Written evidence submitted by AnyBody (MISS0054)

Summary

Poor body image is a public health concern, backed up by decades of research that has established its negative associations and effects on self-esteem, mental health, eating, exercise, and lifestyle habits. Also supported by much evidence is the clear relationship between environmental influences that glorify the ‘ideal’ body, particularly the role of media (both traditional media and social media), and poor body image. AnyBody, founded by Dr Susie Orbach, has provided such evidence since its inception in 2002 to various different parliamentary enquiries and groups[1], as have other world-leading experts in body image and eating disorders, namely the Centre for Appearance Research at the University of the West of England. As your committee has access to these comprehensive report(s), the focus of our current contribution pertains to our recommendations regarding the introduction of government regulatory practices to mitigate the insidious messaging and practices regarding beauty standards in UK society, the majority of which promotes weight stigma, known to lead to body dissatisfaction, one of the leading risk factors for poor body image and eating disorders.

Who Are We?

AnyBody is the UK branch of global-local initiative Endangered Bodies, which aims to challenge the limited representations of bodies in contemporary society. In 2012, we launched our Ditching Dieting campaign, which aimed to educate people of the dangers of dieting and the false claim the diet industry sells that permanent weight loss is possible, as well as to provide an opportunity for people make peace with their bodies. We have successfully petitioned high-profile companies such as Facebook and Apple to implement better practises relating to body image including the removal of a “feeling fat” status update and the regulation of cosmetic surgery apps for children respectively. Most recently we have worked with parents in our Play Not Weigh campaign to assess the damaging effects of weighing children in schools.

Food Labelling in Schools

Of great concern are the governmental initiatives surrounding healthy eating lessons in schools. These include the Whole-School approach and the latest Eatwell food plate promoted by the NHS. These types of initiatives are problematic because they do not account for the complex nature of food; they are contradictory to food standards and advertisements in the real world, which can bring the opposite intended effects of promoting unhealthy relationships with food – obsession, guilt and binging – and thus have a negative impact on children’s body image.

The intention to promote informed choices around food intake has been overshadowed by the emphasis on ‘good’ and ‘bad’ food types. Clinical Psychologist, Tara Porter, states that “messages about avoiding or banning certain types of food is completely counterproductive.”[2] She has pointed to the lack of confectionary included in both the Whole-School and the Eatwell approaches. The Eatwell food plate has confectionary placed in a section outside of the plate, which makes it easy to infer that it does not fit into a balanced diet, particularly when this is paired with the Whole-school approach actively banning this type of food.

These ‘good’ and ‘bad’ labels create an unhealthy relationship with food resulting in feelings of obsession and guilt. There is evidence that both children and adults will crave a food more when being told it is off limits, meaning that restricting foods is more likely to result in binge eating than a balanced diet. Many nutritionists advise against this banning of particular foods. For example, health coach Brittany Dixon[3], has found it is much more effective to be neutral about all foods and have open discussions about why we eat more of certain foods and less of others without labelling them as ‘good’ or ‘bad’.

Food is too complex to quantify into a particular category since all foods tend to fit into a multitude. Nutritionists have argued this when discussing the problems with ‘good’ and ‘bad’ food labels. Priya Tew points out “no single food is to my knowledge nutritionally complete.”[4] Paediatrician Valerie Gent has also argued this in order to debunk the way we teach children about foods  – although carrots are considered a ‘good’ food it would be just as unhealthy to eat only carrots, as it would be to eat only cakes.[5] Based on this information it would be more effective to teach children intuitive eating – allowing them to listen to their own bodies – and an understanding of everything in moderation without a sense of guilt.

A much more effective government intervention would be to reduce the amount of unnatural sugars, colourings, and preservatives within foods, particularly those marketed to children, and decrease the amount of food related advertisement. This would help to prevent obsessive thoughts and unhealthy relationships around foods and label checking. These changes alongside an emphasis on intuitive eating and the ‘Health At Every Size’ (HAES) approach would be far more effective than the current methods in place.

The Current System of Weighing Children in Schools is Detrimental to Children’s Body Image

The National Child Measurement Programme (NCMP) was introduced in 2006 by the Department of Health for England as part of the Government’s ‘Healthy Weight, Healthy Lives’ initiative. Primary school children in Reception (4-5 year olds) and Year 6 (10-11 year olds) have their weight and height recorded and evaluated to determine whether they are “underweight”, “healthy weight”, “overweight”, “very overweight”, or “obese”. A letter is then sent to the parents, with the results of the measurements and advice on how to be “healthy”. We are a charity who champion positive body image and we have seen first-hand how an obsession with weight and dieting during childhood can have a detrimental effect on body image and mental health growing up and on into adulthood. Furthermore, children who are preoccupied with their weight and dieting in childhood are more likely to develop eating disorders later on.

AnyBody UK’s 2019 Campaign #PlayNotWeigh

In October 2019, we launched a campaign to raise awareness of the NCMP and let parents know that they could opt out of the scheme. We ran a short survey to gain a general opinion on how useful parents felt the NCMP had been for them and we gathered individual responses on whether parents felt that the NCMP had had a negative impact on their family. We promoted the survey on our social media pages and in a large London parenting Facebook group. The survey received a total of 100 responses.

77% of parents responded that they felt the current system of weighing and measuring children in school had not been helpful to them or their child. 26% of parents felt that the NCMP had a negative impact on them or their child. These are some of the individual responses we received, which are included here with their permission:

"I am surprised that there is not more concern about the effect of this on the mental health of children. Children are already bombarded with images of what they ‘should’ look like and this just seems to be adding further pressure. Eating disorders have the highest mortality rate of all mental illnesses so it’s not something to be taken lightly. Obesity is obviously an issue that needs dealing with but haven’t initiatives such as The Daily Mile been shown to be effective whilst promoting a healthy lifestyle, rather than shaming children for their weight?”

“I feel it is generally inaccurate and sends negative messages about body image and also can be confusing and worrying for parents who already offer their children a healthy balanced diet and exercise. One of my children came back as overweight and he doesn’t have a scrap of fat on him. It also doesn’t take into account how children grow, which in my experience is often out and then up. My eldest child asked for a long time afterwards about everything he ate - is this healthy? Am I allowed this? etc etc and I don’t think it’s healthy for a young child to have that frame of mind.”

"We got a letter home to say that our daughter was rated as borderline obese, that she was 3 percentile points away. She has a small frame and is short compared to other children but is muscly [sic] as she is constantly on the move, she's very physical. Consequently she's very heavy which is why she came out as borderline obese. You just have to eyeball her to know that she is not. I was incredibly angry that the focus had been on sending home a letter containing a single digit that said nothing about her health or fitness, but which clearly communicated 'you are not parenting this child well, please take better care of her'. I was also incredibly angry that had I been inclined, I could have shared this letter with her and caused her to be preoccupied with scales rather than health and fitness. I won't give permission for her to be weighed again, nor my second daughter."

"I received a letter saying my daughter was obese. I never told her but I did take her to the Dr and handed her the folded letter and just said I'd received this letter - what did she think. Across the top of the letter I wrote in red pen 'do not tell my daughter what this letter says'. The Dr was brilliant and we had a very coded conversation about how stupid she thought the whole thing was and all she was interested in is if the child was active and happy. We left the appointment without my daughter having a clue what we were talking about. The Dr said that she got loads of parents turning up in a panic and that she'd get the whole thing banned if she could. Having said all of that, it is true that there seems to be an increase in unhealthy children and I guess it would be good to find a way of identifying children whose parents need some extra support. I don't think this is the right way of doing that though."

"I always opt out for the exact reasons mentioned above. I grew up with an eating disorder for years (started about 12 and went on for about 15 years).... It wasn't just me it affected, it was my whole family. A negative body image is something I try really hard to ensure my children never experience."

The primary objective of the NCMP is to collect data for National Statistics reporting and Public Health England. A secondary outcome of the NCMP is a letter sent to parents, informing them of their child’s individual weight category. Some local authorities will also offer a referral to a “weight management programme” or a general follow up with parents; however, this is not consistent across the country. We believe that the current system of weighing children in school is not fit for purpose and has the potential to be a contributing factor towards negative body image and poor mental health in childhood and subsequently in adulthood, too.

During our campaign #PlayNotWeigh, we were contacted by many parents of children who had been incorrectly labelled in the “overweight”, “very overweight”, and “obese” categories. These letters caused confusion and stress, and undermined their parental intuition with regards to knowing what was best for their child. There is currently no study that has researched the negative implications of the post-measurement process. Many of the parents who contacted us, told us that they did not communicate the information to their child; however, it is important to consider the number of parents who do share their child’s NCMP weight status with their child and the negative consequences that can ensue. Body dissatisfaction and disordered eating are more prevalent in children whose parents encourage weight loss[6]. Even when parents do not discuss their child’s results, all children will be aware of being weighed and will have thoughts relating to their body weight and what it might mean. Some children are even aware of their weight and or BMI from the process. During our campaign, a parent told us that her child’s Reception class had been “rating” themselves in the playground, according to their BMI number:

“The kids all knew where each other were in relation to each other’s weight or BMI, I think from discussing and comparing it among themselves afterwards. My thought was just the fact that the school had made a point of measuring, made the children suddenly start comparing and talking about and looking at each other in terms of physical differences in weight, size in the class. It was certainly the spark that got them thinking and talking about it.”

Children are particularly susceptible to weight stigma and bullying. In 2017, WHO[7] reported that children in higher-weight categories were 63% more likely to experience bullying. The NCMP places children into these higher weight categories, without taking other health indicators into account.

Furthermore, Black children are more likely to be placed in the “very overweight” and “obese” weight categories due to the racially-biased method of calculating BMI[8]. Adjustments for Black children are not used, despite the research available, which not only invalidates child-weight data in areas that are ethnically diverse but increases the risk of weight stigma, bullying, and negative body image for Black children.

Focusing on weight in childhood can cause children to feel negatively about themselves and their bodies. Poor body image and a preoccupation with weight increase the risks of food restriction and developing eating disorders later on[9]. In a 2015 study, food restriction in 5-year old girls was correlated with weight bias favouring thinner bodies, with almost half of the girls expressing an internalisation of the “thin ideal” and 34% intentionally restricting their food intake[10].

The sharp increase in children suffering from eating disorders is a worrying trend. According to the recent Children’s Commissioner's report on the state of children’s mental health services, published in January 2020, there has been a 50% increase in children accessing services for eating disorders, up from 2016/17[11] and it isn’t only older children and teenagers who are at risk. The teacher’s union NASUWT published survey results in 2017, revealing that teachers had encountered children as young as 4 who were struggling with eating disorders[12].

We believe that the current system of weighing children in school should be stopped and fully reviewed for its efficacy and negative impact on children’s mental health. We would like to emphasise that mental health is equally as important as physical health in children and weight stigma in particular can have long lasting negative consequences to emotional wellbeing and quality of life. Children who are preoccupied with their body size and weight are at a greater risk of developing disordered eating and eating disorders later on. We need a better, holistic-centred approach of monitoring children’s health.

Healthcare and Weight Stigma

Weight stigma is rife within health-care settings. There are clear associations between weight stigma and poor mental health[13]. 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, and many patients are unaware that they have a choice whether to get weighed or not. Health professionals are not equipped to take a nuanced patient-centred approach to wellness, and many are troubled by disordered eating and poor body image themselves. This can lead to serious medical issues being disregarded as simply the patient being “overweight”. 

Health professionals are in a uniquely trusted position. For this reason, weight loss companies should not be permitted to sponsor the work of health professionals (as seen by Royal College of Midwives and their unseemly relationship with Slimming World[14]). The promotion of diets (marketed as ‘lifestyle changes’) should be contingent upon an evidence base of real and sustained efficacy.

Mental health is given no consideration when organisations such as Cancer Research UK are permitted to stigmatise obesity on billboards across the country[15] as though it was well in the power of individuals to make significant and sustained change to their BMI. This campaign likened obesity to smoking and was hugely triggering for people who saw it.

The prevailing discourse around obesity presents it as purely an individual responsibility, which warrants blame without taking into account issues of (for example) genetics and social inequality, or how our food is produced and marketed. Fat people are so trampled and shamed by the system that they may avoid seeking timely health advice, which can lead to devastating consequences.

Weight-loss and Muscle-building Products

Also related to the promotion of weight stigma are the extremely lucrative diet and fitness industries that rely heavily on weight-loss products and muscle-building supplements, of which many have proven to be dangerous and even fatal. Research in the New England Journal of Medicine[16] estimates that over 23,000 people in the US visited A&E due to “adverse events related to dietary supplements”, which led to more than 2000 hospitalisations each year. More than half of these cases involved young people between 20 and 34 years of age, who experienced heart-related events induced by weight-loss or energy products.

A research study published in the Journal of Adolescent Health, overseen by Harvard professor Dr Bryn Austin[17], found that health risks related to weight loss, muscle building, and energy supplements were threefold when compared to vitamin consumption. Dr Austin and her colleagues concluded that such supplements demand “proactive enforcement of regulations … to reduce access and consumption among children, adolescents, and young adults.”

As such, Act H.1942, “An Act protecting children from harmful diet pills and muscle-building supplements” has been put forth in the state of Massachusetts that aims to make it illegal for individuals 18 years and under to purchase over-the-counter supplements intended for weight loss or muscle enhancement. It advocates that all such products must be stored in a locked case to ensure that minors do not have access to them. This Act is supported by the National Eating Disorders Association, Harvard, and the UK-based iWeigh community[18], founded and led by UK activist Jameela Jamil.

In the UK, many over-the-counter weight loss and muscle-building supplements are available in health food stores, pharmacies, and sport-related shops for easy purchase with no regulations restricting adolescents and children from obtaining them. Our independent research reveals that it is up to the discretion of shop owners as to how and if they will allow underage consumers to purchase such dubious products. Here are two examples of policies from Boots and Holland & Barrett respectively:

We strongly recommend that the UK government follow suit and implement similar legislation instead of relying on businesses to assume the responsibility of protecting the health and wellbeing of our young people.

Secondly, although the UK has made specific products illegal[19], this only pertains to such products being sold in brick-and-mortar shops. As a result, consumers – many of them under the age of 18 – turn online to obtain them, often via social media. In 2019, the BBC[20] reported that, “the medical director of National Health Service England, Stephen Powis, called for a ban on celebrity-endorsed social media ads promoting weight loss aids, stating that products were having a damaging effect on the physical and mental health of young people.” As of September 2019, the social media giant, Instagram, updated its Community Guidelines[21] restricting users under 18 years of age from viewing any promotion of weight-loss products or cosmetic procedures. Such content will also be removed if it touts unsubstantiated claims or provides a discount on its product or service.

While this is a positive step in the right direction, it is only one social media network out of many. We assert that governments on a global level can be doing more to support social media networks in protecting its young users. In addition to our recommendation of banning the sale of such products to underage consumers throughout the UK, tighter regulations on such products across social media sites are required, as is the clear labelling of adverts as adverts, such as with promoted influencer content.

Diversity in the Media

It is understood that concerns about body image start from a young age and a well-documented vehicle for these ideas is through the media that young people consume.

A 2010 analysis[22] of studies into media and weight stigma over the previous 15 years found that fat characters of animated cartoons were three times more likely to be portrayed as unattractive and often, less intelligent, unhappy, and more violent.

When looking at movies and books aimed at 4-8 year olds, they found that with “72% of the movies and 10% of the books, thin characters were associated with positive traits. In 64% of the movies and 20% of the books, obese characters – human and animal alike – were most often portrayed as possessing negative traits and, subsequently, tended to be disliked by others.”

They concluded that “overall, the data indicate that a wide range of media – from television shows to books, newspapers, and the internet – portray overweight and obese individuals in a stigmatising manner.”

A paper published in the Journal Pediatrics[23] in 2017 states that: “Beyond the school and home settings, youth are additionally vulnerable to weight stigma through the media. Content analyses of popular children’s television shows and movies reinforce weight stigma through stereotypical portrayals of characters who appear to have larger body sizes. Characters who are visually slim in children’s media are often portrayed as being kind, popular, and attractive, but characters with larger body sizes are depicted as aggressive, unpopular, evil, unhealthy, and the target of humour or ridicule. A content analysis of recent children’s movies found 70% included weight-related stigmatising content, of which 90% targeted characters with obesity. Similarly, research examining popular adolescent television shows identified a significantly higher proportion of weight-stigmatising content in youth-targeted shows (50%) compared with shows targeting a general audience (38.3%). Given that youth spend multiple hours per day watching television and other media, there is a considerable likelihood they are exposed to negative weight-based stereotypes and stigma. Furthermore, research has documented associations between greater media exposure among youth and increased expressions by those youth of weight stigma toward peers with overweight and obesity. Taken together, this evidence highlights youth-targeted media as sources of weight-based stereotypes that may reinforce and add to stigmatising messages communicated to children at school and home.”

To tackle this, we need to increase diversity of marginalised populations in children’s literature and all media. This includes fat bodies, Black and Brown bodies, queer bodies, non-binary and trans bodies. This can be achieved by ensuring that libraries stock a diverse selection of books for all ages, making sure that books used in schools contain a diversity of characters and creating a rating for media which identifies how diverse it is. This will allow parents to better monitor the media that their children consume.

Conclusion

Given the UK government’s investment in understanding and acting on the issue of poor body image, the UK is positioned to be a leader in educating other nations by example in aiming to eradicate the body image risks children, teens, and adults are face every day.

July 2020

Endnotes