Background

There are high levels of concern about body size in young people in the UK: young people can experience physical and psychosocial problems when young as a result of having a large body size, and young people’s attitudes to and beliefs about their bodies, which can include high levels of body dissatisfaction, have also raised concern.

Despite growing understanding about the need to tackle a multitude of complex and multi-levelled influences on body weight, research from the USA in particular shows that blame and responsibility is often placed mainly on those who are overweight. Weight-related stigma and discrimination are widespread, and these impact considerably, both on the well-being of those who are very overweight and on their attempts to modify their size.  

Unfortunately there is limited evidence from well-conducted studies to help us decide what can be done to prevent or deal with obesity. Furthermore, little is known about young people’s own perspectives on obesity and body size, shape and weight. This systematic review aims to address this gap and to examine recent research findings from the UK where young people aged from 12 to 18 provide views about their own body sizes or about the body sizes of others. It is hoped that this can help inform the development of practice and policy-based initiatives and the commissioning of further research in ways that put young people’s experiences in the forefront.

Methods

This systematic review aims to identify, appraise and synthesise published and unpublished research on young people’s views about obesity and body size, shape and weight. The review focuses upon young people aged 12 to 18 living in the UK and addresses the following questions:

• What are young people’s views about the meanings of obesity or body size, shape or weight (including their perceptions of their own body size), and what experiences do they describe relating to these issues?
• What are young people’s views about influences on body size?
• What are young people’s views about changes that may help them to achieve or maintain a healthy weight?

Studies were identified through sensitive searches of 18 electronic databases supplemented by searches of other sources such as websites, and contact with experts. Studies needed to have been published since 1997 and to collect the views of young people in the UK aged 12 to 18 using qualitative methods. Views were defined as attitudes, opinions, beliefs, feelings, understandings or experiences. Reports also needed to describe basic aspects of a study’s methods.

Data extraction of the included studies was carried out using a framework, specifically designed for this review, to record information from each study (e.g. details of the study population and methods of sampling, recruitment, consent, data collection and analysis). The quality of each study was assessed in terms of its methodological rigour, including sampling techniques, data collection, data analysis and grounding of the findings within the data. The extent to which young people’s views had been privileged and the breadth and depth of the findings were also used in order to assess the relevance of each study to the review’s questions. Data were extracted and studies were assessed independently by two reviewers.

A thematic analysis was conducted to synthesise the studies’ findings. A consultation was held with young people (The National Children’s Bureau’s PEAR group) to explore the credibility of a subset of the findings and their possible implications.

Findings

A total of 28,267 citations were identified and screened for relevance, and the findings from 30 studies were found that could be incorporated into the review’s syntheses. The 30 studies varied in terms of their size, aims and approach.

Qualitative analysis of the findings of each study resulted in three main themes and an additional 11 sub-themes. The themes related to young people’s views in three areas:

• General perceptions about different body sizes and society’s responses to them (It’s on your conscience all the time);
• Overweight young people’s beliefs about influences on size and experiences related to their size (If I had the choice, I wouldn’t be this size); and
• Overweight young people’s experiences of trying to lose and maintain weight and their suggestions for action (Make sure, even when it’s hard, you’ve got people there).

It’s on your conscience all the time

Young people were more likely to identify personal behaviour, rather than environmental factors, as the main influence on their body size. Larger young people were blamed for their size, but also blamed themselves.

Young women were identified as being particularly concerned about body size, but concern amongst young men and pressures to appear unconcerned were also discussed. Being overweight was something to be avoided mainly for social reasons, as it would result in negative judgements from others. Moral terms were used frequently. Young people of all sizes characterised overweight people as being lazy and lacking in self-discipline. Discussion of body size held considerable potential for offence.

Young people, of various sizes, made it clear that body size was an important issue in their lives, for social reasons. The experience of body image and body size was understood by young people differently according to gender, with young women expected to be ‘thin’, ‘slim’ or ‘skinny’ and young men expected to be muscular. Overweight young people’s views on the acceptability of larger body sizes were more nuanced. References to their own bodies included positive appraisals.

If I had the choice I wouldn’t be this size

Overweight young people talked about frequent difficulties with social activities and friendship, and about size-related abuse. It was hard to find and wear fashionable clothes. Shopping trips and other interactions with peers could leave them embarrassed, isolated and marked out as being unacceptably different.

Abuse was seen by young people of all sizes as something that was experienced when you had a large body size. Overweight young people recounted severe incidents of physical abuse and reported high levels of distress at receiving unrelenting taunts and less direct forms of abuse. They felt particularly vulnerable to abusive attack in school, and in particular during physical education classes. For some, participation in school had become impossible. These young people identified how these difficulties, and others related to being a large size, could impact on their emotional health. 

These experiences of stigma and abuse had led some young people to withdraw in an extreme way from other people and, sometimes, to comfort eating. They described feeling trapped in vicious circles, where size-related bullying, or feeling bad about their size, could lead to overeating, which led to further weight gain, feeling bad because of overeating, and yet more bullying, and so on.

Make sure, even when it’s hard, you’ve got people there

Larger young people described frustration at repeated attempts to lose weight. They were sensitive to the additional effort they felt that they had to put into regulating their food intake compared to their peers. They reported barriers around physical exercise and had experienced problems with health care services and professionals. Home could also be a difficult environment for weight loss and larger young people described getting unhelpful feedback and criticism from family or friends. Success was often seen as being dependent on a person’s psychological state, and an emphasis was placed on avoiding laziness.

Larger young people described frustration at the slow rate at which substantial weight loss is achieved. They reported a fear of weight rebounding. They described how feedback on progress was helpful. Also helpful was support from, and giving support to, others who were going through, or had gone through, the same set of experiences.

When asked what should be done to help them and others with their body sizes, young people tended to emphasise things that they, or other high weight young people should do to help themselves, such as eating healthily and exercising, learning more about nutrition and accessing their own psychological resources. When it came to suggestions about what others could do, these centred around the need for professionals and other people to be less judgemental and to give encouragement and other, practical, forms of support.

Conclusions

This review identified a substantial amount of recent research into views about obesity amongst young people in the UK aged between 12 and 18. It finds that these young people discuss larger body sizes in overwhelmingly social terms. Their accounts state that an overweight body size is to be avoided for social, rather than health reasons. Amongst young people with healthy weights, these reasons include not being attractive to others and having fewer friends. Ideal sizes differ to some extent between young women and young men, but these findings suggest that young women might not always be more concerned about their own size than young men. The accounts of young people with experience of being very overweight also make reference to the social nature of size, but here consequences appear far graver. These young people report how their size has impacted seriously on their ability to socialise with their peers, and has also led to severe and unrelenting size-related abuse, and a resultant sense of isolation and of being marked out as unacceptably different.

Young people also emphasise personal responsibility when talking about body size. Regardless of their own size, they also tend to be judgemental of, and apportion blame to, individuals who are very overweight, identifying this as due to a lack of willpower. And yet overweight young people, when reporting their experiences of trying to lose weight, describe a social environment that contains multiple barriers in the way of their success. They describe surveillance and abuse experienced while exercising or attempting to eat healthily, unhelpful food environments at home, and the receipt of unhelpful advice and criticism from others. These young people report how, as a result, they can often withdraw from social contact, avoid school-based physical activity, and eat for comfort. Their accounts also describe the vicious circle of increased weight gain, guilt and otherwise lowered mood that such strategies are likely to incubate. In contrast, positive accounts of weight-loss attempts might be expected to emphasise the benefits of contact with others who are going through, or have gone through, similar experiences.

The accounts of young people who have experience of being very overweight include numerous references to emotion and well-being. As well as the feelings of exclusion, shame and lowered mood described above, they report being offended by terms used to indicate size, including those used to identify people’s weight status for health purposes. They express frustration at the time required for substantial weight loss, and fear that weight might easily rebound. Good mental health is seen as key for substantial weight-loss and having taken active steps to reduce weight can be a source of considerable pride, especially when successful.

Young people in the UK have not been asked by researchers to reflect to any great extent on what might help them achieve and maintain a healthy weight. This review suggests, again, that young people will tend to focus on their own behaviour. As well as making more careful efforts to eat healthily and exercise, young people in this review mentioned the need for young people to access their own psychological resources. Only one study in this review included reference to what other people should do. Here young people, many of whom who had experience of trying to achieve, and sometimes achieving, substantial weight loss, emphasised how health professionals and others should be less judgemental, and give encouragement and other practical forms of support.

Implications

Implications for public health and health promotion practice  

The findings suggest that there is a need:

• for interventions designed to support young people around body size, shape and weight to build on the knowledge young people have already acquired, while recognising the physical, psychological and social constraints young people face when trying to reach or maintain a healthy weight;
• for programmes aimed at supporting young people who are overweight to consider how they can reduce the stigma that comes with living with a larger body to minimise any potential harm by, for example, focusing on barriers to and enablers of healthy behaviours, more than weight loss itself;
• to consider including a component of peer support and social activity in weight reduction interventions, as young people place value on the shared understanding, encouragement and solidarity gained from being with individuals with similar concerns about and experiences of body size, shape and weight; opportunities for overweight young people to socialise and make friends may go some way to reducing the social isolation they may well be experiencing;
• to provide young people with practical skills to support their emotional health, to help support the daunting task of losing weight and maintaining weight loss, especially after experiences of repeated failure;
• to provide young people with practical skills for identifying patterns of comfort eating and the use of food as a tranquilliser when stressed or angry, a stimulant when bored, or an anaesthetic when in mental distress;
• to deliver long-term weight-loss and maintenance interventions, as young people want time to gain sufficient confidence to engage and to receive ongoing and continued support;
• to support parents and health professionals in understanding and responding effectively, and yet sensitively to the physical, psychological and social challenges faced by very overweight young people.

Implications for policy

The findings suggest that there is a need:

• to address weight stigma in society through social interventions;
• to consider the full range of factors that contribute to obesity, especially those that are social or environmental in nature, and provide opportunities for young people to engage in positive healthy behaviours and to achieve and sustain a healthy weight;
• to involve diverse groups of children in the development and evaluation of initiatives.  

Implications for research

The findings suggest that there is a need:

• for research which not only explores the social implications of body size with young people in greater depth but which actively engages young people in how to address these issues both in society generally and through social interventions;
• for further research on young men and on young people from minority ethnic and differing socio-economic groups, and for research to provide a breakdown of the participants who form the sample based on those categories;
• to conduct research which privileges young people’s views and which makes attempts to reduce the power imbalance between researchers and young people during data collection the methodological norm rather than the exception.