Introduction by Croakey: The Conversation recently asked five experts whether school nurses should weigh students, as suggested by a controversial Australian College of Nursing position statement, ‘Working with Children Above a Healthy Weight: Nurse-led interventions’.
All five experts responded with a firm ‘no’.
Associate Professor Brett Montgomery, Senior Lecturer in General Practice at the University of Western Australia, said that while the proposal was well-intentioned, he did not think it would work.
Professor Clare Collins, Laureate Professor in Nutrition and Dietetics at the University of Newcastle, said a better strategy was to nourish children while they are at school, especially when the school is in a socioeconomically disadvantaged area, including through school breakfast programs.
Dr Natasha Yates, a GP and PhD Candidate at Bond University, raised concerns about the risk of stigma, bullying and mental health impacts, and said funding should instead be directed to evidence-based approaches that are holistic, de-stigmatising, empowering and support the health of whole families.
Dr Rachael Jefferson, Lecturer in Human Movement Studies (Health and PE) and Creative Arts at Charles Sturt University, said the ACN plan was “doomed” and could lead to body shaming of children and young people at a time when they are already extremely vulnerable to mental health conditions.
Dr Vivienne Lewis, Assistant Professor of Psychology at the University of Canberra, also raised concerns about body shaming, and warned that drawing negative attention to a child’s weight will increase their risk of developing eating disorders.
Meanwhile, Dr Tim Senior, a GP working an Aboriginal Community Controlled Health Organisation (ACCHO) in NSW, explains below why he is urging the ACN to reconsider this proposal.
Tim Senior writes:
I’ve learned to be very careful discussing weight with school age children. By the time they see me as a GP, if we want to discuss weight, it’s probably already being talked about at school. Quite often if they are deemed to be above a healthy weight, they are being teased or bullied about it.
My own daughters have told me about the pressure they felt from their peers about body image, and about disordered eating, mental health pressures and sometimes clinical eating disorders that arose from this sort of pressure.
Therefore I was sad to read the headlines about the Australian College of Nursing’s proposal to tackle obesity by measuring the weight of every school child.
I thought perhaps the headlines were misleading, so I went to read the position statement, and, no, this is the genuine proposal.
While well intentioned, there are a lot of ways in which this position statement is misguided and potentially harmful.
The position statement starts with a quick summary of some of the evidence relating to the health effects of obesity and the involvement of nurses.
The evidence summary states several times: “However, the effectiveness of these individual programmes on population behaviour changes has yet to be tested on a mass scale”, and: “However, limited economic evidence has been put forward to evaluate these strategies”.
This is hardly the strength of evidence to advocate for a widespread measuring of children’s weight in schools outside any other program being implemented. There are many different types of intervention referenced in these studies, which should make us cautious about suggesting just weighing children.
Obvious harms
There are no harms reported in the research summarised, but the immediate reaction of eating disorder charities, as well as commentary on Twitter, (and also the instant reactions of my own daughters!) show that there are obvious concerns about harms from this proposal.
However, the ACN’s summary of the evidence mentions no potential harms.
Anyone who has spent time in a school would know that the moment you are routinely recording weights, then children will be comparing them, seeing where they measure up compared to their peers. Some children will be teased and bullied over it.
The ACN do mention stigma five times, acknowledging that it needs to be “combatted,” and also mention that obesity is a “complex condition influenced by genetic, biological, social, economic, historical, and environmental factors rather than merely, individual choices about diet and physical activity”.
It’s a little surprising therefore that the actions they propose take none of this complexity into account. The concrete actions are that every child gets a nurse, and every child gets weighed.
There’s a more vague recommendation about providing interventions. It’s strongly implied earlier that these will be about providing education to children and families, and there’s also mention of “addressing weight stigma in poor communities” and conducting “stigma reduction workshops”.
I suspect that making sure every child has their weight measured and recorded is a good way to increase weight stigma, and it will be hard to undo with a workshop.
There is an accompanying fact sheet providing advice for nurses on ”working with children above a healthy weight”. Despite all the instructions about “using positive language,” it is all focussed on weight, not on the child or the family. All the advice is about individual lifestyle changes, even while their own position paper suggests this is incorrect.
The underlying assumptions in these instructions become clear. There is an assumption that this is just about children and families not knowing some simple facts, rather than being subject to powerful social, cultural, economic and corporate forces.
Missed opportunities
I can’t go past the complete misunderstanding shown in the single mention of culture. “Cultural factors connected to tradition, identity and courtesy should be considered when providing consultation, especially in rural and remote settings.”
Have they never visited Fairfield or Liverpool or Cabramatta or Auburn or similar suburbs in Melbourne?
Culture is not something that only happens in rural and remote areas. There’s no mention of perhaps one of the most visible representations of culture, which would be highly relevant if you were going to talk to someone about their weight: food! Certainly, the small suggestions relating to food in this advice aren’t taking culture into account.
Just as significantly, there is no mention at all of socioeconomic factors or class or poverty.
There’s no advice to listen to people about what food they can afford, no advice about how to access food affordably, no wondering about whether people have homes with fridges and cooking facilities, where they can afford the energy bills. No questions about who is missing out on food to enable others to eat. There are no questions advised about availability of safe, local parklands, sporting or recreational groups, or availability of transport.
As the late Dr Julian Tudor Hart says (in The Political Economy of Health Care), “obesity has become the most visible outward indicator of social class”.
It’s possible that in measuring children’s BMI, we are doing not much more than noting a marker of the school’s postcode – or perhaps whether it’s a well-funded private school or an under-funded public school.
There are so many missed opportunities here. There’s the potential that children going through mental health difficulties or having difficult times in their family would consider telling a trusted adult, such as a nurse but choose not to, because the nurse only seems interested in their weight.
There’s the missed opportunity to involve a primary care team in health promotion and health prevention, suggesting instead that a nurse operating in isolation should be doing it all.
Most importantly, this is a missed opportunity to promote the evidence that body mass index (BMI) may not be a good measure of health in children, and that it’s certainly not a good measure of a person.
This is a missed opportunity to ask children “What do you love doing? What gives you joy?” and to encourage them to play sport, be in nature, dance, enjoy food, connect to their own cultures, and ultimately to say that it doesn’t matter what size or shape you are, you are beautiful, you are seen and you are loved.
• Dr Tim Senior is a contributing editor and member of Croakey Health Media
Response from ACN
The ACN provided the following comments in response, on behalf of Karen Grace – National Director of Professional Practice:
“At the ACN, our focus is on supporting the long-term health and wellbeing of children. Our recommendation to normalise the collection of height and weight data is part of a larger effort to prevent chronic conditions such as diabetes and heart disease later in life. This aligns directly with the National Obesity Strategy 2022-2032.
“By providing school-aged children with access to qualified nurses, we aim to offer proactive and non-judgmental care that helps families make informed decisions about their children’s health. Nurses are uniquely positioned to identify at-risk children, educate families, and provide sensitive, private, and supportive care, ensuring that all children have the opportunity to maintain healthy lifestyles without fear of stigma.
“We understand the sensitivities surrounding body image, which is why our approach emphasises privacy, respect, and sensitivity in how these measurements are handled. Nurses are trained to engage with families in a way that promotes healthy behaviours and positive discussions around overall well-being, rather than focusing solely on weight.
“ACN is committed to promoting a supportive, stigma-free environment where children feel empowered to maintain healthy lifestyles. Our focus is on preventing chronic disease and ensuring a healthy future for every child, with a holistic view of health that includes physical, mental, and emotional wellbeing.”
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