Written evidence submitted by the Mental Health Foundation (IBI0046)

The Mental Health Foundation

Our vision is for a world with good mental health for all.

The Mental Health Foundation works to prevent mental health problems.

We drive change towards a mentally healthy society for all, and support communities, families and individuals to live mentally healthier lives, with a particular focus on those at greatest risk. The Foundation is the home of Mental Health Awareness Week.

Website:              www.mentalhealth.org.uk

Contact:                 Adam Nice, Senior Policy and Public Affairs Officer, ANice@mentalhealth.org.uk

 

The impact of body image on physical and mental health

Summary of recommendations

What is the relationship between people’s perception of their body image and their physical and mental health?

  1. Having body image concerns is not a mental health problem in and of itself; however, it can be a risk factor for mental health problems.
  2. Higher body dissatisfaction is associated with a poorer quality of life and psychological distress[1], a higher likelihood of depression symptoms[2] [3] and the risk of unhealthy eating behaviours and eating disorders.[4] [5] Conversely, body satisfaction and appreciation are linked to better overall wellbeing[6] and fewer unhealthy dieting behaviours.[7] [8]
  3. Body image is closely linked to mental health problems such as body dysmorphic disorder (BDD) and eating disorders like anorexia and bulimia.
  4. For Mental Health Awareness Week 2019,[9] we focused on the relationship between body image – how we think and feel about our bodies - and mental health. To inform our work, we ran two surveys with YouGov in March 2019 of 4,505 UK adults (aged 18+) and 1,118 GB teenagers (aged 13-19). We found that one in five adults (20%) felt shame because of their body image, just over one third (34%) felt down or low, and 19% felt disgusted. Among teenagers, 37% felt upset, and 31% felt ashamed because of their body image.
  5. Additionally, just over one third of adults said they had ever felt anxious (34%) or depressed (35%) because of their body image, and one in eight (13%) experienced suicidal thoughts or feelings because of concerns about their body image.
  6. As a society, we tend to place a great deal of importance on our appearance. Nearly half of adults (47%) in the British Social Attitudes Survey felt that ‘how you look affects what you can achieve in life’ and nearly one third (32%) felt that ‘your value as a person depends on how you look’.[10]

How can the Department of Health and Social Care and its arms’ length bodies work collaboratively with the Department of Digital, Culture, Media and Sport and other parts of Government to tackle the health impacts of a negative perception of body image?

  1. Body image can be influenced by a variety of societal factors. For example, body image can be affected by our relationships with our family and friends;[11] how our family and peers feel and speak about bodies and appearance;[12] exposure to images of ‘idealised’ or unrealistic bodies through the media or social media;[13] [14] [15] and pressure to look a certain way or to match an ‘ideal’ body type.[16]
  2. DHSC should work across Government to mitigate the body image pressures listed above and interrupt the causal pathways that can lead to these significant negative impacts on mental health.

Online Safety Bill

  1. The Online Safety Bill and the work surrounding it will present an important opportunity to protect people’s body image online.
  2. Algorithmically served content is the defining feature of most social media platforms and defines users’ experiences, yet users are rarely given meaningful control of this experience.
  3. We propose that social media companies are required to develop clear plans to give individuals control over the ways that algorithms serve them content.
  4. We agree with the finding of the House of Lords Communications and Digital Committee report that:
  5. ‘[…] the Online Safety Bill should require category 1 platforms to give users a comprehensive toolkit of settings, overseen by Ofcom, allowing users to decide what types of content they see and from whom. Platforms should be required to make these tools easy to find and use. The safest settings should always be the default. The toolkit should include fair and non-discriminatory access to third-party content curation tools.’[17]
  6. While it will never be possible to perfectly determine content that is harmful to body image, there are ways in which users can be given more control, and through this reduce its quantity to a level which is likely to be less harmful. Some ways in which this can be done are:
  1. Pro-anorexia or other eating disorder content clearly has specific and greater harms; the Government should clarify that this falls specifically under its definition of ‘harmful’ content.

Advertising

  1. DHSC should work closely with the Advertising Standards Authority (ASA) to tackle body image pressures linked to advertising. Currently, the ASA focuses primarily on ‘unhealthy body image’ in the physical health sense – for example images of bodies that appear underweight. The underlying logic seems to be that unhealthy body image is related to striving to achieve a body that is itself unhealthy. While this is one dimension of an unhealthy body image, we contend that unhealthy body image is much broader: it is any dissatisfaction with a person’s appearance that causes distress.
  2. DHSC should encourage the ASA to update their Social responsibility: body image guidance to reflect a broader definition of unhealthy body image. We also recommend that the ASA should recognise body image as a distinct harm in the Committee on Advertising Practice (CAP) and Broadcast (BCAP) codes.

Image editing apps

  1. Following on from some of the themes we identified in Mental Health Awareness Week 2019, we produced a briefing on image-editing apps and body image.[18] We discovered that there are a large number of apps, available to download from application stores (Apple App Store and Google Play primarily), which can be used to edit a person’s appearance.
  2. We consider it vital that we take action to understand how these apps influence people’s body image and their mental health. It is an industry that is growing largely unchecked, in a space where the potential to negatively impact people’s lives is significant.
  3. To protect the young people who currently have access to these apps, DHSC should encourage app stores to update their guidelines for developers to explicitly include ‘mental health’ in the range of harms that are unacceptable. All body and face image-editing apps should be rated as PEGI 12/16 and 13+ respectively, to ensure that children and young people who are below the legal age for having a social media account (13 years old) are not using these apps.

Education

  1. Given that body image pressures are especially prevalent amongst young people, education is an important tool to help young people practice body kindness. We have produced guides for both parents[19] and young people[20] providing helpful insights and advice on how children and young people think and feel about their body and their body image.

Training

  1. Training for GPs, health visitors, dietitians and other frontline practitioners advising parents and carers on both parenting and healthy eating should also include information about how parents and carers can, from a very early age, positively influence their children’s feelings about their bodies through the behaviours and attitudes they express. Training on this issue should also be given to the early years childcare workforce, including childminders, nursery nurses, nannies and others who care for young children in loco parentis, whose comments and behaviours are also strongly likely to influence young children’s developing sense of their bodies.

How can the Government strike the right balance between tackling obesity in order to help prevent serious diseases, and reducing weight-based stigma that leads to mental and physical health problems? How best can public health campaigns tackle negative perceptions of body image?

  1. It is not accurate to suggest that tackling obesity and preventing mental health problems due to weight-based stigma are opposite ends of a spectrum with a balance to be found between them.
  2. Studies investigating the impact of various obesity-related public health campaigns have found that campaigns perceived as stigmatising or shaming were received least favourably by recipients, and were no more likely, and in some cases the least likely, to motivate people to change their behaviour. These preferences were the same regardless of the individual’s own body weight.[21] [22]
  3. By contrast, campaigns that focus more generally on themes of healthy eating and health-promotion for all adults were received the most positively.[23] This demonstrates not only that it is possible for campaigns to both seek to tackle obesity and avoid weight-based stigma, but that these are the most effective campaigns for achieving the desired behaviour change.
  4. Concerningly, the Government’s obesity strategy takes a stigmatising, individualistic approach, which is focused on ‘people who want to help themselves’, without having undertaken any reviews or evaluations to justify its strategy. In its report on body image, the Women and Equalities Committee noted:
  5. “The Government’s latest Obesity Strategy is at best ineffective and at worst perpetuating unhealthy behaviours. We are disappointed to learn that there have been no reviews of the effectiveness of the current or previous obesity strategies. The Government must only use evidence-based policies in its Obesity Strategy and should urgently review it to determine the evidence base for its policies. We cannot support much-criticised and unevaluated weight-loss policies.”[24]
  6. They also cite research from the University of Cambridge which found that Government obesity campaigns over the last 30 years have largely been unsuccessful, in part due to an over-reliance on trying to persuade individuals to change their behaviour rather than addressing the unhealthy environments and emotional and mental health factors that lead to obesity.[25]
  7. We support the Women and Equalities Committee recommendation that the Government should review and critically evaluate its current obesity strategy and move towards a more evidence-based strategy which promotes healthy eating for all adults, while tackling the unhealthy environments that lead to obesity.

To what extent are people who have a negative body image drawn to cosmetic procedures, and how do cosmetic procedures affect their body image?

  1. Our March 2019 YouGov poll on body image (mentioned in paragraph 4) found that 8% of adults (4% of men and 13% of women) said they had considered cosmetic surgery, fillers, or Botox in the last year because of their body image.
  2. The pressure for people with poor body image to consider body modification begins early. One survey of UK adolescents by Be Real, a campaign on body image coordinated by YMCA England and Wales in partnership with Dove, found that 36% agreed they would do ‘whatever it took’ to look good, with 57% saying they had considered going on a diet, and 10% saying they had considered cosmetic surgery.[26]

What form should a regulatory regime for non-surgical cosmetic procedures take in order to improve patient safety?

  1. Government regulation should require practitioners to: belong to a mandatory register of approved practitioners; undertake accredited training which includes a psychological component; screen for psychological concerns as part of the initial consultation; check the age of potential clients; and obtain professional insurance cover.
  2. Beauty therapists and medical professionals who administer non-surgical cosmetic procedures should belong to a mandatory register. Voluntary registers only protect customers who are knowledgeable about the existence of and value of registered providers. This leaves a large portion of the market prey to unsafe providers who do not meet the minimum requirement for registration, with little to no recourse to redress if something goes wrong. Mandatory registration would mean that providers would have to meet minimum requirements to be able to operate, outlawing those providers that do not meet these standards.
  3. Mandatory registration could also include standards for psychological best practice to account of the psychological vulnerability of many potential clients. Without this, the psychological harms non-surgical cosmetic procedures can cause and exacerbate will remain largely unaddressed.
  4. Practitioners need to be capable of screening their patients for mental health problems and be able to understand their patient’s motivations for wanting a procedure. This must include a detailed consultation with the patient, not just a questionnaire which can be manipulated to secure the answers that will allow practitioners to undertake their procedures.
  5. For practitioners to be able to consult patients in a mental health- and trauma-informed way, they must be well trained. Health Education England needs to work with training providers to deliver comprehensive training for all types of practitioner who can carry out procedures. Training should be accredited by a body like the JCCP. If the Government were to introduce a mandatory register, accredited training should be a prerequisite for belonging to the register.
  6. The Government must do more to protect young people. The charity Save Face discovered that 90% of practitioners in London and Essex were not asking children their age before booking them in for lip fillers, and none required a child’s ID for a consultation.[27] This strongly suggests that, in the absence of clear legal guidance, a significant majority of cosmetic practitioners will not consider age when deciding whether to go ahead with a procedure. There is therefore a clear need for age limits, with enforcement action taken against those practitioners who do not comply.
  7. The law should also require that practitioners must be insured in order to practice. Further, insurance should not be offered unless practitioners have undergone accredited training which includes a mental health component, that has led to their registration.
  8. The Government should also establish a regulatory body, which would provide a single point of contact for patients if things go wrong. To guarantee adherence to the rules outlined above, this body must be empowered with the ability to levy fines and to ban practitioners from practising. It should also be tasked with monitoring new and emerging treatments so that the regulations can keep pace with a constantly evolving surgical and non-surgical cosmetic procedure landscape.

 

February 2022


[1] Griffiths S, Hay P, Mitchinson D, Mond J, McLean S, Rodgers B, et al. Sex differences in the relationships between body dissatisfaction, quality of life and psychological distress. Aust N Z J Public Health. 2016 Dec;40(6):518–22

[2] Jackson KL, Janssen I, Appelhans BM, Kazlauskaite R, Karavolos K, Dugan SA, et al. Body image satisfaction and depression in midlife women: The Study of Women’s Health Across the Nation (SWAN). Arch Womens Ment Health. 2014 Jun 13;17(3):177–87.

[3] Goldschmidt AB, Wall M, Choo THJ, Becker C, Neumark-Sztainer D. Shared risk factors for mood-, eating-, and weight-related health outcomes. Heal Psychol. 2016 Mar;35(3):245–52.

[4] Ibid.

[5] Smolak L, Levine MP. Body Image, Disordered Eating and Eating Disorders: Connections and Disconnects. In: Smolak L, Levine MP, editors. The Wiley Handbook of Eating Disorders, Assessment, Prevention, Treatment, Policy and Future Directions. Chichester, UK: John Wiley & Sons, Ltd; 2015. p. 1–5

[6] Swami V, Weis L, Barron D, Furnham A. Positive body image is positively associated with hedonic (emotional) and eudaimonic (psychological and social) well-being in British adults. J Soc Psychol. 2018 Sep 3;158(5):541–52.

[7] Andrew R, Tiggemann M, Clark L. Predictors and Health-Related outcomes of positive body image in adolescent girls: A prospective study. Dev Psychol. 2016 Mar;52(3):463–74.

[8] Gillen MM. Associations between positive body image and indicators of men’s and women’s mental and physical health. Body Image. 2015 Mar;13:67–74.

[9] Mental Health Foundation. Body image: How we think and feel about our bodies. [Internet]. London; 2019. Available from: https://www.mentalhealth.org.uk/sites/default/files/DqVNbWRVvpAPQzw.pdf

[10] Government Equalities Office. Body confidence: Findings from the British Social Attitudes Survey October 2014. [Internet]. London; 2014. Available from: https://www.gov.uk/government/ publications/body-confidence-a-rapid-assessment-of-the-literature

[11] Holsen I, Jones DC, Birkeland MS. Body image satisfaction among Norwegian adolescents and young adults: A longitudinal study of the influence of interpersonal relationships and BMI. Body Image. 2012 Mar;9(2):201–8.

[12] Neves CM, Cipriani FM, Meireles JFF, Morgado FF da R, Ferreira MEC. Body image in childhood: An integrative literature review. Rev Paul Pediatr. 2017;35(3):331–9.

[13] Burrowes N. Body image - a rapid evidence assessment of the literature. [Internet]. London; 2013. Available from: https://www.gov.uk/ government/publications/body-confidence-arapid-evidence-assessment-of-the-literature

[14] Holland G, Tiggemann M. A systematic review of the impact of the use of social networking sites on body image and disordered eating outcomes. Body Image. 2016; 17:100-10

[15] Cafri G, Yamamiya Y, Brannick M, Thompson JK. The influence of sociocultural factors on body image: A meta-analysis. Clin Psychol Sci Pract. 2005 May 11;12(4):421–33.

[16] Cafri G, Yamamiya Y, Brannick M, Thompson JK. The influence of sociocultural factors on body image: A meta-analysis. Clin Psychol Sci Pract. 2005 May 11;12(4):421–33

[17] House of Lords Communications and Digital Committee. Free for all? Freedom of expression in the digital age. [Internet]. London; 2021. Available from: https://committees.parliament.uk/publications/6878/documents/72529/default/

[18] Mental Health Foundation. Image editing apps and mental health. [Internet]. London; 2020. Available from: https://www.mentalhealth.org.uk/sites/default/files/MHF-Image-Editing-Apps-Briefing.pdf

[19] https://www.mentalhealth.org.uk/sites/default/files/MHF_Parenting-For-A-Healthy-Body.pdf

[20] https://www.mentalhealth.org.uk/sites/default/files/MHF_MindOverMirror_Tips-For-Young-People_v03_0.pdf

[21] Puhl R, Peterson JL, Luedicke J. Fighting obesity or obese persons Public perceptions of obesityrelated health messages. Int J Obes. 2013 Jun 11;37(6):774–82

[22] Puhl R, Luedicke J, Lee Peterson J. Public reactions to obesity-related health campaigns: A randomized controlled trial. Am J Prev Med. 2013 Jul;45(1):36–48.

[23] Puhl R, Peterson JL, Luedicke J. Fighting obesity or obese persons Public perceptions of obesityrelated health messages. Int J Obes. 2013 Jun 11;37(6):774–82

[24] Women and Equalities Committee. Changing the Perfect Picture: an inquiry into body image. [Internet]. London; 2021. Available from: https://committees.parliament.uk/publications/5357/documents/53751/default/

[25] News Medical, Researchers identify seven criteria to tackle obesity problem in the UK, 19 January 2021

[26] Be Real. Somebody Like Me: A report investigating the impact of body image anxiety on young people in the UK. [Internet]. 2017. Available from: https://www.berealcampaign.co.uk/research/somebody-like-me

[27] https://www.saveface.co.uk/revealed-lip-fillers-are-being-offered-to-children-in-the-uk/