Changing the perfect picture: an inquiry into body image: Government Response to the Committee’s Sixth Report of Session 2019–21

Second Special Report

The Committee published its Sixth Report of Session 2019–21, Changing the perfect picture: an inquiry into body image (HC 274), on 9 April 2021. The Government response was received on 10 June 2021 and is appended below.

Appendix: Government Response

The extent, causes and impact of negative body image

1.The EHRC should produce guidance for individuals seeking to use the existing Equality Act legislation to challenge appearance-based discrimination within three months. The Government should widely promote the EHRC’s new guidance and publish the proposals resulting from its own research and update us on these within 6 months. (Paragraph 20)

2.EHRC have responded directly to the Committee, a copy of their response is attached.

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

3.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. (Paragraph 45)

4.Improving eating disorder services is a key priority for the government and a fundamental part of our commitment to improve mental health services. The Department has funded various studies through the National Institute for Health Research (NIHR) that aim to understand and mitigate harms of eating disorders.

5.The NIHR is the largest funder of mental health research in the UK. It invested £93.4 million in mental health research in 2019/20. This significant investment in mental health research aligns with the NHS long term plan in which mental health is a priority. The NIHR supports a wide portfolio of mental health research, including research on eating disorders through various funding streams. Policy officials in DHSC work closely with the NIHR to take forward proposals for research.

6.The Government is funding via the National Institute for Health Research a new eating disorder study jointly led with Kings College London and eating disorder charity, Beat. The study launched in February 2020 and is the largest ever study of eating disorders in England, which aims to recruit at least 10,000 people in England who have experienced an eating disorder at some point in their life. The study aims to help researchers better understand these conditions and enable the design of new treatments aimed at improving the lives of patients.

7.DHSC through the NIHR has also funded a systematic review1 to explore the relationship between social networking sites and other online content and body image and disordered eating in children and young people. The systematic review is being led by the Evidence for Policy and Practice Information and Co-ordinating Centres (EPPI-Centre).

8.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, ring fenced 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. (Paragraph 46)

NHS Long Term Plan

9.Under the NHS Long Term Plan, by 2023/24, we will invest almost £1 billion extra in community mental health care for adults with severe mental illness, such as eating disorders.

10.The NHS Long Term Plan has committed to the implementation of new integrated models of primary and community mental health care that improve care for adults and older adults with a range of severe mental health problems, including eating disorders, in all Sustainability and Transformation Partnerships (STPs) in England by 2023/24.

11.A four-week waiting standard for adult community mental health services, including eating disorder services, is being piloted and considered as part of the clinically led review of NHS access standards. Further information on the definition of a potential standard will be shared in 2021/22.

12.We have set up the first waiting time standard for children and young people eating disorder services so that 95% of children with an eating disorder will receive treatment within one week for urgent cases and within four weeks for routine cases.

13.Since 2016, extra funding is going into children and young people’s community eating disorder services every year, with £53 million per year from 2021/22.

14.This extra funding will enhance the development of more than 70 new or improved community eating disorder teams covering the whole of the country.

Funding of Eating Disorder services

15.As part of the NHS Long Term Plan we are investing £2.3bn in additional funding in mental health services each year.

16.We have also announced that in 2021/22 the NHS will receive around an additional £500 million on top of this, which will support people with a variety of mental health conditions, including eating disorders. This includes programmes to address waiting times for mental health services, give more people the mental health support they need, and invest in the NHS workforce.

17.As part of this, £79 million of this extra funding will be used to significantly expand children’s mental health services allowing 2,000 more children and young people to access eating disorder services.

18.This will also be used to grow the number of mental health support teams in schools and colleges from 59 to 400 by April 2023, supporting nearly 3 million children. This will allow teachers and health care professionals to detect early signs of eating disorders in children and young people.

19.£58 million will be allocated to accelerate the adult community support to bring forward the expansion of integrated primary and secondary care for adults with severe mental illness, including eating disorders.

Early Intervention services

20.To accelerate the provision of early intervention eating disorder services, NHS England and NHS Improvement are funding the roll out of the First Episode Rapid Early intervention for Eating Disorders (FREED) model in 18 sites across the country. FREED is an evidence-based early-intervention model, for people aged 16–25, presenting with a first episode of eating disorders that has lasted for less than three years.

21.The FREED model advocates treatment within 2–4 weeks and aims to contact patients within 48 hours of referral. Evidence shows that this model reduces the waiting times for assessment and treatment and that patients experience better outcomes.

22.By delivering swift access to treatment for young adults, the FREED model will support the improvements achieved for Children and Young People who experience an eating disorder. Latest data shows that over 85% of children and young people (up to 19 years) with a suspected eating disorder start treatment within 1 week if their case is urgent and 4 weeks if their case is non-urgent.

23.The implementation of FREED is part of a broader ambition to create a more comprehensive and integrated mental health offer for 0–25 year olds, which sees children and young people’s and adult eating disorder services working together to improve the pathway of care for young adults.

Research funding

24.The Department has funded various studies through the National Institute for Health Research (NIHR) that aim to understand and mitigate harms of eating disorders.

25.The NIHR supports a wide portfolio of mental health research, including research on eating disorders through various funding streams. In 2019–20, the NIHR spent £93.4 million on mental health research, of which £52.4 million was spent through NIHR research programmes and £41 million through our NIHR research infrastructure. This significant investment in mental health research aligns with the NHS Long Term Plan, published in January 2019, in which mental health is a priority.

26.As is common with other research funders, it is not usual practice for the NIHR to ring- fence funding for particular topics or conditions. The NIHR welcomes funding applications for research into any aspect of human health, including eating disorders. Applications are subject to peer review and judged in open competition, with awards being made on the basis of the importance of the topic to patients and health and care services, value for money, and scientific quality.

27.The NIHR does launch highlight notices and ‘themed calls’ seeking research proposals in specific topic areas. The NIHR is open to launching calls in areas of need including for mental health conditions.

28.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. (Paragraph 47)

29.Every individual who comes into contact with the NHS and organisations providing health services should always be treated with respect and dignity, regardless of whether they are a patient, carer or member of staff. This value seeks to ensure that organisations appreciate and respect different needs, aspirations and priorities, and take them into account when designing and delivering services.

30.Public Health England (PHE) is developing training and education to offer all Primary Care Networks the opportunity to equip their staff to become healthy weight coaches. This will include ways to avoid weight stigma by looking at attitudes, behaviour and communication. It will also reflect on what a ‘health at every size approach’ is and how this can be beneficial when talking to service users. This training is planned to be launched this summer on the e-Learning for Health platform. Information on healthy weight coaches is provided in “Tackling obesity: empowering adults and children to live healthier lives”.2

31.The development of PHE’s Better Health campaign3 took into account the experience of people living with obesity, organisations supporting people living with eating disorders and health professionals so as to reduce weight stigma. PHE also researches and advises how best to talk to families about their weight in the most enabling and positive way.

32.Body Mass Index (BMI) is used as a tool to help identify whether someone is living with excess weight or is underweight and can be a starting point for further discussion with a healthcare professional on their general health. It is important that it continues to be used to help provide people with the best care in line with the National Institute for Health and Care Excellence (NICE) guidelines and in conjunction with other follow- up assessment tools such as waist circumference.4

33.PHE has a responsibility to follow NICE clinical guidance, developed using evidence- based research, and so will continue to advise that BMI is a useful and effective way of considering whether someone is a healthy weight or living with excess weight. PHE will continue to use BMI as a means of presenting data on the proportion of people at a population level, living for example with obesity.

34.BMI ranges and thresholds are based on long term studies of several million people from a wide range of backgrounds.5 It is recognised as the most practical and reliable population wide measure for assessing future risk of illness and to prevent health problems from arising.

35.Different people are affected by obesity at different BMIs. Factors such as fitness, age and ethnicity must be considered. For instance, NICE guidance recommends lower BMI thresholds for people from Black African, African-Caribbean and Asian (South Asian and Chinese) origin as they are at an increased risk of health issues such as type 2 diabetes even if their BMI is 25 or under.6 Therefore, an individual might be advised to lose weight or keep their weight steady even if their BMI looks like it is within the healthy range.

36.The Government should immediately scrap its plans for calorie labels on food in restaurants, cafes, and takeaways. (Paragraph 48)

37.Obesity is a complex problem caused by many different factors to which there is no single solution. It is a leading cause of serious diseases such as type 2 diabetes, heart disease, some cancers7 and is associated with poorer mental health.8 It also increases the risk of serious illness and death from Covid-19.9 This represents a huge cost to the health and wellbeing of the individual, the NHS and the wider economy.

38.Data shows 6 in 10 adults and more than 1 in 3 children aged 10 to 11 years old overweight or living with obesity.10 Obesity prevalence is highest amongst the most deprived groups in society. Children in the most deprived parts of the country are more than twice as likely to be obese as their peers living in the richest areas.11 This is sowing the seeds of adult diseases and health inequalities in early childhood.

39.As a country we consume too many calories, as well as too much sugar, saturated fat and salt. We know that regular overconsumption of a relatively small number of calories leads to individuals becoming overweight or obese. We are determined to tackle the problem of obesity across all ages, with an increased focus on prevention to help reduce the health risks that being overweight or living with obesity brings.

40.We published “Tackling obesity: empowering adults and children to live healthier lives” in July 2020.12 The strategy demonstrates an overarching campaign to reduce obesity, takes forward actions from previous chapters of the childhood obesity plan, including our ambition to halve the number of children living with obesity by 2030, and sets out measures to get the nation fit and healthy, protect against Covid-19 and protect the NHS.

41.It is likely that eating out frequently, including eating takeaway meals, contributes to the gradual overconsumption of calories. Research suggests that eating out accounts for 20–25% of adult energy intake,13 and that when someone dines out or eats a takeaway meal they consume, on average, 200 more calories per day than if they eat food prepared at home.14 Data also tells us that portions of food or drink that people eat out or eat as takeaway meals contain, on average, twice as many calories as equivalent retailer own-brand or manufacturer-branded products.15

42.Eating out or getting a takeaway is common; surveys tell us that 96% of people eat out and 43% do so at least once or twice a week.16 Research also suggests that people are eating out more often; in 2014, 75% of people said they had eaten out or bough takeaway food in the past week, compared to 69% in 2010.17 Consumption of fast food and takeaways is particularly prevalent among families, as evidence from 2016 showed that 68% of households with children under 16 had eaten takeaways in the last month, compared with only 49% of adult-only households.18

43.However, it is often difficult for customers to make informed, healthier choices when they do not have access to basic nutritional information, such as the calorie content of the food they are purchasing. Customers are already accustomed to seeing calorie information on prepacked food items sold in supermarkets and other retailers and we are seeing strong demand for nutritional information in the out-of-home sector; 79% of respondents to a Public Health England survey said they think that menus should include the number of calories in food and drinks.19 Another survey from Diabetes UK showed that around 60% of the public said that they would be more likely to eat at an establishment that offered calorie labelling on its menus.20

44.That is why, following consultation in 2018, we have introduced legislation to mandate calorie labelling for out-of-home food businesses, such as restaurants, cafes and takeaways, in England. The Government has decided that in the first instance, calorie labelling should only be mandatory for large businesses with 250 or more employees. We have published a regulatory impact assessment which sets out the impact we expect the policy to have and evidence used to support our analysis.21

45.We have been careful to consider the views of a wide range of experts in response to our public consultations on this policy proposal. As a result of consultation feedback, we have decided to exempt schools from the requirement to display calorie information given concerns about exposing children to calorie information in school settings and eating disorders. Additionally, we have included within the Regulations a provision which permits businesses to provide a menu without calorie information at the express request of the customer. As a result, people who may find viewing calorie information more difficult may be able to avoid this information in certain situations when eating out.

46.The Government is committed to review the policy within 5 years of its implementation and will use that evaluation to consider extending the requirement to include smaller businesses. Evaluation will consider the effectiveness and implementation of the policy and officials are developing plans on how best to do so.

47.It is not our intention that anyone should be harmed by our strategy. We recognise the importance of using appropriate language to avoid having an adverse impact on particular groups. Helping people to achieve and maintain a healthy weight is one of the most important things we can do to improve our nation’s health.

48.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. 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. (Paragraph 49)

49.The Department of Health and Social Care’s (DHSC) overarching, peer-reviewed evaluation strategy for the childhood obesity programme aims to maximise learning and feedback from what are clearly innovative interventions as well as supporting a wider programme of more cross-cutting research that will help us understand more about the systems that sustain and promote obesity and how ordinary people, particularly those from more deprived circumstances, are responding to our policies. Resources for the evaluation strategy come from a range of sources including the National Institute for Health Research (NIHR), a flexible programme budget and by influencing and co-ordinating wider research activity conducted by academic and health systems collaborators. As the DHSC’s work extends to address adult obesity through its Weight Management Programme of investment and evidence building, this approach will be reviewed and refreshed to take on this wider scope.

50.The policies in our strategy are informed by the latest research and emerging independent and peer reviewed evidence, and debates in Parliament and various reports from key stakeholders including the Health and Social Care Select Committee. We have also captured analysis from the NIHR Obesity Policy Research Unit,22 which was established in 2017 as part of our initial childhood obesity plan,23 and is funded to carry out policy related research until the end of 2023. The NIHR has committed to launch commissioning calls to evaluate policies contained within the obesity strategy which could include research to understand and mitigate possible negative consequences.

51.Alongside this, we have been careful to consider the views of stakeholders and experts, including mental health charities, as we developed our plans for implementing the strategy and we will continue to listen going forwards. This includes feedback from a wide range of experts in response to our public consultations on specific policy proposals.

52.We have seen some important successes since publication of chapter one of the childhood obesity plan in 2016, including the average sugar content of drinks subject to the soft drinks industry levy decreasing by 43.7% between 2015 and 2019. There has also been success in some categories of the sugar reduction programme including around a 13% reduction of sugar in breakfast cereals, yogurts and fromage frais.24

53.The high prevalence of obesity in adults and children has been decades in the making. It is going to take time to see results.

A positive body image for future generations

54.We recommend that the Department for Education regularly reviews the new RSHE curriculum to ensure that it is having a positive impact on wellbeing and decreases levels of body dissatisfaction. Additionally, the Department for Education should explore other policy initiatives to encourage schools to take a ‘whole school approach’ to encouraging positive body image. (Paragraph 58)

55.The statutory relationships, sex and health education (RSHE) curriculum became compulsory in September 2020, with flexibilities introduced so schools did not have to start teaching until the summer terms 2021, to accommodate COVID-related school closures.

56.Through statutory health education secondary-aged pupils will be taught about the similarities and differences between the online world and the physical world. This will include content on the impact of unhealthy or obsessive comparison with others online, including through setting unrealistic expectations for body image, how people may curate a specific image of their life online, how information is targeted at them and how to be a discerning consumer of information online.

57.The RSHE curriculum supports the development of a whole school approach to wellbeing and contributes to the spiritual, moral, social and cultural development of pupils.

58.Ofsted will inspect schools on their RSHE provision under the personal development category which includes assessing how schools develop pupils’ confidence, resilience and knowledge so that they can keep themselves mentally healthy.

59.We have developed teacher training modules to build teacher confidence in delivering RSHE and will, subject to approval, undertake quantitative and qualitative research to understand perceptions of the RSHE support material (provided by the DfE and wider sector), and their confidence and capability to deliver the new subjects.

60.Ofsted will inspect schools on their RSHE provision under the personal development category which includes assessing how schools develop pupils’ confidence, resilience and knowledge so that they can keep themselves mentally healthy.

61.We have developed teacher training modules to build teacher confidence in delivering RSHE and will, subject to approval, undertake quantitative and qualitative research to understand perceptions of the RSHE support material (provided by the DfE and wider sector), and their confidence and capability to deliver the new subjects.

62.We recommend that the Government urgently reviews the National Child Measurement Programme to ensure it is not creating undue body image pressures in children. The Government should urgently assess the need for the programme and seek other ways to collect this data. (Paragraph 59)

63.Public Health England (PHE) has a rigorous approach to reviewing the National Child Measurement Programme (NCMP) on an annual basis, which includes extensive review of evidence and consultation with stakeholders including families, and healthcare professionals across the fields of psychology, weight management, mental health and eating behaviours.

64.The psychological impact of the NCMP was researched by University College London in 200825 prior to parent feedback letters being introduced and more recently, the PROMISE Trial looked at the benefits and harms of the programme.26 Both showed that body image, self-esteem, weight-related teasing and restrictive eating behaviours did not change as a result of being measured or providing feedback for overweight children. These studies also found that most children (96%) are indifferent or unconcerned about being weighed or measured. The small number of children (4%) that disliked the process were mainly from year six (children aged ten-11 years) which highlights the need for sensitivity when weighing and measuring older children.

65.PHE recognises the importance of the wellbeing of the children and families involved in the NCMP, to ensure the measurements are conducted in a sensitive way. Operational Guidance on how the programme should be delivered is issued.

66.PHE has produced guidance27 to support practitioners delivering the programme locally to engage in supportive conversations with parents about the NCMP and their child’s health.

67.PHE will ask members of the NCMP Board to consider the concerns raised in the report.

68.In England, the UK90/WHO growth reference is the standard used to assess body mass index in all children between two and 18 years. This is recommended by NICE CG189 and the Royal College of Paediatrics and Child Health child growth charts.

69.PHE is aware of emerging research around the validity of using BMI centile for certain minority ethnic groups and whether it underestimates body fatness in South Asian populations and overestimates it in Black African populations. NICE has not provided any ethnic-specific guidance or recommendations on BMI and health risk concerning children from Black, Asian or minority ethnic groups because the evidence base is not yet sufficient.

70.PHE will continue to explore the impact of the NCMP on children and their parents.

#NoFilter: Is this advert real?

71.We recommend that the Government works with companies and the ASA to further encourage the use of diverse and representative images of people in advertising. (Paragraph 88)

72.The ASA has a number of work streams that consider diversity in advertising and its impacts. One of these important strands is their work to review racial and ethnic stereotyping in advertising.28 The Government will continue to engage closely with the ASA to support this work addressing some of the intersectional issues discrimination poses.

73.The ASA’s UK Code of Non-broadcast Advertising and Direct & Promotional Marketing (CAP Code) and the UK Code of Broadcast Advertising (BCAP Code) prohibit misleading, exaggerated and irresponsible advertising, which does include imagery. These rules cover offence and social responsibility to ban adverts that include gender stereotypes on grounds of objectification, inappropriate sexualisation and depiction of unhealthily thin body images.

74.They were enhanced in June 2019 with a new rule prohibiting negative gender stereotypes. Ads which pressure the audience to conform to an idealised gender- stereotypical body shape or physical features are likely to breach this rule. ASA rules on social responsibility and misleading advertising can be applied to advertising of cosmetic interventions and advertising featuring digitally altered images. The ASA’s proactiveness to adapt and add to their codes gives the Government reassurance that they are tackling the issue of diversity in advertising, and the Government will work with them across their work streams, including on body image in advertising and racial and ethnic stereotyping.

75.We recommend that the Government works closely with the ASA to ensure its future work on body image is inclusive and that substantial changes are implemented after its consultation. (Paragraph 89)

76.We will continue to work with industry and the ASA, who held a public consultation on cosmetic interventions in 202029 and are following this up with a call for evidence on body image.30 Government will remain closely in touch with the ASA as they undertake this consultation, and will consider what further action may be appropriate if the result of the consultation is not sufficient. The government will be launching the Online Advertising Programme (OAP) later this year which will explore how to address harms in the content and placement of advertising online, and to ensure the regulatory regime for the online advertising ecosystem is coherent, clear and effective. As part of this work, the government will be considering whether any additional measures should be brought forward to address body image concerns.. We will consult on this later in the year.

77.We recommend that the Government works with the advertising industry and TfL to consider what impact banning adverts has on protecting people from developing negative body image. It should update us within 6 months. (Paragraph 90)

78.As part of the Government’s Online Advertising Programme we will further engage with stakeholders such as TfL and the wider advertising ecosystem on this issue. We will provide the Committee with an update in November on our findings, as part of the Online Advertising Programme and also in the round on the issue of body image, as we engage with stakeholders on body image through our regular engagements with the sector.

Context of TfL’s work

79.In addition to TfL banning adverts to protect people from developing negative body image, February 2020 was the first anniversary of their introduction of restricting advertising for food and non-alcoholic drinks high in fat, sugar or salt (HFSS). Reflecting on this shift, TfL have changed the way they work with agencies and brands. They have invested time in working with them to ensure the policy is understood and leads to appropriate advertising. There is an interplay here with their approach to reducing advertising that portrays body image in a negative way, which Government is keen to engage further with them on. The Government would support any work between TfL and the wider advertising sector to further promote the messaging as conveyed in the TfL codes that specifically address body image.31

80.The TfL Advertising Steering Group who oversaw the implementation of the policy changes around body image have noted the reduction of problematic copy in this area. The group also reviews the range and number of complaints received and provides regular comment and insight.

81.Furthermore, by engaging with TfL’s annual Diversity in Advertising competition, government officials will explore the issues of intersectional representation of body image. Through this competition TfL looks to directly challenge attitudes around gender inequality and the representation of women. In 2019 TfL asked entrants to submit campaigns which featured authentic representations of London’s Black, Asian or Minority Ethnic communities.

82.The Government should bring forward legislation to restrict or ban the use of altered images in commercial advertising and promotion. (Paragraph 91)

83.It is not the government’s current intention to legislate on altered images in advertising. We want to make sure that any government intervention on body image makes a real and positive difference. At present, there is insufficient evidence to conclude that legislation on digitally altered images would have the desired impact. New regulations for digitally altered images would also need to work effectively with the existing approach to advertising content and regulation in the UK, which holds advertisers to account for the content of adverts in accordance with the relevant advertising codes.

84.The ASA has demonstrated a proactive approach to socially-responsible advertising and made several significant changes to its rules, including around misleading advertising, with little government intervention.

85.The ASA’s existing rules on social responsibility and misleading advertising are already applied to advertising of cosmetic interventions and advertising featuring digitally altered images.

86.Further work is needed to build the evidence base in order to determine the best course of action to address issues on body image further. To that end, the government will consider carefully the additional evidence provided through the ASA’s consultation on body image, as well as the conclusions that the ASA draws from this. The government will also be looking at body image as part of the Online Advertising Programme and will consider any further action as part of this work, in light of the findings of the ASA work.

Body image harms online

87.The Online Harms Bill should be a legislative priority and the Government should inform us of its proposed timetable within two months. We recommend that harms related to body image and appearance-related bullying are included within the scope of the Online Harms legislation due to the foreseeable risk of a significant adverse physical or psychological impact on individuals who are at risk of developing negative body image. (Paragraph 113)

88.The Online Safety Bill was published in draft on 12 May, and will be subject to pre- legislative scrutiny in this session. This is a major milestone in the development of a new regulatory framework which will hold platforms to account on tackling harmful content and behaviours online. We want to make sure we take the time to get the legislation right, which is why we have laid the Bill in draft for pre-legislative scrutiny.

89.The Online Safety Bill will place significant obligations on companies to address content that is not illegal but is harmful to children or to adults. Where there is harmful content related to body image that risks significant adverse physical or psychological impact, the regulatory framework will require platforms to protect children from that content. High-risk, high-reach services (known as category 1 services) such as the largest social media companies will also need to address this content when accessed by adults.

90.Companies that operate services that are likely to be accessed by children and category 1 services will have duties to assess the level of risks presented by content that is harmful to children and content that is harmful to adults respectively on those services. This will include looking at the nature and severity of the harm that might be suffered.

91.In both cases companies will have to assess the risk to children or adults from a range of harms set out in secondary legislation. They will also have to assess the risks from other types of harmful content and, if they find it, notify the regulator.

92.While we recognise that most children have a positive experience online, the impact of harmful content and activity online can be particularly damaging for children and there are growing concerns about the potential impact on their mental health and wellbeing. That is why protecting children is at the heart of the government’s online safety legislation and the strongest protections will be for children.

93.Companies which are likely to be accessed by children will have a duty in legislation to undertake regular ‘child risk assessments’. They will be required to assess the nature and level of risk of their service specifically for children, identify and implement proportionate mitigations to protect children, and monitor these for effectiveness. Child risk assessments will assess the risk for priority harms that the government will set out in secondary legislation and any other types of harm present or at risk of arising to children.

94.Companies that operate category 1 services will be required to set out how, for those services, they will treat each type of content that is harmful to adults (both that listed in secondary legislation and other harmful content they identify in their risk assessments) in their terms of service. They will be required to make these terms of service both clear and accessible and to apply them consistently.

95.We are already working closely with Ofcom to ensure that the implementation period that will be necessary following passage of the legislation is as short as possible, whilst ensuring the required preparations are completed effectively. We expect companies to take steps now to improve safety, and not wait for the legislation to come into force before acting.

96.Alongside the Online Safety Bill, we are also taking steps to educate and empower users to make more informed and safer choices online. The Media Literacy Strategy will promote media literacy as a complementary tool to the new regulatory regime, supporting users with the skills and knowledge they need to stay safe online, such as critical thinking skills, whilst making the most of what the internet has to offer. The Strategy will be published later this year.

97.We recommend that the Government should ensure that social media companies enforce their advertising rules and community guidelines and introduce strong sanctions for failing to do so, including but not limited to, significant fines. (Paragraph 114)

98.In the case of advertising, the ASA sets out the advertising rules for social media companies (and all other actors who advertise online) through their CAP codes. These codes form a self-regulatory framework that hold the advertising sector to account. The ASA have been proactive to update their codes to tackle new challenges as posed by the likes of social media. The Government will continue to work closely with them as the regulator of online advertising.

99.Following a call for evidence last year, the Government’s work on the Online Advertising Programme will resume shortly with a planned consultation before the end of the year. This work will be focused on addressing harms caused within the content and/or placement of advertising online, and will consider the roles and responsibilities of different actors involved in the delivery of advertising online, including online platforms.

100.In the case of user generated content, as per the answer to recommendation 13, please note that, under the new Online Safety legislation, companies that operate Category 1 services will be required to set out their terms of service for material that is harmful. They will be required to make these terms of service both clear and accessible and to apply these terms consistently. Ofcom will have a robust suite of enforcement powers available to use against companies who fail to fulfil their new duties, including those relating to legal but harmful content. Ofcom will be able to:

101.We recommend that the Government works closely with social media companies and academics to ensure that research on social media use and body image are up-to-date, evidence-based, and sufficiently funded. (Paragraph 115)

102.We know that more needs to be done to understand the link between online harmful content and eating disorders. DHSC through the NIHR has funded a systematic review to explore the relationship between social networking sites and other online content and body image and disordered eating in children and young people. The systematic review is being led by the Evidence for Policy and Practice Information and Co-ordinating Centres (EPPI-Centre). We will report on findings in due course. DHSC is also working with DCMS on the online harms legislation to fully consider pro-eating disorder content online.

103.As set out, the Government’s Online Advertising Programme will be focused on addressing harms caused within the content and/or placement of advertising online. This will consider the role of online platforms.

104.We recommend that the Government work closely with the UKRI and Ofcom to ensure that online harms legislation sufficiently encompasses protections from harms caused by body image pressures. We also ask that the Government engages with social media companies on developing innovative solutions to protect users from body image harms encountered online, and that Ofcom works with groups at high risk of developing poor body image to ensure the new regulatory system works for them. (Paragraph 116)

105.The legislation will define the harmful content and activity covered by the regime. This includes illegal content and activity, legal but harmful content and activity for children, and legal but harmful content and activity for adults. The government will set out in secondary legislation the priority categories of criminal offences, legal but harmful content to children, and legal but harmful content for adults, that companies must take action on.

106.We will be working with stakeholders and parliamentarians on identifying priority harms, and they will be subject to the usual secondary legislation processes. The regulator will have a duty to advise on categories of harm to children and categories of content and activity which is legal but harmful to adults, and will want to draw on evidence and stakeholder views.

107.Ofcom will have a statutory duty to establish mechanisms for user advocacy. This will ensure Ofcom understands the experiences of users and is able to detect and address issues early on. We would also expect these mechanisms to pay regard to the experiences of people with intersecting characteristics online.

108.In response to your comments regarding Ofcom working with groups at high risk of developing poor body image, the Government would like to highlight their ‘Making Sense of Media’32 programme of work. This programme looks to improve the online skills, knowledge and understanding of UK adults and children.

109.Ofcom works closely with their advisory panel, which is made up of relevant stakeholders, to understand their ongoing workstreams. Current members of their advisory panel, which sits alongside the wider programme of work, includes (but is not limited to) representation from Google, UNESCO, Facebook and the BBC.

110.The aims of this programme, which looks to improve the online media literacy of UK adults and children, includes facilitating media literacy discussion, collaboration and activity across the UK, including particular support for media literacy activities in underrepresented communities and vulnerable groups. The Government is engaging with Ofcom on this work and we will build momentum here when the Online Advertising Programme consults later this year to ensure that regulatory system considerations take into account the views and needs of those at high risk of developing poor body image.

111.We recommend that the Government ensures that any age verification or assurance processes used by online companies are effective and protect young people from harmful content. We ask the Government to respond to us within 12 months on how effectively age controls have restricted access to harmful content for young people. (Paragraph 117)

112.The Online Safety Bill is intended to protect children wherever they are online. This includes services which are not targeted at children but which they are accessing. All services in scope will need to prove children are not accessing their service, or they will need to conduct a child safety risk assessment and provide safety measures for child users, keeping these under regular review.

113.Under our proposals, we are actively encouraging companies to take steps to ensure that only users who are old enough are able to access services which have age restrictions or risk causing them harm. Companies should use age verification technologies to prevent children from accessing services which pose the highest risk of harm to children. Companies will also need to provide age-appropriate protections for children using their service. This includes protecting children from harmful content and activity on their service and reviewing children’s use of higher risk features, such as live streaming or private messaging. To support this requirement, companies should implement age assurance solutions so they have confidence about which of their users are children and can provide them with higher levels of protection.

114.Ofcom will take a robust approach to sites that pose the highest risk of harm to children and will expect companies to put in place the strongest safety measures, including where appropriate preventing children from accessing their service. As part of this, Ofcom may recommend the use of age verification technologies to support age-gating for high-risk services. Companies would need to put in place these technologies or demonstrate that the approach they are taking delivers the same level of protection for children, or face enforcement action by the regulator.

115.The government is working closely with stakeholders across industry to establish the right conditions to grow the age assurance market and other technical solutions ahead of the legislative requirements coming into force. The DCMS Secretary of State wrote to technology platforms on 21 May with concerns over their current efforts to prevent under age children accessing their sites. The letter calls for greater collaboration and transparency from companies over their current and future age assurance plans. It also asks that they commit their significant resources to developing innovative age assurance solutions that effectively identify child users on their platforms.

Annex A- EHRC response

2 https://www.gov.uk/government/publications/tackling-obesity-government-strategy/tackling-obesity- empowering-adults-and-children-to-live-healthier-lives

4 National Institute for Health and Care Excellence (2014) Clinical Guideline 189: Obesity: identification, assessment and management. Available at:
https://www.nice.org.uk/guidance/cg189/resources/obesity-identification-assessment-and- management-pdf-35109821097925

5 Bhaskaran K, dos-Santos-Silva I, Leon DA, Douglas IJ, Smeeth L. Association of BMI with overall and cause-specific mortality: a population-based cohort study of 3.6 million adults in the UK. The lancet Diabetes & endocrinology. 2018 Dec 1;6(12):944–53. Available at: https://www.thelancet.com/action/showPdf?pii=S2213–8587%2818%2930288–2

7 Guh et al. (2009) The incidence of co-morbidities related to obesity and overweight: A systematic review and meta-analysis, BMC Public Health.

13 NatCen Social Research. National Diet and Nutrition Survey Years 1–6, 2008/09–2013/14 [data collection]. MRC Elsie Widdowson Laboratory, University College London. Medical School; 2017, 8th Edition

14 Nguyen and Powell. (2014). The impact of restaurant composition among US adults: effects on energy and nutrient intakes. Public Health Nutrition 17(11) 2445–52

15 Public Health England (2018). Sugar reduction and wider reformulation programme: report on progress towards the first 5% reduction and next steps

16 Food Standards Agency. (2016). Food and You survey.

17 Food Standards Agency. (2010). Food and You survey and Food Standards Agency (2014). Food and You survey.

18 Food Standards Agency. (2016). Food and You survey.

19 Public Health England. (2018). Calorie reduction: The scope and ambition for action.

20 Diabetes UK. (2018). Public Views on food labelling survey. ComRes interviewed 2,121 UK adults online, aged 18+, between 12th -14th Jan 2018. Data were weighted to be demographically representative of all UK adults by age, gender, region and social grade. ComRes is a member of the British Polling Council and abides by its rules.

22 NIHR Obesity Policy Research Unit at UCL - UCL – University College London

24 Sugar reduction: report on progress between 2015 and 2019 - GOV.UK (www.gov.uk)

25 Grimmett C, Croker H, Carnell S, Wardle J: Telling parents their child’s weight status: psychological impact of a weight-screening program. Pediatrics 2008, 122(3):e682.

26 Falconer CL, Park MH, Croker H, Skow Á, Black J, Saxena S, Viner RM. The benefits and harms of providing parents with weight feedback as part of the National Child Measurement Programme: a prospective cohort study. BMC Public Health 14, 549: 2014.

28 “Tackling racial and ethnic stereotyping in ads - the role the ASA is “ 11 Dec. 2020, https://www.asa.org.uk/news/tackling-racial-and-ethnic-stereotyping-in-ads-the-role-the-asa-is-playing.html. Accessed 20 May. 2021.

29 “Consultation on the placement and scheduling of ads for... “ 10 Sept. 2020, https://www.asa.org.uk/news/consultation-on- the-placement-and-scheduling-of-ads-for-cosmetic-interventions.html. Accessed 21 Jan. 2021.

30 “Bringing body image into sharp focus - ASA | CAP.” 21 Dec. 2020, https://www.asa.org.uk/news/bringing-body-image-into- sharp-focus.html. Accessed 21 Jan. 2021.

31 “TfL Advertising Policy - effective from 25 February 2019.” http://content.tfl.gov.uk/tfl-advertising-policy- 250219.pdf. Accessed 12 May. 2021.
2.3 (d) could reasonably be seen as likely to cause pressure to conform to an unrealistic or unhealthy body shape, or as likely to create body confidence issues particularly among young people;
(e) it relates to lap-dancing, ‘gentlemen’s clubs’, escort agencies,massage parlours, or unproven health and weight loss products

32 “Making Sense of Media - Ofcom (UK).” https://www.ofcom.org.uk/research-and-data/media-literacy- research. Accessed 20 May. 2021.




Published: 23 June 2021 Site information    Accessibility statement