in 2006, the university instituted a policy that requires undergraduates with a body mass index (BMI) of 30 or above to enroll in a fitness course that meets for three hours per week. If a student is assigned to the course but does not complete it, he or she is not allowed to graduate. In order to control for some of the weaknesses of the BMI (e.g., the scale does not differentiate the weight of muscle from the weight of fat and thereby causes muscular individuals to appear overweight), the university also measures the waists of each student. In the CNN article, James McCoy, the chairman of the university's Department of Health and Physical Education, explained the policy by saying "we, as educators, must tell students when we believe, in our hearts, when certain factors, certain behaviors, attitudes, whatever, are going to hinder that student from achieving and maximizing their life goals."
Not surprisingly, there have been some vocal responses to this issue. People on one side of the argument are passionate about potential invasions of privacy, misuse of power, an obesity tax (it is unclear if students must pay for credits involved in the course, which obviously impacts the validity of this particular concern), and unbalanced treatment. People on the other side of the argument are passionate about the health of students and desperate to find a method by which to increase the health of undergraduates. Like most, I had a fairly strong emotional response to this story, but the way I see it, although we are all entitled to our emotions, such passion does not necessarily get to the heart of the issue. The real question here is whether this particular policy is effective at accomplishing its goal. In other words, regardless of how we feel about the policy...does it actually even work? After all, on PBB we spend a great deal of time discussing the evidence for and against the efficacy and effectiveness of particular forms of therapy for particular diagnoses, so it seems reasonable to approach this issue from that same perspective.
All that being said, the goal of helping students achieve and maximize "life goals" is rather vague. Because not all students are assigned to the course, the administration's goal does not seem to be centered on providing general education on health. Instead, it appears that Mr.McCoy's statement prioritizes weight loss. With that in mind, the question becomes whether this sort of policy is an effective means by which to help individuals accomplish and sustain weight loss, as this is presumably associated with later success in "life goals." Fortunately, this issue has actually been studied empirically.
Work in this area has been driven by the fact that weight loss programs are plagued by high drop-out and relapse rates. In fact, Kramer and colleagues (1989) reported that less than 3% of patients in one weight loss program maintained full weight loss over a four year follow-up. This, of course, paints a rather dark picture for the utility of weight loss programs. Along these lines, researchers have devoted substantial attention to a theory that has been of great help in the treatment of substance use disorders: self determination theory (SDT; Deci & Ryan, 1985). SDT posits that sustained behavioral changes are substantially more likely when an individual is motivated internally rather than externally. In other words, when behavior change occurs because the individual him or herself chooses to change for their own reasons, sustained change is substantially more likely than when such endeavors are prompted by the requirements or requests of others. Motivational interviewing, which we have discussed previously on PBB, was derived from this theory.
Theories are a pivotal component of scientific endeavors, but actual data are substantially more important in evaluating outcomes. That being said, let's take a look at one particularly relevant outcome:
Williams, Grow, Freedman, Ryan, & Deci (1996)
Geoffrey Williams and colleagues (1996) examined this issue in a particularly compelling manner. 52 severely obese individuals enrolled in the Optifast weight loss program in a community hospital, completed all 26-weeks of the intervention, and provided weight information at a follow-up appointment approximately 2-years after beginning the program. The results indicated that the degree to which individuals were autonomously motivated to participate in the program predicted the number of weekly meetings they attended, the amount of weight they lost during the program, and the maintenance of weight loss at follow-up. In other words, individuals who entered the program because they wanted to rather than because they felt pressured to by others attended more meetings, lost more weight, and were substantially more likely to sustain their weight loss. Additionally, the authors found that when participants felt that the staff supported autonomy rather than applying pressure, they developed a greater degree of autonomous (intrinsic) motivation.
So...how does this relate to the Lincoln University story? The school is identifying overweight students and forcing them to engage in a fitness program. Based upon these findings, it appears that, no matter how pure the intentions of the administration might be, such an approach simply will not work, at least not with any regularity. The program will almost certainly result in a slimmer student body during the graduation ceremony, but the evidence indicates that these gains are unlikely to be sustained, which is bad news for the "life goals" of the students.
What is particularly troubling about this issue is that this study was published 10 years before Lincoln University instituted their policy. Since then, additional studies have provided further support for the role of intrinsic motivation in successful and sustained behavior change with respect to eating behaviors (e.g., Cassin, von Ranson, Heng, Brar, & Wojtowicz, 2008; Treasure et al., 1999) and has pointed towards motivational interviewing as a potentially invaluable tool in enhancing weight loss programs and binge eating treatments. Did the university consult any empirical literature prior to developing their program? Did they consider whether there is any scientific evidence to support their belief that this program would be successful in accomplishing their goals? Unfortunately, it does not appear that they did and, sadly, this is not particularly surprising. When we see an important issue in front of us, it is understandable to develop a strong urge to solve it immediately. Similarly, it is understandable for us to feel compelled to pursue an approach that seems philosophically strong. That being said, it is completely untenable to follow such approaches without first investigating whether scientists have already studied the issue and provided data one way or another on the efficacy of the approach.
Increasing the health of students is an admirable goal. Helping students accomplish and maximize "life goals," while vague, also seems fairly admirable. That being said, whether the university is within its rights to manipulate such things is open to question and, perhaps more importantly, the means they chose to guide the outcome in this situation shows little hope of actually being effective. Changing behavior is not an intuitive endeavor. Approaches that seem logical do not always work. This is why so many people are able to make their living systematically studying various treatments. It therefore seems reasonable to expect an academic institution to take a look at the data before instituting a policy like this.
If you would like to learn more about motivational interviewing, obesity, the treatment of binge eating, or self-determination theory, we recommend the following items, each of which is available through our online store of scientifically-based psychological resources:
- Motivational Interviewing, Second Edition: Preparing People for Change by William Miller and Stephen Rollnick
Overcoming Binge Eating
by Christopher Fairburn
- Cognitive-Behavioral Treatment of Obesity: A Clinician's Guide
by Zafra Cooper, Christopher Fairburn, and Deborah Hawker
- Binge Eating: Nature, Assessment, and Treatment
by Christopher Fairburn
- The Handbook of Self-Determination Research
by Edward Deci
- Why We Do What We Do: Understanding Self-Motivation by Edward Deci