Second Report - The impact of body image on mental and physical health

We urge the Government to immediately initiate a comprehensive cross-government strategy that brings together, at the very least, the Department of Health and Social Care, the Department for Digital, Culture, Media and Sport, and the Department for Education to tackle the current growing problem of body dissatisfaction and its related health, educational and social consequences. This strategy should include, but not be limited, to education about self-worth, body positivity, critical thinking and appraising images, as well as wider health advice such spotting signs and symptoms of eating disorders, anxiety and depression and body dysmorphia, within educational, health and online/media settings. (Paragraph 14) What drives poor body image and who does it impact?

We recommend that the Department of Health and Social Care, along with the National Institute for Health Research, commission and fund new research to understand the causal pathways that are leading to a rise in body image dissatisfaction across the population and the impact of social media on body image. This is of particular importance in relation to groups that are known to be particularly affected by body image dissatisfaction: for example, adolescents, people with disabilities and LGBT people. However, it is also vital for groups in relation to which the understanding of body image dissatisfaction is less clear, such as those from BAME communities and older people. (Paragraph 31) Impact of body image on health and lifestyle

We urge the Department to ensure more is done to make the diagnosis and treatment of Body Dysmorphic Disorder (BDD) a priority. From a diagnostic perspective, we recommend that Health Education England update the IAPT (Improving Access to Psychological Therapies) and EMHP (Educational Mental Health Practitioner) curricula to make training in BDD compulsory for all mental health practitioners. The Government should ensure BDD is included in the PSHE (personal, social, health and economic) education curricula within the section on body image, to promote early detection and early intervention within schools. As well as improved diagnosis rates, suitable care for those living with BDD must be available. We recommend that BDD specialist practitioners are eventually embedded into the multidisciplinary teams in every new community model for adults severely affected by mental illness.

We call on the Government to better equip future generations and their families with the skills and resources required to tackle body image issues. These skills and resources include critical thinking, particularly when it comes to appraising images, and self- worth. We recommend that the Government explores the use of family hubs as a route to educate parents and young people about body image, self-worth, and body positivity. (Paragraph 45) 34 The impact of body image on mental and physical health

We commend the Government’s work to date to introduce Education Mental Health Practitioners within school-based Mental Health Support Teams across the country, as well as the commitment to have a Mental Health Lead teacher in schools. We recommend that the Government review the training of these practitioners to ensure it includes spotting early signs of conditions related to body image issues. We ask the Government to provide us with a further update on their progress in introducing these roles and to set out the timeframe for establishing them in every school in England.

While we commend the funding set aside for eating disorders to date and the actions taken by the Government so far, we are now of the opinion that a more co- ordinated approach is essential to properly understand and tackle this growing issue

We recommend that the Government develops a national eating disorder strategy that aims to understand the causal mechanisms that lead to the development of eating disorders and earmarks adequate funding to bolster existing services as well as to increase investment in research. We further recommend that alongside the quarterly publication of data on existing access and waiting time standards across every region, the Government pledges and provides additional resources to address any increase in the need for treatment identified, in order to eliminate regional inequalities in care.

We recommend that the Department commissions a national review of the growing use of anabolic steroids in England as it relates to body image. We further recommend that the Department introduces a national awareness campaign around safe anabolic steroid use. This ought to be coordinated through existing steroid user support groups and targeted at areas of highest risk, such as gyms with a high proportion of body builders.

We call on the Government to work with advertisers to feature a wider variety of body aesthetics, and work with industry and the ASA to encourage advertisers and influencers not to doctor their images. We believe the Government should introduce legislation that ensures commercial images are labelled with a logo where any part of the body, including its proportions and skin tone, are digitally altered.

We echo the call of our witness Professor Sandeep Ranote for the creation of a national public health strategy akin to the 1970s ‘Green Cross Code’. A ‘Screen Cross Code’ would be a nationwide public health campaign, which would use short effective messages to educate the public on best practice with screen use for children and young people, as well as the potential negative health impacts resulting from excessive screen use or exposure to content that may lead to body dissatisfaction. This should include limits on daily screen use, promotion of social media sabbaticals, having digital sunrises/sunsets, as well as prompts to encourage discussion between parents and their children if there is content that could cause concern relating to body image and self-esteem. We recommend that the Department of Health and Social Care plays a leading role, in collaboration with the Department for Education and the Department for Digital, Culture, Media and Sport, in this work, given its implications for young people’s health. (Paragraph 69) The impact of body image on mental and physical health 35 Body image and experience of healthcare services

We urge Health Education England, the General Medical Council and Nursing and Midwifery Council to collaborate with third sector organisations that are currently educating people about, and promoting awareness of, body image issues, and after a period of assessment, integrate the most effective existing training and resources into all training programmes within the medical, nursing and midwifery fields within the next two years. We echo the Mental Health Foundation’s recommendation for any further training for professionals interacting with parents - that is, GPs, health visitors, dietitians and other frontline practitioners - to 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. (Paragraph 77) The balance of tackling obesity and reducing weight stigma

We were extremely disappointed that during the inquiry, the Government delayed the introduction of restrictions on multibuy deals on food and drinks high in fat, salt, or sugar, including buy-one-get-one-free deals. It is essential that the Government prioritises interventions that provide a healthy environment, rather than focusing solely on individual action. We are frustrated that the Government has not made more progress in tackling the obesity crisis in our population.

We propose that, in line with the introduction of Integrated Care Systems which seek to tackle health inequalities and focus on prevention, the Department ought to bolster the Healthy Child Programme, the programme for prevention and public health of children and young people aged 0–19-year-old and their families. We propose that the Government introduce annual holistic health and wellbeing assessments for every child and young person, using the existing workforce of school nurses, health visitors, as well as those in associated roles such as community paediatrics and primary care. These assessments should monitor a range of physical and mental health markers including, but not limited to, weight and mental wellbeing. They should provide an opportunity to explore the context in which the young person and their family live, how these circumstances can relate to their health. They should aim to engage the wider family (if appropriate, depending on age) to ensure early detection of potential health risks, with signposting to appropriate services if required.

We urge the Government to implement population-level policies that ensure healthier choices and lifestyles are made a priority in tackling obesity rates, rather than schemes that focus solely on weight loss and can engender weight stigma and result in adverse health outcomes. We were disappointed by the Government’s delay in restricting multibuy deals for foods and drinks high in fat, salt, or sugar–including buy one get one free. We urge the Government to reconsider this decision and to implement this measure immediately.

Throughout the inquiry, we have been aware of the importance and complexities involved in tackling obesity rates to improve population health and reducing weight stigma to not perpetuate mental and physical health issues.

We recommend that the Government undertakes an urgent review of its current campaigns related to obesity and alters any language or media used that fail to 36 The impact of body image on mental and physical health mention being underweight is as big a risk as being overweight. We also recommend that training on weight stigma is integrated into undergraduate and trainee curricula in all medical, nursing and other allied professional programmes to address stigma early on. This requires professional bodies and Health Education England to update their curricula and training standards, coupled with training offered to all current clinical staff, on how best to discuss weight and health.

There needs to be further research to establish how best to tackle obesity while eliminating weight stigma and discrimination, and to establish the efficacy of weight- neutral interventions, and we recommend that the National Institute for Health Research put aside funding for this purpose. (Paragraph 97) Non-surgical cosmetic procedures

The risk of exploitation of vulnerable groups seeking non-surgical cosmetic procedures is too great and we recommend that to prevent further exploitation, the Department immediately draws up a clear timeframe for the consultation process. We urge the Government to make this a priority and to introduce the licensing regime for non-surgical cosmetic procedures by July 2023

The dangers posed by non-surgical cosmetic procedures in vulnerable groups have been evident throughout the inquiry. The new licensing regime provides an opportunity to ensure that anyone planning to undertake a non-surgical cosmetic procedure has the time and space to consider their decision, and weigh up the risks and benefits. It is clear this is not currently the case for everyone in that position.

We recommend that the new licensing regime for non-surgical cosmetic procedures includes a commitment to a two-part consent process for anyone considering having a non-surgical cosmetic procedure, including, at a minimum, a full medical and mental health history, as well as a mandatory 48-hour cooling off period between the consent process and undergoing the procedure. We further believe that information provided to patients or clients who are considering any treatments should always be provided with information in an accessible format to ensure they are able to make an informed choice about their proposed treatment.

There should be specific premises standards for all beauty salons and non-CQC registered premises providing non-surgical cosmetic procedures. Local Authority Enforcement Officers should be given extended powers to enforce compliance with a nationally agreed set of premises standards.

We are convinced that there is a need for a minimum standard to be met in regards to the education and training of practitioners who perform non-surgical cosmetic procedures. It is essential to ensure patient safety, and thus should be a central pillar of a future licensing regime. The Professional Standards Authority should be given the power to oversee a register of approved training providers. All training providers should have to meet an Ofqual-regulated standard. (Paragraph 120) The impact of body image on mental and physical health 37

We recommend that the Department review the licencing of dermal fillers to be prescription-only substances, in line with Botox, in order to provide more protection for people undertaking procedures involving dermal fillers.

We recommend that the Department establish a ‘Non-Surgical Cosmetic Procedures’ safety taskforce that comprises each of the regulatory bodies that have input into the sector, including the MHRA, the nine statutory bodies, the ASA and stakeholders like the JCCP, Save Face and other industry bodies. This taskforce’s remit should be centred on patient safety and should include, but not be limited to, examining the issues of remote prescribing, appropriateness of premises, education and training standards as well as accountability and governance. The existence of a taskforce should provide the opportunity for a more co-ordinated approach. The taskforce should also review the impact and operation of the future licensing regime when it is in place. We also heard evidence about the difficulties in enforcing existing regulations of non-surgical cosmetic procedures, as complaints relating to an aesthetic practice often span a number of different regulators. The new safety taskforce must ensure a coordinated approach to the enforcement of new and existing regulations in the industry, and the Government must ensure sufficient resources are available to the relevant bodies.

We welcome the decision to prohibit advertising for cosmetic procedures being directed at under-18s and we look forward to the results of the 12-month review of this new measure

We recommend that the new licensing regime should include the requirement to display a kitemark and a warning logo on any advertisement for treatments that fall within the regime’s scope. (Paragraph 129) 38 The impact of body image on mental and physical health