Eating Disorders Awareness Week

George Howarth Excerpts

Thursday 5th March 2020 Westminster Hall

[Sir George Howarth (Knowsley) (Lab)]

I beg to move,

That this House has considered Eating Disorders Awareness Week 2020.

It is a pleasure to serve with you in the Chair, Mr Rosindell. May I say how glad I am to have secured this debate during Eating Disorders Awareness Week? I am glad that we have the opportunity to talk about how people acquire eating disorders and how they can, or should, be able to get the help they need.

Let me place on record my thanks to all the people and organisations who helped me to prepare for this debate. It is a long list, so I hope hon. Members will bear with me, because they deserve to be highlighted: Sandie Atkinson from Diabetics with Eating Disorders, Beat Eating Disorders, the Royal College of Psychiatrists, the British Psychoanalytic Council, the Musicians’ Union, Equity the acting union, the British Dietetic Association, Professor Khalida Ismail of King’s College, London, Hope Virgo of the Dump the Scales campaign, the Priory Group, the House of Commons Library, which has produced a really good briefing, as always, the Parliamentary and Health Service Ombudsman, which has also provided a briefing, and Julia Tyson.

Some 1.25 million people are living with an eating disorder, 10% of whom suffer with anorexia nervosa, and 40% with bulimia; the remainder suffer from other forms such as binge eating. Research shows that the earlier the treatment is accessed, the better the chance of recovery. The figures show that 50% recover and 30% experience some improvement. Worryingly, however, 20% remain in a chronic condition. The most common age of onset is 15 to 25, although there is growing evidence that older people are affected as well.

I want to touch on three areas: first, diabulimia, which is a form of eating disorder that many may be unaware of; secondly, the interplay between the entertainment industry and social media, and the impact they have on people’s sense of their own appearance; and thirdly, treatment.

Diabulimia is a form of eating disorder that affects thousands of people with type 1 diabetes. We cannot give an accurate figure, because of how incidents are recorded—it will show up as an eating disorder but not necessarily for somebody who has diabetes. Simply by withholding insulin, type 1 diabetics are able to attain rapid weight loss. There are, however, serious physical health consequences, and it can be fatal. I will not say too much on this topic, although I will return briefly to it later, other than that the right hon. Member for Maidenhead (Mrs May) has agreed to co-chair an inquiry into this matter with me, which we hope to commence later in the year. The right hon. Lady and I intend that the inquiry will raise awareness of diabulimia and look at evidence of what practical steps can be taken to improve the treatments available.

The relationship between the entertainment industry and eating disorders is complex but real. It has been described as a vicious circle, whereby some musicians and actors are put under pressure to look a certain way. In many well-documented cases they subject themselves to eating habits that, as they see it, enable them to achieve that appearance. However, that is not without consequence for their mental and physical wellbeing.

Let me explain what I mean. The actress and Equity activist Jean Rogers has drawn my attention to the work of Dr Sara Reimers of Royal Holloway, University of London, on aesthetic labour, which is defined as

“the employment of workers with desired corporeal dispositions”

whereby

“employers intentionally use the embodied attributes and capacities of employees as a source of competitive advantage.”

That work formed the basis of the “Making an Appearance” research she conducted with the Equity women’s committee.

Maureen Beattie, the president of Equity, has given an account of her own eating disorder as an actress, which she struggled with from the age of 14 to 30. She said:

“When I was at drama school I found the mixed messages I received very confusing—on the one hand I was told I was a big, fat lump of a girl and on the other hand was always cast in leading lady roles which required elegance and charm and attractiveness. There was a lot of pressure on me to lose weight, but the more the staff (and my parents who were both in the entertainment industry) lectured me about my weight the more I needed to eat. I ate so much I sometimes felt like I had been drugged. I realise now I was protecting myself”.

She says that the pressure of acting contributes to eating disorders:

“The feeling of being an object to be pushed and pulled and commented on and criticised and laughed at by the public is very real to many people.”

Recently, on “Desert Island Discs”, Melanie Chisholm, the former Spice Girl Mel C, said:

“I was described as the plain one at the back…I ended up making myself really ill. I was anorexic for a few years. I was exercising obsessively, and I ended up being incredibly depressed. I was in denial.”

After being diagnosed, she described going from anorexia

“to having a binge-eating disorder”.

Tellingly, she concluded that her

“appearance began to change, which was the biggest fear”.

In the documentary “Miss Americana”, the hugely successful international singer Taylor Swift talked about how, as an 18-year-old, she was portrayed on the cover of a magazine. She said:

“The headline was ‘Pregnant at 18?’ and it was because I had worn something that made my lower stomach look not flat. So, I just registered that as a punishment”.

Consequently, she said of her performances that she

“thought I was supposed to feel like I was going to pass out at the end of a show, or in the middle of it”.

It is not only young women who are affected by eating disorders—the singer Sam Smith has talked about starving for weeks to prepare for photoshoots.

A 2016 Credos survey of 1,000 boys aged between eight and 18—“Picture of Health?”—found that 55% would consider changing their diet to look better. Interestingly, the survey also found that respondents felt under pressure from other factors to look good, with 68% citing friends, 58% social media, 53% advertising, and 49% celebrities.

Another disturbing aspect is how a performer’s body shape is changed digitally. Victoria Hesketh, who performs under the name Little Boots, has drawn attention to the use of photoshopping to alter the appearance of artists, citing the case of the singer Meghan Trainor, herself a campaigner on the misuse of body image, whose 2016 video “Me Too” had been digitally manipulated to reduce her waist size without her express consent. Ms Hesketh commented in an article in The Independent:

“This stuff is nothing new, but I’m not sure if people really realise the extent to which image manipulation really matters, especially in pop music videos and even more so with female artists.”

She continued:

“I remember a music video director once telling me”—

this is really shocking—

“‘You should have seen Beyoncé’s ass before we got in the edit’.”

Let us think about the implications of what the editor in those circumstance thought was his responsibility. It is quite frightening.

In 2011, as part of their “Pretty as a picture” project, Jo Rigby and the advertising think-tank Credos commissioned Panelbase to conduct an online survey of 1,000 girls and young women aged between 10 and 21. Since that time, the fashion industry has become significantly more sensitive about body shape for models, which is to be welcomed. The survey found that 53% of young women took

“inspiration from adverts for their appearance”,

and that 37% wanted to

“look like models they see in adverts”,

even though 85% of them

“recognise that...images in advertising have been altered using airbrushing.”

Worryingly, about half of the young women involved admitted:

“Seeing adverts using thin models makes me want to diet/lose weight/feel more conscious of the way I look.”

On the issue of social media, Girlguiding UK’s “Girls’ Attitudes Survey 2019” concluded:

“Girls and young women say they’re aware of the difference between real life and what they see represented online and in the media. Almost half of girls regularly remind themselves that social media is not a real reflection of others’ lives. One solution may be making sure airbrushed pictures are always labelled as such, with over half of girls agreeing to this. Nearly half of girls agreed there should be a more diverse range of people on screen too.”

My point in citing those examples is to make a connection between what we see and the reality of young people trying to emulate the stars that they see as role models, which I described earlier as being a vicious circle.

Another pressure turbocharges this phenomenon—namely, the way in which social media can serve as a means of shaming people about their appearance. I confess that I find that to be an ethical minefield. In an open society, we rightly defend the principle of freedom of speech, but when that freedom normalises abuse and shaming, the platforms and the individuals who use them surely have to take responsibility for what is said and the potential consequences. What might seem a bit of fun can very easily have devastating consequences when it targets people in such a way as to drive them towards eating disorders.

In last week’s New Statesman, Amelia Tait wrote about personal responsibility for those who engage with social media. She stated:

“It’s not up to algorithms to change our behaviour, it’s up to us. We have to stop celebrating cruelty with our clicks, and instead make a conscious effort to reward people who are kind to others or people who call out poor behaviour when they see it.”

Social media platforms need to recognise how they can profoundly affect people’s mental health and behaviour. Either they accept that responsibility or, sooner rather than later, they will have to be regulated to do so. We all have an important role to play through the language we use. When we say things such as, “You need to grow a thicker layer of skin”, or “Get a grip”, that is not helpful. The effort required to tackle an eating disorder of any description is profound and massive. Simply telling people to “get a grip” does no good at all.

I said earlier that I am indebted to the charity Beat, among others, for its help in preparing for this debate. Its key policy suggestions are based on the current treatment available for adults, treatment for young people, medical training and research funding. My constituent Emily helps raise funds for Beat and has organised sponsored walks with her family and friends, which I have been pleased to support and I am probably healthier for having taken part.

Beat has pointed out:

“Adults with eating disorders in England face a postcode lottery”

in trying to access treatment. Only 26% of adult patients commenced treatment at a specialist service within four weeks of being referred. The average wait is nine weeks. In some clinical commissioning groups, adults are first referred to a non-specialist health service or to a panel for approval before being referred to a specialist service. That inevitably creates delays, which in some cases can have tragic consequences.

Beat and the Royal College of Psychiatrists suggest that a funded access waiting time standard should be introduced for all adults with eating disorders in England. An access and waiting time standard has already been introduced for the treatment of young people with eating disorders. By 2020-21, it is hoped that 95% of children and young people will commence treatment approved by the National Institute for Health and Care Excellence within one week of referral for urgent cases and within four weeks for less urgent ones. The most up-to-date information across clinical commissioning groups, however, shows that the rate for meeting the urgent referral target varies between 22% at worst and 100% at best. Beat is calling for the access and waiting time standard for children and young people with an eating disorder to be met in every area across England.

A further concern raised by Beat is that eating disorders are not sufficiently covered during medical training. On average, medical schools spend less than two hours teaching about eating disorders. One in five provide no training at all, and many do not even include a question on eating disorders in their final exams. As one fourth-year medical student put it:

“We don’t get any clinical skills experience.”

For those reasons, Beat recommends:

“Eating disorders are appropriately taught and assessed at all medical schools”,

and that all junior doctors in the UK

“gain...clinical experience during their foundation training.”

The Royal College of Psychiatrists has called on the Government to double the number of medical school places in order to provide the specialists needed to help people with eating disorders. I echo that call.

Beat’s final point relates to research funding. Given that the broader category of mental health accounts for 23% of NHS activity in 2018-19, 10% of the Department of Health’s research funding goes to mental health research, with just 0.09% devoted to eating disorders. That amounts to 96p per sufferer, compared with £228 per person spent on vital cancer research that has led to survival rates for cancer doubling over the past 40 years. I mention that not to suggest that too much money is being spent on cancer research, but because it shows that if more money is put into research, results follow. Beat is calling for a “significant increase” in funding for research into eating disorders.

Hope Virgo of the Dump the Scales campaign last week launched the z-cards campaign, a guidance resource for those with eating disorders and those supporting them. It has the timely and important aim

“to raise awareness of eating disorders”

and provide

“an educational piece for all frontline staff.”

Dump the Scales is asking the Government to recommit to NICE guidance 1.2.8:

“Do not use single measures such as BMI or duration of illness to determine whether to offer treatment for an eating disorder.”

The Royal College of Psychiatrists makes the same point. Hope Virgo is also calling for support for the roll-out of the z-card, training for GPs on eating disorders, and the development of a meaningful way of measuring the implementation of the guidelines, together with an annual implementation review.

I want to deal with the question of the best form of treatment for eating disorders. I have spoken to many people who have experienced them, and some believe that long-term residential treatment, sometimes including cognitive behavioural therapy, has been beneficial. There is, however, no consensus about cognitive behavioural therapy. Some experienced psychiatric specialists argue that although it may be a short-term way of dealing with the immediate problem it is not necessarily a long-term solution, in that it does not address the underlying cause of the disorder. I do not intend to draw any conclusions on that difference of professional opinion because, frankly, I do not feel equipped to do so, but I will refer back to the matter shortly. Some treatments at private healthcare facilities have been cited as having a positive effect on people’s eating disorders. However, such treatment can be very expensive and is usually beyond the means of most sufferers and their families.

Sandie Atkinson of Diabetics with Eating Disorders has said that there is still a desperate need to make insulin omission for weight loss, also known as diabulimia, a diagnosable condition. DWED supports the use of “type 1 eating disordered”, or T1ED, as an umbrella term for all disordered eating occurring in type 1 diabetes. The diagnosis would include subcategories for anorexia, bulimia and diabulimia, as insulin omission can occur separately or alongside other eating disorder symptoms.

I have a number of questions I want to address to the Minister, although I do not necessarily expect answers to all of them today. First, will she give careful consideration to the suggestions that DWED, Beat, and Dump the Scales have made about eating disorders, and will she undertake to respond in some form of written statement when she has had the opportunity to look at them more carefully? Secondly, will she undertake a review of the long-term effectiveness of cognitive behavioural therapy to assess its efficacy for treating eating disorders? Thirdly, will she undertake to meet representative bodies of the entertainment industry, Equity and the Musicians’ Union, to discuss the relationship between the promotion of a certain type of body image and the way in which it can affect young people? Finally, will she hold a similar meeting with social media providers to discuss what more they should do to prevent their platforms from enabling abusive behaviour, which shames some young people into acquiring eating disorders?

I hope we can agree that the issue of eating disorders is in need of urgent attention, not least because of the serious implications it has for the health and wellbeing of so many people and their families.

--- Later in debate ---

[Sir George Howarth]

It is always a pleasure to talk to the Minister. I start by thanking everybody who took part in the debate. The hon. Member for Broxbourne (Sir Charles Walker) spoke movingly on behalf of his constituents. As he knows, I have met them. They are a formidable couple who are trying to turn their grief into something positive, and I applaud them for that.

The right hon. Member for Romsey and Southampton North (Caroline Nokes) has been, along with me, ploughing this somewhat lonely furrow over many years. It is always a pleasure to have her as a combatant in the battle that we have been conducting. As ever, we saw the compassion of the hon. Member for Strangford (Jim Shannon), which is legendary—in this Chamber and elsewhere and certainly in his own constituency. The hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron), who spoke for the SNP, made a very helpful contribution, as did my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), who spoke from the Labour Front Bench. I will take the Minister up on her invitation. I am very grateful to everybody for contributing to the debate.