Dear Dame Rachel,
The Children’s Commissioner’s Big Ask Survey (2021) gave voice to children and revealed the state of their nation. Children said they want good mental and physical health, and the survey demonstrates, they know exactly how to achieve it. They want to be outside, playing in open spaces. They want to participate in sports and activities. They think about regional inequality and want to improve their local areas (T.C.s.C.f. England 2021).
The current approach to addressing children’s health through a focus on obesity, combines high level policy output mixed with individual responsibility. The approach fails to reduce obesity and threatens mental health through weight stigma.
I am writing to ask you to call for an end to the objectifying National Child Measurement programme that reduces individual children to their bodily measurements. Instead, call for grounded research on the structural, environmental, social, and cultural determinants that shape children’s health. Give voice to children as stakeholders in the changes they need to be healthy.
Despite policy interventions aimed at ‘tackling’ obesity, elevated levels have plateaued for years. (A quarter of Year 6 children are considered to be an unhealthy weight (Fisher et al. 2022). This is creating a pipeline for Type 2 Diabetes. Normally associated with ageing, Type 2 Diabetes is rising in children and adolescents and in the five years since 2017, diagnoses in young adults have jumped by 23% (Diabetes UK).
In the UK we tackle this problem with a top-down approach. We are missing the cultural and environmental knowledge from the ground up; knowledge from the social body in which children live and their situational, lived experience that affects their physical bodies (Scheper-Hughes and Lock 1987). We have a public health system that weighs and measures individual children’s bodies, but how much agency do individual children actually have in fostering good health? What choices are available to children and what determines the choices they make?
The reductive and stigmatising National Child Measurement Programme (NCMP) must end. Children are weighed at school and parents informed by letter if their child is overweight or obese. Parents have voiced concern that BMI is an inflexible metric for variable bodies. They argue the NCMP over-emphasises the importance of weight to children, it stigmatises individuals at school, causes distress to children and distress to parents who feel blamed for their child’s weight. Parents argue that there are other determinants of a child’s weight such as school lunches and access to activities (Kovacs, Gillison, and Barnett 2018). There is evidence that informing parents of their child’s weight status has insubstantial impact on ‘lifestyle’ behaviour and may have harmful effects (Isaacs et al. 2014). Despite this evidence, letters are still sent, and individual children asked to change their behaviour.
Global, ethnographic research echoes the views of families affected by the NCMP in the UK. The medical framing of weight creates a global phenomenon of fat stigma, enhances the suffering of individuals, and distracts from the structural and environmental factors that determine who has health. A study across Japan, USA, Paraguay, and Samoa revealed that people understood their weight to be affected by changing environments, loss of traditional foodways, work demands, and pressures of contemporary, urban life. Yet still participants felt individual responsibility and blame for their weight (SturtzSreetharan et al. 2021).
A different approach would be to look at the context in which weight gain occurs and see how healthier choices can be enabled. The NCMP statistics inform high level policy and, on the ground, attempt to address individual behaviour. What is missing, is everything in between those levels, that affect children’s health. The focus on individual behaviour, without context, hinders progress on addressing obesity and health issues that affect children.
The abundance of quantitative data on obesity, reveals that obesity rates cluster in certain areas. Obesity in England is entirely mappable (Fisher et al. 2022). Can this possibly be down to individual ‘lifestyle’ choices? More likely it’s the circumstances of the local population. Stigmatising weight causes division along class lines. Internalizing self-blame for obesity mutes public outrage at the causal factors of obesity and poor health (SturtzSreetharan et al. 2021). We know that children are more likely to be obese where there is poverty, poorer access to places to exercise, lack of green spaces, complex social and environmental factors. Qualitative research, at a local level, to gain cultural and environmental knowledge, is the key to supporting all children towards better health (Fisher et al. 2022).
Without such knowledge, we simply don’t know how to make things better. 2016 saw the publication of the Childhood Obesity Plan and the highlight policy to introduce a soft drinks levy to encourage producers to lower the sugar content of drinks (UK Government 2016). The Medical Research Council (MRC) Epidemiology Unit at University of Cambridge tracked levels of obesity levels between 2014 and 2020 and compared changes in the 19 months after this ‘sugar tax’ came into effect in 2018. Their headline results are positive and associate the tax with an 8% reduction in obesity levels in girls in Year Six (Rogers et al. 2023). The results are not straightforward though and statistics alone will not answer the questions they raise. There was no change in obesity levels of younger children and mysteriously, there was no change in obesity levels for boys in Year Six. The qualitative context is missing, and researchers can only hypothesise what is happening on the ground.
An ethnographic study in the London Borough of Lewisham, Great Yarmouth and Stoke on Trent revealed how food environments might push low income families towards unhealthy products, while, paradoxically, supporting other family well-being needs such as social interaction (Isaacs et al. 2022). Research published in the American Anthropologist revealed how work structures can deplete health and cause diabetes (Chard 2020). In Los Angeles, a study demonstrates how diabetes requires a racial and economic justice framework (Garth 2020) and an Australian example explores how household and community habits of eating calory dense food, are not ‘lifestyle’ choices but driven by circumstance (Manderson 2020).
The Children’s Commissioner represents children’s voices in the corridors of power. Children can speak for the cultural circumstances of their own environments, particularly in their school lives. In 2013 the School Food Plan was introduced with guidelines to improve the quality of nutrition in schools, school meal uptake, school cooking lessons and improved school dining environment (Dimbleby and Vincent 2013). In the decade since, the School Food Plan has not been evaluated.
Grounded, qualitative research that takes account of the lived experience and the cultural life of children and teenagers, provides insight into how they engage with their food environments. If teenagers are skipping lunch and eating at fast food outlets on the way home – what drives that behaviour? Is it uncool to eat healthy food? Is the dining room intimidating? Long queues? Not enough time? (Rose 2019). This behaviour is culturally and environmentally driven. A Swedish ‘empathy-based’ study of the lived experience of school lunch, revealed the association with emotion and the physical environment of the school dining room. School lunches are about more than food on a plate to the children that experience them. To children, the primary meaning is social, and children’s well-being is affected by the environment, the noise levels, seating arrangements and time pressures. This study showed that for some, the school dining room is an exposed and vulnerable place (Berggren et al. 2020). The book, “School and Food Education in 21st Century” looks at the culture of ‘foodieness’ in school food policies and the perceived association of that culture with class categories. It reveals a social tension in some communities where certain food knowledge is marginalised and this affects school dining (Earl 2018).
Data on levels of physical activity in children, is collected by Sport England and the annual, Active Lives Children and Young People Survey (Sport England). The statistics are given greater meaning though, when research on children’s physical activity, includes children’s voices. Bristol University asked children what motivates them to engage in physical activity, what factors influence them and what activities they like to engage in. It identified cultural and practical barriers, environment factors, peer culture and other social agents that have a positive or negative affect on physical activity. (Emm-Collison et al. 2022).
These research examples demonstrate the need for policy to be grounded in information from the local environment and culture to be effective. In the Big Ask, children said they want to be active, and they want to be healthy. Let’s stop measuring their bodies and put an end to the stigmatising, blame culture that fails to optimise children’s physical or mental health. Instead, children should be stakeholders in determining their health environments at a local, school level and in national policy. This will ground policies in the reality of how children live now, to give children the health they want in the future.
Berggren, L, C Olsson, S Talvia, A Hornell, M Ronnlund, and M Waling. 2020. “The lived experiences of school lunch: an empathy-based study with children in Sweden.” Children’s Geographies 18 (3): 339-360.
Chard, Sarah. 2020. “Unending work and the emergence of diabetes.” American Anthropologist 122 (3).
Dimbleby, Henry, and John Vincent. 2013. The School Food Plan.
Earl, Lexi. 2018. School and Food Education in 21st Century. Routledge.
Emm-Collison, Lydia, Rosina Cross, Maria Garcia Gonzalez, Debbie Watson, Charlie Foster, and Russell Jago. 2022. “Children’s Voices in Physical Activity Research: A Qualitative Review and Synthesis of UK Children’s Perspectives.”
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England, The Children’s Commissioner for. 2021. The Big Ask. Big Answers. The Children’s Commissioner for Englans. https://www.childrenscommissioner.gov.uk/wp-content/uploads/2021/09/the_big_ask_big_answers_09_21.pdf.
Fisher, Elizabeth, Eilis Keeble, Charlotte Paddison, Ronny Cheung, and Dougal Hargreaves. 2022. Childhood obesity: is where you live important? Nuffield Trust.
Garth, Hannah. 2020. “The violence of racial capitalism and south Los Angeles’s obesity “epidemic”.” American Anthropologist 122 (3).
Government, UK. 2016. Childhood obesity: a plan for action. edited by Department of Health and Social Care, Prime Minister’s Office, 10 Downing Street, HM Treasurey and Cabinet Office.
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Isaacs, Anna, Joel Halligan, Kimberley Neve, and Corinna Hawkes. 2022. “From healthy food environments to healthy wellbeing environments: Policy insights from a focused ethnography with low-income parents’ in England.” Health and Place 77.
Isaacs, Anna, Joel Halligan, Kimberley Neve, Corinna Hawkes, Sonia Saxena, Anthony S Kessel, Saffron Karlsen, Stephen Morris, Russell M Viner, and Sanjay Kinra. 2014. “The benefits and harms of providing parents with weight feedback as part of the national child measurement programme: a prospective cohort study.” BMC Public Health 14.
Kovacs, B.E., F.B. Gillison, and J.C. Barnett. 2018. “Is children’s weight a public health or a private family issue? A qualitative analysis of online discussion about National Child Measurement Programme feedback in England.” BMC Public Health 18.
Manderson, Lenore. 2020. “”Lifestyle” diseases on the margins.” American Anthropologist 122 (3).
Rogers, Nina T, Steven Cummins, Hannah Forde, Catrin P Jones, Oliver Mytton, Harry Rutter, Stephen J Sharp, Dolly Theis, Martin White, and Jean Adams. 2023. “Associations between trajectories of obesity prevalence in English primary school children and the UK soft drinks industry levy: An interrupted time series analysis of surveillance data
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Rose, Kelly. 2019. “Why are school lunches still so unhealthy.” The Independent, 2019.
Scheper-Hughes, Nancy , and Margaret M. Lock. 1987. “The mindful body: A prolegomenon to future work in Medical Anthropology.” Medical Anthropology Volume 1 (Issue 1): P. 6-41.
SturtzSreetharan, Cindi, Alexandra Brewis, Jessica Hardin, Sarah Trainer, and Amber Wutich. 2021. Fat in four cultures: A global ethnography of weight. University of Toronto Press.
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