AED Guidelines for Childhood Obesity Prevention Programs
Sigrún Daníelsdóttir, Cand.Psych., Deb Burgard, Ph.D., & Wendy Oliver-Pyatt, M.D.
Studies from around the world show that body weight in youth has increased over the past decades (Chinn & Rona, 2001; Kautiainen, Rimpelä, Vikat, & Virtanen, 2002; Tremblay & Willms, 2000; Troiano & Flegal, 1998), although the most recent evidence suggests that this increase may be leveling off, at least in the United States (Ogden, Carroll, & Flegal, 2008). Concern over rising weights has spurred various community and school-based interventions aimed at decreasing childhood “overweight.” These include the mandatory screening of children’s BMI, banning of “junk food” in school cafeterias, limiting vending machines in schools and promotional campaigns emphasizing the dangers of excess weight. Many health professionals have voiced concern about the safety and efficacy of these interventions, fearing that they have little positive effect and may inadvertently contribute to overconcern with weight and shape, unhealthy weight control practices, and weight bias (e.g. Berg, 2001; Cogan, Smith, & Maine, 2008; Ikeda, Crawford, & Woodward-Lopez, 2006; Neumark-Sztainer, Wall, Story & van den Berg, 2008).
A substantial body of evidence from the eating disorder literature demonstrates that a general emphasis on appearance and weight control can promote eating disordered behaviors. For example, when important agents in children’s social environment (e.g. parents and peers) endorse a preference for thinness and place an importance on weight control, this can contribute to body dissatisfaction, dieting, low self-esteem and weight bias among children and adolescents (Davison & Birch, 2001; Davison & Birch, 2004; Dohnt & Tiggemann, 2006; Smolak, Levine, & Schermer, 1999). Additionally, weight-control practices among young people reliably predict greater weight gain, regardless of baseline weight, than that of adolescents who do not engage in such practices (Neumark-Sztainer et al., 2006). Thus, it is important to evaluate the unintended consequences of “obesity prevention” programs, which may lead to unhealthy behaviors and weight displacements in both directions.
Unfortunately, few studies have examined the effects of “obesity prevention” efforts on risk-factors for eating disorders, such as body dissatisfaction and weight loss dieting. Those that have suggest that focusing on health, not weight, may be key to avoiding harm to body image and eating behaviors. For example, Austin, Field, Wiecha, Peterson & Gortmaker (2005) found lowered rates of disordered eating in a school-based intervenion that focused on promoting healthy diet and activity patterns, rather than on weight per se. These findings emphasize the feasibility of simultaneously promoting body esteem and healthy lifestyle behaviors in youth, as others have suggested (Neumark-Sztainer, 2005). Expanding the vision of “obesity prevention” programs to include the prevention of eating disorders and related issues, may help to ensure that they promote overall health and safety.
Body weight cannot be evaluated in a vacuum. It is not a reliable proxy for eating behaviors and physical activity. Although statistical associations exist between body weight and risk for morbidity and mortality, being heavy or slender is not by definition pathological. Correlation does not imply causation and the middle of the weight spectrum can cloak a panoply of unhealthy practices. Since healthy living is important for children of all sizes, interventions should focus on lifestyle rather than weight.
The Academy for Eating Disorders applauds efforts to make children’s environments as healthy as possible. However, it is important that special care be taken in the construction and implementation of “obesity prevention” programs to minimize any harm that might result. To this end, the following guidelines have been developed for school-and community-based interventions addressing rising weights in youth.
- Interventions should focus on health, not weight, so as to not
contribute to the overvaluation of weight and shape and negative
attitudes about fatness that are common among children and have harmful
effects on their physical, social and psychological well-being.
- The World Health Organization defines health as a state of
complete physical, mental and social well-being and not merely the
absence of disease or infirmity. Consistent with this definition,
interventions aimed at addressing weight concerns should be constructed
from a holistic perspective, where equal consideration is given to
social, emotional and physical aspects of children’s health.
- Interventions should focus not only on providing opportunities for
appropriate levels of physical activity and healthy eating, but also
promote self-esteem, body satisfaction, and respect for body size
diversity. Prospective studies show that body dissatisfaction and
weight-related teasing are associated with binge eating and other eating
disordered behaviors, lower levels of physical activity and increased
weight gain over time. Thus, constructing a social environment where all
children are supported in feeling good about their bodies is essential
to promoting health in youth.
- Interventions should focus only on modifiable behaviors (e.g.
physical activity, intake of sugar-sweetened beverages, teasing, time
spent watching television), where there is evidence that such
modification will improve children’s health.
- Weight is not a behavior and therefore not an appropriate target for
behavior modification. Children across the weight spectrum benefit from
limiting time spent watching television and eating a healthy diet.
Interventions should be weight-neutral, i.e. not have specific goals for
weight change but aim to increase healthy living at any size.
- It is unrealistic to expect all children to fit into the
“normal weight” category. Thus, interventions should not be
marketed as “obesity prevention.” Rather, interventions
should be referred to as “health promotion,” as the ultimate
goal is the health and well-being of all children, and health
encompasses many factors besides weight.
- School-based interventions should avoid the language of
“overweight” and “obesity” since these terms may
promote weight-based stigma. Moreover, several of the most effective
interventions have not focused on weight per se.
- 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 the
community setting, these include making neighborhoods safer, providing
access to nutritious foods, constructing sidewalks and bicycle lanes,
building safe outside play areas, and encouraging parents to serve
regular family meals, create a non-distracting eating environment, and
provide more active alternatives to TV viewing.
- Interventions should be careful not to use language that has
implicit or explicit anti-fat messages, such as “fat is
bad,” “fat people eat too much”, etc.
- Children of all sizes deserve a healthy environment and will benefit
from a healthy lifestyle and positive self-image. School-based
interventions should not target heavier children specifically with
segregated programs aimed at lowering weights. However, this should not
discourage efforts to provide physical activities tailored for larger
bodies or to address the experiences that heavier children share as a
- Determining normal or abnormal growth in children should be
dependent on the consistency of their growth over time and not just the
percentile at which they are growing. Childhood overweight should be
defined as an upward weight divergence that is abnormal for an
individual child, which can be determined only by comparing the child to
him- or herself over time. This can be accomplished by consulting an
individual growth chart, rather than an arbitrary BMI cutoff.
- Interventions should aim for the maintenance of individually
appropriate weights—that is, that children will continue to grow
at their natural rate and follow their own growth
curve—underscoring that a healthy weight is not a fixed number but
varies for each individual.
- A sudden shift away from the growth curve in either direction may
indicate a problem, but further information about lifestyle habits,
physical markers and psychological functioning is needed before a
diagnosis can be made. Changes in weight are not always a sign of
abnormal development. An increase in weight often precedes a growth
spurt in children and some girls begin to gain body fat as part of
normal adolescence at a very young age.
- Weighing students should only be performed when there is a clear and
compelling need for the information. The height and weight of a child
should be measured in a sensitive, straightforward and friendly manner,
in a private setting. Height and weight should be recorded without
remark. Further, BMI assessment should be considered just one part of an
overall health evaluation and not as the single marker for a
student’s health status.
- Weight must be handled as carefully as any other individually
identifiable health information
- The ideal intervention is an integrated approach that addresses risk
factors for the spectrum of weight-related problems, including screening
for unhealthy weight control behaviors; and promotes protective
behaviors, such as decreasing dieting, increasing balanced nutrition,
encouraging mindful eating, increasing activity, promoting positive body
image and decreasing weight-related teasing and harassment.
- Interventions should honor the role of parents in promoting
children’s health and help them support and model healthy
behaviors at home without overemphasizing weight.
- Interventions should provide diversity training for parents,
teachers and school-staff for the purpose of recognizing and addressing
weight-related stigma and harassment and constructing a size-friendly
environment in and out of school.
- Interventions should be created and led by qualified health care
providers who acknowledge the importance of a health focus over a weight
focus when targeting lifestyle and weight concerns in youth.
- Representatives of the community to be studied should be included in
the planning process to ensure that interventions are sensitive to
diverse norms, cultural traditions, and practices. In this spirit,
it is important that interventions be pilot tested before implementation
in order to collect quantitative and qualitative feedback from the
- It is important that interventions be evaluated by qualified health care providers and/or researchers, who are familiar with the research on risk factors for eating disorders, as the interventions are being implemented in schools or communities. Ideally, the assessment should not only evaluate changes in eating and activity levels but also self-esteem, social functioning, weight bias and eating disorder risk factors, such as body dissatisfaction, dieting and thin-ideal internalization.
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