Written evidence submitted by Hannah Lewis (CYP0111)


About the authors

Hannah Lewis[1] is a PhD student at the Centre for Psychiatry, Queen Mary University of London. She is funded by the London Interdisciplinary Social Science Doctoral Training Partnership (LISS-DTP 1+3), which is a collaboration between Queen Mary University of London, King’s College London, and Imperial College London. She is studying the role of body dissatisfaction as a target for preventing eating disorders and body dysmorphic disorder among ethnically diverse adolescents and plans to co-produce a cultural adaptation of a peer delivered cognitive-dissonance school-based intervention (The Body Project). As part of her MRes, Hannah conducted a systematic review on the procedures, benefits and risks of involving people with lived experience of eating disorders in prevention and treatment interventions.


About this submission

This submission will draw upon the authors’ expertise in body image and eating disorder research, policy and practice from both an academic and lived experience perspective. It will be focused on the proposals on page 22 of the green paper, which stated that the Mental Health Support Teams (MHSTs) will deliver group-based intervention engaging participants in critiquing the ‘thin ideal’, which can be effective in reducing eating disorder symptoms and body image concerns, when targeted toward high-risk adolescent girls.” It is the authors belief that this proposal is referring to the Body Project, cognitive dissonance-based intervention which challenges the thin ideal.


The author would be happy to be contacted to provide further information and be involved in any further activities related to this inquiry, including the provision of oral evidence. Please contact Hannah Lewis

This response will address the following questions from the call for evidence:

      What progress have the Government made on children and young people’s mental health, including but not limited to: The ambitions laid out in the 2017 Green Paper; Provision of mental health support in schools; Provision of support for young people with eating disorders; and Addressing capacity and training issues in the mental health workforce


Early intervention and prevention of eating disorders: MHSTs as a vehicle for delivering group interventions


  1. It is widely accepted that schools and educational settings are well placed to deliver prevention and early intervention strategies to address risk-factors for the development of eating disorders[2].


  1. Recent policy developments include a mandate for mental wellbeing – which covers healthy eating and disordered eating – to be a compulsory part of the curriculum from 2020[3] as well as the establishment of Mental Health Support Teams (MHSTs) who are proposed to deliver group-based body image interventions for those at risk of developing eating disorder, as proposed in the Transforming children and young people’s mental health provision: a green paper[4].


  1. On page 22 of the green paper, the remit of the MHSTs is outlined to deliver “group-base interventions engaging participants in critiquing the ‘thin ideal’, which can be effective in reducing eating disorder symptoms and body image concerns when targeted toward high-risk adolescent girls”. It is the authors’ belief that this recommendation is referring to the implementation and dissemination of The Body Project interventions, a cognitive dissonance-based intervention which aims to alleviate body dissatisfaction through critiquing appearance ideals.


  1. However, we are concerned about the lack of mention of this proposal in consequent literature from NHS England and Health Education England about the implementation of MHSTs.


  1. The Body Project has evolved over the last 16 years and has produced a small number of adaptations of the initial intervention scripts, resources and lessons plans. The intervention largely covers a critique of appearance ideals and involves dissonance-based activities such as role plays, letter writing and behavioural challenges.
  2. It is also promising to see that after successful efficacy trials of The Body Project, Stice has investigated its effectiveness on some ethnic minority groups in randomised trials[5]. For example, a cultural adaptation of the traditional Body Project was recently produced to be suitable for orthodox Jewish adolescent girls[6]. Results from other studies have suggested that The Body Project was similarly effective for African American, Asian America, European American and Hispanic female students [7]. However, similar studies which evaluate the acceptability and efficacy of this intervention among ethnically diverse adolescent girls in the UK are yet to be conducted.
  3. In response to this, the author has planned to co-produce a cultural adaptation of The Body Project with ethnically diverse adolescent girls[8]. The authors will be happy to share the outcome of this project in 2023 and hope it will inform the delivery in MHSTs interventions moving forward.
  4. The author recommends that the MHST training curriculum and competence framework includes comprehensive guidance on how to deliver cognitive dissonance based interventions such as The Body Project, as well as guidance on appropriate signposting to other services. We also advise that the roll-out of The Body Project is consistently evaluated by NHS Trusts and CAMHS services, ensuring its acceptability in diverse UK settings.


Co-production: a vehicle for advancing mental health equality in child and adolescent eating disorder services


  1. In conjunction with the rapid-assessment of the evidence of co-production, the NCCMH published ‘Advancing Mental Health Equality: Steps and Guidance on Commissioning and Delivering Equality in Mental Health Care’ commissioned by NHS England[9]. This document recognised that co-production is a vehicle for the inclusion of under-represented groups.


  1. This guidance document outlined that fundamentally, involvement in the co-design, co-production, or co-delivery of any research study, project or intervention empowers those with seldom-heard voices to collaborate meaningfully. We must acknowledge that co-production is a key principle in the document, and thus ought to be utilised to address the inequalities in mental health service provision – including eating disorders where stereotypes surrounding gender, ethnicity and age are rife.


  1. Whilst people have traditionally assumed that sufferers of an eating disorder are white, middle class and female[10], we know now that is far from the case, and that eating disorders can affect people off all ethnicities, class and gender. Therefore, in order to ensure that service provision matches the diversity of its service-users – and as per Section 5.1.3. of the Royal College of Psychiatrists’ Quality Standards[11] – the co-design, co-production and co-delivery of eating disorder services, programmes and projects with minority groups is paramount.



  1. We recommend that eating disorder service programmes and projects at a Trust level potentially funded by Quality Improvement (QI) initiatives, implement the guidance from the NCCMH surrounding co-production as a vehicle for advancing mental health equalities. In turn, this can broaden the research agenda, so that more eating disorders research investigates the experiences of people from under-represented groups.


[1] Hannah Lewis - Wolfson Institute of Preventive Medicine - Barts and The London (qmul.ac.uk)

[2] Yager, Z., Diedrichs, P., Ricciardelli,L.A., Halliwell, E. (2013).What works in secondary schools? A systematic review of classroom-based body image programs. Body Image, 10 (3) pp: 271-281

[3] Department for Education. 2017. Policy Statement: Relationships Education, Relationships and Sex Education, and Personal, Social, Health and Economic Education. [Online] Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/595828/170301_Policy_statement_PSHEv2.pdf

[4] Department for Education and Department for Health and Social Care. 2017. Transforming Children and Young People’s Mental Health Provision: a Green Paper. [Online] Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf

[5] Stice, E., Marti, C.N. and Cheng, Z.H. . 2014. ‘Effectiveness of a dissonance based eating disorder prevention program for ethnic groups in two randomised control trials’. Behaviour Research and Therapy. [Online] 55 Available from: https://www.ncbi.nlm.nih.gov/pubmed/24655465

[6] Casasnovas, A.F, Huryk, K.M., Levinson, D., Markowitz, S., Friedman, S., Stice,E. & Loeb, K.L. 2019.Cognitive dissonance-based eating disorder prevention: pilot study of a cultural adaptation for the Orthodox Jewish community’, Eating Disorders: The Journal of Treatment and Prevention [Online] Available from: https://www.tandfonline.com/doi/abs/10.1080/10640266.2019.1644797

[7] Stice, E., Marti, C.N. and Cheng, Z.H. . 2014. ‘Effectiveness of a dissonance based eating disorder prevention program for ethnic groups in two randomised control trials’. Behaviour Research and Therapy. [Online] 55 Available from: https://www.ncbi.nlm.nih.gov/pubmed/24655465

[8] Hannah Kate Lewis – LISS-DTP (liss-dtp.ac.uk)

[9] National Collaborating Centre for Mental Health. (2019). Advancing mental health equalities. [Online] Available from: https://www.rcpsych.ac.uk/improving-care/nccmh/care-pathways/advancing-mental-health-equality

[10] Gordon, K.H., Perez, M., Joiner, T.E. Jr. (2002) The impact of racial stereotypes on eating disorder recognition. Int J Eat Disord, 32(2) pp: 219-224.

[11]Royal College of Psychiatrists. (2020) QED Quality Standards for Adult Community Eating Disorder Services. [Online] Available from:  https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/quality-networks/eating-disorders-qed/qed-community-standards---second-edition.pdf?sfvrsn=f6e36b36_2



March 2021