Being the “fat kid” in school is a very physical experience: whether it’s your fellow pupils teasing you or the adults stressing about your size, the attention you receive is all about what you look like. The psychological side of your situation - ie, the fact that you actually have feelings - is often forgotten.

The focus from adults on physiological factors is understandable: faced with an overweight individual, it is intuitive to concentrate on physical health and improving it through physical interventions - exercise and diet being chief among them. But the experience of being an obese child should be viewed differently; particularly in schools, we need to be much more aware of the psychological impact and how to support young people with that.

The scale of the psychological challenges are huge. “There’s a lot of research that suggests kids with obesity are more likely to have mental health problems than other children…there are clear psychological consequences and long-term health effects of living with obesity as a child,” explains Eric Robinson, reader in psychological sciences at the University of Liverpool, who has researched eating behaviour and obesity.

Indeed, a review of 53 pieces of research in 2016 (bit.ly/ObesityPsychology) found that, in general, childhood obesity was “negatively associated with psychological comorbidities such as depression, poorer perceived health-related quality of life, emotional and behavioural disorders, and self-esteem during childhood”.

Do these negative psychological effects result from being obese or do they instigate behaviours that can cause obesity? We don’t actually know, says co-author of the above review, Jean Rankin, from the University of the West of Scotland. She stresses that it remains “unclear as to whether psychiatric disorders and psychological problems are a cause or a consequence of childhood obesity”.

Knock-on effect

What we do know is that being obese can exacerbate mental health issues because of the behaviour it attracts from others.

“There’s evidence which shows that kids with obesity are more likely to be bullied and victimised by peers,” she says. “As you might imagine, when that happens it’s associated with worrying outcomes, such as increased risk of mental health difficulties, suicidal thoughts, unhealthy coping strategies, eating disorders and drug/alcohol misuse.”

Predictably, this has a knock-on effect on academic attainment. One US study (bit.ly/Weight-basedTeasing) that looked at the effect of weight-related bullying on academic performance found that it explained much of the association between higher weights and lower achievement.

What does not help is that teachers might underestimate overweight or obese children because of prejudice about the kinds of student who are obese. Studies in the US (bit.ly/ObeseStudentGrades) show that those classed as “obese” tend to be awarded lower grades than their peers in upper primary, secondary and tertiary education, despite no differences in intelligence or scores in standardised tests of maths and English.

In the UK, meanwhile, the Avon Longitudinal Study of Parents and Children followed nearly 6,000 children in the South West of England and found that higher body weight at age 11 in girls predicted lower scores on standardised tests at age 11, 13 and 16. The decline was not explained by lower IQs or mental health, but the study was inconclusive as to the actual causes (bit.ly/ObesityAttainment).

So the research paints a somewhat bleak picture of overweight and obese children suffering in multiple ways - from prejudice, bullying and the knock-on effects on mental health, perceived and actual quality of life, and grades.

It’s a fate that also disproportionately affects the already disadvantaged, says Max Davie, officer for health improvement at the Royal College of Paediatrics and Child Health. “The thing about obese children is they are already likely to be disadvantaged,” he states. “What’s more and more clear about the pattern of obesity from an epidemiological perspective is that it is increasingly a disease of the less well off.

“I think it has become almost subconsciously or culturally associated with being poor, low income, less educated, so therefore if you are obese, that is how you are almost routinely seen. So you already have children who are already feeling a little inferior to their peers and who are now obese. [And] obesity is one of the only medical conditions where you have overt blaming either of the young person themself or their family, by peers and society, and the guilt and shame of obesity is really strong.”

There’s also the fact that a “disproportionate number” of children with special educational needs are obese, adds Davie. “You have a group of children who are, by association, disadvantaged in multiple ways, who are also blamed for their own disadvantage,” he says.

So how do we shift the narrative? And how do we ensure that the psychological impact of being obese is treated as much as the physical symptoms? Perhaps obesity itself should be seen as a special educational need, suggests Davie. “We have children who have physical limitations but actually the thing that’s getting in the way of their education is the behavioural and emotional consequences of that original disability, and that’s a special educational need,” he says.

Certainly, classing obesity in this way would help schools to view the child with less blame attached to them or their families. It would also push forward a more holistic view of the issue, and potentially pave the way for support structures to be put in place for academic and psychological challenges, as well as the physical ones.

But all this has to be done sensitively, says Davie: “It’s really, really difficult because if you single them out, it’s going to increase their self-consciousness.”

Teachers, check your biases

Davie adds that teachers also have to be aware of their own psychological reaction to obese and overweight children. Staff should “constantly, as professionals, check our implicit biases” in the same way they would with race, gender or social class, he insists.

As for the treatment of these children by other pupils, he says schools are usually excellent at policing overt discrimination.

“I think schools are generally very good on overt bullying: they will not allow people to be called ‘fatty’ and laughed at,” he says.

However, it is much more difficult to police less overt forms of prejudice such as social exclusion, snide comments and the little jokes made in class that everyone laughs at.

“Those sort of little things do chip away at the self-esteem of people,” says Davie. “In the children I see, the obesity is an additional vulnerability to their social interactions…It puts you in a disadvantaged and ostracised category, and then it puts obstacles in the way of your success and getting out of that category. It’s then extremely hard to be an overweight or obese child even in a school that is trying its best.”

Alone, there is not much a school can do to tackle this: the prejudice of the wider community leaks into the playground, no matter how much PSHE you put behind it, he says. “It’s so much about society - the way we see obesity - and also the condition itself mitigates against these children and makes things miserable for them,” adds Davie.

Ultimately, much of what can be done to help a child who is overweight is not something a school should tackle alone. Davie says the best advice he can give is to refer to experts from outside wherever possible. “The best thing that schools can do is to facilitate referral to whatever services are available locally,” he urges.

But, unfortunately, as every teacher will tell you, access to external services is not always as simple as it should be.

Irena Barker is a freelance journalist

This article originally appeared in the 6 November 2020 issue under the headline “Tes focus on… obese children and mental health”