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Written Evidence Submitted by Beat (MISS0020) Recommendations • the Government and Other Key Health Research Funders Increase

Written Evidence Submitted by Beat (MISS0020) Recommendations • the Government and Other Key Health Research Funders Increase

Written evidence submitted by (MISS0020)

Recommendations

 The Government and other key research funders increase funding for research into the aetiology, prevention and treatment of disorders in line with the prevalence and severity of these conditions. This could significantly develop our understanding of the interactions between poor and the development and maintenance of eating disorders.

 NHS England and NHS Improvement ensure that any Support Team which plans to design and/or deliver interventions aimed at reducing symptoms and body image concerns are a) able to benefit from the expertise of a local Community Eating Disorder Service for Children and Young people and b) subject to robust evaluation of the outcomes of such interventions.

 NHS England and NHS Improvement support South London and Maudsley NHS Foundation Trust’s outpatient eating disorder service and the ‘First Episode Rapid Early Intervention for Eating Disorders’ (FREED) network to share with other treatment providers the knowledge they have developed in supporting patients to use social media and apps in positive ways.

 The Government facilitates dialogue and collaboration between the professional fields of public health and eating disorders, to ensure that media campaigns and public health programmes aimed at reducing do not inadvertently undermine efforts to encourage healthy body image and cause harm to people with eating disorders and those who may be vulnerable to developing one.

 The independent regulator for online safety works with UK Research and Innovation and other partners to commission further research into the impacts of social media on body image and eating disorders.

 The independent regulator for online safety includes within a code of practice that users who search for or are exposed to content that encourages eating disorders, and users who attempt to post/upload such content are directed to appropriate sources of support, such as Beat.

 The independent regulator for online safety includes within a code of practice that social media algorithms must not promote content that encourages eating disorders.

 The independent regulator for online safety includes within a code of practice that social media companies work with experts in eating disorders to ensure that their policies and practices protect the welfare of users with eating disorders (and that moderators receive appropriate training).

Introduction

As the UK’s eating disorder charity, Beat often serves as a first port of call on the journey to recovery, supporting both people with eating disorders and their families and friends through their helplines and support groups. We raise awareness through our network of Ambassadors, as well as providing services such as training in schools, universities, and among healthcare professionals.

We are submitting evidence to this inquiry to highlight to Government and other policy makers that poor body image can be a for the development of eating disorders and can further complicate recovery. We make recommendations to Government and other policy makers regarding the steps they can take to help improve body image/reduce body dissatisfaction, based on what we have learnt from the experiences of people with eating disorders and those who support them.

About Eating Disorders

An estimated 1.25 million people in the UK have an eating disorder1. The most common age of onset is between 15 and 25 years old, during a developmentally sensitive time2. Although prevalence is higher in young females, males constitute approximately one in four cases3 and recent research suggests that prevalence in middle aged and older people may be much higher than previously assumed4;5. Eating disorders are severe mental illnesses6. nervosa has the highest mortality rate of any mental health condition, and the mortality rates of , disorder and other eating disorders are also high7; 8. People with eating disorders typically develop serious physical health problems through , bingeing, purging or over- exercise. An eating disorder can often exacerbate symptoms associated with other mental health conditions including , and OCD9. In many cases participation in education or employment is significantly compromised or becomes impossible2. Feelings of loneliness and isolation are common. Overall quality of life in eating disorders has been estimated to be as low as in symptomatic coronary heart disease or severe depression2.

1.0 The impact of poor body image 1.1 Eating disorders are serious and complex conditions caused by a combination of risk factors. Poor body image can be one of these factors that increases the risk of developing an eating disorder10; 11; 12. It typically co-exists with low self-esteem which has also been identified as an important risk factor12. However many people will experience poor body image/body dissatisfaction during their lives without developing an eating disorder. 1.2 Further research is required to develop our understanding of how poor body image - through interaction with biological, psychological and environmental factors – can increase the risk of developing an eating disorder. 1.3 Poor body image is common in eating disorders13. In a recent study of eating disorder treatment outcomes body image flexibility (a protective positive body image construct) was the strongest predictor and moderator of the severity of eating disorder symptoms; with higher scores for body image flexibility predicting lower eating disorder psychopathology14.

1.4 Further research is required to test whether these findings are replicated, to investigate the impact of prioritising positive body image within eating disorder treatment and the most effective ways to do this14; 15.

1.5 Analysis by the charity MQ found that just £9 per person affected is spent by UK- based funders on mental health research per year, with eating disorder research receiving just 96p per person affected16. Although Mental ill health accounts for approximately 23% of NHS activity17, the National Institute for Health Research (NIHR) awarded just 10% of its research funding to mental health research in 2018/201918. Just 0.09% of its health research budget was awarded to eating disorders research18.

1.6 Beat recommends that the Government and other key health research funders increase funding for research into the aetiology, prevention and treatment of eating disorders in line with the prevalence and severity of these conditions. This could significantly develop our understanding of the interactions between poor body image and the development and maintenance of eating disorders.

2.0 Media

2.1 It is important to recognise that social media platforms can be used to promote positive body image and can help users to access information and support on eating disorders.

2.2 Research suggests that use of image-based social media can lead to greater body dissatisfaction, particularly when used in ways that facilitate unhealthy social comparison19.

2.3 Some content which does not actively promote eating disorders, for example images of very individuals, can still be harmful and triggering to people with eating disorders.

2.4 In section 3.0 we have made recommendations around the regulation of social media companies aimed at improving understanding regarding both the impacts that social media use can have on body image and eating disorders and how these can best be mitigated.

2.5 Greater diversity in the images used by media companies and advertisers could help to reduce the pressures which some people feel to adhere to a narrowly defined ‘body ideal’, which is often - but not exclusively - based around the pursuit of thinness in females and muscularity in males20; 21.

3.0 Regulation

3.1 The evidence review conducted for the Government’s Transforming Children and Young People’s Mental Health Provision: a Green Paper22 found that group-based interventions targeting internalisation of the ‘’ can be effective in reducing eating disorder symptoms and body image concerns in adolescent females.

3.2 This Green paper22 suggests that the new Mental Health Support Teams (MHSTs) could deliver such interventions in schools and colleges. Beat recommends that NHS England and NHS Improvement ensure that any Mental Health Support Team which plans to design and/or deliver interventions aimed at reducing eating disorder symptoms and body image concerns are a) able to benefit from the expertise of a local Community Eating Disorder Service for Children and Young people and b) subject to robust evaluation of the outcomes of such interventions.

3.3 South London and Maudsley NHS Foundation Trust’s outpatient eating disorders service has published a useful guide for patients and carers: Social Media and Apps – Friends or Foes?23 This includes information on media literacy and advice on how to use social media and apps in positive ways.

3.4 The ‘First Episode Rapid Early Intervention for Eating Disorders’ (FREED)’ network has created an animation in collaboration with experts by experience which explains how unhealthy interaction with social media can hinder recovery from an eating disorder24. The FREED care pathway is designed to provide treatment which “pays special to the challenges which young people with an eating disorder face”, including learning to develop a healthy relationship with social media25.

3.5 The Mental Health Implementation Plan 2019/20-2023/246 states that “NHS England and NHS Improvement will document and share learning from areas that are already delivering an enhanced offer to young adults so local systems can adapt their models of care.” (p.20). Beat recommends that NHS England and NHS Improvement support South London and Maudsley NHS Foundation Trust’s outpatient eating disorder service and the ‘First Episode Rapid Early Intervention for Eating Disorders’ (FREED) network to share with other treatment providers the knowledge they have developed in supporting patients to use social media and apps in positive ways.

3.6 Some public campaigns aimed at reducing obesity such as the ‘100 calorie snack’ campaign have endorsed restrictive dietary rules and framed certain foods as ‘bad’. This poses significant risks to those who are vulnerable to developing an eating disorder (or experiencing a ), including people with poor body image. For people with an eating disorder it can make recovery more difficult, as it can reinforce some of the beliefs and behaviours which treatment aims to challenge26.

3.7 Multiple factors (including mental health and socio-economic status) can contribute toward obesity27. Public health campaigns which present behavioural change as a simple ‘choice’ have the potential to exacerbate stigma and appearance-based bullying, which can have major detrimental effects on body image and help seeking27; 28.

3.8 The Government mandates Public Health England and local authorities in England to deliver the National Child Measurement Programme29. The focus that this programme places on weight, rather than health, can lead to poor body image/body dissatisfaction and pose significant risks to children who may be vulnerable to developing an eating disorder27; 30; 31.

3.9 Beat recommends that the Government facilitates dialogue and collaboration between the professional fields of public health and eating disorders, to ensure that media campaigns and public health programmes aimed at reducing obesity do not inadvertently undermine efforts to encourage healthy body image and cause harm to people with eating disorders and those who may be vulnerable to developing one.

3.10 To support the Government to create appropriate policies regarding the impact of social media on body image and eating disorders, further research is required to address various gaps in the evidence-base19. Beat recommends that the independent regulator for online safety32 works with UK Research and Innovation and other partners to commission further research into the impacts of social media on body image and eating disorders.

3.11 Some social media accounts, websites and forums contain ‘pro-eating disorders’ content, such as ‘tips’ about extreme and concealing symptoms33. Some people who develop an eating disorder may not have insight into their illness and may come to perceive the associated behaviours and symptoms as being part of their identity. Eating disorders are often described as isolating34 and it is common for people with eating disorders to worry about being judged and misunderstood9. Research has found that generally access to pro-eating disorders websites, forums and social media accounts is motivated by a desire to feel understood and accepted as part of a community35.

3.12 Beat offers a range of moderated pro-recovery online peer support services (including some designed for children and young people). These groups are confidential, inclusive and welcoming spaces for anyone with an eating disorder where they can share experiences with others in similar situations 36.

3.13 ‘Pro-eating disorders’ content is typically posted/uploaded by people who themselves are suffering with an eating disorder, without being deliberately malicious. 3.14 Beat recommends that the independent regulator for online safety32 includes within a code of practice that users who search for or are exposed to content that encourages eating disorders, and users who attempt to post/upload such content are directed to appropriate sources of support, such as Beat.

3.15 The algorithms developed by social media companies can mean that those who search for or engage with any harmful eating disorder-related content are quickly directed down a ‘rabbit hole’ of similar content. Beat recommends that the independent regulator for online safety32 includes within a code of practice that social media algorithms must not promote content that encourages eating disorders.

3.16 Eating disorders are serious and complex conditions. Social media can be a vital source of information and support for people with eating disorders, including for vulnerable users who have posted potentially harmful content. Beat recommends that the independent regulator for online safety32 includes within a code of practice that social media companies work with experts in eating disorders to ensure that their policies and practices protect the welfare of users with eating disorders (and that moderators receive appropriate training).

June 2020 References

1 Beat. (2018) How many people have an eating disorder in the UK? Available from: beateatingdisorders.org.uk/how-many-people-eating-disorder-uk. 2 Schmidt, U., Adan, R., Böhm, I., Campbell, I.C., Dingemans, A., Ehrlich, S., Elzakkers, I., Favaro, A., Giel, K., Harrison, A., Himmerich, H., Hoek, H.W., Herpetz-Dahlmann, B., Kas, M.J., Seitz, J., Smeets, P., Sternheim, L., Tenconi, E., van Elburg, A., van Furth, E. and Zipfel, S. (2016) Eating disorders: the big issue. The Lancet . Vol. 3(4), p.313-315. Available from: researchgate.net/publication/300368547_Eating_disorders_The_big_issue 3 Sweeting, H., Walker, L, MacLean, A., Patterson, C., Räisänen U. and Hunt, K. (2015) Prevalence of eating disorders in males: a review of rates reported in academic research and UK mass media. International Journal of Mens Health. Vol.14(2). Available from: ncbi.nlm.nih.gov/pmc/articles/PMC4538851 . 4 Micali, N., Martini, M.G., Thomas, J.J., Eddy, K.T., Kothari, R., Russell, E., Bulik, C.M. and Treasure, J. (2017) Lifetime and 12-month prevalence of eating disorders amongst women in midlife: a population-based study of diagnoses and risk factors. BMC Medicine. Vol.15(12). Available from: doi.org/10.1186/s12916-016- 0766-4. 5 Conceição, E.M., F.V.S., Gomes, Vaz, A.R., Pinto-Bastos, A. and Machado, P.P.P. (2017) Prevalence of eating disorders and picking/ nibbling in elderly women. International Journal of Eating Disorders. Vol.50(7) p.793-800. Available from: doi.org/10.1002/eat.22700. 6 NHS England and NHS Improvement. (2019) NHS Mental Health Implementation Plan 2019/20 – 2023/24. Available from: longtermplan.nhs.uk/wp-content/uploads/2019/07/nhs-mental-health-implementation-plan- 2019-20-2023-24.pdf. 7 Arcelus J., Mitchell A.J., Wales J. and Nielsen S. (2011) Mortality rates in patients with and other eating disorders. A meta-analysis of 36 studies. Archives of General Psychiatry. Vol. 68(7), p.724-31. Available from: jamanetwork.com/journals/jamapsychiatry/fullarticle/1107207. 8 Chesney, E., Goodwin, G.M., and Fazel, S. (2014) Risks of all-cause and mortality in mental disorders: a meta-review. World psychiatry: official journal of the World Psychiatric Association (WPA), Vol.13(2), p.153–160. https://doi.org/10.1002/wps.20128. 9 NHS England. (2015) Access and Waiting Time Standard for Children and Young People with an Eating Disorder. Available from: https://www.england.nhs.uk/wp-content/uploads/2015/07/cyp-eating-disorders- access-waiting-time-standard-comm-guid.pdf. 10 Rohde, P.. Stice, E. and Nathan Marti, C. (2015) Development and predictive effects of eating disorder risk factors during : Implications for prevention efforts. International Journal of Eating Disorders. Vol.48(2), p.187-198. https://doi.org/10.1002/eat.22270. 11 Stice, E., Gau, J.M. Rohde, P. and Shaw, H. (2017) Risk factors that predict future onset of each DSM–5 eating disorder: Predictive specificity in high-risk adolescent females. Journal of Abnormal Psychology, Vol .126(1), p.38-51. https://doi.org/10.1037/abn0000219. 12 Santarossa, S. and Woodruff, S.J. (2017) #SocialMedia: Exploring the Relationship of Social Networking Sites on Body Image, Self-Esteem, and Eating Disorders. Social Media + Society, Vol.3(2). https://doi.org/10.1177%2F2056305117704407. 13 Amianto, F. and Fassino, S. (2018) Body Image and . In: Cuzzolaro, M., Fassino, S. (Eds.) Body Image, Eating and Weight. Cham: Springer. https://doi.org/10.1007/978-3-319-90817-5_10. 14 Pellizzer, M.L., Waller, G. and Wade, T.D. (2018) Body image flexibility: A predictor and moderator of outcome in transdiagnostic outpatient eating disorder treatment. International Journal of Eating Disorders. Vol. 51(4), p.368-372. https://doi.org/10.1002/eat.22842. 15 Anderson-Fye, E. R. (2018) Cultural influences on body image and eating disorders. In: Agras, W.S. and Robinson, A. (Eds.) Oxford library of psychology. The Oxford handbook of eating disorders. Oxford: Oxford University Press. P.187-208. [Abstract available from: https://psycnet.apa.org/record/2018-08896-009.] 16 MQ (2019) UK Mental Health Research Funding 2014-2017. Available from: https://www.mqmentalhealth.org/articles/research-funding-landscape. 17 Independent Mental Health Taskforce (2016) The Five Year Forward View for Mental Health. Available from: https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf. 18 UK Parliament (2020) Eating Disorders: Research: Written question – 12277. Available from: https://www.parliament.uk/business/publications/written-questions-answers-statements/written- question/Commons/2020-02-04/12277/. 19 Holland, G. and Tiggemann, M. (2016). A systematic review of the impact of the use of social networking sites on body image and outcomes. Body Image. Vol.17. 100-110. https://doi.org/10.1016/j.bodyim.2016.02.008. 20 Mental Health Foundation. (2019). Body Image: How we think and feel about our bodies. Available from: https://www.mentalhealth.org.uk/sites/default/files/DqVNbWRVvpAPQzw.pdf. 21 Butterfly Foundation (2020) Frequently Asked Questions. Available from: https://butterfly.org.au/resources/frequently-asked-questions/. 22 Department of Health and Department for Education (2017) Transforming Children and Young People’s Mental Health Provision: a Green Paper. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Trans forming_children_and_young_people_s_mental_health_provision.pdf. 23 FREED (2020a) Social media and Apps: Friends or Foes? Available from: https://freedfromed.co.uk/img/guides/Social_Media_And_Apps-FREED.pdf. 24 FREED (2020b) Social media, food and me. Available from: https://freedfromed.co.uk/news-and- stories/37/social-media-food-and-me. 25 FREED (2020c) What is FREED? Available from: https://freedfromed.co.uk/freed-for-all. 26 Beat (2018) Beat’s response to Change4Life’s 100 calorie snacks campaign. Available from: https://www.beateatingdisorders.org.uk/news/change4lifes-100-calorie-campaign. 27 BPS (2019) Psychological perspectives on obesity: Addressing policy, practice and research priorities. Available from: https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20- %20Files/Psychological%20Perspectives%20on%20Obesity%20- %20Addressing%20Policy%2C%20Practice%2C%20and%20Research%20Priorities.pdf. 28 Butterfly Foundation (2020b) Health not Weight. Available from: https://butterfly.org.au/body-image/health- not-weight/. 29 HM Government (2020) National child measurement programme. Available from: https://www.gov.uk/government/collections/national-child-measurement-programme#guidance-for-local- authorities. 30 Nnyanzi L. (2012) The national child measurement programme: Its value and impact. Available from: https://research.tees.ac.uk/en/studentTheses/the-national-child-measurement-programme-its-value-and- impact. 31 JM, Tomiyama AJ. (2018) Weight labeling and disordered eating among adolescent girls: Longitudinal evidence from the national heart, lung, and blood institute growth and health study. Journal of Adolescent Health. Vol.63(3), p.360–2. Available from: https://www.jahonline.org/article/S1054- 139X(18)30011-9/fulltext. 32 HM Government (2019) Online Harms White Paper. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/793360/Onlin e_Harms_White_Paper.pdf 33 Rodgers, R. Lowly, A. Halperin, D.M. Franko, D.L. (2016) A Meta-Analysis Examining the Influence of Pro- Eating Disorder Websites on Body Image and Eating Pathology. European Eating Disorders Review. Vol.24(1), p.3-8. Available from: http://onlinelibrary.wiley.com/doi/10.1002/erv.2390/abstract. 34 Treasure, J. Nazar, B.P. (2016) Interventions for the Carers of Patients With Eating Disorders. Current Psychiatry Reports. Vol.18(2):16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4718944/. 35 Gale, L. Channon, S. Larner, M. James, D. (2016) Experiences of using pro-eating disorder websites: a qualitative study with service users in NHS eating disorder services. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. Vol. 21(3), p.427-434. Available from: https://link.springer.com/article/10.1007/s40519-015-0242-8. 36 Beat (2020) Support services. Available from: https://www.beateatingdisorders.org.uk/support-services.

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