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Loughborough University
Leicestershire, UK
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The View - Spring / Summer 2008

Plate with lettuce leaf

Health education - in good shape?

Eat less, exercise more, lose weight. The pressure on us all these days to be aware of our health is enormous. But how are the seemingly ubiquitous health messages being communicated to and interpreted by the young, and what impact are they having?

Drawing on the experiences of young women with eating disorders, two Loughborough researchers have revealed how well-meaning advice can propel some towards potentially health-damaging behaviour.

Virtually everyday, scientists, Government ministers, the media tell us, unequivocally, that as a population we’re getting fatter and unhealthier; that measures need to be taken now to avoid an obesity time-bomb. Children in particular are increasingly considered to be an ‘at risk’ group and consequently the UK Government has introduced school-based health imperatives in a bid to ensure that young people exercise more, change their diets and manage their weight. But just how is official advice being recycled in schools, and could it ultimately be having a detrimental effect on the health of some youngsters?

Professor John Evans and Dr Emma RichDr Emma Rich and Professor John Evans, from Loughborough’s School of Sport and Exercise Sciences, spent a significant period of time with girls and young women suffering from eating disorders, such as anorexia nervosa and bulimia, to see if their experiences at school were in any way a contributory factor in them developing these conditions. Over the course of four years, they interviewed around forty girls, aged between 11 and 18, while they were resident at a clinic specialising in the treatment of eating disorders. It soon became apparent that the way in which messages about health had been communicated was an important backcloth to the girls’ decisions about eating and exercise, with many of them strongly believing their illness was nurtured, exacerbated or sometimes even caused, albeit inadvertently, by the well-meaning actions in schools.

“The tales they told were incredibly revealing about what schools were doing, in good faith, that was inadvertently propelling these girls towards this damaging relationship with food and exercise,” says Professor Evans. “But some of the stories were really quite shocking. One girl told us how during class the PE teacher pointed to a broomstick in the corner of the room and said ‘That’s the shape we’re aiming for.’ Another was repeatedly told that if she was thinner she could swim faster. Others recalled the indignity of being weighed in class and their peers’ cruel comments if they were said to be ‘overweight’. That’s not the kind of thing girls, or boys, need to hear when they already might be feeling sensitive about their bodies.”

In the UK, around 1.5 million people are estimated to have an eating disorder. Girls as young as eight and nine are reportedly concerned about their weight and watching what they eat, and there’s also been a marked increase in body dissatisfaction and eating disorders among men – a consequence, perhaps, of the omnipresent health advice, suggests Dr Rich.

“The pressures on young people to monitor their bodies are relentless, and they’re not just confined to school in PE and health lessons. They occur everywhere – in playgrounds, in corridors, on TV, in the home. Everyone these days – teachers, friends, family – is watching what children are eating.”

It’s a sentiment borne out by Tracey, one of the girls at the residential unit. “Everyone at school’s got food issues,” she says. “All the girls are always looking for what’s got the least fat, and people will comment on each other. If someone has two chocolate bars, someone will say ‘Haven’t you had one already’.”

According to another resident, Lara, there’s an element of competition involved as well. “I started not eating and then everyone else did too… well, a lot of people did, and that made me feel like I couldn’t start eating. When I was trying to get better, no one else ate, so I didn’t want to be the only one starting eating.”

The researchers also found that some young people were using official advice to rationalise their behaviour and disguise the harmful relationships they had developed with food or exercise.

“I started following the Government guidelines, like five portions of fruit and veg a day, and I was completely obsessed with that,” explains Jane. “At first it was just healthy eating but I took that to extremes. Then I started just eating fruit and veg and nothing else. Eventually I didn’t really eat anything.”

The residential unit tries to address the negative relationships the young people have developed with food, by dismantling the ill-advised messages they constantly hear in the media from obesity spokespeople and the many ‘experts’ now offering advice on nutrition and food. “These girls can’t even look at very ordinary foods without a sense of fear and trepidation about the effect the calories will have on their bodies,” says Professor Evans. “Staff at the unit help them realise, for example, that diets aren’t inherently ‘good for you’; that chips or chocolate, for instance, can be part of healthy eating and aren’t ‘bad’ foods to be thought of as weapons of body mass destruction.”

The centre offers a total sanctuary away from outside pressures, providing schooling alongside treatment, but many of the girls admit to being nervous of leaving.

“They’ve come out of mainstream schooling and are now in, what they perceive to be, a safe context. Having to go back to school in three or four weeks time and face many of the things that contributed to their condition in the first place is a daunting prospect for many of the girls,” explains Dr Rich.

Nowadays it seems health is treated in much the same way as any academic subject – as something to be managed, regulated, measured and compared. The National Healthy Schools Programme, launched in 1999 by the Department of Health, requires schools to provide visible evidence of healthy eating, physical activity and emotional wellbeing, with the aim of achieving National Healthy School status. The Government’s target is for all schools to be participating in the programme and for 75 percent to have achieved healthy school status by 2009.

Then, around four years ago, three Government departments put in place an agreement that sought to halt, by 2010, the year-on-year rise in obesity among children under the age of 11. Among the initiatives subsequently introduced was the routine weighing and measuring using the Body Mass Index (BMI) scale of primary school children at age four and ten. These far-reaching initiatives have created unprecedented levels of surveillance for managing the weight of young people.

“Health has been reduced to something that can be measured, so that weight, exercise and diet have become the gold standards by which success is defined,” says Professor Evans. “A school’s achievement should be measured, it seems, not just in terms of its academic performance, but also by how well it has reduced the collective waistline of its student population.”

Based on their own and others’ research evidence, the Loughborough team believe that a degree of panic has been generated about the issue of obesity, and child obesity in particular, which is often ill-founded.

Professor Evans explains: “Many scientists researching this topic are cautious over what they claim, but that’s not always reflected in the media – to the general public it’s presented with absolute certainty. I’ve also heard prominent and well respected spokespeople on the subject of health compare obese people to the so-called ‘freaks’ that used to appear in circuses in the 20s and 30s. The message to the audience of health workers and teachers present that day was clear – that overweight and obese people can be legitimately laughed at, stigmatised and considered irresponsibly abnormal.”

He adds: “These are well-intentioned people who recognise that obesity at its extreme is a real problem, but the way in which the messages are being communicated is potentially incredibly damaging. Obviously not everyone ends up with an eating disorder as a result, but how education and health professionals recycle these messages is clearly important, as we’ve shown.”

The researchers know their views and findings are controversial, and admit they have attracted criticism and even disdain from certain quarters. “There have been some adverse reactions when we’ve presented our research, because we’re offering an alternative viewpoint to the currently accepted wisdom. Some, especially those who feel they’re on an obesity crusade, have gone as far as to urge people to completely disregard what we and the young women in our study have to say,” says Professor Evans wryly.

Although the researchers’ work has been acclaimed in social science and education communities and warmly welcomed by many parents and health professionals, some remain sceptical. “To some working in the field of obesity our research doesn’t mean a lot because we’ve only worked with a sample of forty people. But it’s qualitative research. They consider our four years’ in-depth work to be almost irrelevant because they have a bigger sample – they’ve perhaps completed a survey of 1,000 people which tells them, without doubt, that people are getting bigger and therefore, they incorrectly assume, unhealthier.”

“Ultimately though we all have the same goal – for people to be healthier. We just want a view of health that isn’t reduced to weight, size and shape, and takes in all the socio-economic and cultural factors that affect young people’s lifestyles.”

Out of their research Dr Rich and Professor Evans have drawn up a list of advice points for those trying to communicate health issues in schools.

“We want to get schools to take a more rounded approach when talking to children about health,” explains Professor Evans. “It’s absolutely crucial that the focus isn’t on weight as an indicator of health. It can’t be safely assumed that a thin person is healthy while an overweight or obese person isn’t. In fact some studies have suggested that people who are ‘overweight’ according to their BMI but are physically active may be healthier than their thinner counterparts who are not physically active. The BMI should be handled with kid gloves and never used as the sole indicator of someone’s health.”

As the next phase of their research, Professor Evans and Dr Rich are undertaking a collaborative project with colleagues in Australia and New Zealand to determine the extent and impact of health advice in schools worldwide. And it’s already revealing quite disturbing evidence of the damaging effects that messages about obesity can have on the lives of children in mainstream schools.

“Both these countries have school curricula that place far greater emphasis on health education than in the UK. New Zealand has adopted a particularly holistic approach to health which doesn’t simply focus on weight loss or management. By comparing the impact of measures put in place by governments around the world, we’ll perhaps be able to identify more constructive initiatives for the UK, which may help, in some small way, to prevent yet more young people from starting on the path of potentially health-damaging behaviour,” Dr Rich concludes.

Want to know more?

Contact:

Dr Emma Rich

Professor John Evans

A book of the researchers' work - 'Education, Disordered Eating and Obesity Discourse. Fat Fabrications' (J Evans, E Rich, R Allwood (2008) London Routledge) - will be published later this year.

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