PublicationsSystematic reviewsObesity - children's viewsSummary
Children’s views about obesity, body size, shape and weight: a systematic review. Summary

Background

The review has been conducted in the context of high levels of concern about obesity in children in the UK. Children are likely to experience immediate physical and psychosocial problems as a result of being obese and are at a higher risk of obesity as they grow older. Increases in obesity also represent considerable financial costs. Children’s attitudes to and beliefs about their bodies, which can include high levels of body dissatisfaction, have also raised concern.

There is a growing awareness of the importance of the social and environmental determinants of obesity and of the ways in which many central factors might be out of an individual’s own control. Obesity is most likely to be experienced by people who are socio-economically disadvantaged. Despite growing understanding about the need to tackle the ‘obesogenic environment’, research from the USA in particular shows 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 a dearth of evidence from well-conducted studies to help us decide what can be done to prevent or deal with obesity. In particular, little is known about research that asks children for their own perspectives on obesity and body size, shape and weight. Such perspectives can inform the ways in which interventions aim to bring about positive outcomes. This systematic review aims to address this gap and to examine recent research findings from the UK where children aged from four to eleven provide views about their own body sizes or about the body sizes of others. It is hoped that this can help inform policy and the commissioning of further research in ways that put children’s experiences in the forefront.

Methods

This systematic review aims to identify, appraise and synthesise published and unpublished research on children’s views about obesity, body size, shape and weight.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

  • What are children’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 children’s views about influences on body size?
  • What are children’s views about changes that may help them to achieve or maintain a healthy weight?

We searched eighteen electronic databases, searched three key journals and sixteen websites by hand, scanned reference lists, looked for papers that had cited key studies, and contacted key informants for research to include in the review. Studies needed to have provided findings for children in the UK aged four to eleven and to have described basic aspects of their study methods. They needed to have been published since the start of 1997.

We examined 28 studies in detail, using a standardised framework to describe key aspects of each study (including population, research methods and findings). We also assessed the study findings in terms of whether the studies had used rigorous methods and whether they provided rich data that were likely to be rooted in children’s perspectives. This was used to make a judgement about each study’s overall ‘weight of evidence’. The judgement was based on how reliable the study’s findings were and how useful the study was in answering the reviews’ questions from a child’s perspective.

Findings were synthesised in two, separate analyses. One synthesis is of findings where children had been asked open-ended questions. These children’s responses provided predominantly qualitative data which were then interpreted so as to develop understandings of children’s views of body size. The second synthesis is of findings where children were asked to select from responses already set by researchers. These responses provided predominantly quantitative data. The findings from the two syntheses were then juxtaposed. A consultation was held with young people that explored the credibility of a subset of the findings and their possible implications.

Findings

It is not always easy to describe the children who participated in the studies in this review. Children’s ethnicity and socio-economic status, in particular, were frequently not stated by the study authors. While it is clear that a range of children had been involved in many of the studies, some children appear to be underrepresented, in particular children not at school, socio-economically disadvantaged children and young children. Very overweight children were the focus of a small number of studies; otherwise, views are most likely to have come from children with body sizes within the healthy range.

Recent research that asks children for their views about body size, shape and weight was found to be very limited in its scope. No studies were found, for example, that explicitly asked children what they thought might help them to achieve or maintain a healthy weight. Studies did not always report rigorous methods or methods designed especially to encourage children to share their perspectives. The data from individual studies were often not very detailed.

Nonetheless, when synthesised together, these studies do provide a coherent collection of views and experiences. The richness of detail contained within the syntheses cannot be summarised adequately here. Please see Chapters 4 to 6 for a comprehensive account of the findings of this review. The children’s views can be summarised as follows:

  • Children, unless they were very overweight, often did not see body shape as an immediately relevant issue. Children in general did see body size as an issue for others, and some reported negative feelings around body size.
  • Children, whatever their body size, did not emphasise the health implications of being overweight. Instead they saw – and had experienced – overweight bodies as having problematic social and psychological consequences, including bullying and isolation.
  • Children assessed their own and others’ body sizes critically. They described how they compared their bodies over time and with other peoples’ bodies. Very overweight children spontaneously described their own bodies as being a larger size.
  • Children’s responses to body fat were almost exclusively negative and were infused with moralistic ideas involving blame, responsibility and due punishment.
  • Many, but not all, children’s experiences of their own body size were negative.
  • While attitudes to thinness and dieting for weight loss were not always positive, girls, in particular, were aware of social pressures to be thin and were sometimes applying them to themselves. Boys may also have picked up on these ideas.
  • Gender plays a large role in children’s views about body size.
  • Very overweight children and those who are not overweight had very different ideas about children’s control over their body sizes.
  • Children identified multiple influences on their body size and discussed some in complex terms. Children’s recommendations for other children who seek to lose weight, however, focused mainly on eating.
  • Children emphasised the importance of support for helping them deal with pressures around body size and helping them have a healthy weight.
  • Very overweight children identified other barriers to and facilitators of their own attempts at weight loss.

Conclusions and implications

Conclusions

Children experience obesity largely as a social problem

This review indicates that children in the UK who have a healthy body size often may not have body size very high on their everyday agendas. When these children see body fat as a problem it is because of the impact it has on other children’s lives as social beings. Children identify very overweight children as being less popular.

Many very overweight children, however, experience body size as a big problem. They are likely to experience unhelpful responses to their own body sizes from other children, as well as adults. Fat-related name calling and bullying is currently considered by children, whatever their body size, to be a normal occurrence.

Children, whatever their body size, often may not consider the health consequences of obesity to be important.

Children appear to be aware of the influence of both food and exercise on body size but emphasise food the most. They appear most aware about influences on body size when they are themselves very overweight

Children hold complex views about influences on body size that tend to focus on individual behaviours. Overweight children are likely to be perceived by their peers as being responsible for their own size. Children with healthy body sizes appear less aware than their very overweight peers of the potential influence of factors – other than individual behaviour – on their own body size.

Children appear to be critical about their own body sizes and are highly aware of our society’s heightened interest in body size

Children appear to be aware of the actual size of their own bodies. They are likely to have judged the acceptability of their own body by the time that they are 12 and many are dissatisfied. Girls are likely to want to be leaner, regardless of their size. Boys and girls with body sizes within the healthy range may feel anxious when considering their own bodies and the negative reactions their bodies might produce if they are exposed in some way to their peers. They may often feel they should aspire to very lean body shapes that are unattainable and likely to be unhealthy.

The adult world does not appear to be helping children much with the different problems that can arise around body size

Very overweight children are likely to be experiencing considerable social and physical difficulties as a result of their size. They also encounter many barriers, and a lack of support, when they try to take action. Parents and friends appear to be the most helpful source of support, but this is not always unproblematic.

Actual body size and gender are central to understanding children’s views around body size

While very overweight children and girls bear the brunt, the combined impact of our obesogenic environment and our society’s ongoing preoccupation with body size appears now to be affecting the body image ideals and body satisfaction of boys as well. Girls and boys aged under 12, however, differ considerably, both in their aspirations for their bodies and ideas about others’ bodies.

Research that has asked children for their views about body size has often been of a low methodological quality

Studies of children’s views have not always reported rigorous methods, or have not adequately described the children involved. The data from individual studies have often not been very detailed.

Research has so far failed to engage children properly in the debate about obesity and public health

There is a striking lack of studies that can serve to privilege children’s views. No studies appear to have been done that directly ask children what they think should be done to support them in developing or maintaining a healthy body size. Few studies appear to have used methods that can support children’s own framing of issues in their lives. Many reports make no mention of seeking children’s informed consent for participation.

Implications

Children in this review’s synthesis were often not encouraged to go into much detail about their views and experiences. This review has also not considered available or evaluated interventions (although see Section 8.2 for two initiatives we were asked to consider). As a result, the implications of the above conclusions need to be general in form, relating to areas that need to be addressed, rather than specific ways in which issues might be addressed.

Implications for public health and health promotion practice

The findings suggest there is a need for those who run or develop initiatives:

  • to target commonplace, unhelpful beliefs, attitudes and discriminatory behaviours around body size;
  • to bolster overweight children’s self-esteem and assertiveness skills;
  • for action to increase understanding among children and adults about multiple influences on body size;
  • to modify beliefs about the limits to an individual’s control over their own body size and to encourage action to tackle obesity at community and other important levels;
  • to consider reducing the emphasis on body size and physical health as an intervention outcome when marketing initiatives;
  • to consider the role of positive social outcomes, such as friendship, support and social inclusion, in attracting children to interventions, and maintaining their interest and commitment;
  • to consider exploring with children the full range of consequences of obesity, including those for mental and physical health;
  • to develop materials and processes that respond appropriately to the differing values, aspirations and concerns held by girls and boys around their own body sizes.

Implications for policy

The findings suggest there is a need:

  • for population-level efforts that counter and aim to reduce the stigma associated with very large body size;to consider initiatives to address the support needs of parents, other adults and children in their discussions of children’s body sizes;
  • to involve diverse groups of children in the development and evaluation of initiatives.

Implications for research

The findings suggest there is a need:

  • for research that actively engages children in identifying forms of support around body size that they consider might be appropriate;
  • to rigorously explore the views of very overweight children about their support needs, for example about possible ways of supporting their social inclusion, providing psychological support as well as for their modifications to exercise and diet;
  • for research that seeks children’s views on how public health campaigns and interventions can help children understand influences on obesity, as well as the full range of its negative consequences, without contributing to the stigma felt by those most adversely affected;
  • for more attention to description and analysis in research findings;
  • for research to explore with children the contexts for their views and the rationales they consider to be important;
  • for those who conduct research with children to aim to clarify and report the meanings these children ascribe to the descriptive terms that they use;
  • for research on body size to be influenced more by the children who participate, and be more sensitive to children’s rights and engagement;
  • for studies that aim for more generalisable findings about children’s views, where questions in these population-based studies are derived from studies that have themselves used methods that aim to privilege children’s views.

This report should be cited as:

Rees R, Oliver K, Woodman J, Thomas J (2009) Children’s views about obesity, body size, shape and weight: a systematic review. London: EPPI Centre, Social Science Research Unit, Institute of Education, University of London.

  
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