Changing the perfect picture: an inquiry into body image Contents

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3How can we stop negative body image affecting our mental and physical health?

21.Poor body image is associated with weight-based health problems such as eating disorders and obesity, as well as mental health problems including anxiety and depression.52 The GEO wrote to us and acknowledged that poor body image can lead to anxiety, depression and eating disorders, citing research found that over a third of 13–19 year olds have stopped eating or have restricted their diets as a result of low body image.53

22.The Committee also received evidence that mental health conditions such as Body Dysmorphic Disorder (BDD) and Muscle Dysmorphia - in which an individual is consistently preoccupied with imperfections in their appearance/muscularity - appear to be increasing rapidly among young men.54 The NHS estimates that around 1% of people under the age of nineteen suffer with BDD.55

Eating Disorders

23.Beat, the eating disorder charity, estimates that 1.25 million people across the UK have an eating disorder, with one quarter of sufferers likely to be male.56 They also told us recent research suggests that prevalence in middle aged and older people may be much higher than previously assumed.57 Eating disorders are severe mental illnesses; Anorexia nervosa has the highest mortality rate of any mental health condition, and the mortality rates of bulimia nervosa, binge eating disorder and other eating disorders are also high. People with eating disorders typically develop serious physical health problems through starvation, bingeing, purging or overexercise. An eating disorder can often exacerbate symptoms associated with other mental health conditions including anxiety, depression, and OCD.58

24.Beat states that young women are most likely to develop an eating disorder, particularly those aged 12 to 20.59 Research also indicates that anorexia rates have doubled for pre-teen children in the last 10 years.60 The Children’s Society informed us that eating disorders are rising along with rising poor body image. Over 19,000 people were hospitalised for an eating disorder in 2018/19, a quarter of whom were under 18. There has also been a 50% increase in children accessing services for eating disorders since 2016/17.61 We also heard that older women who suffer with eating disorders don’t benefit from increased health spending targeted at young people and face a slower wait for diagnosis and treatment.62

25.The number of hospital admissions for eating disorders is rising at a faster rate among people from ethnic minorities in England than among white ethnicities. For white ethnicities, hospital admissions for eating disorders rose by under a third (31%) across three years, whereas admissions among ethnic minorities rose by more than a half (53%). Hospital admissions for white ethnicities, however, remain higher having increased from 13,340 in 2017–18 to 17,467 in 2019–20 but the rise is more pronounced for ethnic minorities where there was a steeper increase from 1,115 admissions in 2017–18 to 1,702 admissions in 2019–20.63

26.The GEO informed the Committee that the Government is “expanding and transforming” mental health services for adults, children and young people in England and are investing record levels in mental health with the NHS Long Term Plan set to increase funding further by at least £2.3 billion a year by 2023/24. Along with this, they are implementing waiting time access standards to ensure that more people can receive treatment and care when they need it.64

27.YoungMinds informed us that there has been a significant increase in the resources provided to children and young people’s eating disorder services in recent years. Notably, in 2014 the Government announced an additional £30 million in recurrent funding over five years to improve support, care and treatment options for children and young people through community eating disorder teams. Additionally, they welcomed the commitment in the NHS Long Term Plan to continue the investment in community provision for children and young people’s eating disorder services.65

28.However, some respondents to our body image survey remarked that they had struggled to get help for their eating disorder or disordered eating:

Mental health services are woefully underfunded and inadequate in their entirety, not least CAMHS and eating disorder therapy. Support for compulsive overeating is effectively non-existent and medical professionals are largely dismissive of those self-presenting with disordered eating of all types unless an individual is officially dangerously underweight.66

Impact of the COVID 19 Pandemic

29.Our survey reported that 53% of adults and 58% of children found the (first) lockdown made them feel worse or much worse about their appearance.67 YoungMinds found that 26% of young people who were accessing mental health support from NHS, private providers, school counsellors, charities and helplines before the pandemic were no longer able to access any support. In some cases, this was due to services being withdrawn; in others, young people felt unable to access remote support or face practical barriers to doing so. Additionally, there is emerging evidence of a reduction in new referrals to Child and Adolescent Mental Health Services and its expected that there will be an increase in the demand for young people’s mental health services as we recover from the pandemic.68 Beat reported a 173% increase in demand for support between February 2020 and January 2021.69

30.The Government informed us it is aware of two groups of people which have been adversely affected by the pandemic: young women aged 15 to 26, manifesting eating disorders, and people with pre-existing mental health conditions. In response to this, the Government told us it has provided an extra £10.2 million in additional funding to charities such as Beat , to help it increase the number of calls it can receive on its helplines during the pandemic, and has established a further 18 eating disorder in-patient units.70 When we questioned the Government on claims that there has been difficulty accessing support for mental health conditions including eating disorders during the pandemic, Minister Dorries told us that no mental health services have ceased as a result of the pandemic; in fact, they have increased as 24-hour, seven-days-a-week crisis helplines across the UK for mental health patients were established, as were digital Child and Adolescent Mental Health Services (CAMHS).71

Early intervention

31.Experts from organisations such as Beat, YoungMinds and the Royal College of Psychiatrists have called on the Government to promote early intervention in the development of eating disorders as accessing early support can prevent problems from escalating, meaning young people are more likely to fully recover.72 They request the Government make prevention and early intervention a priority for every child struggling with their mental health, to ensure that they get help as soon as they need it.73 PwC, in research commissioned by Beat, found that the estimated cost to society of eating disorders is c. £15 billion per annum and that early intervention can pay massive dividends given the high relapse rates.74 Analysis by the charity MQ found that just £9 per person affected is spent by UK-based funders on mental health research per year, with eating disorder research receiving just 96p per person affected. Although mental ill health accounts for approximately 23% of NHS activity, the National Institute for Health Research (NIHR) awarded just 10% of its research funding to mental health research in 2018/2019 (0.09% of its health research budget).75 More recent research from the International Alliance of Mental Health Research Funders shows mental health research funding in the UK by specific mental health conditions is as follows:76

32.We questioned the Government on its plans to specifically increase funding for research, preventive, and early intervention strategies. We were informed that it is constantly reviewing where the evidence gaps are and what research is needed but couldn’t confirm what and if any action will be taken.77 The Government also drew attention to its early intervention policy which includes a mental health taskforce in schools to give children strategies to manage their mental health and also to train staff to identify those at risk of developing eating disorders and other mental health conditions.78

BMI and weight-based discrimination

33.There are clear associations between weight stigma and poor mental health. AnyBody told us that weight stigma is endemic within health-care settings. A ‘routine’ procedure such as being asked to stand on scales within the GP surgery can have unseen consequences for those already struggling with marginalisation. Health professionals are not equipped to take a nuanced patient-centred approach to wellness, which can lead to serious medical issues being disregarded as simply the patient being “overweight”.79 Respondents to our survey, particularly people with disabilities, agreed with AnyBody’s view and told us they are anxious about visiting the doctor and feel ‘shamed’ into trying to lose weight which is often a result of a medical condition.80

34.People with a higher BMI told the Committee that they felt it was difficult to access quality healthcare as health complaints were automatically diagnosed as weight-related and not properly investigated:

I’ve never recovered from a GP telling me they could see how overweight I was just from me sitting in front of them (she then pointed at my arms and made a hefty gesture). I was 8lbs overweight and just 22 years old. This was 10 years ago, and I’ve never been to the GP since. (Woman 25–34)

It is from the medical community that I feel most shamed for my size 16–18 figure. BMI should be abandoned as a measure and all GPs and health professionals should receive training on Health At Every Size. (Woman 35–44)81

35.Throughout our inquiry, we heard criticism of the use of BMI as a measure of health. Dr Solmi of UCL University College London (UCL) told us that BMI is a very poor proxy of health for several reasons and focusing solely on BMI can be misguided as two people with the same BMI can have very different physical and mental health. She told us health measurement that focuses solely on BMI as a measure of health will lead potentially to more harm than good.82 It has been widely reported that historically BMI was established as a measure of health for populations rather than individuals, and was based on studies of European men. It has been argued that BMI does not give an accurate portrayal of health, particularly for BAME groups and women.83

36.Anybody places emphasis on the ‘Health At Every Size’ (HAES) approach as a more effective means to prevent weight based discrimination and an overreliance on BMI.84 The Health at Every Size approach involves treating patients whilst honouring differences in size, age, race, ethnicity, gender, dis/ability, sexual orientation, religion, class, and other human attributes.85

37.We questioned the Government on weight and appearance-based discrimination and the overreliance on BMI. Minister Dorries acknowledged that shaming people into losing weight or eating a healthy diet is unlikely to be effective and medical professionals do not receive enough training on promoting positive body image.86 We also asked the Government if it has any plans to review the use of BMI, and we were informed that BMI is something that the Government is constantly discussing and reviewing, and that information changes will lead to policy changes. There was an awareness that doctors, and particularly GPs, have an over-reliance on BMI, particularly when diagnosing eating disorders. The Minister acknowledged there was ‘good and bad’ in the use of BMI but they need it to gauge whether a person is a healthy weight or not.87

The Obesity Strategy

38.In July 2020, the Government’s Obesity Strategy was published to tackle obesity and help adults and children to live healthier lives.88 The Committee received numerous submissions criticising public health campaigns around obesity.89 The Mental Health Foundation said that public campaigns on nutrition and obesity should avoid the potential to create stigma and indirectly contribute to appearance-based personal dissatisfaction, mental health problems and bullying. They should instead focus on healthy eating and exercise for all members of the population, regardless of their weight.90 Similarly, the Centre for Appearance Research told us that anti-obesity language and campaigning are stigmatising and weight-focused public health initiatives risk perpetuating weight stigma, disordered eating, and health inequalities, by focusing on weight as a metric for health.91 Eating disorder survivors and representative organisations have criticised the Government’s plans to add calories information to menus at cafes, restaurants and takeaways as that can lead to disordered eating and eating disorders.92 For those in recovery for eating disorders it can also be a trigger—people with eating disorders, regardless of their weight are hyper-vigilant to calorie consumption. This was highlighted by a respondent to the Committee’s survey:

I’d also like to make a specific comment on the policy of forcing restaurants to put meal calories on their menus, which I know has been touted. This would be an absolute disaster for so many people struggling with body image issues or eating disorders, who would likely automatically gravitate to the lowest calorie option or be worried about eating at all. I think the total lack of nuance in this approach is an example of the government’s disengagement with the issues around body image.93

39.In January 2021, researchers at the University of Cambridge found that Government campaigns over the last 30 years around obesity have been largely unsuccessful due to problems with implementation, lack of learning from past successes or failures, and a reliance on trying to persuade individuals to change their behaviour rather than tackling unhealthy environments.94 The Centre for Diet and Activity Research said that

In almost 30 years, successive UK governments have proposed hundreds of wide-ranging policies to tackle obesity in England, but these are yet to have an impact on levels of obesity or reduce inequality. Many of these policies have largely been flawed from the outset and proposed in ways that make them difficult to implement. What’s more, there’s been a consistent failure to learn from past mistakes.95

40.Witnesses told us that there is no evidence that recent weight-loss campaigns have been successful as the prevalence of people who have a BMI in the overweight and obese categories, which are the measures that these weight loss campaigns tend to rely on, have remained stable in the past 10 to 20 years.96 There is little to no evidence that weight-focused public health campaigns have long-term effects and that these approaches achieve what they aim to achieve.97

41.We also heard that policies around weight and obesity, and the way they are framed, are potentially causing dangerous behaviours, especially in young people. Academics noted that there has been no reviews into the link between public health campaigns and body image.98 In 2020, over 100 medical and scientific organisations signed a pledge to eliminate weight bias and stigma of obesity, recommending that public health practices and messages should not use stigmatizing approaches to promote anti-obesity campaigns. The pledge notes that these practices are objectively harmful and should be banned and instead public health authorities should identify and reverse policies that promote weight-based stigma, while increasing scientific rigor in obesity-related public policy. Signatories to this included Diabetes UK, British Obesity and Metabolic Surgery Society (BOMSS), Obesity UK, Kings College London Hospitals, University College London Hospitals, North Bristol NHS Trust, APPG on Obesity and WW (Formally WeightWatchers).99

42.We questioned the Government on the potential impacts of the Obesity Strategy on body image, eating disorders and nation’s health. Minister Dorries told us that currently, due to covid-19 pressures, the Government doesn’t yet have a plan on measuring the potential success or otherwise of the obesity strategy but that PHE’s work on updating its obesity campaign is ongoing and the Government is keen to focus on positive messaging around better health and improved lifestyle rather than fat-shaming.100

43.Beat writes that previous and proposed anti-obesity strategies, such as changes to menus and food labels, information around ‘healthy/unhealthy’ foods, and school-based weight management programmes all pose a risk to those with eating disorders. A person with lived experience of an eating disorder told Beat that:

Encouragement of calorie counting and fear of obesity in public campaigns was the main source of the beginning of my eating disorder. As someone growing up with a perfectionist mindset, it truly made the fuel behind the fire worse.101

44. Psychologists from the Oxford Centre for Eating Disorders (OCED) agreed with Beat that the Government’s plan will have a further detrimental effect on those with or at risk of developing an eating disorder. They said that going to a restaurant would likely induce hypervigilance and anxiety and that there is no clinical evidence that they have encountered that supports consistent measuring of calories.102 The Government defended its pledge to add calorie information on menus, despite soaring levels of eating disorders because:

Lots of people aren’t even aware of calorific content—people who go into a fast-food shop are not aware that you have got around 1,000 calories in a bacon cheeseburger and fries, and those kinds of things. We want people to know what it is that they are consuming so that they can make better choices, but we are aware of those people with eating disorders and making sure that we protect them as much as we can.103

45.Lockdown has undoubtedly worsened existing body image anxieties and inspired new insecurities for thousands of people across the country. In particular, we are alarmed by the rapidly rising rates in eating disorders and other mental health conditions. The impact of the pandemic, both on eating disorder sufferers and those at a high risk of developing an eating disorder, has been devastating. We recommend that the Government reviews why eating disorder rates in the UK are rising. Any research undertaken must be inclusive of all groups in which eating disorder rates are rising including men, women, children, older people and BAME groups. We request that the Government respond to us with its findings and policy interventions to tackle these devastating rises within six months.

46.Many organisations and academics have found that prevention and early intervention are likely to reduce eating disorder rates as well as hospitalisations and deaths. It is important that the alarming rise in eating disorder rates is addressed as the country reopens post-pandemic. We recommend that in the short term, the Government focuses on rapidly developing early intervention strategies for those with mental health issues related to body image, including eating disorders. Given the high mortality rates associated with eating disorders, and that eating disorder research receives just 96p per person affected annually, ringfenced funding for eating disorder research should be increased to at least £9 per person, the same amount that is spent per person on general mental health research. Funding for eating disorders must be in line with the prevalence and severity of the condition.

47.We are hugely saddened to hear of the number of people who have faced appearance and weight-based discrimination when accessing NHS services. There is no way to quantify the damage this has done to individuals’ mental and physical health. We are not satisfied with the use of BMI as a measurement to evaluate individual health. It is clear that the use of BMI inspires weight stigma, contributes to eating disorders, and can damage an individual’s body image and mental health. We recommend that the Government urgently commissions research into the extent and impact of weight-based discrimination for people accessing NHS services. PHE should stop using BMI as a measure of individual health and adopt a ‘Health at Every Size’ approach within twelve months.

48.The current Obesity Strategy is at best ineffective and at worst perpetuating unhealthy behaviours. It is likely to be dangerous for those with negative body image, including those at risk of developing eating disorders. In the short term, we have specific concerns that calorie labelling will contribute to growth in eating disorders and disordered eating. The Government should immediately scrap its plans to for calorie labels on food in restaurants, cafes, and takeaways.

49.We are disappointed to learn that there have been no reviews of the effectiveness of the current or previous obesity strategies, and we cannot support much-criticised and unevaluated weight-loss policies. The Government must only use evidence-based policies in its Obesity Strategy. The Government should urgently commission an independent review of its Obesity Strategy to determine the evidence base for its policies within 3 months. It should publicly report the findings of this review within six months.