Friday 20 March 2020

Food shaming is not a game

Posted by Sarah Dempster, Registered Nutritionist (Public Health)

“Our current learning focus is food. We are exploring what makes a food healthy / unhealthy” says the notice board in the entrance to my daughter’s nursery. I sigh. Is this a battle I want to pick? I already had some difficult words with the Head Teacher last year about food-based rewards, and I don’t really want to become known as that mum who complains about every food-related activity that happens in the school. Especially when people don’t seem to get what it is that I’m actually complaining about.

I’ve worked in and around public health nutrition for ten years. Over the past few years - probably since having children of my own - I’ve become increasingly concerned about the way we communicate to children about food. Take this “teacher tested” educational game for four to eight year olds as an example:

I wonder if, in our worthy quest to do everything we can to improve children’s eating patterns, some of the things we say and do are having unintended consequences. What might be the impact of teaching nursery-age children to polarise foods into “unhealthy” versus “healthy” categories? What are we saying when we imply that people who eat so-called “junk” foods like burgers or pizza are “greedy”? What happens in children’s minds when they’re presented with those same “unhealthy” or “junk” foods as a reward for good behaviour? Or when their parent’s food choices are so constrained that a hotdog is the only option for dinner?

Mixed messages

My biggest concern relates to the disconnect between nutrition education and children’s day-to-day experiences of food. One UK study involving 9-10-year olds showed that children have difficulty interpreting healthy eating messages. An example quote was:
“it’s not true that chocolate’s bad for you because I eat chocolate, and I’m not completely fat, am I?” (Fairbrother, Curtis, & Goyder, 2016, p. 481)
Overall, it is thought that what children believe and know from their own experiences about food has a greater influence on their eating behaviours than what they are taught (Schultz & Danford, 2016). This makes me wonder why we’re teaching children about “healthy eating” at a young age at all - shouldn’t we just be showing them through the experiences we facilitate and/or provide for them and their families? 

What do children understand from nutrition education?

Health is an abstract concept and we know that young children are concrete thinkers. While they may be able to categorise foods as “healthy” or “unhealthy” by rote in pre-school, they are unlikely to make sense of why each food is in each category. They can understand that food provides energy but it isn’t until they are much older that they can accurately explain physiological reasons for eating (Inagaki & Hatano, 2006; Nguyen, Gordon, & McCullough, 2011; Slaughter & Ting, 2010). They find the concept of “prevention” particularly difficult (Legare & Gelman, 2014).

There’s little research on the impact this may have. However, Pinhas et al. (2013) found some evidence that healthy eating lessons could trigger eating disorder development in susceptible children, who may become preoccupied with food after learning about nutrition. We know that children are under pressure to conform to the “thin ideal” body type from a young age. One Australian study found that 34% of 5-year old girls were already restricting food (Damiano et al., 2015). Meanwhile, children demonstrate anti-fat attitudes from as early as two years old (Di Pasquale & Celsi, 2017). Oversimplifying the relationship between food and size in a game like Greedy Gorilla will at best be ineffective and at worst, fuel the well-known negative consequences of weight stigma (World Health Organization, 2017).

What does the curriculum actually say?

Food and nutrition is a focus area in UK curriculum frameworks, with defined knowledge and skills outcomes at specific ages or stages. Food literacy is covered in a much broader way than just teaching kids what to eat for health. This provides the opportunity for rich, multi-sensory learning experiences… how food is grown, how people from different countries and cultures eat, what different foods look, smell and taste like, how to prepare foods… and as children get older, bringing in critical appraisal around what influences our food choices (e.g. social, health-related or financial factors, the food industry, diet culture). There are lots of examples of good practice around this and it can be done in very positive and inclusive ways.

Until recently, there was little evidence of moralistic language such as “junk food” or reference to “unhealthy eating” within the curriculum. However, the Department for Education (2019) now states that by the end of primary school, children should know: “the characteristics of a poor diet and risks associated with unhealthy eating (including, for example, obesity)”. This worries me, especially for young children who are dependent on adults for all the food they consume, and because we know that weight bias is prevalent in education settings (Nutter et al., 2019).

Food education is really important for young children, but I think we need to look at how public health and education professionals collaborate to get it right for all children. This means improving our understanding of the impact of the language we use, to ensure that we are not fuelling fear, shame or stigma around food or body size.

  1. Fairbrother, H., Curtis, P., & Goyder, E. (2016). Making health information meaningful: Children’s health literacy practices. SSM - Population Health, 2, 476–484. 
  2. Schultz, C. M., & Danford, C. M. (2016). Children’s knowledge of eating: An integrative review of the literature. Appetite. 
  3. Inagaki, K., & Hatano, G. (2006). Young Children’ s Conception of the Biological World. Current Directions in Psychological Science, 15(4), 177–181.
  4. Nguyen, S. P., Gordon, C. L., & McCullough, M. B. (2011). Not as easy as pie. Disentangling the theoretical and applied components of children’s health knowledge. Appetite, 56(2), 265–268. 
  5. Slaughter, V., & Ting, C. (2010). Development of ideas about food and nutrition from preschool to university. Appetite, 55(3), 556–564. 
  6. Legare, C. H., & Gelman, S. A. (2014). Examining Explanatory Biases in Young Children’s Biological Reasoning. Journal of Cognition & Development, 15(2), 287–303. 
  7. Pinhas, L., McVey, G., Walker, K. S., Norris, M., Katzman, D., & Collier, S. (2013). Trading Health for a Healthy Weight: The Uncharted Side of Healthy Weight Initiatives. Eating Disorders, 21(2), 109–116. 
  8. Damiano, S.R., Paxton, S.J., Wertheim, E.H., McLean, S.A. & Gregg, K.J. (2015) Dietary restraing of 5-year old girls: Associations with internalization of the thin ideal and maternal, media and peer influences. International Journal of Eating Disorders, 48: 1166-1169.
  9. Di Pasquale, R. & Celsi, L. (2017) Stigmatization of Overweight and Obese Peers among Children. Frontiers in Psychology. 
  10. World Health Organization (2017). Weight bias and obesity stigma: considerations for the WHO European Region. WHO: Geneva.
  11. Department for Education (2019) Relationships Education, Relationships and Sex Education (RSE) and Health Education: Statutory guidance for governing bodies, proprietors, head teachers, principals, senior leadership teams, teachers. Department for Education: London.
  12. Nutter, S., Ireland, A., Alberga, A.S., et al. (2019). Weight Bias in Educational Settings:a Systematic Review.Current Obesity Reports, 8, 185-200.

Thursday 12 March 2020

A decade of school food policy inertia

To mark International School Meals Day, we asked former-schoolteacher turned school food researcher Kelly Rose from Teesside University to reflect back on the progress of school food over the last decade.

As a former schoolteacher, now researching the secondary school food environment and adolescent dietary habits, it seems fitting to mark school meals day 2020 by reflecting on a decade of secondary school food policy.

Of late, ‘other’ focuses you could say, have overshadowed the important fact that our young people’s diets are nutritionally poor in the UK. But that begs the question, why are the population of future parents and workforce not a priority at all times?

Currently more than 91 million school children around the world are reported to be living with obesity, with the UK being in the top 20 countries for childhood obesity levels, doubling during the primary school years and increasing further into secondary education. The majority of adolescents in the UK have nutrient deficient diets, high in processed foods and very low in fruit and vegetables. With only 4% of teenagers meeting UK public health fibre recommendations, a significant concern given that dietary fibre is linked to a decreased risk of heart disease, type 2 diabetes and cancers. Furthermore, the health inequalities gap is a devastating burden of poor health for our children living in more disadvantaged areas and minority communities, in comparison to those from more affluent areas.

"In my research I have noticed a level of inertia on the evaluation or policing of school food policy this decade"

In my research I have noticed a level of inertia on the evaluation or policing of school food policy this decade, impacting on school’s healthy food choice offerings. Only the other day my friends 11-year-old daughter explained to me the best thing about her new (secondary) school was the food; “I can eat pizza and cookies every day” - oh dear. Kind of explains why our young people are generally low in at least five micronutrients essential for growth, development mood, reproductive health, energy levels and immunity.

2009 – The Nutrient based standards (NBS)

In 2009 the NBS were rolled out to secondary schools in England, after first being introduced into primary schools. Not only were these food standards focused on meeting young people’s nutrient requirements, but also the mapping of 4 areas of influence provided a framework for which to apply the policy across the nation (Haroun et al 2011). These were considered ‘the most detailed and comprehensive in the world’ (Harper and Wells 2007; Evans and Harper 2009). Plus the Initial evaluations were encouraging (Adamson et al 2013; Stevens et al 2013). However, the NBS was for some a ‘complex task’ to implement (Rose et al 2019).

What happened in 2010?

A change in government (the introduction of the Coalition led by David Cameron) meant a change to school food. Firstly, any ‘newly established academies and free schools’ were not required to adhere to the NBS. A decision which some viewed as a deregulation of school food. Quite soon, school food standards were under review, and in 2013 the School Food plan (SPF) developed by Henry Dimbleby and John Vincent (Long, 2019) was introduced.

The School Food Plan

Over the next few years we see SFP replacing NBS as a legal requirement for ‘all food served in most schools’ (Rose et al 2019). Remember the decision in 2010 to release the new academies and free schools? Well, this means that these schools are still exempt from following the standards, however, some have signed up voluntarily. The aim of the SPF is to transform what children are eating in school and to support schools to create a ‘healthy school ethos’. The SFP is certainly visual, providing ease of use, and the comprehensive resources give schools checklists and guidance. But, here lies a problem, where is the school support system?

Part two of the decade

The first chapter of the UK childhood obesity strategy published in 2016 (DHSC, 2016) provided some recommendations and support for school health initiatives, for the most part within primary aged children. Then in 2017 two things of note happened. The School Food Trust integral to the systems mapping approach of the NBS had been an independent organisation since 2011 providing school resources and opportunities for research closed without funds to carry on. The second was an independent review (the Food Education and Learning Landscape review (FELL)) carried out by The Jamie Oliver Food Foundation. The researcher reported a vast difference in the approach to healthy eating and food education in secondary school environments, stating to be ‘alarmed’ at the state of the problems surrounding the “secondary school food environment”.

Chapter two of the Childhood Obesity strategy (DHSC, 2018) included a pledge to commit to support ‘all children with high quality nutrition’ by conducting consultations on nutrition within buying standards for school catering services and introducing ‘a healthy rating scheme’ allowing for ‘self-evaluation’, whilst also providing a more robust Ofsted framework. My issue as a former food and nutrition teacher/head of health education in a school with supportive leadership is that schools need support externally to evaluate and help develop menus and implement nutritious school meals. The capacity, knowledge and often willingness of school leads, along with the lack of monitoring of adherence to school food standards remain huge barriers to effective school food provision.

2020 current picture

This is where we find the current school food picture in England, no real change from 2018. Awaiting the healthy school’s framework and a priority to be placed on school food provision policy. And, in the meantime social norms of poor teen diets are becoming more and more acceptable, healthy food is so ‘uncool’ to a teenager’s street cred. With the myriad of fast food options on the ‘School fringe’ less expensive and more convenient, thus appealing to the innate biology and the impulsivity of teenagers. A plan to shift teen risk perception of unhealthy eating (i.e. behaviour change) as well as consistency in following the SFP is needed.

A big question

The big question here is why has there been no evaluation of the SFP? There is limited evidence of schools following the school food plan. School staff and leaders have in my mind the most strenuous roles in terms of juggling priorities and educating young people. To expect schools to take on the huge role of making sure food provision meet the nutrient requirements of the nations young people without support is to my mind crazy and as we see presently, will not work…

About Kelly:

Kelly is a registered nutritionist and a former school teacher, currently investigating ways to reduce the obesogenic environment with a secondary school food focus as part of her PhD. She is passionate about the impact of nutrition on adolescent health and has spoken locally, nationally and internationally on the topic of school interventions and the importance of social influence on food choice and the impact of nutrition on mood and behaviour. Kelly is registered with the Association for Nutrition (AFN), a member of Plant based health professionals UK, Nutrition Society, British Nutrition Foundation, Fuse: the Centre for Translational Research in Public Health and The Association for the Study of Obesity.

Adapted with thanks to Food Active

Image: 'primary school, lunch, break, school, activities' by Amanda Mills, USCDCP via PIXNIO ( (Personal & commercial use (CC0).

Friday 6 March 2020

Out of the shadows: Corporate activity and our health

Posted by Nason Maani, Harkness Fellow, Boston University School of Public Health

When considering the impact of commercial actors on health, our minds in public health turn immediately to tobacco. However, while the tobacco industry has earned its reputation and associated exclusion from policymaking, what is unique about those actors misleading policymakers and the public for commercial advantage? Arguably, nothing at all. Asbestos, leaded paint, fossil fuel, sugar-sweetened-beverage and alcohol companies and their proxies have been found to pursue similar tactics.

This is not to say that large commercial actors cannot in many cases benefit society while making a profit. Rather, it is to say that such commercial actors have a track record of focusing on maintaining profit while avoiding litigation, negative PR, and regulatory burdens. When these goals conflict with population health, such actors have the power and scale to negatively influence health, the evidence base, policy options, and even public discourse. The commercial determinants of health, in their broadest sense, are defined as activities of the private sector that affect the health of the population.

As we discussed in a recent commentary, there is a need to progress our understanding in this area because all these areas of influence matter to societal progress, and there are commonalities across many different industries in terms of their motivations, strategies, networks, tactics and interventions that merit the attention of public health researchers.

There is also currently a lack of conceptual focus on these powerful actors by policy-makers and non-governmental organisations, and some gaps in our thinking about these issues. We know that it is largely the conditions in which we are born, grow, live, work and age that determine our health, sometimes called “the social determinants of health”. However, in a recent review, we showed that commercial determinants were often absent from conceptual frameworks of the social determinants of health. This is problematic because such actors have the incentives, resources and strategic ability to influence everything from individual behaviours, attitudes and preferences, to the pollution of the environment, and the funding of politicians who are unwilling to consider the weight of evidence on a particular issue.

Oxfam’s infographic making the connections between big companies and some very familiar brands.

There is a large space for study in this area, but many challenges to doing so, not least because there is relatively little research funding or political will to tackle these issues directly. Many researchers and advocates remain “silo-ed”, focusing on a particular product, or discipline. This “zoomed-in” view stands in contrast to the intersectional ways in which a single large company might act, never mind an industry sector as a whole, or different industry sectors with overlapping interests, acting, for example, to diminish employment rights or environmental standards. We argue that there must be much greater scope for the convening of interdisciplinary research to explore these issues and offer potential solutions.

What about practice?

Aside from research, what about practice? There is also a need for the evidence that does exist to translate more effectively into policy. The challenge public health practitioners often face is that there is a strong political will for partnership and collaboration with the private sector at the local, national and global level, both through direct partnerships, and multilateral engagements. Such arrangements are, on the face of it, appealing. Access to the resources of the private sector is an obvious solution to the problem of increasingly restricted budgets for public health departments, particularly as these private resource pools are so large. Voluntary commitments between the public and private sectors are also conceptually appealing, echoing the type of multi-stakeholder engagement that public health advocates strive for.

However, in the UK, the evidence suggests such activities are often characterised by an abundance of words (in the form of voluntary pledges) and a paucity of deeds (in the form of meaningful changes to how harmful products are produced and marketed). Without regulatory safeguards, it appears unlikely that harmful product manufacturers will voluntarily act in ways that could reduce their own profit margins or lead to “stranded assets”. Instead, such actors will go to great lengths in framing themselves as part of the solution to a “complex” problem, while attempting to diminish the role they play in creating that problem, and rejecting what they termed “one size fits all” approaches such as policy best buys.

There is, however, progress on the research front. Research on specific harmful products and the industries that produce and market them continue apace, and commonalities in corporate strategies are being increasingly discussed. Networks of interested researchers in related topics are beginning to emerge. Perhaps most promisingly, it is becoming clear that commercial determinants are an important component of the broader determinants of health. As the “elephants in the room” become more widely perceived in issues such as alcohol harm, climate change and the opioid crisis, let us hope that, informed by a growing evidence base, the tools to properly address them will follow.

Photo attribution:
  1. "140/365 - Coke Shadow" by Adam Wyles via, copyright © 2011: (CC BY-ND 2.0).
  2. Oxfam infographic courtesy of Oxfam, copyright © 2013: