Obesity and young people: Are we listening?
Our health decisions are largely determined by the environments in which we live and the resources and information we have available. The World Health Organization has highlighted the importance of the social determinants1 and the commercial determinants2 of health which raise significant implications for the drivers of the high levels of obesity now seen in the general population.3 However, little is known about the relevance of these general drivers of obesity to young people whose experiences of the world are very different to those of older generations.
The present supplement reports some of the findings of the EU-supported Co-Create project (Confronting obesity: Co-creating policy with youth),4 which started from the premise that young people should be involved in shaping obesity prevention policies. In the process of bringing young people together and developing methods for assessing their views, it became clear that researchers were in many ways “too old” to fully comprehend the world experienced by modern youth. As one adolescent said, “You ask me about access to green spaces, but I don't live there. I live online.”
Alongside the rapid expansion of social media technologies and their uptake by school-age children has come increasing concern about the mental health implications of this new social environment. Adolescents' social media peers and popular online influencers provide opportunities for selective or distorted information to spread rapidly, without filters or context, and this has exposed young people to potentially harmful material, capable of exacerbating anxiety, stigma, eating disorders, depression and suicidal behaviour.5-7
There is growing evidence of an association between obesity and an increased risk of psychological ill-health including depression and anxiety.3 The relationship can be found in adolescence8 and appears to be bi-directional9 with longitudinal surveys indicating that stress and depression can raise subsequent obesity risk, while individuals living with obesity may develop mental distress alongside social stigma and discrimination. Understanding how these factors interplay can help prevent obesity as well as improving the wellbeing of young people living with obesity. Intervening at an early stage is clearly preferable and, given the high levels of overweight among children10 and adolescents11 in the European region, it is important to understand what policies might effectively prevent young people's excessive weight gain and also maintain their good mental health.
This is where the Co-Create project is relevant. The project was a multicountry research programme involving academic institutions, governmental bodies and civil society organizations, which aimed to develop tools for encouraging youth participation in forming policies to tackle obesity.12 The original design of the project did not anticipate the results, but instead it allowed the priorities expressed by young people to emerge during the stages of the programme of research. It should be acknowledged that a research project funded from public resources, which did not have a clear empirical objective but which left the agents in the process to discover the outcomes is clearly unusual, and the European Commission's reviewing process for grant-aided research should be acknowledged for taking the risk that this implies.
The results are worthwhile. The tools developed are able to generate a level of ‘co-creation’ with young people to understand their experience of obesity, the triggers for weight gain, and their perceived solutions, while providing for young people the platform they need to arrive at new and unexpected expressions of their views and priorities. What became clear was that high among the priorities expressed by young people is a concern for their own mental health, and that they are aware of the influence of social media, the problems of bullying and stigma, and that policies to prevent obesity needed to take these into account while also being sensitive to health and social inequalities.13-15 Researchers need to take care that they consider their own assumptions, experiences, and age perspectives when working with young people and ensure that young people can express themselves objectively (e.g., using tools such as group model building and Photovoice14).
For young people, the issue of obesity is embedded in a wider context concerning their peer groups, their body image, self-confidence, and self-determination, and these in turn are shaped by media influences and role models, some of which are promoted by commercial interests from clothing and cosmetics to music and sports. As a teenager develops into an adult, avoiding obesity is unlikely to be the highest priority as they strive to maintain day-to-day functioning and competence and form their social identity while trying to remain free of anxiety from peer pressure, to avoid withdrawal and depression, and cope with their post-pubescent developing physiology. Additionally, if an adolescent is living with obesity, weight loss will be only one of many issues they need to deal with, including social exclusion, discrimination, bullying (including online bullying), media-reinforced stigma and internalized self-hatred.16, 17
The most recent Health Behaviour of School-Children survey18 conducted before the COVID-19 pandemic found a rise in the prevalence of overweight and obesity among children 11–15 years old compared with earlier surveys, along with a low level of participation in physical activity, and a decline in mental well-being among adolescents in many of the countries surveyed, especially among girls. It is anticipated that the COVID-19 pandemic may have increased the risk of overweight in adolescents, reduced their physical activity levels and led to a deterioration in their levels of mental well-being19, 20 while WHO21 noted in 2022 “the impact of COVID-19 on mental health and suicidal behaviour, particularly in specific vulnerable groups and for a broader range of mental health outcomes (e.g., eating disorders, ….)” (p. 6).
Sadly, the interaction between body weight and mental health in young people, which is acutely perceived by the young people themselves, is not reflected in the policy literature. Neither the 2016 conference report European Framework for Action on Mental Health and Wellbeing22 nor the 2017 report Joint Action on Mental Health and Well-being23 mention obesity or overweight or body image. Nor does the WHO European region's WHO European framework for action on mental health 2021–2025,24 although this document makes clear the importance of building mental health resilience among young people and urges the development and dissemination of mental health literacy and social–emotional learning programs for children and adolescents.
According to the Joint Action report,23 “Mental disorders affect 10% of children and adolescents in Europe with a much larger proportion experiencing sub-threshold mental disorder” (p. 94). The report notes “Mental disorders during childhood and adolescence are associated with increased risk of a range of adverse outcomes, which include poor educational outcomes, as well as adulthood adverse outcomes, such as low earnings, unemployment … marital problems … and physical illness” (p. 50). This list overlaps considerably with the prognosis for a young person living with obesity.
The Co-Create project has shown that the lives of young people can be blighted by poor mental health and by weight gain. Efforts by policy makers and policy advocates to tackle obesity in adolescence need to take account of the social and psychological context experienced by young people and strengthen their physical health and their psychological resilience. It means understanding the drivers of weight gain and the drivers of mental distress, as experienced by young people. It means finding the right policies to protect the health of the next generation of adult citizens. This is what young people need, and which they themselves are telling us.
