Unintended Consequence of 'An Ounce of Prevention, Worth a Pound of Cure'

Based on a qualitative study from the UK, the answer is not a definite yes, because screening comes with issues. I know that firsthand because we all had our eyesight tested in second grade. I failed miserably but loudly protested that the “nurse had made me stand farther back than other kids;” for me, this was an existential struggle against being labeled “four eyes.” [1]

The National Child Measurement Programme (NCMP) was launched in 2006 to assess the rates of obesity in public schools. Children were weighed and measured for height at ages 4-5 and then at ages 10-11. Those measures were used to calculate a BMI, and letters were sent to parents of those children at the extremes of being underweight and very overweight. Children in the most extreme, the top and bottom 0.4%, were “proactively followed by local authorities as a “minimum duty of care.”

The researchers viewed the NCMP from a lens of culture and behavior, ethnography. While that may seem a “bit squishy” to basic and medical researchers, it is free of p-values and statistical analysis. It sheds some light on how people experience our interventions. The research is a systematic analysis of eight papers involving 17,270 participants in the NCMP.

Those eight papers had a bias found in their narratives:

• “Most authors framed the NCMP as a justified countermeasure to the serious ‘threat’ of childhood obesity,… using metaphors of catastrophic events such as flooding and combat.”
• “Parental concerns … were often downplayed or countered within authors’ “Discussion”.”
• “Parents were described as being in a state of “obliviobesity” – seemingly unaware of their child’s weight issue [framing] parents as responsible for their child’s weight and responsible for changing it.

Much like my experience of being told I needed glasses, not everyone welcomed the news.

• “The NCMP process was an emotionally significant event for children categorised as overweight, causing anxiety and embarrassment about the weighing process, the result and the potential for weight-related teasing.”
• “Parents voiced concerns that the NCMP weighing, measuring and notification process sensitised their children to weight, and this focus on weight could potentially lead to body esteem issues, dieting and eating disorders for their child in the future.”

The letter from the NCMP tried to nudge parents by characterizing their children's future with the negative consequences of excess weight. And while some of those parents took that message to heart, others felt blame and shame.

“For parents of overweight children, the NCMP letter represented a government-sanctioned judgement of their past parenting behaviour as responsible or irresponsible, coupled with an imperative to parent their child according to the programme’s aim – weight management or loss amongst overweight children.”

Put another way, communication with NCMP was tone-deaf, and many parents upset with the results responded emotionally, describing anger, disgust, etc. Some parents opted out of the program, claiming “government intervention for an issue that was perceived as private.” In other instances, the parents questioned the accuracy of the measurements, particularly for their child, the “exceptional case” – but aren’t we all exceptional? Parents justified these claims with the feelings of like-minded peers who had “successfully resisted” the NCMP findings and recommendations. And some parents deflected those emotions directing their concerns to “others” less responsible in parenting.

“These ‘other’ types of parents were depicted as being unconcerned and incapable of managing themselves, with some participants using coded language to point more specifically to those from working class backgrounds.”

Overall, some of the ones targeted for help were paradoxically the most at risk for harm, certainly emotionally if not medically. Could we generalize this study to other public health issues and government recommendations? I believe in vaccination for COVID but fail to fully understand the third of the American population choosing not to be vaccinated. Go back to the quotations from this current research and substitute vaccination in place of those obesity and weight-related terms. There are a lot of echoes. Crafting a national, one-size-fits-all public health message may be a bit of a fool's errand. To paraphrase, “All public health messaging is, or at least should be, local.”

[1] I quite rightly needed glasses and went from the lowest of the reading groups to the highest in a few weeks. Who knew that those vague blurs on the page were words? Certainly not me.  

Source: Weighing up the future: a meta-ethnography of household perceptions of the National Child Measurement Programme in England Critical Public Health DOI: 10.1080/09581596.2023.2169599