Schools health promotion, body confidence, diets, disordered eating and obesity: what to do?

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Is your school’s health promotion doing any good?

Schools often wish to address:

• health promotion
• body confidence, satisfaction or acceptance,
• obesity
• disordered eating prevention
• eating disorder prevention

You should only use programs that have been validated as safe and effective.

Below I will explain the surprising truth that if your school is relying only on common sense to teach health promotion, your programs are probably not working. Worse, they could be doing great harm. You might also start to think differently about obesity.

I’ve already discussed what you can do to help those with an eating disorder. Now you can discover prevention programs and address body image problems and disordered eating.  I’ll also introduce you to food-neutral language, and by the end of this page you will have become highly sensitised to diet talk!

Health promotion and body confidence programs that have multiple benefits

There are a number of well-researched programs to promote a positive body image (other terms are body satisfaction, body acceptance, body confidence). Depending on the program, outcomes include an increase in body confidence and self-esteem, a reduction in disordered eating and in weight control behaviours (purging, diet pills), improvements in nutrition and physical activity, and a reduction in behaviours that are often associated with obesity.

Because negative body image is one of the risk factors involved in eating disorders, some programs have also shown a reduction in the number of pupils later developing an eating disorders.

We therefore have three reasons for using validated programs.

• They may help to prevent eating disorders in those at risk (though sadly no program has been shown to reduce the incidence of anorexia)
• They are very likely to increase body satisfaction in the large number of pupils who are very preoccupied with a negative body image
• They may be effective in promoting healthy behaviours… which means you are doing effective health promotion

A fourth reason is that if you are under pressure to ‘fight obesity’ (see further down), you can argue that these programs are likely more effective than any other initiative.

Body confidence programs challenge cultural images of self-worth and often have a media literacy component to counter toxic cultural messages of thinness or tone for women and muscularity for men.

The benefits to your school could be major. 70 to 80% of young girls opt out of activities because of low body confidence. Negative body image is present in 25 to 75% of children and adolescents. There is harm in ‘fat-talk’. There is harm in youngsters aspiring to the looks of male or female models. There is harm in a culture of body dissatisfaction. It increases stigma for pupils in larger bodies. It is linked to poor self-worth, poor confidence and poor self-acceptance/self-esteem. For some it is linked with depression.

I would urge you to take body confidence just as seriously for boys as for girls. There is fast-growing pressure on males to be lean and muscular, and they don’t have the equivalent of feminism to counteract it.

Different programs target different age groups and sexes. Some require expert staff or have a ‘train the trainer’ system, while others are freely available and may be led by teachers or even peers.

This is a big field and I have tried to get experts to give us some shortcuts. Here are some of the programs which are recommended by reputable sources:

• The Body Project for small groups girls in secondary/high school and university
• Dove Confident Me : Dove Self-Esteem Project for boys and girls 8 to 16 years  (an extension of The Body Project)
• Free Being Me: delivered to girl-only groups through the girl guiding organisation (an evaluation is underway but hasn’t been completed yet)
• Media Smart :  for girls and boys in late primary and 11-14 years. Impressive results from several studies indicate it is helpful for both ED and obesity risk factors.
• Planet Health for 12-14 years
• Happy Being Me
• Healthy Bodies
• Healthy schools-healthy kids for 9-14 years

I don’t know which of these is the best (you can read a review of the first four here). To keep things simple you could safely go for the program that seems to be backed by the biggest studies and that has been used widely in several countries. This is The Body Project. The sessions need to be delivered in small groups of 8 – 15 students. Teachers need training before they can deliver this program in schools. Unfortunately the female version is the only evidence-based version, yet nowadays, young males need just as much help with body attitude as females do. There are two male versions that are experimental and have some way to go: ‘Body Project Pride’ and ‘More Than Muscles’.

For 8 to 16 year old boys and girls in schools and scout groups I suggest you can safely go with the equivalent of The Body Project for younger pupils, and the materials for teachers are freely available online: see the five sessions in Dove Confident Me. There is more information on Dove Self-Esteem Project.

The school’s role in preventing exercise compulsion

Many people with an eating disorder develop a harmful obsessive, compulsive relationship with exercise. Exercise can also provide a trigger for the start of an eating disorder, when a person over-exercises and under-eats because they believe the sport requires it.

There are many things that schools and sports clubs and gyms can do to create a positive attitude to exercise. I recommend you read the ‘Coach and Trainer toolkit’ from NEDA. It’s comprehensive and practical.

Eating disorder prevention: don’t use guest speakers

Sometimes schools hope to raise awareness and prevent eating disorders with a guest speaker who has recovered from an eating disorder. The idea is to warn pupils of the horrors of eating disorders and get them never to go down that road. But there is no evidence that this is effective prevention. Worse, youngsters vulnerable to an eating disorder will use whatever they hear as a ‘how-to- manual. They may also decide they should be a ‘better anorexic’ than the speaker by eating less, weighing less and exercising more.

One sign that a speaker is not well-informed of the risks is if any of their materials disclose before-and-after photos or if they quote numbers: how much weight they lost, how much they weighed before or after, how many calories they ate. These numbers are  well-known in the field to be ‘triggering’.

If you are tempted to get a speaker in to ‘raise awareness’ or ‘reduce stigma’ there is also a danger that the speaker has outdated theories of causation and of treatment (so much has changed in the last few years), so you could get a lot of misinformation and end up with more stigma. For instance many recovered people are certain that starving was a way for them to exert control over their lives, whereas nowadays the thinking is that this is a post-hoc rationalisation. The urge to restrict is driven by biology, and the person has no control over it.

Anorexia memoirs present risks similar to those of guest speakers.

Health promotion and why common sense doesn’t work

Just now I introduced you to validated health and body confidence programs which you can safely use.

Health promotion programs, on the other hand, are a bit of a minefield, to the extent that if I was the head of a school I would steer clear of them.

These are the programs that teach healthy nutrition and encourage physical activity (why is sleep rarely mentioned?!) The aim of these programs may be health for all, but often the underlying motivation is to ‘fight obesity’.

The latest and biggest 2018 study, published in the BMJ (the highly reputable British Medical Journal), indicates the failure of a promising, common sense, school ‘obesity-prevention’ program. The program taught healthy eating and ran cooking workshops for families. It increased physical activity in schools and promoted the benefits of exercise, even nurturing links with sporting heroes. All this sounds great, yet the program had no effect on pupils’ diet, habits or weight. On a positive note, it reportedly did no harm, though I question whether the sample size was large enough, and the follow-up long enough, to detect any harm in those vulnerable to anorexia.

An editorial in the same BMJ concludes that anti-obesity programs haven’t been working and that we need to ‘try something else’. I will return to obesity further down.

Why health promotion can endanger your pupils’ health

So it looks like health promotion programs are not working.

What I now want to highlight is they may not be safe. In fact there are many first-hand accounts of great harm being done.

Harm is done when pupils are told that it is bad to be overweight, and when they are exhorted to:

• eat more ‘healthy’
• exercise more,
• cut out sugar
• cut out ‘junk’ food,
• read nutrition labels
• keep food diaries,
• add up calories or fat units
• use an activity tracker.

Most people see these messages as pretty sensible, so what’s wrong with them? How could health promotion do the opposite of what it’s supposed to do?

“The class was taken to a supermarket to learn to read food labels. My son, age 8, learned that a red label on fats or sugars was ‘bad’. He took it to heart – he’s a very conscientious boy who wants to please and do things right, and his thinking is very black-and-white. This is how the anorexia started. Now it’s very hard to feed him what he needs to grow as he’s genuinely scared of ‘red’ foods.”

• Some pupils’ health will deteriorate if their understanding of ‘healthy’ is to restrict food or to over-exercise. If this persists they could suffer from disordered eating and increased body dissatisfaction.
• The majority of your pupils hopefully still have well balanced intuitive hunger and satiation cues that serve their body’s needs. They are in danger of losing these if they get the message that their body cannot be trusted and that instead, healthy eating requires rules, eating less, consulting labels or counting calories. (If this is new to you, you could start by reading about ‘intuitive eating‘)
• For pupils at risk of developing an eating disorder, school health promotion is very often the trigger for the illness. These pupils conscientiously start eating ‘healthier’ by cutting down on ‘unhealthy’ foods. They may exercise more and want to replace body fat with muscle. Soon they are compelled to take these behaviours to dangerous extremes.
• Some pupils will take your health messages very literally (while others will quickly forget them and resume their normal habits). Especially when they’re young, they can get very black-and-white about fats or sugars being dangerous or ‘wrong’. This can lead to malnutrition and the start of an eating disorder.

• Pupils in larger bodies may feel stigmatised. There may be an underlying message that fat people are morally deficient. Other pupils’ prejudices may be reinforced. We are, after all, in a society that judges people according to their size and body shape. Your messages could inadvertently increase obesity if overweight pupils experience more stigma, weight-teasing and shame.
• Pupils in any size bodies may get the message that they are only worthy if their body is a certain (average or below-average) weight. This easily becomes more prominent in their minds than anything else, including academic achievements. This gets in the way of developing a healthy sense of self.
• And as I’ll explain below, the last thing you want is for your health promotion message to leads pupils to diet.

More expert resources on this topic: from dietitian Leslie Schilling… from author and doctor Katja Rowell…  from Sunny Side Up, a mother/dietitian team

Lunch matters!

Given all that doesn’t work with health promotion, what can you do? One thing you can do is make it easy for pupils to get regular nutrition.

What should your school canteen serve? When Jamie Oliver started his schools campaign he did a great job in challenging the dismal food that used to be served in canteens. Ideally plenty of the food on offer will be freshly cooked or baked. Your cafeteria offerings should be varied and attractive, and priced or bundled in such as say that a meal covers all the food groups. That way pupils get a balance of nutrients and learn by experience what a normal meal consists of — this surely is more effective than lecturing them about what they ought to eat.

Whenever we’re concerned about someone’s eating habits because they could be missing out on nutrients, it’s useful to think in terms of adding particular foods to their meals, rather than removing so-called ‘junk foods’.

As we’ve seen, you should avoid labelling foods as good or bad. You should also remember that eating is not just about nutrients – at times it’s about celebration, social interactions, and of course, pleasure . Finally, your reason for providing good nutrition should be to serve pupils’ health, not to ‘fight obesity’ (more on obesity later).

Don’t allow activities to compete with lunch or snacks. Do you have sports or arts clubs running while children should be eating? If you care about health promotion, find another solution. With younger children, and depending on school hours, make sure they also eat a snack mid-morning and mid-afternoon. With older children, make time for snacks. Most of us need to fuel up to some extent every 3 or 4 hours — in your staffroom it’s probably normal to have a nice cup of tea and a bite of something to top up the energy levels. If you have clubs running into late afternoon or evening, consider that a fair number of pupils will have forgotten to bring a snack from home, so review what is available for them to buy.

If staff in the dining room regularly see a pupil putting tiny amounts of food on their tray, have a system for this pupil’s situation to be assessed, and if you have significant concerns, involve the parents. In primary school it may usefully be part of the culture for portions to be served by the lunch staff, for the adults to check that children are not binning their meal, and for a young child to be gently prompted to have more if they have chosen tiny quantities.

Conversely, make sure nobody shames a pupil for eating ‘too much’:

 There are coaches who go into the cafeteria and shame pupils/athletes for eating unhealthy foods, or make weight comments. These coaches are often role models so their comments have a lot of influence.

I would love to give you evidence-based guidelines on meals and snacks in school. In so many schools, ‘common sense’ results in policies that backfire. One source that might help steer you (it’s not all perfect) is the Ellen Satter Institute, because some of what they recommend is based on research (the devil is in the detail, though). See for instance ‘Prevention of child overweight in the school setting‘.

Why your school should be no-diet zone

One of the most helpful actions your school can take is to create a non-dieting culture.

Here are some reasons you really don’t want your pupils to diet:

• Depriving the body of energy or nutrients is counter to the development needs of children and adolescents.
• While pupils are feeling hungry and weak from a diet, and their brain is not getting its large energy needs met, they are less able to concentrate, reflect and learn.
• Calorie restriction, ‘clean’ or ‘healthy’ eating is at the root of much disordered eating. ‘Clean’ eating is often a weight-loss diet in disguise.
• For those with a vulnerability, dieting, ‘clean’ or ‘healthy’ eating is the most common trigger to a diagnosable eating disorder.
• For pupils with an eating disorder who are working on recovery, it is risky to be surrounded by people who diet. It makes them want to diet too, which makes them very vulnerable to a relapse of the illness.
• Pupils may get stuck in a cycle of disordered eating, as each diet leads to weight gain.

Yes, weight gain. Dieting during childhood and adolescence predicts future weight gain and obesity. In adults, weight regain is generally the rule, with at least one-third of dieters regaining more weight than they lost (an incentive to stop the diet talk in the staffroom?) You probably haven’t heard this often enough to believe it, so I invite you to google it — for instance writer and TED speaker Sandra Aamodt provides numerous links to the research on her website www.sandraaamodt.com).

With adolescents the weight-gain effect of dieting is very strong. If you think your pupils weigh too much, let me be clear: your pupils’ weight-reduction efforts are likely to result in extra weight gain. Dieting makes them 2 to 5 times more likely to transition from average weight to overweight in the next two years.

If you need more convincing, here’s the take-home message from the American Academy of Pediatrics in Preventing Obesity and Eating Disorders in Adolescents:

“Dieting, defined as caloric restriction with the goal of weight loss, is a risk factor for both obesity and eating disorders. Dieting behaviors were associated with a twofold increased risk of becoming overweight…"

and here’s the bit that is seriously worrying in terms of physical and mental health:

"… and a 1.5-fold increased risk of binge eating at 5-year follow-up”

Sadly for those of us with an underweight child suffering from anorexia, dieting does not make them gain weight.  They really get a raw deal.

The main reason your school should very much discourage dieting is that dieting is bad for your health. Deny the body its nutritional needs and you have the potential for disruptions in a person’s growth, metabolism, endocrine system, nervous system, and so on. The body and brain need nutrition, they need fat, they need calories.

When people diet and the diet ‘fails’, they often get into yo-yo dieting, with their weight cycles up and down. Research indicates that this in itself has long-term adverse consequences on cardiometabolic health.

If you’ve ever gone hungry, remember what it’s done to your mental state, your mood, your ability to concentrate and learn. There’s even a term for it: ‘hangry’. Are you trying to teach biology to a classroom of hangry pupils?

Never encourage diets and make it known that diets are counterproductive. If staff insist on dieting, ask them to be very discreet.

Why your school should discourage fasting

Sometimes schools lead a fast to fundraise or to raise awareness of poverty in other parts of the world. This is highly dangerous, as food restriction is a common starting point for an eating disorder in vulnerable individuals, and you are bound to have vulnerable individuals in your school. For those in treatment or who are well but vulnerable to relapse, fasting is harmful: they should be eating every 3 or 4 hours and guarding against energy deficits.

For all your other pupils, given our society’s dieting culture, a fast may covertly be used as a worthy excuse to lose weight or to engage in a fashionable ‘cleanse’ or ‘detox’. It could be the start of a longer diet, and you now know why the last thing you want is for pupils to diet.

A fast gives the wrong message from a school about the role of nutrition and about respect of the body’s needs. There are surely other ways of nurturing empathy and promoting action for people in poverty.

For anyone with an eating disorder, it’s important to have a dispensation from religious fasts on medical grounds.

Deal with fat talk

If you use a validated program for body confidence, you will learn to recognise negative body talk, or ‘fat talk’ and you will have strategies to deal with comments on people’s weight and appearance.

Examples of ‘fat talk’ or diet talk to be discouraged are:

• “I’m so fat”,
• “She’s so skinny”,
• “I’m so bad, I had a doughnut”
• “Now I’ve eaten so much, I must go to the gym”
• “I’m getting beach-body-ready”
• “I’m on a diet”
• “How many calories in this?”
• “Her tummy sticks out”
• “He’s got a great six-pack"
• "Tonight we go clubbing and burn calories"

Such talk reinforces body dissatisfaction, identifying one’s value with one’s looks. It creates pressure to force one’s body into an unhealthy mould. It contributes to shame among larger pupils or among anyone who thinks they should be thinner. It ‘triggers’ those battling an eating disorder. Consider size-ism and fat talk to be just as rude, discriminatory and harmful as racism or sexism or homophobia. Indeed, consider ‘fatphobia’ a social justice issue.

* More from me: ‘How to overcome weight bias and fat phobia‘ *

Why your school should use food-neutral language

We commonly talk of food in terms of good, healthy, bad, clean, naughty, or junk. In some schools, particular meals served in the canteen are labelled ‘healthy’, while chips on a Friday are implied to be a naughty treat.

What’s wrong with labelling food good or bad? Well, it’s not scientific. All foods serve a purpose, whether for nutrition, pleasure, celebration or social bonding. Different people will benefit (or be harmed) by different foods in different quantities at different times.

• If you’ve come out of an exercise session hungry and shaky, then a muffin is a healthier choice than an apple.
• If you are celebrating with friends then pizza and cake have an important social function.
• If you are underweight with anorexia, the healthiest choice may be a portion of chips, and you will not be recovered until you are able to enjoy pizza and ice cream.

The only foods we can objectively label as bad are those that will give you food poisoning.

Pupils are likely to be exposed to many ‘rules’ about food. For some this gives rise to guilt or shame (they think they ought to stick to the rules but can’t). It may be the start of yo-yo dieting or of a restrictive diet.

At the other extreme, those who follow the rules obsessively can end up malnourished (as in ‘orthorexia’). For someone vulnerable to an eating disorder, describing foods as ‘healthy’ or ‘naughty’ reinforces an obsessive attention to rigid food rules. It could trigger an eating disorder or relapse. Recovery from an eating disorder means freedom from food rules, finding satisfaction in a wide variety of foods, and becoming attuned to the needs met by various foods.

Examples of food-neutral language

To use neutral language you can refer to food as:

• sustaining you
• giving you energy or nutrients
• feeling good
• feeding a hard-working brain
• satiating hunger
• responding to appetite
• stabilising blood sugar levels
• being balanced
• offering variety
• being satisfying or delicious
• being central to social interactions and celebrations

“The school asked her to journal her food intake for a week and count the calories. Foods were deemed as good and bad. She said she wanted to be healthier, so we happily bought her more fruits and vegetables and granola.  She lost weight, became obsessed with counting calories and restricting her eating, and it spiralled out of control as she got deep into an eating disorder.”

You could bring food-neutral talk to the staffroom. When I have lunch in a school staffroom, I often notice staff discussing their weight-loss diets and referring to the doughnuts on the table as ‘naughty’.

Are your teaching materials food-neutral and body-shape-neutral?

Review the materials you give: do they label foods as good or naughty? Do they overvalue thinness? Are lazy or stupid characters usually depicted as fat? These prejudices are so ingrained in our society that you may find them in many teaching materials that are otherwise good. If you need to keep these materials, I suggest you bring the hidden judgements out in the open.

“Her Spanish class was doing a unit on food vocabulary.  When I learned Spanish it was all about paella, tapas – a cultural sharing. In my daughter’s class it was all about labelling foods as good and bad, along with dialog about working out at the gym or exercising after eating.  They showed pictures of a skinny model and of an overweight person.  Seems they were trying to cram information about diet and health into curriculum. After the class my 11-year old stepped up her dieting.”

In the following example, the teaching method  might have been weight-neutral in the teacher’s mind, but I doubt it was for most of the 14-year olds in the class:

In science class they were learning about the gravitational forces on different planets. Each student had to walk to the front of the class, weigh him/herself and calculate what they would weigh on different planets! How could it possibly be a good idea to make middle school kids weigh themselves publicly?

My daughter advocated well for herself, telling her teacher that she ‘wasn’t allowed to know her weight for medical reasons.’ But she had to say this publicly, and she had to stand firm when the teacher pushed back.

Animal welfare: spare pupils the horrors of the meat industry

Don’t expose pupils to emotional sessions showing the horrors of the meat industry. For those currently affected by an eating disorder, becoming vegetarian or vegan is a strategy to eat less. It increases their rigidity around food, which delays their recovery. Also, an eating disorder can  begin when someone loses weight because they’ve cut out meat without introducing alternatives.

Balance these risks against the unknown benefits: among the meat-eaters who are not vulnerable to an eating disorder, how many might eat less factory-farmed meat as a result of watching a gruelling documentary?

I care a lot about animal welfare, and I suggest a more responsible way forward: have the school source its food from ethical providers.

“My daughter stopped eating meat while recovering from anorexia, after the home economics teacher showed the class an emotional film about factoring farming and abattoirs.  The other pupils went on eating meat. And the eggs provided for the class, and in the canteen, were cheap eggs from battery hens.”

‘Obesity prevention’

What do the experts recommend?

Schools are under pressure to prevent childhood obesity, the idea being that if you catch it early you will arrest the ‘obesity epidemic’. Indeed many government and health bodies see obesity as a rising problem for the health of the nation, and accordingly, they run public health interventions which may well involve schools.

Some interventions are ineffective and some are harmful, even though they may seem like they’re following ‘common sense’. The harm can be to everybody, not just those vulnerable to an eating disorder. See this comprehensive round-up of the subject: ‘Going too far? How the public health anti-obesity drives could cause harm by promoting eating disorders‘ (Tan, Corciova, Nicholls, 2019)

It may surprise you that the most effective prevention approaches do not focus on weight. In their report Preventing Obesity and Eating Disorders in Adolescents, the American Academy of Pediatrics, concerned about the relationship between health, obesity, and eating disorders, recommend the following ‘evidence-based strategies’. My comments are in italics.

• don’t diet: dieting with the goal of weight loss is a risk factor for both obesity and eating disorders. Make the school a no-diet zone.
• have family meals: they are associated with improved dietary quality, and have been shown to protect girls from disordered eating behaviours
• parents avoid ‘weight talk’ (encouraging their children to diet or talking about their own dieting), as studies have shown that weight talk is correlated with  overweight and disordered eating behaviours (note that we don’t know about causation). On the other hand there is correlation between ‘overweight’ adolescents using fewer unhealthy weight-control behaviours and parental talk that focuses only on ‘healthful eating behaviours’. Presumably you could substitute ‘parents’ with ‘teachers’ and this would still be true. 
• don’t allow weight teasing:  adolescent girls who were teased about their weight were at approximately twice as likely to be overweight 5 years later. Family teasing predicts the development of overweight status, binge eating, and extreme weight-control behaviours in girls and overweight status in boys.  Family talk is outside your control, but you can give weight-teasing zero tolerance in schools.
• promote a health body image:  adolescents who are more satisfied with their bodies are  less likely to diet and more likely to favour healthful eating and exercising. Use a validated body confidence program.

For more on what schools can do, the Academy for Eating Disorders, in their ‘Guidelines for childhood obesity prevention programs‘ recommend:

‘Interventions should focus on making children’s environments healthier rather than focusing solely on personal responsibility. In the school setting, these include:

• serving healthy meals,
• providing opportunities for fun physical activities,
• implementing a no-teasing policy, and
• providing students and school staff with educational sessions about body image, media literacy, and weight bias.’

In short, the recommendations for obesity prevention are the same as the ones regarding disordered eating and body dissatisfaction. If you use the dos and don’ts on this page, use a validated body confidence program and steer clear of anything to do with weight, you are doing the best that is currently known towards all these health aims.

If you’re happy with this, you can skip to the end. But if you are finding it hard to believe that nothing more can be done in ‘the war against obesity’, then feel free to read on.

Is obesity prevention your job? The short version

You may be confused about what’s wrong with tackling pupil’s weight. Maybe you want to ‘fight obesity’ head on?

I am not an expert on obesity even after hours of research, and my guess is that school staff are even less so. So I’ll share my conclusions so far, based on what I have read and discussed with experts.

• Anti-obesity programs could harm all pupils (i.e. those classified as overweight or obese, those of average or low weight, and those vulnerable to an eating disorder)
• Anti-obesity programs in schools don’t work — there is no long-term behaviour change or weight loss (and in any case, we should not be aiming for children and young people to lose weight)
• Any obesity intervention that leads to dieting is highly likely to produce long term weight gain, disordered eating behaviours and adverse health effects
• What matters most for health is a healthy lifestyle (and good genes and body confidence)
• High weight does not automatically equal poor health (the same with low weight – it’s all very individual)
• It shouldn’t be your job to pronounce on an individual’s weight and health and what to do about it. Let the experts put their own house in order before you get involved.

If you’re curious about all this, read on, as I go into some level of detail to explain what may be pretty surprising to you. Otherwise feel free to skip to the end.

Obesity — where’s the problem?

Definitions first: someone is categorised as ‘overweight’ or ‘obese’ when their body mass index (BMI), which computes their height and weight, is over a particular figure.

The message we most commonly hear is that overweight or obesity causes health problems. It is often bundled with the simplistic message that the cause of overweight is excessive eating and not enough exercise, presumably because of ignorance or lack of self-discipline.  ‘Fighting obesity’ or ‘obesity prevention’ usually mean getting all of us to eat less and exercise more. Those assumption is that those who are overweight should lose weight, or at least not gain any more.

In scientific papers you will find a more nuanced message that obesity is associated with increased risk of health problems. These writers are aware that correlation isn’t the same as causation. When an obese person is in poor health, the cause may not be their high body fat. The body may be doing something that causes poor health and — through poorly understood mechanisms — high body fat.

There is an even less well-known view and we should all pay attention to as it as it is promoted by a number of health experts, and backed up by reports in scientific journals. It goes like this. An above-average weight does not mean poor health. ‘Thin’ doesn’t always mean ‘healthy’ and ‘fat’ doesn’t always mean ‘at risk’.

For instance, in your school right now, those at the greatest risk to health are probably those with insufficient body fat. How many girls are failing to have a regular menstrual cycle because of low weight and/or low nutrition?

An individual categorised as overweight or obese may be in excellent health right now and also long term. They may be healthier than their neighbour of average size. And this doesn’t just apply to the odd lucky individual. There are studies that look at entire populations and find no problem with overweight or obesity. It seems that a marginally high weight may be protective to health. Some experts are scratching their heads over what they call the ‘obesity paradox’. They expect obese people to be in worse health, so they wonder how come obese people have been shown to survive various health conditions better than average-weight people.

Some experts argue that lifestyle is what predicts health. Mortality is better correlated with healthy lifestyle habits than with weight. Everyone needs good nutrition and some amount of movement (and I would add, sufficient sleep). These are the lifestyle factors we need to focus on to improve the nation’s health.

To find out more, I recommend this compilation of the research: ‘What’s Wrong With the ‘War on Obesity?’ You could also check out ‘Health at every size‘, a movement supported by many health professionals, and is therefore not as outlandish as you may think.

In summary we have two main views:

• The traditional view: weight is a problem when you’re in the overweight or obese categories.
• The view such as the one described in ‘Health at every size’: weight is not a problem

and in between we have various shades of ‘There seems to be an association between obesity and poor health and if that’s true, then there might be a common factor causing both’.

Whichever view you buy in to, the recommendations are the same. You can safely contribute to pupil’s health by concentrating on a healthy lifestyle and on body confidence, whatever a person’s size. Use a validated body confidence program, and don’t get involved in weight issues.

‘Yes, but…’ (if you really want to ‘fight obesity’)

If in spite of all the nuanced thinking above, you are certain that something must be done to prevent children going into the overweight or obese categories, your first hurdle will be to choose an anti-obesity program that won’t waste everybody’s time, since (as I mentioned in the health promotion section) anti-obesity programs are not working. They are having no effect on pupils’ eating or exercise habits.

Nor are they having an effect on pupils’ weight, and that is a good thing. A school cannot safely intervene on any individual’s weight. The blanket approach — to eat less and exercise more — would be the equivalent of a weight-loss diet, and we know that such diets are likely to lead to weight gain and long-term disordered eating behaviours.

As a school you do not have the competence to judge whether any pupil’s weight is problematic or healthy. Assuming someone’s weight is judged excessive, it is very much an expert clinician’s job to work out a solution that doesn’t have adverse physical and mental effects.

Perhaps your aim is to reduce obesity in the future, reducing the rate of weight gain of young people. To do that you would need to understand the causes of overweight and obesity.

For most laypeople, it is common sense that people become overweight because they eat too much and are sedentary. But experts nowadays say that causation is complex and poorly understood. For instance, there is research in the factors that affect the hormones that regulate appetite, fat storage and metabolism. Semi-starvation (dieting) is a sure culprit, and so perhaps are antibiotics in early life, sleep, stress, and some of the bacteria in your gut (to name just a few).

For some individuals there is an overlap between an eating disorder (in particular, binge eating disorder), body dissatisfaction and obesity. Disordered eating behaviours can disrupt how appetite is regulated and can mess with metabolism.

In short, there is no uniform mechanism behind obesity, but a whole lot of individual factors. So blanket approaches (such as urging people to exercise more) don’t work.

If you do take the simplistic view that people are in higher weight categories because they are sedentary and eat too much, you must find a way to promote a healthy lifestyle while making sure it doesn’t lead to dieting. A validated body confidence program might help you there (and it might also challenge your beliefs about obesity).

Work with the ‘First do no harm’ principle. Are you sure that your obesity messages are not leading to dieting, disordered eating, eating disorders,  increased body dissatisfaction, stigma, bullying?

“In science class, the kids were shown a video of a woman having liposuction, and there was much hilarity about how gross the fat looked. My girl got the message that the less body fat, the better. In her whole school life she only ever had one class – sex education – where an adult stressed the need for body fat.”

Think of the cost-benefit equation. You probably have a far greater number of pupils at risk from disordered eating. They may well subvert your health promotion message by going on diets, over-exercising, bingeing or purging. Whereas obesity may or may not be linked to health in the far future, your actions could push a vulnerable child into an eating disorder, putting their health at immediate, serious risk.

In ‘fighting obesity’ there is a danger of making thinness an ideal. If as a result, your pupils go on a diet, you could inadvertently be setting them up for a lifetime of disordered eating as they fight the weight they gained from dieting.

So there are big risks to a school’s anti-obesity initiatives, and maybe no payoff whatsoever.

How could we possibly be barking up the wrong tree? One reason there is so little guidance for you is that there is virtually no collaboration between health departments working on obesity, and mental health services with expertise on body image, disordered eating and eating disorders. Another reason is that we are all bathing in a culture which judges thin to be good, beautiful and healthy, and fat to be bad and shameful.

Can you assess a pupil’s health based on their (over)weight?

The short answer is no. You’re a member of school staff, not a health professional. You should never be expected to comment on a pupil’s health just because their weight falls into the overweight or obese category.

A health professional cannot gauge someone’s health status based on weight either. What they can do — unlike you — is carry out a raft of assessments and tests. So if you’re asked to make judgements on the health of your pupils based on their weight, I advise you to resist. You are not competent to do so and your actions could do harm.

A shoe store can tell us what size shoe they sell the most of, yet we cannot predict which shoe will best fit any individual. Likewise an individual’s health status and their physical needs cannot be deduced from a number off a chart or from their looks. There is general agreement among experts that BMI is only a statistical tool (just like a shop owner may want data on the most common shoe sizes) and that when BMI is used for any particular individual you get flawed results.

A pupil’s BMI might be high because they have more muscle than average (muscle weighs more than fat). Or because they were weighed at a weird time when they had a lot of fluid retention or were wearing Doc Martens. They might indeed be larger than average while being perfectly healthy, with a weight that suits them biologically. A noticeable increase in weight may be a preparation for a growth spurt or maturation. To keep growing ‘up’, many young people will go through phases of growing ‘out’.

In short, there are many reasons why the alarm you raise may be a false alarm, and when it comes to questions of obesity, false alarms can cause harm.

* More from me on BMI: ‘What do BMI and Weight-for-height mean?" and the YouTube below *

Don’t weigh pupils

In some parts of the world, schools weigh pupils and notify parents of their child’s body-mass index (BMI), flagging up those classified as overweight or obese.  Yet the child may be perfectly healthy, with a weight that suits their health. You can do harm by sounding a false alarm because in our society, weight is a more emotional issue than, say, iron levels. When children learn that others consider their weight to be excessive, they often engage in diets and in other disordered eating behaviours — in other words they put their health at risk.  Most parents are very unlikely to know the science of weight and dieting, and upon receiving a notification of their child’s weight being above average, may well do harm by pushing their child to diet. For the most vulnerable, these school reports are often at the origin of an eating disorder.

For these reasons I suggest that if your school is forced to weigh and measure children according to a national data collection programme, you don’t send individual reports to families, and you make the weighing process as smooth and trivial as possible.  Such programs seem common in the USA. In Scotland it happens in Primary 1; in England the National Child measurement Programme (NCMP) measures all children in Reception and in Year 6. Parents can chose to withdraw their child from the process, and I think that is a wise decision.

Pupils who seem to be getting thinner

Whereas I am unhappy with schools writing to parents about their child having falling in the overweight or obese category, I do believe you should raise concerns when you think a pupil is getting thinner.

Every young person’s weight is supposed to increase as they grow and this goes on into their twenties. Flat-lining, for a young person, is the equivalent of an adult’s weight loss.

If you see a young person going from fat to average, they may be dangerously ill from partial starvation.

Although you are not health experts, in these cases I do believe you should alert parents so that professionals can assess this pupil’s health. The risks of malnutrition and/or of an eating disorder are immediate and serious. If it turns out the pupil is fine in mind and body, there is less risk that your false alarm will cause them to engage in disordered eating. It’s less risky to be told ‘you might be too thin’ than ‘you might be too fat’, given our society’s thin-bias.

To be clear: please only comment on thinness in a health context. "You’re so thin" in a social context (usually meant as a compliment) is ‘fat-talk’ and not helpful.

My views

While I know a lot about eating disorders and quite a lot about disordered eating, I don’t consider myself an expert on health promotion, body image or obesity. There are experts in each individual field, but nothing much to link it all up. As a result it seems an impossible task for schools to know what is effective and what does no harm. That’s what I am trying to do in this page. I will keep updating this as I learn more. Join my mailing list for news.

For more information

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