Eating Disorders Caused By Nutrition/Fitness Education In Schools? I’m Not Buying It

Last week I came across several news reports of a study that had me flummoxed.

The C.S. Mott Children’s Hospital National Poll on Children’s Health claimed to have found a “possible association between school-based childhood obesity prevention programs and an increase in eating disorders among young children and adolescents.”   The media coverage of this study (no doubt influenced by the study sponsors’ own press release) invariably mentioned that 82% of parents surveyed with children aged 6-14 had such programs in their schools and 30% of these parents reported signs of eating disorders in their children.

This was an alarming finding, to be sure, and I initially assumed that the “school-based childhood obesity prevention programs,” in the study must have been heavy-handed interventions where kids are overtly shamed or coerced into losing weight, or why else would eating disorders be on the rise?

But when I dug deeper, I shocked to find that the offending programs were these:

  • Nutrition education at school;
  • Limits on sweets and junk food in the classroom;
  • Providing incentives for children to increase their physical activity; and
  • The taking of height and weight measurements at school.

That’s it.  All positive programs, with the possible exception of taking body measurements, but those are needed so schools can identify students at risk of serious diseases like Type 2 diabetes, and to monitor the overall effectiveness of any intervention.  (Such measurements are also supposed to be taken under conditions to protect student comfort and privacy.)   Meanwhile, health-concerned parents and childhood obesity experts are clamoring for the other items on this list — nutrition education, limiting junk food in class, more physical activity  – that are supposedly at the root of a serious problem.

But what negative behaviors, exactly, are resulting from something as benign and helpful as nutrition education?  Are kids running to the bathroom to throw up after lunch?  Are they taking laxatives or exhibiting other symptoms of anorexia nervosa?

The “worrisome behaviors” observed by parents ranged from the objectively troubling — “inappropriate dieting” — to behaviors which could be signs of an eating disorder but which might actually reflect a child’s heightened awareness about food’s effect on health, like a new interest in vegetarianism, looking at food labels and or wanting to eat something other than the food served at family meals (which, of course, might not be healthful if the parents themselves are not educated about nutrition).

But there’s actually no need to try to figure out it whether these reported behaviors are signs of an eating disorder or not.  Why?  Because the study did not find ANY of these behaviors to be correlated with school-based  programs, with the exception of one:

In this study, we found only one worrisome weight-related behavior to be associated with school-based nutrition interventions:  where there were school-based interventions for physical activity, more parents reported their kids to be “too physically active” . . . .

Otherwise we did not find school-based obesity prevention programs to be associated with the other worrisome eating and physical activity behaviors among children that parents reported.

So in the end, the only correlation between school-based anti-obesity programs and student behavior found in this headline-making study is that if you provide incentives to increase physical activity, some kids will become “too active.”  And how widespread is this “worrisome behavior?”  According to the study, it was reported by 11% of parents whose children attended a school with an incentive program, versus 4% of those whose school did not offer such a program.  And what did those extra 7% of parents mean when they reported “excessive physical activity?”  Are their kids suddenly training for triathlons?  Doing push-ups twenty times a day?  Or are the parents themselves leading a sedentary lifestyle and therefore unable to objectively view what might just be a normal level of physical activity?

We’ll never know, because the study designers admit that

[o]ir study was not designed to quantify the actual level of physical activity nor to understand what aspects of “too much” activity parents found most worrisome.

Now, no one denies that eating disorders are a serious problem, and if 30% of parents claim to be seeing potential signs of eating disorders in their children, that’s a finding worthy of concern and further study.  But the hollow attempt by the C.S. Mott group to link this phenomenon to school-based interventions (which I can only assume was motivated by a desire to make news) is highly counterproductive in an era in which 30% of our nation’s children are overweight or obese.

Schools are where our children spend the bulk of their waking hours.  They can provide kids with anywhere from one to sometimes three meals a day, they can allow junk food in the classroom or they can ban it, they can promote recess or they can take it away in favor of test prep, and they can teach children useful information about their bodies and nutrition or they can fail to do so.  Accordingly, what happens at school undoubtedly shapes a child’s lifelong health habits, for good or for ill.  Misleading “findings” like those released by C.S. Mott, which can only discourage those schools trying to do the right thing, simply do not serve our children well.


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  1. says

    This is a ridiculous and flawed study, and it almost certainly diminishes the seriousness of eating disorders by virtue of the fact that it clearly planted generalized “red flags” in the minds of parents and asked them to self-report without any kind of measurable evaluatory tool.
    That being said, I’ve got to comment on the taking of children’s measurements in schools. Got to. I followed the links you provided, and I cannot see any evidence in those materials that taking kids’ measurements at school is “necessary” so schools can figure out who may be at risk for Type II diabetes, etc.; nor can I find anything in those materials that makes me, as a parent, comfortable with the measurements and evaluation processes being used. The whole thing basically hedges around how effective a BMI measurement actually is, says that kids will be scored as healthy or needing improvement based on the BMI, and that the alternative is the skinfold test (but most people won’t know how to do that accurately, so it may not be part of the picture). There is more to health than BMI, and even this site which uses BMI as a measurement knows it.
    Here’s the thing: I know people whose kids have been measured at school, and who received a dutiful follow-up from the school nurse telling them that they needed to work with their doctors to control the kid’s weight. (*eye roll*) They’ve had to provide documentation that they were working with a pediatrician to address the “weight problems” their kids supposedly had. In the end, most of the kids were fine — they hit a growth spurt and reached “normal” again, but in the interim, the whole family had to go through the stress and anxiety of being part of the “needs improvement” category and thinking that there was a “fatness” problem where none existed. More insultingly, the parents basically had to prove, by virtue of medical paperwork and follow-ups, that they were actually caring, involved parents — a measuring stick parents of “normal” weight children didn’t have to pass. It’s not the job of the school to tell a doctor that a kid is “unhealthy;” it’s the job of the doctor to communicate that to the school, which is done yearly on the required physical forms at the start of a term. When schools can start using this data, however “sensitively” pulled, to force parents to take their kids for unnecessary medical exams and follow a family’s habits, I think we’re overstepping. Hugely.

    • Bettina Elias Siegel says

      Bri – I feel I could have done a much better job providing a good link discussing the reasons why schools take these measurements and how they’re used. For example, here in Houston, I’m almost positive that the BMI data collected isn’t linked to any individual child and that separate screenings are done for pre-diabetic symptoms, when of course you really must get a parent involved. But I may have that wrong and will investigate by asking members of our SHAC who are more knowledgable than I am about it. And, either way, I have no idea if parents are simply notified when a child is deemed at risk or if they have to go through the process you describe, of getting verification from a physician, etc.

      But with all that said, I do understand the stress that could result from this kind of screening. The only thing making me wonder if it’s still worthwhile is the repeated finding that parents, statistically speaking, have a tendency to underestimate the degree to which their child is overweight (or even see that it’s a problem at all.) In those cases, isn’t a wake-up call from school a useful thing?

      • says

        I don’t know if a wake-up call from school is a useful thing or not. Truly. Because 1) if a child is severely overweight, it’s unlikely that the parents haven’t received that news from the child’s doctor before; 2) if a child is mildly overweight and the family’s doctor has decided, for whatever reason, that it’s not of great concern, then being contacted by the school to be told that your child is overweight is annoying at best; and 3) while it’s true that parents do tend to underestimate the degree to which their child is overweight, it’s also true that those of us with overweight children do care — whether the results show on the scale or not, and whether or not my perception of how overweight my son is matches the statistical perception. Often parents are doing the best that they can, and unless the school plans to provide substantive resources for that family to help them, it’s just another “here’s what we think is wrong about your kid” call. Easy to dismiss, no? Particularly if you happen to disagree with the school’s assessment (“He’s just big-boned”)?
        Also, I wonder what message the whole thing sends to the children anyway. Schools should, rightly, be teaching kids how to be healthy; but by taking height-weight measurements and all of that, they’re inserting body size and shape into what should be a purely educational program. If you’re heavy and you eat lots of fruits and veggies and play sports, you’re better off than a kid who’s skinny and NOT eating well and not being active. The self-care aspect should be the role of the school — encouraging activity and healthy habits — whereas the determination about relative “health” (weight-based or not) should be left to the doctors. Otherwise we create a perception for children that their weight will be a measurement of significance to people no matter where they go.

  2. says

    I read this study when it came out and I too was discouraged that anyone found any of its “results” to be newsworthy; just goes to show how far some folks will go to grab headlines. The fact is that while the eating disorders that most parents fear, such as anorexia or bulimia, affect only about 1% of the kid population, fully 1 in 3 kids today are overweight or obese, so clearly this is the far more pervasive societal problem. Not to take away from the importance of addressing eating disorders in the relatively small number of kids who have them; obviously, if your child suffers from anorexia, then statistics don’t mean a thing. Just saying that whatever is going wrong in this country around kids and eating and physical activity, it is clearly manifesting more commonly as overweight than underfeeding.

    The issue of taking measurements at school is an interesting one. Here in California, statewide physical fitness testing in schools was first introduced in 1976, and it has been mandated by the California Code of Education since 1995 (ES section 60800.) The test used here is called the Fitnessgram; it is given to students in 5th, 7th and 9th grades, and it is prone to both errors and misinterpretation.

    Some here in San Francisco may remember a minor brouhaha back in autumn of 2006, when the results from the previous spring’s administration of the Fitnessgram were posted on the California Department of Education’s website; the results showed that not one single student in San Francisco’s public schools had been able to pass the “flexibility” portion of the test (1 of 6 areas tested), meaning that not one single student was able to pass all 6 areas of the test!

    A local news service jumped on this and blasted a headline far and wide “SF kids out of shape: Every 9th-grader failed test —
    educators are in disbelief.” The story went on to quote the usual experts dispensing the usual party line about how kids are too sedentary, etc.

    As it turns out (and as those of us wonkish enough to follow statistics like this closely knew immediately), this was the result of a coding error when posting results; in fact, the usual percentage of SFUSD students did pass the flexibility test (between 76-83% depending on grade), and between 30-38% (again depending on grade) passed all 6 portions of the test, similar to previous years. A colleague of mine from our district’s student nutrition committee made the necessary follow up phone calls to the school district and the CDE, to get them to address the miscoding and post accurate test results, and to the news service that blasted the “big story” to inform them of the CDE error.

    Because only a fraction of the people who read a “big story” ever bother to read the (invariably) tiny “corrections” that most papers run, I am sure there are still people tsk tsking about how out of shape SFUSD kids are.

    • Bettina Elias Siegel says

      Terrible! Another case of misleading headlines. But speaking of Fitnessgram, that’s what we use in HISD, too, and I was wondering if you can answer the questions I ask myself below, in my response to Bri. Is Fitnessgram data linked to any particular student or just used in the aggregate? I’m pretty sure it’s just the latter here in HISD but wondering what the practice is in SFUSD.

      • says

        It’s been about 6 years since my youngest was part of the Ftinessgram testing, but I seem to recall that parents would get a summary of their kid’s performance on the test. However, I am pretty sure that only aggregate results are ever made public; certainly there is nowhere you (as a parent) can go and look up how individual students did. Presumably the schools can look up individual kid data. Sorry I can’t be more helpful on that.

  3. Emma says

    Flawed studies like this drive me nuts. Not only are most of the supposedly worrisome behaviors not particularly worrisome, but also correlation does not equal causation! I know that more kids are suffering eating disorders, but I’m also pretty sure that isn’t because their schools aren’t letting them have cupcake parties in class….

    And for the record, I was in middle school when I became a vegetarian, and somehow I’ve managed for that not to become an eating disorder, unless you count mad love of pretty much all veggies as disordered.

    Now please excuse me; I have some latkes in the office fridge and they’re calling my name.

    • Bettina Elias Siegel says

      Yeah, as someone who is right now on the verge of making a complete conversion to vegetarianism (more on that to come), I was dismayed that that was categorized as a sign of an eating disorder. It made me wonder if the Cattlemen’s Association was funding the study! LOL. :-) Enjoy your latkes!

  4. Self says

    As someone who works with people with eating disorders, I’m disappointed to hear you dismissing the potential for harm that nutrition interventions can cause. I’ve seen plenty of casualties, and this is a serious issue. Whether or not this particular study effectively demonstrated that may be up for debate; however, I believe we will be seeing a number of similar studies appearing soon. Any time we disrupt a person’s ability to detect their natural hunger/fullness cues while encouraging them to rely on outside indicators (i.e calorie counts, fat grams), we put someone at risk of starting down a path of disordered eating. And the vast majority of eating disorders start with a “diet”.
    Actually, we’re already seeing more studies on this subject. Here are several examples, discovered during a 5-minutes Google search. I’m not even going to dig through my library of journal articles that I’ve downloaded on this topic, which is fairly extensive:
    Teens who beat obesity at risk for eating disorders:

    Does Obesity Prevention Cause Eating Disorders?

    School-based ‘healthy living’ programs triggering eating disorders in some children: Canadian study (from Toronto Hospital for Sick Children)

    Prevention of obesity and eating disorders: a consideration of shared risk factors

    Also check out more studies by Dianne Neumark-Stzainer and Project EAT.
    Whether you are a fan of this particular study or not, PLEASE pull your head out of the sand and realize that poorly-designed anti-obesity efforts can cause real damage. The Academy for Eating Disorders gives a good general overview of which types of messages are most problematic, and makes suggestions for giving helpful information without causing harm:

    • Bettina Elias Siegel says

      Self: I went back and re-read this post (which appeared a year and half ago on TLT), just to refresh my memory. Having done so, I absolutely stand by my analysis of this study, which it sounds like we both agree was pretty weak. That said, by virtue of working with people with eating disorders, you necessarily have far more expertise in this area than I do and I look forward to reading the studies you’ve provided. Afterward, I may comment back here but I’ll likely write a new post so other readers can share in the discussion, incorporating your comment as well. Thanks in advance for providing all of this information. I appreciate it. – Bettina

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