Prevention efforts need to address both obesity and eating disorders in comprehensive ways that do no harm. They will include preventing the problems of hazardous weight loss, undernutrition of teenage girls, dysfunctional eating and size prejudice.Comprehensive prevention programs focus on healthy lifestyles for children of all sizes. They encompass the needs at both ends of the weight scale and any extreme of eating behavior. No child is left out. Prevention involves intervention at three levels:
- Primary aimed at preventing eating and weight problems in the general population
- Secondary focused on early stage problems or high-risk individuals
- Tertiary treatment of weight and eating problems
Currently, both primary and secondary prevention are in their infancy. Obesity and eating disorders are being addressed at the third or treatment level. However, eating disorder treatment is often prolonged and expensive, and while it results in improvement or recovery for a majority, advanced cases end in death in alarmingly high numbers. Similarly, obesity has been treated by diet and other weight loss methods for many decades with little success.
Therefore, primary prevention in schools is urgent getting to the problem at an earlier stage. The sooner sound preventive programs that reach all students with the same healthy messages from all school staff can be put in place, the less need there will be for treatment.
Secondary prevention in schools may involve counseling, weighing and measuring students if deemed appropriate, screening for possible eating and weight problems, and referrals to health professionals. Counselors and school nurses are usually key to this process.
For a comprehensive and sustained program a health advisory team is needed. If the team includes health providers as well as school staff, it might address all three levels of prevention.
“Prevention is a marathon, not a sprint,” says Linda Johnson, MS, Director of School Health Programs for the North Dakota Department of Public Instruction. “Many prevention programs have fallen short because our approach has been single-pronged and of short duration. Often what is convenient, easy and cheap does not benefit youth.”
She contends that a successful prevention program will: develop a needs assessment; build in measurable goals and objectives; use researched, theory based, proven effective programs; deal with problems in a comprehensive way; work with an active advisory council; include ongoing evaluations
“A comprehensive effort that includes school, community and families is most likely to bring about real change,” advises Johnson. “Prevention programs also must do no harm to vulnerable individuals. It’s clear the wrong kind of prevention is useless and can make matters worse.”
What does not work are one-shot programs or prepackaged events used in isolation, with no long-term effort, she says. Information-only programs that change knowledge, but do not teach skills or change behavior, do not make people healthier. Scare tactics don’t make them safer. It is illogical to spend time, money, and energy on untested programs or efforts that will not be sustained over time.
Eight components for schools
Most schools use the Comprehensive School Health Program , developed at the Division of Adolescent School Health, Centers for Disease Control and Prevention in Atlanta, which recognizes that education and health are interrelated and that healthy children who feel safe and accepted in their environment can learn better and achieve more academically.
This program integrates the following eight components, all important in a school program that addresses eating and weight issues:
- Health education in the classroom. Curricula in nutrition, healthy body image, child development, and family living give all students, K through 12, a solid foundation to incorporate healthy living concepts into their lives.
- Physical education and activity. Federal guidelines call for daily physical education for all students and that 50 percent of class time be spent actively by every child . Focusing on life skills, fun and creativity is helpful for all students, especially those who may be physically underdeveloped.
- Counseling services. School counselors and nurses play key roles in prevention programs and advisory boards, identifying factors that may hinder optimal school performances and adjustment, and connect students to appropriate services.
- Food service. Nutritious and appealing meals that coordinate with health education help students develop strong healthy bodies and good eating habits. Scheduling adequate time for eating is important. Vending machine offerings may be a concern.
- Healthy school environment. Physical, emotional and social surroundings that are safe, secure and accepting of each individual enhance the well-being of students and staff. Keeping the school free of bullying and harassment is an important and challenging goal; so is establishing a policy of zero tolerance for size bias in classrooms, hallways, and grounds.
- Health programs for faculty and staff. Educators with healthy lifestyles and attitudes are powerful role models. They can benefit from in-service training and help with their own weight and eating issues.
- Health services. The school nurse, public health nurse, and other school health resources provide support and a consistent approach for weight and eating issues.
- Parent and community involvement. Successful prevention programs integrate parents into both planning and implementation so that school efforts will be supported and reinforced in the home and community. The challenge is to integrate the prevention of weight and eating problems into each of these eight components. This can do much to stimulate the students’ intellectual growth and their ability to learn.
Measuring safety and effectiveness
In obesity prevention programs, the wrong kind of intervention is worse than the condition, warns Ellyn Satter, author of How to Get Your Kid to Eat — But Not Too Much. She advises that any programs for overweight children need to enhance psycho social effects and ensure that no child is stigmatized. “Don’t rate progress by numbers on a scale, or how much weight kids lose,” adds Linda Omichinski, RD, author of Teens & Diets: No Weigh, a program being used in schools to encourage healthy lifestyles and help empower teens .
Whether to weigh and measure students is controversial. Some states and school districts regard measuring as necessary for tracking individual growth, screening, establishing comparable group statistics, or evaluating preventive programs. Others are concerned that safeguards may not be in place to protect children. They suggest that if the statistics are not being used or used effectively, perhaps they should not be gathered.
If weight is measured, perhaps eating and other factors may need to be measured and tracked, as well. These might include nutrition, dysfunctional eating, weight loss practices, body image issues, size prejudice, and medical risks. Increases in any adverse effects should be grounds for making changes.
An awareness is needed by the health team that overemphasis on the risks of overweight can quickly escalate for vulnerable children into promoting thin mania, disturbed eating and social discrimination.
Teachers understand this. When the federal agency charged with implementing the Obesity Education Initiative in schools convened a major school conference in 1992 , it was soon clear that educators were asking for a new approach. They warned policy makers not to rely on traditional thinking, but to provide sound information. They bluntly expressed concern that national messages on obesity can further stigmatize high-risk children and lead to worse problems. And they criticized changes that some conference experts were recommending, changes that focused more on restricting diet than increasing physical activity.
The teachers recommended targeting all youth, not singling out those at high risk for special efforts. “Focus on how to make them healthier, as opposed to thinner, especially because making them thinner often does not make them healthy.”
What teachers were asking for in 1992 were preventive programs based on healthy lifestyles for children of all sizes. They still are. Programs with this new approach empower and strengthen all youngsters.