Weighing up the future: a meta-ethnography of household perceptions of the National Child Measurement Programme in England

ABSTRACT

The English National Child Measurement Programme (NCMP) is a nationally mandated public health programme. It provides data for child excess weight indicators in the Public Health Outcomes Framework, part of the government’s approach to reducing childhood obesity. Drawing on a meta-ethnographic synthesis of household members’ experiences of the programme, we conceptualise the NCMP as a ‘technique of futuring’ to generate new insights into how it (re)shapes and (re)imagines past, present, and future responsibilities and practices for overweight children, parents, and carers, in potentially harmful ways. For children categorised by the NCMP as overweight, the NCMP is an emotionally significant event, driving new bodily practices, new food practices and changed relationships with peers. This paper outlines how parents come to resist and reframe the programme and its results, to protect their children from a weight-focused future. They consider the potential risks of bullying, dysfunctional eating, and mental health consequences more important than future risks of overweight. We show how parents of children categorised as overweight preserve their claim to ‘responsible’ and ‘good’ parenting amongst peers, whilst shifting the blame for childhood obesity to other, ‘irresponsible’ parents, thus reproducing moralising and responsibilising discourses inherent within the ‘behaviour change’ messaging of the NCMP and associated research. Finally, we consider a central paradox of this programme and the use of NCMP population level monitoring data to (re)shape lives at the individual and social level – the children it sets out to help are the most likely to experience harm as a result of it.

KEYWORDS:

• NCMP
• obesity
• synthesis
• perspectives
• child weight

Introduction

Reducing childhood obesity is a major priority for public health policy. In England, this is reflected in the deployment of the National Child Measurement Programme (NCMP), a government mandated national surveillance programme for assessing levels of childhood obesity in primary school children. In this paper, we synthesise the experiences and perspectives of families on the NCMP. Previous qualitative syntheses have examined: patient experiences of weight management services and interventions (Bradbury et al., 2018; Garip & Yardley, 2011; Henderson, 2015; Jones et al., 2017); children’s views on body size (Rees et al., 2011); views held by healthcare professionals, parents, and children on obesity (Lachal et al., 2013), but none has focused on the NCMP which is unique to the English context, covers the majority of primary-school aged children and aims to be ‘a vehicle for engaging with children and families about healthy lifestyles and weight issues’ (NHS Digital, 2022).

National Child Measurement Programme

The NCMP was introduced in 2006. A contested programme from conception, it was originally set up as an epidemiological surveillance tool which, at a later date became transformed into a screening programme with the addition of individual communications to parents and follow up weight management interventions (Lake, 2009; Rich et al., 2011). It assesses rates of childhood obesity amongst primary school aged children attending state-maintained schools in England (Public Health England, 2021). As part of this programme, children are weighed and measured at school in reception year (aged 4–5 years) and year 6 (aged 10–11 years) by trained professionals, with the results used at national and local levels to inform public health initiatives. Children are categorised according to BMI using either the British 1990 Growth Reference (UK 90) cut offs based on population growth survey data collected between 1978 and 1994, or clinical cut offs, into four categories: underweight, healthy weight, overweight, and very overweight (sometimes referred to as obese and including children who have severe obesity) (Public Health England, 2021). Being mindful about language, in this paper we use the term ‘children categorised as overweight’ to denote all children categorised by the NCMP as either overweight or very overweight in communications to parents, whilst remaining critically engaged with the problems of labelling people as such (Rich, 2010; Rich et al., 2019; Warin & Gunson, 2013), the consequences of which we aim to uncover in this paper.

Early iterations of the NCMP involved parents contacting their local health authority to be informed of NCMP results. In recent years, local authorities were advised to notify parents of the results using a standardised letter, which can be adapted locally. Children who fall on ‘extreme BMI centiles’ (below the 0.4th centile, on or above the 99.6th centile) must be proactively followed up by local authorities as a ‘minimum duty of care’ (Public Health England, 2021). The letter can also be used to prompt parents of children categorised as falling on an ‘extreme’ BMI centile – whether over or under weight – to consult healthcare professionals or undertake home-based interventions to achieve a healthier weight. Whilst some children will be identified as underweight, arguably the programme is primarily focussed on identifying children in the higher weight categories due to ‘apocalyptic’ narratives around childhood obesity (Gillborn et al., 2020). If consulted, healthcare professionals may, in turn, refer children to locally offered weight management programmes (WMPs) or lifestyle interventions. Parents are able to opt their children out of the programme.

Public health practitioners acknowledge that the NCMP has limitations, including concerns about parents reacting negatively to their child’s results, weight-related bullying in schools and the use of stigmatising language when referring to weight (Public Health England, 2021). Public Health England has recently published a guide to equip professionals delivering the programme to undertake ‘challenging conversations’ to manage the emotional reactions of parents (Public Health England, 2019). These efforts suggest parental resistance to the programme (Gainsbury & Dowling, 2018; Kovacs et al., 2018). Staff are also concerned; a survey of NCMP leads across England found that one third thought the programme did more harm than good (Statham et al., 2011).

Rethinking the NCMP

In this paper we consider the NCMP through a temporal lens, exploring how the programme reconfigures past actions, current practices, and future imaginaries. In public health disciplines, the past, present and future are connected and (re)constructed through data analysis, decision tools, projections and modelling (Oomen et al., 2021). These future-focused tools give shape to a politically sanctioned way of understanding and ‘doing’ childhood obesity that in turn aims to shape citizen’s actions in the present. The documents, practices, technologies and tools of the NCMP (re)present an official, government led, monologic – characterised by a single dominant point of view – discourse of child weight that centres future health ‘risks’ and individual and parental responsibility for weight (McNaughton, 2011). Critical obesity scholars have engaged with and challenged this framing of weight and health and the bodily monitoring and intervention associated with it (Griffin et al., 2021; Lake, 2009; Rich, 2010; Rich & Evans, 2005). They problematise the dominant focus on weight and body mass index as an indicator of health, morality and ‘good’ citizenship (Anderson, 2012; Campos et al., 2006; Evans et al., 2008; Gard, 2011; Gillborn et al., 2020; Medvedyuk et al., 2017). This paper contributes to this growing critical scholarship by highlighting the social, moral and ‘futuring’ impacts of nationally mandated weight surveillance on children and their families through the synthesis of empirical evidence.

The enactment of the programme on the ground, however, gives rise to opportunities for different collective imaginings about child weight amongst children, their families, and their social connections. We intend to contrast the government-sanctioned NCMP messaging with the multiple, negotiated ways of knowing and ‘doing’ child weight that emerge from actors’ interaction with and about the NCMP programme, attending to ‘the way people imagine their social existence, how they fit together with others … and the deeper normative notions and images that underlie these expectations’ (Taylor, 2004). To do this we situate the NCMP as a set of practices through which imagined futures become collectively held – a ‘futuring’ practice. Hajer and Pelzer define these ‘techniques of futuring’, as ‘practices bringing together actors around one or more imagined futures and through which actors come to share particular orientations for action’ (Hajer & Pelzer, 2018, p. 222). Here we will argue that the NCMP can be considered a ‘technique of futuring’ that (re)constructs and reconfigures the pasts and possible futures for parents and children who participate in the programme. Parental and carer perspectives, and those of their children, have been explored in a number of qualitative studies on the NCMP (Gainsbury & Dowling, 2018; F. Gillison et al., 2014, 2017; Grimmett et al., 2008; Kovacs et al., 2018; Nnyanzi, 2016; Nnyanzi et al., 2016; Syrad et al., 2015). However, this empirical evidence on experiences of the NCMP has not been synthesised and remains undertheorized. Meta-ethnography allows us to synthesise existing research in order to generate new insights and interpretations that go beyond the contributions of the original studies to generate a ‘line of argument’. Our aim was to conduct a synthesis using meta-ethnography to explore published qualitative evidence on household members’ (parents, carers and/or children) experiences of and views on the NCMP. A secondary aim was to consider how the participants’ views and perspectives were framed and interpreted by authors in the qualitative literature. We focused on experiences relating to children categorised by the NCMP as ‘overweight’ and ‘very overweight’, this being the group of children whom the NCMP sets out to assist.

Methods

Meta-ethnography is a creative and iterative method for synthesis used to progress the field by generating a new conceptual interpretation of the included literature that goes above and beyond what the individual studies contribute, through the development of a new ‘line of argument’. We followed the seven stages for meta-ethnography described by Noblit and Hare (1988), and later extended by France et al. (2019): getting started; deciding what is relevant; reading the studies; determining how the studies are related; translating the findings; synthesising the translations; presenting the synthesis. We refined our research aim (stage 1 - getting started) through a scoping exercise. We then conducted a systematic literature search of 8 public health, medical and social science databases for papers published in English between January 2004 and March 2020 (n = 17,270) (Stage 2). Duplicates were removed and title and abstracts screened by MH against SPIDER criteria (Cooke et al., 2012):

• Sample: household members (parents and significant carers – referred to as ‘parents’ throughout – and primary school aged children (4-11 years)).

• Phenomenon of Interest: UK public health programmes entailing routine measurements of child height and weight undertaken in primary school settings with communication of results.

• Design: data from interviews, focus groups, ethnography, and case studies.

• Evaluation: views, opinions, attitudes, beliefs, and experiences.

• Research type: qualitative or mixed methods.

Full texts of selected papers from the first round of screening were screened by MH (n = 474), with 50% double screened by DS, with disagreements resolved through discussion.

At Stage 3, MH read and familiarised herself with 12 included studies (supplementary file). DS read a subset (3 papers), acting as a ‘critical friend’. For each paper we hand annotated and discussed key concepts, extracted study characteristics into a shared spreadsheet, and undertook a quality appraisal using Joanna Briggs Institute (JBI) criteria (The Joanna Briggs Institute, 2017). We then extracted first and second order constructs into shared documents for further coding and analysis. First order constructs include the raw qualitative data presented in the paper, whilst second order constructs are defined as the author’s interpretations of that data. Any further interpretations as a result of the synthesis are referred to as third order constructs. To determine how studies were related (Stage 4), we drew from each shared document to create a table of key concepts, phrases, illustrative quotes, and analytic ideas in an iterative process. We then used constant comparison to ‘translate’ these findings (Stage 5) from the studies into each other into a separate shared document, noting where findings supported (reciprocated) or refuted each other, and noting alternative interpretations. To ensure rigour we held data analysis sessions with six experienced qualitative researchers at each stage. Finally, we created a diagram (Stage 6) to develop our overarching ‘line of argument’ from the constructed threads and themes. We followed eMERGE guidelines (France et al., 2019) whilst presenting these findings (Stage 7).

Results

We included 12 papers detailing studies located in England utilising different types of qualitative methods (eight used interviews, three focus groups, two open ended survey questions and one online fora) (supplementary file). The majority of participants across all papers were mothers, and three papers included the views of children. Most (n = 10) used thematic analytic methods and very few drew on theory to underpin their findings. Quality score range was 4–9 out of 10 (The Joanna Briggs Institute, 2017).

Most authors framed the NCMP as a justified countermeasure to the serious ‘threat’ of childhood obesity, with some framing the issue using metaphors of catastrophic events such as flooding and combat. Parental concerns reported as research ‘Findings’ were often downplayed or countered within authors’ ‘Discussion’. The NCMP assumes that by making parents aware of their child’s diagnosis as overweight that parents will take remedial action to reduce their child’s weight. For instance, NCMP operational guidance states that more than 50% of parents ‘underestimate their child’s overweight or obesity status’, going on to claim that following NCMP feedback ‘most parents (72%) reported an intention to change health-related family behaviours’ (Public Health England, 2021). We saw this replicated by authors when framing the ‘problem’ their paper tackles across our synthesis. In one paper, parents were described as being in a state of ‘obliviobesity’ – seemingly unaware of their child’s weight issue (Povey et al., 2020). This discourse frames parents as responsible for their child’s weight and responsible for changing it. Notably, some authors described children of different weight statuses with moralistic or problematic language – referring to children with healthy weight as ‘ideal’, ‘normal’ or ‘correct’ (F. Gillison et al., 2017; Nnyanzi et al., 2016). However, first order constructs from the studies displayed parental concerns and resistance to elements of the NCMP, which we have further illuminated in the following sections. Here we present two interlinked third order constructs before discussing how we bring these constructs together in a ‘line of argument’ synthesis. Quotes have been attributed where possible, using the following shorthand: all children categorised as overweight or very overweight (OW/VOW), child categorised as healthy weight (HW).

3^rd order construct: from ‘innocent past’ to ‘planting a seed’ for future issues

For children categorised as overweight, the NCMP weighing process was an emotionally significant moment. It led to changes in diet and weighing-related practices for some children. Children’s relationships with peers became reshaped along new lines that take body size into account. For some parents of children categorised as overweight, the NCMP represented a break between an ‘innocent’ past and a weight-focused future. In this future, the body emerged as a site for critical self-gaze and new, potentially harmful body and food practices. We explore these findings in further detail below.

Innocent childhoods

Prior to participating in the NCMP, children were perceived by some parents as ‘innocent’ and, through the eyes of their parents, did not attend to their weight as something to be concerned with. One parent lamented that the NCMP represented ‘the end of innocence!’ Parent, (Grimmett et al., 2008, p. e688). Some parents felt that children in reception year were too young to participate in the programme and would find it difficult to understand, ‘The only way he would understand is you’d go “someone thinks you’re a fatty” […] it’s a big worry to a 4-year old’ Parent (OW/VOW), (Povey et al., 2020, p. 151). It was clear that some parents wanted to protect and maintain this innocence about the concept and value-system of bodily weight amongst their children. Whilst some parents had concerns about protecting their child from knowledge about the issue of weight, some parents were positive about the programme, particularly if they had concerns about their child’s weight and felt they needed assistance. In these cases, some parents felt they needed an additional authoritative voice to convince their child to change.

Weighing emotions

Some children categorised as healthy weight enjoyed the weighing process, feeling pride and happiness in their results, and were rewarded by their parents with gifts and parties (Nnyanzi, 2016). However, 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 (F. Gillison et al., 2014; Grimmett et al., 2008; Nnyanzi, 2016; Pallan et al., 2019; Povey et al., 2020; Syrad et al., 2015). One child described reactions to getting weighed as follows: ‘children were anxious thinking it was a terrible thing. You could look at the face of the next person and you could see he was absolutely terrified’ Child, (Nnyanzi, 2016, p. 467). There was a social aspect to these concerns, with children feeling nervous about the reactions of peers to their newfound status – for example, one child had concerns that other children might ‘talk’ about their weight if they found out: ‘It was OK because other children didn’t know what your weight was so they couldn’t talk about it’. Child, (Grimmett et al., 2008, p. e688). For another parent, her ‘sensitive’ child found the process of weighing embarrassing and worry-inducing, even when talking to her siblings, ‘Nowadays kids are very, very sensitive and every sort of thing just sticks in their head … she was embarrassed to even tell her brother and sisters what she was going for’ Parent (OW/VOW), (Pallan et al., 2019, p. 10).

Planting a ‘seed’ for future issues

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 (F. Gillison et al., 2014, 2017; Grimmett et al., 2008; Nnyanzi et al., 2016; Pallan et al., 2019; Povey et al., 2020). Some children became aware of their results and upset through reading the results letter, prompting parents to hide or bin it. As one parent explained: ‘that’s why I would never ever let her get weighed because I don’t want her coming home being hung up on it, and going the opposite way and not eating’ Parent (OW/VOW), (F. Gillison et al., 2017, p. 12).

The NCMP was also seen as having the potential to affect a child’s perceptions of themselves as healthy, altering their self-image and confidence. Parents were concerned about marking out their child with a stigmatising label for the future, and prompting possible weight-related teasing (F. Gillison et al., 2017; Grimmett et al., 2008). One parent explained, ‘I have not told my son about this letter. I think it could be a damaging ‘‘seed’’ to plant in any child’s head when they consider themselves healthy’. Parent (OW/VOW), (F. Gillison et al., 2014, p. 990). Preserving happiness and protecting children from mental health disorders, potential eating disorders and unhealthy dieting behaviours in the future was seen by some parents as more important than possible future consequences of overweight (Kovacs et al., 2018; Syrad et al., 2015) ’Parents with more extreme views believed that this meant the process of measuring children is “far more dangerous than the weight itself”’ (Kovacs et al., 2018, p. 7), and some parents did not think that overweight posed a future risk to ill health (F. Gillison et al., 2014; Grimmett et al., 2008; Syrad et al., 2015).

Current weight-related practices

Some children and parents responded to the results of the NCMP by ensuring that being ‘overweight’ was attended to through new diets and weighing practices (F. Gillison et al., 2014; Grimmett et al., 2008; Nnyanzi, 2016), e.g. ‘thanks to your [NCMP result] letter my child now thinks she looks disgusting and looks at the calorie content of everything she puts in her mouth’ Parent (OW/VOW), (F. Gillison et al., 2014, p. 990), and this example: ‘I felt down because of my weight, [before NCMP] I thought I was really skinny, so day after day I would step on the scale to see if anything has changed’ Child, (Nnyanzi, 2016, p. 468).

The NCMP also reshaped relationships for some children categorised as overweight (F. Gillison et al., 2017; Nnyanzi, 2016). This was characterised by children as making new friends with others who shared their experience of being overweight, for example: ‘… I now have a new friend called [name] whose letter also said that he was overweight’. Child, (Nnyanzi, 2016, p. 469). In the following quote, a parent explained how attending a weight management programme as a result of the NCMP led to opportunities for children to feel included and less isolated amongst their peers, ‘I think what it was is that they didn’t feel that they were on their own’. Parent (OW/VOW), (F. Gillison et al., 2017, p. 11).

Alternative imagined futures

For some parents, NCMP messaging highlighting future ‘risks’ of child overweight was internalised and created worry and, in some cases, preventative action. However, in contrast to communications from the NCMP that highlight a potential future involving the negative consequences of overweight, some parents of children categorised as overweight imagined alternative futures for their own children, in which weight either was not an issue, or was an issue that resolved as the child got older without intervention (F. Gillison et al., 2014, 2017; Povey et al., 2020; Syrad et al., 2015). One parent stated: ‘It’s not a huge concern at the moment because I think we’ve got to get through puberty and see how she goes and how she grows’ Parent (OW/VOW), (Syrad et al., 2015, p. 51). Another explained: ‘I know he is going to get taller, so things are going to spread out’ Parent (OW/VOW), (Povey et al., 2020, p. 151).

In these imagined futures, some drew on comparisons with family members and peers, to picture how their child might look and grow in the future (Fleming et al., 2015; F. Gillison et al., 2014, 2017; Syrad et al., 2015). For example, a parent said ‘Cause he’s very much like his dad in a lot of ways, you know, looks and everything. I just thought, “he will lose it [weight] … ” in my mind’. Parent (OW/VOW), (F. Gillison et al., 2017, p. 10). In these alternative futures where a weight issue resolved itself, NCMP warnings about negative health consequences were erased, and parents constructed an optimistic future of their child enjoying a happy, healthy life.

3rd order construct: past parenting and future responsibilities

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. Our analysis identified parents both resisting and reproducing these representations in several ways: opting out of the NCMP programme and voicing opposition to its aims; questioning, softening, and rejecting aspects of the programme; ‘othering’ parents who are perceived as acting differently to themselves. We present these findings below.

Being judged for past parenting

Parents of children categorised as overweight indicated that they felt judged when they received the results letter (Gainsbury & Dowling, 2018; F. Gillison et al., 2014; Nnyanzi et al., 2016; Povey et al., 2020). One parent recounted: ‘I did feel a bit like I’d had my fingers slapped’ Parent (OW/VOW), (Gainsbury & Dowling, 2018, p. 2887). Another explained, ‘you are being heavily criticised as an irresponsible parent’ Parent (OW/VOW), (F. Gillison et al., 2014, p. 990). Central to this response was the notion that parents are responsible for their child’s weight and the NCMP finding therefore represented a lack of care, or poor parenting in the past, as the following quote demonstrates: ‘I felt people were telling me that I wasn’t bringing up [child] in the correct manner’ Parent (OW/VOW), (Povey et al., 2020, p. 149). This conceptualisation was mirrored by some study authors. For example, Gillison et al characterise the NCMP as a ‘judgement on their child’ (F. Gillison et al., 2014, p. 989). Many parents of children categorised as overweight employed emotional language to express their reactions to receiving these findings from the NCMP, describing how they feel ‘anger’, ‘horror’, ‘disgust’, ‘worry’ and ‘disappointment’ (F. Gillison et al., 2014; Grimmett et al., 2008; Povey et al., 2020; Syrad et al., 2015).

Opposing the NCMP

Some parents resisted the entire programme by opting their child out. They justified their position through statements opposing government intervention for an issue that was perceived as private – something that should be dealt with in the home (F. Gillison et al., 2014). Authors interpreted this as an aversion to the ‘nanny state’ or ‘big brother’ policies, including quotes such as ‘the government can mind its own business’ Parent, (Kovacs et al., 2018, p. 7). Some were concerned that information such as children’s weight and height, which they regarded as ‘personal’ information, might become available to others or be entered into their medical record (Fleming et al., 2015; Grimmett et al., 2008).

Rejecting results

In interviews, parents of children categorised as healthy weight said they were reassured and took pleasure and pride in the NCMP result as confirmation of their good parenting skills, for instance: ‘it means I am feeding my children in the right way’ Parent (HW) in interview, (Nnyanzi et al., 2016, p. 7). In focus groups, they were more likely to downplay this reaction and say they were indifferent, e.g. ‘I didn’t think anything of it’ Parent (HW) in focus group, (Gainsbury & Dowling, 2018, p. 2887). In contrast, parents of children classified by the NCMP as overweight showed their resistance to unwanted findings and reasserted their claim to ‘good’ and ‘responsible’ parenting by questioning or rejecting aspects of the programme. Their actions included binning the results letter, ignoring the findings, and diminishing their importance (Gainsbury & Dowling, 2018; F. Gillison et al., 2014; Nnyanzi et al., 2016), as this quote exemplifies: ‘just brush it under the carpet’ Parent, (Nnyanzi et al., 2016, p. 8).

Parents used alternative language to describe their child’s size and shape, such as ‘plump’, ‘portly’, ‘chunky’ and ‘strapping’ (Fleming et al., 2015; Gainsbury & Dowling, 2018; F. Gillison et al., 2014, 2017; Nnyanzi et al., 2016; Pallan et al., 2019; Syrad et al., 2015). They also questioned the accuracy of the BMI measurement, particularly for children from minoritised backgrounds, or those with complex health conditions. Some parents argued that the weight categorisation was difficult to understand and did not adequately account for the healthy and active lifestyles that their children enjoyed (Fleming et al., 2015; F. Gillison et al., 2014, 2017; Povey et al., 2020; Syrad et al., 2015), for instance: ‘it only measures weight to height ratio and doesn’t take into account their lifestyle, their activity and things like that’ Parent (OW/VOW), (Syrad et al., 2015, p. 50).

To support these positions and reassert themselves as ‘responsible’ parents, interviewees reported how their family and peers agreed with them, and those in focus groups collaborated with their friends to dismiss overweight feedback (Gainsbury & Dowling, 2018): ‘My sister was really cross about it’ Parent (OW/VOW), (Gainsbury & Dowling, 2018, p. 2888). By strategically employing peer-supported claims that the NCMP findings were inaccurate, and their own children were actually not overweight and led healthy lives, these parents successfully resisted the NCMP’s imperative to change their parenting without risking censure from other parents taking part in discussions about the NCMP.

Irresponsible others

Whilst parents of children categorised as overweight made efforts to resist the judgement and consequences associated with unwanted NCMP findings, they also simultaneously reproduced these judgements for others, as do parents of children from all weight categories. These imagined ‘others’ were unnamed parents who were characterised as being to blame for their child’s overweight through their irresponsible parenting behaviours and unhealthy lifestyles (Gainsbury & Dowling, 2018; Grimmett et al., 2008; Nnyanzi et al., 2016). One parent said: ‘they [parents] are the ones feeding the kids […] How is that not your fault really?’ Parent, (Nnyanzi et al., 2016, p. 7).

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 (Gainsbury & Dowling, 2018; Grimmett et al., 2008; Nnyanzi et al., 2016). One parent in a focus group explained: ‘what we’re saying is it’s impacting the wrong people because the responsible ones are having sleepless nights about it and the irresponsible ones are ignoring it’. Parent (HW), (Gainsbury & Dowling, 2018, p. 2889). For these ‘other’ parents, imagined futures of weight-related ill-health inherent within NCMP messaging were accepted as a projected reality, and therefore judgements about poor parenting were considered justified. For these imagined others, the expectations of the programme - that lifestyle changes need to be enacted to avoid future health consequences for the child – remained unchallenged, e.g. ‘every parent should receive this information […] parents seem unable to continue this attention unless they are monitored’ Parent, (Grimmett et al., 2008, p. e688).

Discussion

Line of argument

Though conceived as a snapshot in time, the NCMP process (re)shapes and (re)imagines past, present, and future, responsibilities and practices for children categorised as overweight and their parents, in potentially harmful ways.

Children categorised as overweight experienced the NCMP as an emotionally significant event that can drive new bodily practices, new food practices and changed relationships with peers. In this context, parental resistance to the NCMP can be seen as an effort to extend and affirm their child’s ‘innocent’ past and protect them from a weight-focused future.

Some parents of children categorised as overweight felt blamed and criticised for their parenting performance and sought to resist the NCMP findings. The act of resisting overweight categorisation as an individual and as a peer collective can be understood as a way of avoiding blame and judgement about past parenting. It also allowed parents to avoid a morally, politically, and socially sanctioned obligation to change lifestyle habits for the future without facing peer censure.

Whilst taking into account empirical research on all families, our findings here focus particularly on children categorised as overweight or very overweight and their families, as we found this is the group most likely to face a reconstruction of their past, present and future through the NCMP. This demonstrates a central paradox inherent within the NCMP – the children and parents who the programme particularly sets out to help are at most risk of harm as a result of it.

The NCMP process can be seen as a powerful government-led technique that reconstructs past, present, and future, responsibilities and practices of those who it aims most to help. Although conceptualised by the UK Government as a programme to improve child health, it has social, moral and health consequences for children categorised as overweight and their parents who take part.

Principal findings in context

Parental resistance to the NCMP can be interpreted as a rejection of contemporary behaviour change imperatives that do not adequately address the complex upstream social and environmental factors that have contributed to children’s weight status. Whilst much evidence points to the complexity of the obesity ‘issue’, successive UK Governments have focused on individual behaviour change and personal responsibility as the solutions for diet and weight (Savona et al., 2021). Whilst the NCMP is a UK-based programme, the experiences of children classified as overweight or obese that are targeted by anti-obesity initiatives we explore here may provide useful insights for other populations outside the UK. Our findings align with research on weighing children in other contexts showing negative reactions to being weighed amongst children categorised as obese (O’Shea et al., 2014). Furthermore, critical obesity scholars working in countries including the US, Australia and the UK have rejected the centrality of body weight as a potential health issue (Gard, 2011; Rich, 2010, 2011; Rich et al., 2019; Rich & Evans, 2005) and the moral and social imperatives that accompany public health discourses about obesity (Campos et al., 2006; Gard, 2011; Gard & Wright, 2005; Gillborn et al., 2020; Griffin et al., 2021; Wright et al., 2009). These arguments may be reflected in parental resistance to obesity programmes. For instance, parental adoption of alternative futures for their children, as outlined in our findings, may be a manifestation of their efforts to decentralise weight and reject it as a central issue for children’s health in childhood or as the adults they will become.

In line with UK government framings, authors of papers included in this meta-ethnography framed childhood obesity as an issue of parental ignorance or denial, with one study calling this phenomenon ‘obliviobesity’ (Povey et al., 2020). In contrast to this, behaviour change messaging, which constructs future negative health consequences for individual actions and blames (lack of) parental awareness, families may instead want to visualise alternative desirable futures for their children. Health and happiness may be more motivating than ‘doom and gloom’ narratives of cancer, diabetes, and cardiovascular disease (Bai et al., 2016). Additionally, the use of fear-based messaging, disgust, and blame narratives have been problematised as they reinforce stigmatisation and discrimination towards particular, disadvantaged groups (Couch et al., 2018; Lupton, 2015). Warin et al. (2015) have shown that – for those living hard lives – eating can be a way to ‘sweeten the moment’, providing pleasure in the present that are prioritised over imagined difficult timescapes. Where childhood obesity rates are correlated with higher deprivation, this focus on the present and dismissal of dominant public health narratives about future ill health and ‘risk’ may be particularly salient.

A review found that ‘young people with experience of obesity described severe, unrelenting, size-related abuse, and isolation’ (Rees et al., 2011). Alongside experiences of social stigmatisation and discrimination for those categorised as overweight (De Brun et al., 2013, 2014), Rich (2010) has highlighted how obesity-related weight measurement such as the NCMP in schools is inextricably tied to moral understandings of the body and the self in the narratives of young women with eating disorders. Recent research has demonstrated a significant rise in reported weight loss attempts amongst children, including those considered ‘healthy weight’, following the introduction of the NCMP letter in 2010–11 (Ahmad et al., 2022). This scholarship reveals the tensions involved with adapting an epidemiological surveillance tool into a screening programme without long term evidence about the potential consequences of doing so (Lake, 2009; Rich et al., 2011; UK National Screening Committee, 2018). A meta-analysis of the impact of weight-related conversations found that children’s perceptions of being encouraged to lose weight, teasing, or weight-related criticism was associated with poorer self-perceptions, increased dieting, and dysfunctional eating behaviours (F. B. Gillison et al., 2016). Parents face a difficult task of maintaining their child’s self-esteem whilst striving for healthy weight (Andreassen et al., 2013). It is clear from the wider literature that the parental concerns regarding weight-related teasing, dieting, and mental health issues described in this paper are not unfounded. It is therefore understandable that parents would want to protect their child from these experiences in the future.

Alongside future imaginings, in the present, mothers in particular face a non-negotiable moral pressure to place children’s needs first (McCarthy et al., 2000), with managing child weight posing additional moral burdens on parents (Davis et al., 2018). This is particularly salient in the school environment where they are held accountable against a continually evolving set of standards for appropriate or ‘good’ parenting (Harman & Cappellini, 2015). Schools are an increasingly important part of a surveillant ‘obesity assemblage’ which reshapes children’s and their parent’s lives (Rich, 2010). Within this context, resisting the NCMP findings, techniques, or indeed the programme itself, can be understood as a preserve against moral judgement for the parent in the here and now, and harmful outcomes for the child in the future.

Strengths, limitations and reflexivity

A constraint of meta-ethnography is that the findings are inevitably shaped by the quality of the data that is available, published and identified during the search phase. Parents of children from overweight and very overweight categories were more likely to decline participation in the research synthesised in this meta-ethnography (Fleming et al., 2015; Syrad et al., 2015). Additionally, voices from minoritised groups were underrepresented in some studies, with others providing insufficient detail on participant characteristics. This is important in the context of critiques that argue the NCMP centres white bodies and experiences as normative, to the disadvantage of others (Gillborn et al., 2020). Parents in the studies alluded to the inaccuracy of BMI measurements for children from minoritised groups, which has been supported by recent research (Firman et al., 2020). Child maturity also leads to significantly different categorisations for children as girls are more likely to enter puberty earlier (F. Gillison et al., 2017). This may be more impactful for children in year six, who are more likely to be able to read their NCMP letter, and thus find out and discuss their weight categorisation with peers. The use of population level data and research to guide health interventions for individual children has the potential to increase differential stigmatisation for certain groups, and particularly for those children with intersecting identities that are not adequately served by the NCMP.

Across the papers there was an under-utilisation of theory and lack of methodological detail, particularly in relation to sample, author reflexivity and analysis technique. Our search strategy may have missed some papers from other sources, grey literature, or research that was not published in peer reviewed journals. This meta-ethnography was shaped by our research team and the particulars of the papers which it included – which were primarily funded by health or governmental bodies, and some were co-authored by public health practitioners tasked with delivering the NCMP to their local populations. Our meta-ethnography suggests that researchers who are invested in the delivery of the programme may frame narratives about the NCMP in ways that diminish, counter or dismiss concerns from parents and children who take part in their research. Within the wider public health field there is poor evidence for the efficacy of behavioural change interventions for managing childhood obesity (UK National Screening Committee, 2018), with acknowledgement that approaches to tackle upstream determinants on child health may be more ethical and effective for improving child health (Griffin et al., 2021). We found much of the qualitative research on the NCMP fails to address the appropriateness of the NCMP as a screening program, which is not currently recommended for childhood obesity (UK National Screening Committee, 2018). Our meta-ethnography makes plain the value of bringing a more critical lens to the body of existing research that has reported on experiences of the NCMP to date.

As authors, we have differing stakes in the NCMP as a programme. MH is a qualitative researcher with a background in social science and public health and is interested in how families situate and negotiate child weight in their striving towards ‘healthy’ and ‘happy’ lives. DS is a clinical academic focusing on primary care research and CD is an epidemiologist who utilises NCMP data in her quantitative research on childhood obesity. None of the research team have experienced the NCMP on a personal or family level or is involved with the delivery of the programme and can be considered ‘outsiders’ to the NCMP in this respect.

Recommendations and conclusions

Considering the potential harms for particular disadvantaged groups, and the parental concerns about the NCMP discussed in this article, questions can be raised about the future delivery of the NCMP and similar obesity screening programmes for children. Whilst the epidemiological data resulting from the programme can be used to explore upstream determinants on child health, the delivery, individualistic focus and messaging of the NCMP remains problematic. Some papers in this meta-ethnography (F. Gillison et al., 2014; Syrad et al., 2015) argue that it is unethical to measure and weigh children for public health purposes without notifying parents about the outcome, and there is evidence that some parents value this feedback (Bentley et al., 2017). There is a clear need to improve communication of the NCMP results if this is to continue. Beyond this, practitioners and scholars should critically question the appropriateness of continuing the implementation of the NCMP in its current form as both a public health screening and surveillance programme, and our findings should prompt public health scholars in international settings to engage critically with similar child weight screening programmes. As we have shown, the NCMP categorisations have significant emotional and social consequences for children categorised as overweight or very overweight who participate, and their parents. Future research is needed to address whether parental concerns are borne out in the longer term, and to further assess how experience of the NCMP and weight categorisation at primary school age affects children’s relationship, body, and food practices as they grow older. Consideration of how the NCMP acts to disrupt temporalities for participants provides a new lens for evaluating the NCMP in the longer term, to take full account of any social, emotional, and moral harms for participating children and their parents in the future.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/09581596.2023.2169599

Additional information

Funding

Meredith Hawking has received funding through the Economic and Social Research Council (ESRC) LISS DTP, National Institute for Health Research (NIHR) SPCR, and Bart’s Charity (MGU0419). Carol Dezateux receives funding for her research on child obesity from Barts Charity (MGU0419) and the UK Prevention Research Partnership, an initiative funded by UK Research and Innovation Councils, the Department of Health and Social Care (England) and the UK devolved administrations, and leading health research charities (grant reference MR/S037527/). Deborah Swinglehurst is funded by the NIHR through a Clinician Scientist Award CS-2015-15-004 (DS).