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Abstract
Background Despite parental concern, few studies have investigated children’s experiences with school-based screening of growth deviations. This study aimed to explore perceptions of height and weight screening and associations with body size dissatisfaction (BSD) among third-grade children aged 8–9 years in central Norway.
Methods In a cross-sectional study between November 2021 and April 2022, perceptions of height and weight screening and BSD were assessed individually among 209 children (49% girls) through researcher-assisted interviews.
Results Most children indicated satisfaction with the screening by selecting a happy emoji, whereas only 1% indicated dissatisfaction, by selecting an unhappy emoji. However, 23%–30% selected a neutral emoji, indicating either neutrality or a response between satisfaction and dissatisfaction. No difference in the perception of height and weight screening was found between genders or body mass index (BMI). Children with parents from non-Western countries had a higher risk of being less satisfied with the height screening (OR=3.0, 95% CI 1.2 to 7.3) than those from Western origin, and children attending schools with lower socioeconomic status (SES) had increased risk of being less satisfied with both height (OR=5.5, 95% CI 2.2 to 13.5) and weight screening (OR=4.0, 95% CI 1.7 to 9.3), compared with children from schools with medium-high SES. Twenty-three percent reported BSD, in which 14% and 9% desired a thinner or larger body, respectively, independent of gender and BMI. No association was found between BSD and the perception of weighing (OR=1.1, 95% CI 0.6 to 2.4), however, BSD was associated with being more satisfied with height screening (OR=0.3, 95% CI 0.1 to 0.8).
Conclusion In the present sample, most children indicated satisfaction with school-based height and weight screening, with no differences between gender or BMI category. However, more children of non-Western origin and from areas with low SES reported less satisfaction with the screening, independent of BSD.
- growth
- obesity
- psychology
- health services research
Data availability statement
The complete data set will be placed in a depository after all the planned articles are being published. Until then, all the data files are available on reasonable request. Some data relevant to the present study are being uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Parents’ perceptions of school-based body mass index screening programmes have previously been addressed; however, few studies have investigated children’s perceptions of the screening.
Negative body image has been reported across several countries and within different contexts; however, few studies have explored its impact on the perception of height and weight screening among European early primary school children.
WHAT THIS STUDY ADDS
Young children are willing to and capable of sharing their perspectives about height and weight screening and their body image.
In the present sample, most children reported satisfaction with school-based height and weight screening when implemented in a health-promoting context; however, children’s perspectives may differ from their parents, indicating the importance of including children’s perspectives when designing their healthcare services.
Satisfaction with height and weight screening was unrelated to children’s weight categories and body size dissatisfaction among children aged 8–9 years in central Norway.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Future school health programmes should acknowledge children’s perceptions of height and weight measurements, focusing on reducing discomfort with their height and weight, particularly among vulnerable children from other ethnicities and low-income families.
Introduction
Measuring height and weight velocity during childhood is a cornerstone in child health screening programmes, to detect growth deviations and chronic disorders.1 2 As the global increase in paediatric overweight and obesity has become a public health concern, increased efforts have been called for to prevent and treat overweight and obesity.1 School-based height and weight screening programmes have thus been adopted, with variation in terms of implementation and health professionals’ engagement in the screening, and guidance to families.3 4 Parallel to the rise in paediatric obesity and increased pressure towards thin and muscular body ideals among children and adolescents,5 6 concerns about the psychosocial consequences of school-based height and weight screening programmes have emerged,4 7 8 particularly regarding weight-based stigmatisation and its suggested negative association with body image and self-esteem.9
Body size dissatisfaction (BSD), estimated as the discrepancy between perceived current and ideal body size, is a common measure of negative body image, and a potent risk factor for eating disorders among children and adolescents.10 11 Children as young as 3–5 years have indicated BSD,12 with increasing rates towards adolescence.13 Furthermore, BSD is reported more frequently among girls and children with overweight or obesity,6 14 15 with increasing rates reported among boys,16 however, its association with gender, social class, ethnicity and residence6 17 is not fully understood. The reported prevalence of BSD among primary school children (22%–75%) is inconsistent, with variations across countries,13 study samples and the use of different methodologies.6 Although visual methods using body silhouette scales tend to report higher rates of body dissatisfaction than verbal methods, they are considered a reliable and valid method to assess body image in children aged 8 years.6
Despite concerns about the potential harmful effects of height and weight screening, young children’s perspectives are poorly investigated.18 In medical research, young children’s opinions are typically conveyed through adults’ perspectives, often due to concerns about children’s cognitive abilities, powers of communication and ethical difficulties.19 Thus, only a few studies have assessed children’s perspectives of school-based height and weight screening.7 20–25 Existing studies have reported 4%–36% discomfort with screening, particularly among children from higher body mass index (BMI) categories, whereas children with average weight indicated neutral or satisfied responses.7 Variations in children’s perceptions of height and weight screening may be further related to differences in socioeconomic status (SES), ethnicity and body image.17
To our knowledge, only two studies have investigated children’s perceptions of height and weight screening and body image.20 25 A study from 2008 reported no negative association between height and weight screening and body esteem,20 whereas a more recent prospective study indicated a greater increase in weight dissatisfaction among children from schools with height and weight screening programmes, compared with children from schools without this screening.26 Hence, this study aimed to explore perceptions of height and weight screening and its associations with body image in a diverse sample of Norwegian early primary school children, by using validated and child-friendly visual methods.27 We hypothesised that children with BSD would experience less satisfaction with the height and weight screening than children without BSD.
Methods
This cross-sectional study was performed as part of the Norwegian height and weight screening programme,28 where school-based measurements are strongly recommended at grade 1 (5–6 years), grade 3 (8–9 years) and grade 8 (13–14 years). In central Norway, the screening is part of a ‘Healthy Lifestyle Day’, focusing on health promotion. Parents can opt out their child from the screening, and height and weight deviations are communicated to parents, verbally or in a letter, with appropriate referrals for medical examination provided.29 This study was limited to the children’s perceptions of height and weight screening, with no data on the weight feedback.
Procedure
Among 56 eligible primary schools in central Norway, 22 were positive, and 8 schools with a scheduled height and weight screening between November 2021 and April 2022 were included (figure 1). The child’s height and weight were measured according to national guidelines,28 in a private room by trained school health nurses, wearing light clothing and no shoes, using medically approved height stadiometers and digital weights. Immediately after being screened, two experienced researchers interviewed the children individually, to assess their perceptions of the screening procedure and BSD (online supplemental table S1).
Supplemental material
Flow chart for the inclusion of schools and participants. All 56 schools from the municipalities of Trondheim (n=51) and Malvik (n=5) were eligible for inclusion. After 2 reminders, 22 schools agreed and 6 disagreed to participate, and 28 schools did not respond. Eight schools were selected for inclusion, with parental consent being obtained from 67% of the 310 eligible children. Two parents opted their children out of the screening, 11 children were absent on the measurement day and 4 had missing data, resulting in 209 participants.
Participants
Initial parameters were set to include children with different SES and ethnicities and from both urban and rural areas. Age, BMI and ethnicity were registered by the school health nurse. The average student participation rate was 67%, including 209 third-grade children (49% girls) aged 7.9–9.3 years, of which 16.3% were categorised with overweight and 1.4% with obesity. Demographic and anthropometric characteristics for participants and non-participants (n=84) were similar, except for more children of non-Western origin among non-participants (table 1).
Anthropometric and demographic characteristics of participants and non-participants
Measures
Anthropometry
BMI was calculated as weight/height2 (kg/m2) and converted to SD scores using the Norwegian BMI references for children.30 Weight categories were estimated according to the International Obesity Task Force age-specific and gender-specific cut-offs for BMI (IsoBMI): underweight (IsoBMI<18.5), healthy weight (18.5≤IsoBMI<25), overweight (25≤IsoBMI<30) or obesity (IsoBMI≥30).31 Children with obesity (n=3) were merged with the overweight category.
Demographics
Ethnicity was dichotomised, and children having at least one parent born in a non-Western country were described as ‘non-Western’.32 Socioeconomic status (SES) was defined by the proportion of children in persistently low-income households in the child’s school region,33 and categorised as low, medium or high. Medium and high SES were collapsed in the statistical analyses. Two schools were in ‘rural’ areas and the remaining six were ‘urban’ schools.
Evaluation of height and weight screening
Each child was instructed to express their perception of being screened for (1) height and (2) weight verbally, using a 3-point Likert-type scale supported by three emojis,34 followed by an explanation for their choice of emoji (online supplemental table S2). The unhappy emoji was described as ‘Don’t like’, the happy emoji was described as ‘Like’, and the neutral emoji was described as ‘Neither like nor dislike or something in between’.
Body size dissatisfaction
BSD was assessed using a visual and child-friendly method described by Birbeck and Drummond.18 Each child was presented with a series of nine validated35 body silhouettes of same gender, hair colour and equal height, ranging from underweight to severe obesity (figure 2). The body silhouettes were based on figure rating scales for adults by Stunkard et al,36 adapted to children aged 9–10 years by Tiggemann and Pennington.37 Each silhouette was presented on separate A4 sheets, randomly, with the numbers hidden on the backside to avoid potential bias.18 38 The children were asked to identify the body silhouette that looked most like themselves (current), and the one they would like to have (ideal). To minimise response bias, participants were informed about the option to choose identical figures for both current and ideal body size, with those selecting the same figures categorized as satisfied with their body size.
Children’s perceived current and ideal body size figures are presented as percentages (%) for girls and boys, separately, across the nine different figure silhouettes. The figure silhouettes are used with permission by Dr Tiggemann.
The degree of BSD was calculated as the difference between current and ideal body silhouette ratings, with positive scores indicating a desire to be thinner, and negative scores indicating a desire to be larger, according to validated measures of body image.35 38 39
Statistical analysis
Data were analysed using IBM SPSS (V.29). Numbers and percentages were calculated for the categorical variables, and mean and SD for continuous variables. Because few children chose the unhappy emoji (n=4), it was merged with the neutral emoji, with subsequent dichotomisation of children’s perceptions into ‘satisfied’ or ‘neutral/less satisfied’. Participant and non-participant disparities were assessed using the χ2 test for categorical data and the Mann-Whitney U test for continuous data. Binary logistic regression models were used to assess the unadjusted associations between the children’s perceptions of height and weight screening, and BSD (model 1). A priori confounders were added stepwise in the analyses, adjusted for gender/height z-score/BMI z-score (model 2), and SES/ethnicity/rurality (model 3), to show their separate effects on the primary outcome (table 2). Based on estimated rates of 30% BSD, with a predetermined margin of error of 0.05 and a desired statistical power of 80%, a sample size of 134 participants was considered adequate for dichotomous outcome assessment of BSD. The Strengthening the Reporting of Observational Studies in Epidemiology cross-sectional reporting guidelines were used.40
Logistic regression analysis for the association between body size dissatisfaction and children's perceptions of being neutral or less than satisfied with the height and weight screening.
Results
Perceptions of height and weight screening
Most children selected the happy emoji, indicating satisfaction with the screening and only 1% selected the unhappy face, indicating dissatisfaction. Furthermore, 24%–30% selected the neutral emoji, indicating neutrality and perceptions between satisfaction and dissatisfaction (figure 3). Neither gender, height nor BMI were associated with children’s perceptions of the screening, however, children with parents from a non-Western country had threefold increased odds of being neutral/less satisfied with the height screening (OR=3.0, 95% CI 1.2 to 7.3), compared with those with parents born in a Western country. Furthermore, children attending schools with lower SES had more than fourfold increased odds of being neutral/less satisfied with both the height (OR=5.5, 95% CI 2.2 to 13.5) and the weight screening (OR=4.01, 95% CI 1.7 to 9.3), compared with children from schools with medium-high SES (table 2).
Children’s perceptions of height and weight screening.
Body size dissatisfaction
Twenty-three percent of the children indicated a desire for another body size than their perceived current one, with 14% wanting a thinner and 9% wanting a larger body size. No differences in BSD were reported across gender, BMI or demographics (table 3). Silhouette number 4 (healthy weight) was the most frequently selected number for both current (51%) and ideal (49%) body size (figure 2). The discrepancy between current and ideal body size varied from −5 to +4, with 7% reporting more than one deviation from ideal body size.
Body size dissatisfaction according to gender, BMI and demographics
BSD was unassociated with the perception of weighing (OR=1.1, 95% CI 0.6 to 2.4), but associated with neutrality/less dissatisfaction with the height screening (OR=0.3, 95% CI 0.1 to 0.8), compared with those with no BSD (table 2).
Discussion
In this study, a substantial number of third-grade children from central Norway reported satisfaction with being screened for height and weight. However, less satisfaction was observed among children from areas of low SES and non-Western origin. Furthermore, BSD was not associated with less satisfaction with height and weight screening.
The high prevalence of young children indicating satisfaction with the height and weight screening was in line with one study21 and different from others.20 23 24 The inconsistent rates of discomfort with school-based height and weight screening reported by children might be explained by variations in study samples, the context of screening and the different classifications being used to assess the degree of discomfort.20 23 24 However, in contrast with other studies,6 14 23 24 no association between BMI and perception of the screening was observed, suggesting that other unmeasured factors than overweight status may predict dissatisfaction with the screening. Nevertheless, as previous studies have indicated increased discomfort with height and weight screening among children with weight issues or from higher BMI categories,20 24 41 the few children with obesity in our sample may have affected the results.
Furthermore, major contextual variations of height and weight screenings are described in these studies, and the high degree of privacy, access to a trained health nurse and the context of ‘health promotion’ in our study may have had a positive effect on the children’s perceptions. Thus, we cannot disregard the possibility that BMI sensitivity to the screening programme may be context-dependent.
Notably, children of non-Western origin and those attending schools with low SES reported less satisfaction with the screening than their fellow students, which may be of particular concern due to their additional increased risk of obesity.1 However, the role of ethnicity and SES in children’s perceptions of height and weight screening needs to be further explored.
Our results confirmed that BSD was prevalent among 8–9 year olds of both genders, however, the similar prevalence of BSD across BMI categories and demographic variables contrasted with previous studies. Hence, BSD may have become a ‘normative discontent’ affecting all children, possibly influenced by the strong and increasing pressure in society towards certain body shapes.6 The prevalence rate found in our sample (23%) was lower than the average rates found in comparable studies (50%),6 but in line with some European countries in an international survey of those aged 11 years.13 Importantly, variations in study samples and the wide variety of methods applied in the assessment of BSD may explain the inconsistency.6
During the second out of three national height and weight screenings at the participating schools, children with BSD did not report reduced satisfaction with the screening process. Our findings align with a study of UK children, indicating that body esteem was unchanged or improved following the implementation of a new BMI screening programme.21 However, our findings contrast with the results from a large prospective study of US children, where schools randomised to perform BMI screening seemed to increase BSD compared with those not randomised to screening.25 This indication of a causal relationship between BMI screening and subsequent BSD reflects, however, screening programmes with little privacy and limited access to healthcare professionals.24 25
Finally, we observed an unexpected association between BSD and less dissatisfaction with height screening, emphasising that height and weight screening experiences should be recorded separately. However, whether this is a spurious association must be confirmed by future studies.
This study has some limitations. First, the cross-sectional design did not allow us to estimate potential long-term associations between perceptions of height and weight screening and BSD. Second, the limited sample could not explore subgroups with obesity or compare different age groups. Third, the children were not asked directly about BSD, and we cannot exclude the possibility of false positive responses. Finally, despite efforts to include children from other ethnicities, the proportion of children from non-Western countries was higher among non-participants, however in line with regional rates. The generalisability of this study is limited to central Norway.
School-based height and weight screenings may have important practical implications for children’s health. As negative experiences with screening programmes may impede the recruitment of families to guidance programmes targeting obesity, vulnerable children should experience a low degree of discomfort, to secure their access to necessary healthcare. Whether screening programmes increase the risk of future BSD needs to be studied prospectively, considering the programme context and children’s perspectives.
Conclusions
Positive perceptions of height and weight screening were frequently reported in this diverse sample of school children aged 8–9 years from central Norway. Children with non-Western backgrounds and from areas with low SES reported less satisfaction with the screening, however, perceptions of screening were not affected by children’s weight category or body size dissatisfaction.
Data availability statement
The complete data set will be placed in a depository after all the planned articles are being published. Until then, all the data files are available on reasonable request. Some data relevant to the present study are being uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
The study was approved by the Regional Committees for Medical and Health Research Ethics of Mid-Norway in 2021 (no. 244609). Assent and consent were obtained from the child in class and by both parents, either written or digitally, before inclusion.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors TLD, RAØ, TTE-N and EMIE were responsible for the study design and planning of this study. TLD had the main responsibility for data collection, data analysis, interpretation of the data, generation of figures and writing the article. RAØ was responsible for the overall content as a guarantor and contributed to the data collection together with TTE-N. CAK was responsible for the choice of statistical methods and assisted with the analysis and interpretation of the data. All authors were involved in writing the paper and had final approval of the submitted and published versions.
Funding This study was supported by a grant from The Norwegian Women’s Public Health Association (Norske Kvinners Sanitetsforening) and the Liaison committee between the Central Norway Health Authority (RHA) and the Norwegian University of Science and Technology (NTNU) (grant number: 40406).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.