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New Zealand Law Students' Journal |
Last Updated: 7 April 2024
Conceptualising a Preventative
Approach to
Eating Disorders in
New Zealand
BRITNEY CLASPER[*]
Abstract—Eating disorders are taboo, stigmatised and silent. The combination of these three characteristics has influenced the status quo, whereby eating disorder sufferers only seek, or are able to obtain, help when their conditions are most visible and their lives are at risk. Over the past decade or so, many jurisdictions around the world have recognised the insidious impacts that eating disorders can have on both an individual and socioeconomic level. New Zealand’s eating disorder policy mirrors an “ambulance at the bottom of the cliff” approach by focusing on treatment rather than prevention. This article argues that New Zealand ought to engage in eating disorder prevention, as similar prevention-focused public health initiatives have been successfully implemented in New Zealand. This article explores the multiplicity of international policy responses, as well as available evidence concerning the efficacy of these responses. Unfortunately, chronic underfunding of eating disorder research has resulted in policies being introduced without a sound evidential basis. As a result, this article argues first and foremost that the New Zealand government must follow Australia’s lead in implementing a specific research strategy with sufficient funding. Although there is a lack of research into policy efficacy, three policies provide a strong foundation for the implementation of a preventative response in New Zealand: (i) integrating eating disorder education into the New Zealand health curriculum; (ii) a prohibition on the distortion of bodies in advertising; and (iii) alternatively, third party certification for companies which practice the portrayal of realistic body image and inclusive representation in advertising.
This
article argues that the socioeconomic costs of eating disorders warrant a
drastic shift in policy from treatment to prevention-focused
initiatives. Parts
II and III provide an overview of eating disorders and their socioeconomic cost.
Part IV examines the complex
etiology of eating disorders, which encompasses
social, psychological and biological factors. This article focuses its
discussion
of eating disorder prevention policy to those that address social
causes, as these are the most amenable to government intervention.
Part V
examines New Zealand’s eating disorder crisis, and Part VI makes the case
for a preventative approach by considering
the government’s successful
intervention into tobacco consumption.
Having argued in favour of
preventative policy, Part VII discusses policy responses from various
jurisdictions according to their
respective categorisation: awareness and
education around eating disorders; early intervention; and targeting the causes
of body
dissatisfaction.
Even in the absence of empirical evidence proving
its efficacy, a prevention-based approach to eating disorders still has
substantial
merit; the status quo of worsening eating disorder outcomes will
persist without government intervention. Part VIII argues that policymakers
must
allocate resources to understand how preventative approaches can target social
causes of eating disorders. Furthermore, there
are measures that can and should
be adopted to initiate New Zealand’s eating disorder prevention policy
journey: (i) integrating
eating disorder education into the New Zealand health
curriculum; (ii) a prohibition on the distortion of bodies in advertising;
and
(iii) alternatively, third party certification for companies which practice the
portrayal of realistic body image and inclusive
representation in advertising.
An
“eating disorder” refers to a complex range of medical conditions,
with a core commonality being disturbances of eating
behaviours and a hyperfocus
on food, eating and body
image.[1]
The American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) is widely used by healthcare
professionals around the world as an authoritative guide to diagnosing mental
illnesses.[2] The DSM-5 recognises
three primary eating disorder diagnoses: anorexia nervosa (hereafter, anorexia),
bulimia nervosa (hereafter,
bulimia) and binge eating disorder. Anorexia
involves an intense fear of weight gain leading to self-imposed or continual
weight-loss,
usually with a perception of oneself as overweight, despite
emaciation.[3] Bulimia and binge
eating disorder are characterised by regular binge eating episodes. People with
bulimia compensate for binge eating
with behaviours such as purging, excessive
exercising or fasting. In contrast, those with binge eating disorder do not
regularly
engage in compensatory behaviour and are therefore likely to be
overweight or obese. Eating disorder presentations which do not fit
within these
diagnoses, such as dietary restriction and fixation on one’s weight, are
classified under residual categories
such as “other specified” and
“unspecified” feeding and eating
disorders.[4]
Persons with eating disorders are generally stereotyped as young, white,
upper-class
females.[5]
However, a 2015 study found that eating disorder symptoms are distributed almost
equally across levels of socioeconomic
status.[6] The New Zealand Mental
Health Survey, Te Rau Hinengaro, demonstrated that lifetime prevalence rates
were 0.6 per cent for anorexia
and 1.3 per cent for bulimia
for the whole population.[7] For
Māori, this increased to 0.7 per cent for anorexia and
2.4 per cent for bulimia. This study only assessed anorexia and
bulimia,
with the authors anticipating that the prevalence of other eating
disorders such as binge eating disorder would also be higher among
Māori.
Eating disorders can arise at any age and within any socioeconomic group,
ethnicity and
gender.[8]
Stereotypes have been identified as a barrier for accessing
care.[9]
Whether a sufferer is able to access care or not, eating disorders place a
significant burden on not just the individual but also
those around them and
wider society.
The societal burdens
created by eating disorders include financial and economic losses as well as
significant strain on relationships
and communities. Concerning financial
burdens, the expense commonly associated with treating eating disorders often
places immense
financial pressure on parents and caregivers of adolescent
patients.[10]
In 2021, researchers undertook the first New Zealand study exploring the cost of
caring for someone with an eating
disorder.[11]
The study found that, on average, the annual income for those caring for persons
with anorexia was reduced by
27 per cent.[12]
To
provide insight into the individual financial burden of caring for an individual
with an eating disorder, various countries have
undertaken studies to explore
the wider economic cost. In Australia, the Butterfly Foundation’s report
estimated the full socioeconomic
cost of eating disorders to the Australian
economy to be AUD 69.7 billion in 2012. Of this amount, just AUD 99.9 million
stemmed
from direct healthcare costs, as the report’s calculations
included the costs of productivity loss and loss of
life.[13] Another report found that
out of all mental and neurological disorders, eating disorders were associated
with the highest proportion
of direct healthcare costs across 30 European
countries in 2010.[14] Although
there has not been a comprehensive socioeconomic study in New Zealand, the less
visible costs of eating disorders, highlighted
in these reports, underscore the
urgency of policy intervention.
Adding to this impetus is the fact that an
untreated eating disorder can significantly impact one’s length and
quality of life.
The mortality rate for people with eating disorders is the
highest of all mental illnesses.[15]
The fact that there is no one-size-fits-all treatment reflects the complex
etiology of eating disorders, which can involve many social,
psychological and
biological factors.
One research review and synthesis of the relevant academic literature identified the following main causes of eating disorders: idealisation of thinness, personality traits and genetics.[16] These causes are not isolated, but rather, they interact to influence the risk of eating disorder symptom presentation. The following section discusses the research review’s findings for each of these main causes. Importantly, the review’s authors noted that few factors have been studied in a male context, with most of the research focused on young adult women.[17]
In Western societies, an increase in the
idealisation of the “thin-ideal” (a slender physique with minimal
body fat) for
females and the “muscular-ideal” (a lean, muscular
physique) for males has correlated with an increase in eating disorder
incidence
rates throughout the 20th
century.[18] The media plays a
significant role in forming these
ideals.[19]
A 2003 study found that greater media exposure among participants correlated
with the incidence of an eating disorder by contributing
to internalisation of
these generally unattainable
ideals.[20] Body dissatisfaction
emerges due to discrepancies between what society portrays as an ideal body and
a person’s real body.[21]
In 1995, a significant study in Fiji, a country in which no eating disorders
had previously been described, highlighted the role of
the Western
“thin-ideal” in causing eating
disorders.[22] The introduction of
Western television exposed Fijian adolescents to new body image values which
differed to Fijian culture’s
emphasis on a fuller figure. Across the
cohorts, the proportion of girls scoring poorly on the Eating Attitudes Test
(EAT-26), a
26 question screening tool to determine if an individual may have an
eating disorder that requires professional attention, more than
doubled from
12.7 per cent to 29.2 per cent, and the proportion purging
increased from zero per cent to
11.3 per cent.[23]
Qualitative interviews revealed that 77 per cent of the girls noticed
that watching television influenced their body image, with
specific mention made
to the slim figures of characters on shows such as Beverly Hills,
90210.[24] The study’s
author confirmed that exposure to Western media ultimately contributed to
disordered eating.[25]
Social
media is another significant factor promoting the idealisation and
internalisation of thin and muscular
ideals.[26] Studies show that users
post images online that present themselves in line with current social ideals by
selecting photographs that
make the subject appear thinner and more
attractive.[27] A 2019 study found
that the frequency of disordered eating behaviours, such as over-evaluating
weight and skipping meals, increased
alongside the number of social media
accounts that both girls and boys
had.[28] These findings suggest that
body dissatisfaction in association with social media occurs at a younger age
than previously investigated—which
is particularly concerning given these
platforms have a minimum age of 13 years
old.[29]
In sum, Western beauty
ideals are no longer limited to the West. Globalisation, compounded by social
media, has spread pressure to
conform to these unattainable body types
internationally.
However, an eating disorder etiology discussion is incomplete without consideration of internal factors that can predispose an individual to an eating disorder. Certain personality traits increase eating disorder risk. According to one study, such traits may include perfectionism, jealousy and neuroticism (negative emotionality).[30] Interestingly, studies have found that those who share negative emotionality tend to be drawn towards one another.[31] This attraction creates a social environment where weight insecurity and value placed in achieving the “thin-ideal” are magnified. A study of college students found that exposure to friends dieting is a significant predictor for higher body dissatisfaction, extreme weight control behaviours and binge eating five to ten years on.[32]
While certain personality traits are an internal factor where environment can have a degree of influence, the second internal factor—genetics—does not. Various studies emphasise that genetics can substantially contribute to the risk of disordered eating, which can develop into an eating disorder diagnosis.[33] However, despite significant advances in the study of genetic associations over the past two decades, relatively little is known about the genes which predispose a person to eating disorders.[34] Difficulties in identifying genetic precursors to eating disorders also arise because eating disorder etiology results from a combination of genetic and environmental factors. Nevertheless, up to 50 per cent of disordered eating has been described as being hereditarily transmitted, and researchers have suggested that neurotransmitters in the brain are involved in disordered eating behaviours.[35] A family history with leanness can also be associated with anorexia, and a family history of obesity with bulimia.[36] Previous studies have also found that children have a higher risk of eating disorder diagnosis if their mother has disordered eating or self-esteem problems.[37] In sum, the science so far suggests that genetics play a complex role in the development of eating disorders, but its specific role is yet to be fully understood.
Understanding the causes and
symptoms of eating disorders leads to the question of diagnosis and treatment.
Unfortunately, it is estimated
that while 79–88 per cent of
adolescents with eating disorders have contact with a health provider, only
3–28 per cent
receive treatment for their eating
disorder.[38] A systematic
literature review on the perceived barriers to seeking help as an eating
disorder sufferer found that shame and stigma
were identified more frequently as
barriers than practical factors such as costs and
transportation.[39]
The
discrepancy between those suffering from eating disorders and those seeking
medical treatment is alarming given the significance
early identification of
eating disorders has as a critical contributor to better
outcomes.[40] Research has
emphasised that it is appropriate to commence medical management of a patient,
even prior to them fulfilling all of
the diagnostic criteria of a particular
disorder, in order to limit and reverse symptom progression as quickly as
possible.[41]
According
to the National Eating Disorders Collaboration, an initiative of the Australian
Government Department of Health, recovery
rates are between
74–90 per cent in those who have had a history of disordered
eating for less than one year.[42]
This finding contrasts significantly with the recovery rate of
21 per cent in those who have had a history of an eating disorder
for
four years or more. However, lack of symptom awareness frustrates the
possibility of early detection by family, friends or
teachers.[43] Adolescents are the
highest-risk group for eating disorders, but teachers have iterated that they
feel uncomfortable when faced with
students’ eating disorders and lack the
knowledge and confidence to respond
appropriately.[44] The cumulative
impact of stigma and lack of symptom awareness has contributed to poor diagnosis
and treatment outcomes, which were
exacerbated by the restrictions brought about
by the COVID-19 pandemic from 2020–2021.
This part considers the extent to which the COVID-19 pandemic exacerbated poor outcomes in eating disorder diagnosis and treatment in New Zealand by analysing the government’s response preceding and following the pandemic. Though the government is aware of the worsening situation, the policy focus has remained on treatment rather than prevention.
In New Zealand, eating disorder
prevalence has reached crisis levels. Following the first COVID-19 lockdown in
March 2020, eating
disorder specialists were widely reported in the media as
being at a breaking point. Clinical Psychologist Dr Marion Roberts reported
that
families were being told that help in the public sector was a four-to-six month
waitlist away—losing vital time for intervention
to prevent the
entrenchment of disordered
habits.[45] A New Zealand study
considered pandemic-associated stress and anxiety arising from social
restrictions and altered routines as potential
drivers for disordered eating
behaviours, as well as increased exposure to social messaging around exercise
and weight
gain.[46]
These
observations from healthcare professionals and studies suggest that COVID-19 had
a significant effect on the eating habits of
those with and without eating
disorder diagnoses prior to pandemic restrictions. However, while COVID-19
restrictions have largely
been lifted, there is no quick fix for eating
disorders which, as previously mentioned, benefit immeasurably from early
intervention.
This section considers the New
Zealand government’s response to the eating disorder crisis, both prior to
and following the
pandemic. The following analysis benefits from information
provided through a request under the Official Information Act 1982 for
any
documentation and information relating to eating disorder prevention policy and
initiatives, as the government has not yet created
a formal public strategy to
address eating disorder treatment or prevention.
In 2018, the government
initiated the Government Inquiry into Mental Health and
Addiction.[47] The Eating Disorder
Association of New Zealand (EDANZ), a not-for-profit organisation which supports
those caring for individuals
with eating
disorders,[48] submitted
recommendations to increase funding for diagnosis training, evidence-based
treatment and specialist
capacity.[49] However, the
Government Inquiry’s recommendations made no mention of eating disorders.
The Hon Andrew Little MP, the Minister
of Health at the time, acknowledged the
increase in those seeking eating disorder treatment since COVID-19 and pointed
to the government’s
increased funding to treat mental health and addiction
issues.[50] However, Nicki Wilson of
EDANZ was quoted as saying that the increase was making no difference to people
with eating disorders—for
example, EDANZ continued to hear that general
practitioners were under resourced and required better knowledge and support
regarding
eating
disorders.[51]
As a result of
increased media attention to New Zealand’s eating disorder crisis
following pandemic restrictions, the Ministry
of Health confirmed in July 2021
that it would be speaking with stakeholders in the eating disorder community to
“inform policy
around future support and
treatment”.[52]
Advocates criticised the Ministry’s lack of comment on a funding timeline,
stating it was urgent that a strategy be finalised
and funded, or else people
would die waiting for
treatment.[53]
Ministry of Health
briefings reveal that eating disorder prevention initiatives were on the
government’s radar.[54] In
August 2021, Philip Grady, then-Acting Deputy Director-General for Mental Health
and Addiction, responded to a petition by Rebecca
Tom which asked the government
to review current eating disorder treatment and develop an action plan to
provide treatment resources
such as training and funding for health care
professionals and funding for a national organisation to provide support
services.[55]
The Deputy Director-General highlighted the government’s “Access and
Choice” programme which is “based on
a brief intervention model of
support”,[56]
commenting that this programme’s early-intervention strategy would prevent
eating disorders from escalating to the point of
requiring specialist services.
As of June 2021, the new programme had delivered over 170,000 sessions. However,
the Deputy Director-General
did not provide information as to what proportion of
patients were seeking help for disordered eating. Additionally, the government
intends to roll out increased mental health supports in primary and intermediate
schools, including adding eating disorder information
on the “Stronger
Schools”
platform.[57]
These measures read well on paper, but the author has been unable to find
evidence of their implementation at the time of writing
this article.
Consequently, while the government is aware of the current eating disorder
crisis, it has neglected to create a targeted
response.
The
government’s “prevention initiatives” focus too much on
symptom identification and diagnosis, aligning with
an early-intervention
strategy, as opposed to preventing the emergence of disordered eating behaviours
in the first place. A report
to the Associate Minister of Health, the Hon Dr
Ayesha Verrall MP, indicates that the government is aware of the value in taking
a prevention approach. The report
states:[58]
There is a developing evidence base for the effectiveness of health promotion
and prevention initiatives for eating disorders which
aim to address knowledge,
attitudes, behaviours and risk factors associated with eating disorders.
Evidence is mainly international,
but the evidence from Australia offers
insights that could be applied to health promotion and prevention initiatives in
a New Zealand
context.
Despite the report’s ostensible enthusiasm for
prevention, such initiatives have been neglected due to the government’s
focus on early intervention. Consequently, community groups have spearheaded the
prevention approach in New Zealand. For example,
the Regional Eating Disorders
Services, in conjunction with the University of Canterbury and several Nelson
intermediate schools,
is trialling two versions (one online version for
16–25 year olds and one being delivered through school lessons to Year 8
students) of Media Smart, an Australian-developed eight-lesson media
literacy programme.[59] The Ministry
has no connection to the programme’s delivery, which is seeking
philanthropic funding to make the programme available
to all Year 8 students in
Canterbury and Nelson. Interestingly, ministerial briefings state a desire to
establish an eating disorder
advisory group to collaborate on health promotion
and prevention, education and early
intervention.[60] The briefing
elaborates that over the longer-term and with more resources, the Ministry could
work with sector leaders such as EDANZ
in the area of health promotion and
prevention initiatives.[61]
The
Deputy Director-General cited the “still developing” evidence
concerning the efficacy of prevention initiatives as
the reason for their
apprehension to funding prevention
measures.[62] Unfortunately, the
same approach is observed internationally. In Australia, for every autistic
person, around AUD 32 is spent on
research on autism, while just over AUD 1 is
spent on eating disorder research per person with an eating disorder, even
though autism
and eating disorders have similar
prevalence.[63]
The most recent data from the United States reported comparable figures for
research funding, at USD 58.65 for an individual with
autism, compared to
USD 0.73 per individual with an eating
disorder.[64] This lack of research
on eating disorders is paradoxical: a lack of research has led to a general
dearth of empirical data on the
risk factors and efficacy of eating disorder
treatments, preventative or otherwise, leading to little scientific evidence for
policymakers
to rely on.
The government’s low view of the value of a preventative strategy to eating disorders means it is unlikely the government will depart from a treatment-focused approach. The current approach is like an “ambulance at the bottom of the cliff”, providing hospital beds to the most malnourished and using the Mental Health (Compulsory Assessment and Treatment) Act 1992 to involuntarily hospitalise and treat patients. This regime reflects the treatment focus of the government’s regulatory response to New Zealand’s eating disorder crisis. The next part of this article considers the feasibility of a shift from a policy focusing on treatment to one focusing on prevention, and the legislative response that would have to come with that shift.
The New Zealand government
should prioritise a preventative approach to eating disorders. This part
discusses the economics of government
intervention to justify intervention and
uses Smokefree Aotearoa as a case study to demonstrate how government
intervention can lead
to successful public health outcomes.
Negative
externalities are a kind of market failure that occurs when an economic
agent’s actions impose a cost on another without
compensation.[65]
Body dissatisfaction and disordered eating are negative externalities whose
costs producers are not internalising. In this analysis
an economic agent could
be an individual or producer. Here, “producer” refers to the fashion
and modelling industry,
the entertainment industry, the advertising industry,
social media conglomerates, and media outlets who contribute towards
popularisation
of the thin-ideal. Similarly, “consumers” are the
general public who are exposed to “thin-ideal” and
“muscular-ideal”
messaging. Left alone, producers will continue to
produce these negative externalities, such as body-dissatisfaction
messaging.
The performance of a market is a function of economic
agents’ decisions, and thus the government can influence the behaviour
of
producers and consumers to achieve desired
outcomes.[66] New Zealand’s
response to cigarette smoking is a useful example of a government-led
intervention to correct a market failure:
cigarette use causing lung cancer and
cigarette mortality.[67] In 1985,
New Zealand introduced a nationwide Tobacco Control Programme (TCP) with the
goals of reducing tobacco harm by reducing
smoking in general, as well as
smoking amongst youth, Māori and lower income groups in particular,
reducing exposure to second-hand
smoke, and decreasing cigarette
mortality.[68]
The TCP included the Smokefree Environments and Regulated Products Act 1990,
which increased taxes on tobacco, created more legally
mandated smokefree
environments, introduced health warnings on cigarette packets, banned
advertising and sponsorship from tobacco
companies, and restricted adolescent
access to tobacco products. Over the period from 1981–1996, tobacco
product consumption
almost halved in New
Zealand.[69] Furthermore, in 2010,
the government introduced Smokefree Aotearoa 2025, following a Māori Select
Committee inquiry which found
that while overall smoking rates continued to
decline, they were increasing among Māori and Pacific
peoples.[70] By expanding Māori
leadership in the Smokefree policy-making space, Māori smoking rates have
declined from 40.2 per cent
in 2011/2012 to 13.4 per cent in
2019/2020.[71] In this instance, law
and policy proved to be a powerful tool for promoting public health and
prevention of a negative externality.
The establishment of Te Whatu Ora
(Health New Zealand) and Te Aka Whai Ora (the Māori Health Authority)
reflects the increasing
importance placed on both preventative approaches to
public health and on improving Māori health outcomes to ensure everyone
has
the same access to good health
outcomes.[72]
The foundations of New Zealand’s new health system are outlined in the Pae
Ora (Healthy Futures) Act 2022, which states that
adopting preventative health
approaches is a health sector
principle.[73] When performing a
function or exercising a power or duty under the Act, the Minister of Health is
required to consider the health
sector principles “as far as reasonably
practicable”.[74] Many
governments around the world rely on interventional public health laws to
address health conditions and risk factors, and empower
agencies to implement
policy action.
However, such policies ought to be grounded in empirical
evidence to ensure success in correcting negative externalities. A 2009 study
on
public health laws analysed 65 reviews on the effectiveness of 52 public health
laws.[75] The study found that of
these 52 laws, 27 were effective, 23 had insufficient evidence to judge
effectiveness, one was harmful to
public health and one was ineffective. The
study highlights the potential for policy to have an impact in improving public
health
outcomes, while warning that poorly crafted policy can instead have
middling or even harmful effects.
This part evaluates various initiatives from around the world that may directly or indirectly reduce eating disorder incidence. The initiatives are categorised under three headings: awareness and education, early intervention, and targeting the causes of body dissatisfaction. After evaluating these policies, this part will go on to propose an eating disorder prevention policy response for New Zealand.
The United States has been a frontrunner in
proposing legislation to improve eating disorder awareness. For example, the
Supporting
Eating disorders Recovery through Vital Expansion Act (SERVE Act)
would have required military leaders to be trained to recognise
the signs of
eating disorders in service
members.[76] However, the SERVE Act
was referred to the Committee on Armed Services in 2019 and there has been no
further action since.[77] Another
example is House Bill 2158 in Pennsylvania, which seeks to amend the Public
School Code of 1948 by providing for parent educational
information regarding
eating disorders on an annual
basis.[78] The Bill has been with
the Education Committee since December 2021. The Bill’s memorandum
mentions the scientifically proven
connection between media exposure, body
dissatisfaction and eating disorders.
Pennsylvania is following in the
footsteps of Virginia, which in 2013 became the first state to enact mandatory
eating disorder education
into
law.[79] House Bill 1406 amended the
Code of Virginia to require schools to provide parents educational material on
eating disorders to pupils
in Grades
5–12.[80] Examples of the
kinds of material provided to parents include descriptions of eating disorders
and symptoms, and a statement as to
the importance of early detection. The
impact of the law on administrative costs for the state to conform with the
legislation was
deemed nominal and no budget amendment was
necessary.[81]
While no
empirical data exists on the efficacy of the Virginia legislation, the policy is
likely effective because it equips parents
to recognise signs of disordered
eating. Parents are in a unique position to notice changes in their
child’s behaviours, such
as if the child begins to talk more about weight
or stops eating foods they used to enjoy. The materials parents receive
mitigates
the stigma around eating disorders by describing them as
“serious health problems that ... affect both girls and
boys”.[82] Furthermore, the
material itself is practical, providing concise checklists of risk factors and
key things to look out for. It also
advises parents on how to communicate with
their child, and to contact a medical professional if concerned their child has
an eating
disorder, rather than “waiting it out”.
A limitation
of this policy is that education is confined to parents. Ideally, students
themselves should also be taught to recognise
disordered eating among their
peers, as a parent’s ability to do so is limited to the home environment.
As students age and
gain independence, they become more difficult for parents to
monitor. Conversely, peers implicitly supervise one another’s
behaviours
during school hours. An individual engaging in disordered eating behaviours may
also feel more comfortable with a friend
rather than a parent expressing concern
towards them, as they may perceive the latter interaction as an intrusion on
their independence.
Overall, initiatives targeting raised awareness are
valuable. Practically, they equip parents and fellow students—two major
stakeholders in an adolescent’s life—at nominal cost with the
knowledge to identify disordered eating behaviours and
to act accordingly.
Education must be a primary component of a prevention response in New Zealand;
indeed, Part VII of this article
argues that eating disorder education should be
integrated into the New Zealand health curriculum.
At the United States federal level, the Eating
Disorder Prevention in Schools Act of 2020 was introduced in Congress in May
2020.[83] The Bill sought to amend
the Richard B Russell National School Lunch Act by requiring local education
agencies that participate in
school breakfast or lunch programmes to include
goals for reducing disordered eating in children in their local school wellness
policies.[84] The Bill also
encouraged more frequent screening for eating disorders in schools. Although the
Bill was not moved out of committee,
as at the time of writing this article
Congresswoman Alma Adams intends to introduce it again in the
future.[85]
The Bill is
aspirational yet lacks specificity. Its goal to reduce disordered eating is
commendable, but it does not provide guidance
as to what policies schools should
introduce to reduce disordered eating beyond merely encouraging screening. The
Bill does mandate
involving registered dietitians and licensed mental health
professionals in developing a response but is silent on how this involvement
will be achieved. Furthermore, delegating the creation of prevention policies to
professionals who typically focus on diagnosis and
treatment, without any
resourcing, is unlikely to be successful. Notwithstanding these practical
implementation challenges, the screening
that the Bill encourages has at least
been endorsed as an effective eating disorder tool (further explained below).
Screening is a tool to make individuals aware of the significance of their
symptoms and is generally accepted as a crucial first step
in intervention. One
study in collaboration with the National Eating Disorders Association had over
70,000 respondents complete an
online screener over six months, with the
majority screening positive for a clinical eating
disorder.[86] The National Eating
Disorders Screening Program (NEDSEP) in 2000 remains the only national screening
programme to have been conducted
in the United
States.[87]
Although the programme was considered successful, Rindahl noted how researchers
deemed the EAT-26 screening questionnaire as too
lengthy and an administrative
burden in a time where the availability of technology in schools was much
poorer. A literature review
by Rindahl assessed 180 articles on screening for
eating disorders amongst adolescents from 1999 to 2015 and found that the SCOFF
questionnaire is the most useful screening
tool.[88]
The SCOFF questionnaire comprises five yes-or-no questions; two or more
affirmative answers indicates eating disorder risk, and its
brevity means
students can complete it quickly.
The ubiquity of information technology in
modern schooling means accessing an online questionnaire is no longer a
significant issue.
However, nothing prevents a student from lying on a screening
to disguise their disordered eating habits. Eating disorder sufferers
enjoy the
control eating disorders seem to afford them, and a screener could be viewed as
a threat to that sense of control. Consequently,
the use of screening tools may
be more effective as part of a broader education initiative, where students are
first taught about
the long-term implications of having an eating disorder.
Awareness of the social, economic and health consequences of disordered
eating
may provoke honest answers.
While early intervention through initiatives
such as screening are invaluable in stopping disordered eating habits from
becoming entrenched,
they are not as effective as prevention in the first place.
The next section considers preventative policy responses aimed at suppressing
variables which contribute to body dissatisfaction—an indisputable risk
factor for the development of disordered eating behaviours.
Myriad legislation, regulation and other policies have been implemented or proposed around the world which target the causes of body dissatisfaction. This section evaluates nine such policies: reducing diet pill sales, clothing size availability, limiting advertisements, Body Mass Index (BMI) bans, protective factor programmes, warning labels, taxation, codes of conduct and voluntary certification programmes.
Diet pills are a major problem in the United States.
By 2024, the value of the United States’ dietary supplement market is
expected
to reach USD 56.7 billion, and studies have shown that
11 per cent of adolescents have used weight-loss pills in their
lifetime—a
figure comparable to adult
use.[89] California Assemblywoman
Cristina Garcia proposed Assembly Bill 1341 to require a prescription for minors
to purchase weight-loss
or over-the-counter diet pills online or in
store.[90] The Bill was supported by
Professor S Bryn Austin of Harvard Medical School, whose research found that
young women who used diet
pills and laxatives for weight control had a higher
probability of subsequent eating disorder diagnosis within one to three years
than those who did not use such
products.[91]
There is a lack of
data concerning the prevalence of diet pill use in New Zealand. However, there
is less impetus for legislation
like Assembly Bill 1341 as diet pills are less
accessible: only four are approved for sale, with three being prescription-only
and
the fourth requiring assessment by a
pharmacist.[92] For completeness,
the Medicines Act 1981 currently regulates prescription and pharmacist diet
pills in New Zealand, but it is set
to be replaced by the omnibus Therapeutic
Products Act 2023 which will not materially change access to these diet
pills.[93] Overall, New
Zealanders’ limited access to diet pills suggests that diet pill use
amongst young people is low.
Argentina has the second highest rate of
eating disorders in the world, with at least 29 per cent of Argentines
having an eating disorder.[94]
Clothing sizes in retail shops were recognised as a contributor to eating
disorder prevalence, as many stores sold clothing that
only
30 per cent of women could fit
into.[95]
As a response, the “Sizes Law” was enacted in December 2005,
requiring retailers to stock a full range of clothing sizes
equivalent to United
Kingdom sizes 10–20,[96] but
Tucker’s thesis indicates that the law has had little
effect.[97]
Clothing size
availability in New Zealand is not an issue to the same extent as in Argentina.
Most stores go up to a size 16, which
is the average size for women in New
Zealand. Additionally, unlike Argentina, the number of brands making clothes
larger than size
16 is increasing due to a stronger culture of inclusive
fashion. For example, locally owned brand “Ruby” began stocking
clothing up to size 24 in 2021.[98]
Therefore, the need for a strong policy response targeting clothing size
availability is minimal.
In 2010, the Spanish government identified advertising as a force pushing the public into eating disorders.[99] The General Audiovisual Communication Law (Audiovisual Law) was enacted, prohibiting the advertisement of products promoting the “cult-of-the-body” and “rejection of self-image” during minor protection hours (before 10 pm).[100] The Audiovisual Law was amended to remove the “minor protection hours” limitation in July 2022, such that the ban applies absolutely. The absolute prohibition in Article 124 states that:[101]
1. Audiovisual commercial communications must not cause physical, mental or moral harm to minors or incur in the following conduct:
[...]
(g) promote body worship and the rejection of self-image through audiovisual
commercial communications of slimming products, surgical
interventions or
aesthetic treatments, which appeal to social rejection due to physical
condition, or success due to weight aesthetic
factors.
The burden of
compliance is placed upon audiovisual communication service providers, defined
as services with editorial responsibility
through electronic communication
networks and programs with the aim of informing, entertaining or educating the
public, as well as
broadcasting audiovisual commercial
communications.[102] The
prohibition is limited to services which are established in Spain, which covers
entities whose headquarters are in
Spain.[103]
Although
“body worship” is only a small aspect of the Audiovisual Law, one
can infer the law was passed as an attempt
to improve Spanish citizens’
body image. The law is a unique intervention by the government, but the efficacy
of the law is
limited in that it only applies to audiovisual communications by
Spanish-based services, whereas the Internet and globalisation allows
Spaniards
to access content from almost any country. Globalisation allows people to access
almost any jurisdiction’s channels
from almost anywhere. Nonetheless,
there are yet to be any proceedings brought for breach of Article 124, which
suggests the services
are complying with the law. The Ministry of Economic
Affairs and Digital Transformation is tasked with bringing proceedings and the
National Commission of Markets and Competition with supervising
compliance.[104] A failure to
comply with Article 124 is deemed a serious offence under Article 158. Article
160 stipulates fines which depend on
the service provider’s income,
ranging from up to €30,000 for services which earn less
than €2,000,000 and up to
1.5 per cent of income (with a
maximum of €750,000) accrued in the year prior to the breach where income
is greater than €50,000,000.
In New Zealand, it is uncommon to see
advertisements of slimming products or aesthetic treatments on television.
Further, the Advertising
Standards Authority’s “Therapeutic and
Health Advertising Code” sets out stringent content guidelines which,
amongst
other things, prohibit dietary supplements advertisements from making
weight loss claims.[105] Although
compliance with Authority’s advertisement decisions is voluntary, the ASA
has a high compliance rate as decisions
are released to the media and
“negative publicity is a driver for
compliance”.[106]
Consequently, a New Zealand law analogous to Spain’s Audiovisual Law is
unlikely to have a tangible impact on eating disorder
prevalence. A policy
response ought instead to focus on targeting more significant causes of body
dissatisfaction, such as the use
of unrealistic bodies in advertisements.
Minimum BMI thresholds are a policy response aimed at targeting the portrayal of unattainable bodies in the media. Spanish fashion administrators were the first to introduce bans on models with BMIs under 18.5 at Madrid Fashion Week in 2006.[107] Italian fashion administrators followed suit, requiring models to have a BMI of at least 18 to participate in fashion shows. However, anecdotal reports concluded officials did not enforce the obligations. Furthermore, BMI is criticised as a siloed approach to measuring one’s health, with a 2012 study finding that it incorrectly identified 30 per cent of those measured as obese.[108] The medical community has also criticised BMI due to its inability to consider cartilage, water, muscle, race, age or gender.[109] New Zealand policymakers should not endeavour to define “health” as a single metric in a policy response that targets causes of body dissatisfaction.
Given the correlation between media use and
body dissatisfaction, media education is a plausible means to prevent eating
disorders.
Media literacy is a “protective factor” which can disrupt
risk factors (such as social media exposure) by teaching social
media users to
be more critical about what they are
viewing.[110]
A literature review of 42 articles describing 39 studies examined the
success of various eating disorder programmes and lifestyle
interventions.[111]
The review was prompted by studies which showed that girls and boys were
significantly invested in thin and muscular ideals by 5–9
years
old.[112] These studies reiterate
that preadolescence is an important age for prevention initiatives before
weight-loss behaviours and cognitions
become entrenched. Across the reviewed
studies, the implementation of protective factor education showed a trend
towards a reduction
in risk factors and an increase in positive body
image.[113] The programmes
themselves were variable, with the most promising being the interactive learning
opportunities (such as guided group
discussions and role-play) and
gender-specific initiatives (such as sessions focussed on masculine and thin
stereotypes for boys
and girls, respectively). While the New Zealand government
has acknowledged the potential of literacy initiatives, such as Media
Smart, in their internal policy documents, the need for clarity regarding
what constitutes an effective programme has also been
highlighted.[114]
The World
Health Organisation has called for more research on what differentiates
successful and unsuccessful protective factor
programmes.[115] While studies
have shown empirical support for decreasing the internalisation of idealised
body types, they have not found direct
evidence for reduced eating disorder
onset following the workshops. Furthermore, it is problematic that companies can
continue their
advertising practices of presenting unattainable and unrealistic
body imagery, while the onus of reducing eating disorders is placed
on children
to understand that they are being manipulated and on the government to resource
workshops. A stronger intervention into
company advertising practices is
warranted to address body dissatisfaction.
The most eminent example of a legislative attempt to
address body dissatisfaction is Israel’s The Law Restricting Weight in
the
Modelling Industry 2012, commonly known as the “Photoshop
Law”.[116] The Act took
effect in January 2013 and was “designed to minimize the negative impact
of exposure to advertisements depicting
models as extremely thin on positive
body image and self esteem and on the development of eating disorders in
Israel”.[117] The Act
requires models to obtain certification that they have a minimum 18.5 BMI three
months prior to a shoot or
filming.[118] The Act also
requires that if a model is photoshopped to make them appear thinner, a clearly
visible statement, at least seven per
cent of the image size, must be
inserted as a disclaimer the image has been
modified.[119] A breach of the
Photoshop Law incurs civil
liability.[120] In addition to the
civil claim, Israel’s Ministerial Committee for Legislation recently
approved an amended version of the
Photoshop Law to fine publications which fail
to attach clear warnings to altered
photos.[121]
Multiple issues
with the Act exist, even beyond the use of BMI as a health measure. First,
parents likely prefer to devote resources
to helping their child recover from an
eating disorder, rather than suing the entities which caused the eating
disorder. Secondly,
it is difficult to prove that a particular advertisement
partially or wholly contributed to an eating disorder. Thirdly, models can
simply slim down in the three-month period between the certification and
relevant shoot or film or move to another country. Finally,
the law has been
criticised as being unfair to naturally thin models who may lose their jobs if
they choose to stay in Israel. These
issues likely explain why there is no
evidence of a lawsuit being brought under the Photoshop Law.
Warnings are not
the right way to target body dissatisfaction, as they do not prohibit the
continued use of a preferred body type
or the alteration of a model’s
body. This conclusion is reinforced by five studies yielding little support for
the use of media
warning
labels.[122]
Only one study concluded that warning labels prevented an increase in body
dissatisfaction.[123] Most studies
found that the warnings had either no effect on body dissatisfaction or led to
greater body dissatisfaction than images
without
labels.[124] Researchers have
attempted to explain this backfire effect; it is generally thought the inclusion
of warning labels directly increases
attention to idealised images whereby even
the models are not ‘ideal’ enough. Overall, it is arguable that
warning labels
do not actually promote change in beauty standards, but simply
draw more attention to
them.[125]
Furthermore, like media literacy, warning labels focus on the audiences
of publications. Their dubious efficacy adds weight to the argument that the
sources of the publications ought to be the target of a policy response
instead.
Policymakers
have suggested that taxes on sources of body dissatisfaction could correct the
negative externalities they
cause.[126] For example, a direct
sales tax on advertisements using digitally altered images would theoretically
incentivise advertisers to use
unedited images to reduce their costs. However,
consumers would likely be unable to tell which publications were subject to the
tax,
meaning the images would still cause harmful body idealisation.
While a
direct sales tax is a “stick” approach in that it penalises those
purchasing publications with digitally altered
images, a tax credit is a
“carrot” approach in that it rewards companies for renouncing the
use of digitally altered
images. In 2019, Representative Kay Khan proposed a
Bill in the Massachusetts Legislature to offer a tax credit of up to
USD 10,000
for cosmetic, personal care, and apparel companies who refrain
from using digitally altered
advertisements.[127] Progress on
the Bill has stalled since it was accompanied with a study order in February
2020.[128] In principle,
incentivising companies not to digitally alter images is useful. However, for
many companies, a tax credit is unlikely
to be worth overhauling their marketing
strategy.
A third kind of tax was proposed by the Royal College of
Psychiatrists in the United Kingdom: a “turnover tax” on social
media companies to fund research into the impact of harmful internet content on
users.[129]
The Royal College of Psychiatrists has also called for the compulsory sharing of
data from social media companies with universities
to supplement this research.
Taxation of the “digital economy” is a difficult issue which
requires international
cooperation.[130] Nonetheless,
France demonstrated the concept was possible when it imposed a
three per cent levy on digital service companies earning
over
€25 million in France and €750 million
worldwide.[131]
However, the tax was met with retaliatory threats by the United States, where
most social media companies are based, to impose a
100 per cent tariff
on champagne and French luxury
goods.[132]
Consequently, taxing social media companies to fund eating disorder research is
likely unsuitable due to New Zealand’s relatively
small economy and
political power on the international stage. The challenges of using taxation to
change the behaviour of sources
of eating disorders who use altered images
render this government intervention an unattractive avenue to target body
dissatisfaction.
Industry self-regulators across jurisdictions
have increasingly focused their efforts on controlling digitally altered images.
In
many countries, such as the United Kingdom, Australia, Ireland and New
Zealand, Advertising Standards Authorities (ASAs) are used
to independently
regulate advertising across all media
channels.[133] ASAs create
voluntary conduct codes prescribing approved practices and investigate consumer
complaints regarding harmful, offensive
or misleading advertisements. ASAs do
not typically levy fines but rely on negative publicity to incentivise
compliance with publicly
released
decisions.[134] The Commerce
Commission in New Zealand can prosecute advertisers for misleading and deceptive
conduct. Compliance with the codes
is generally seen as a means for businesses
to insulate advertisers from claims brought by government
agencies.[135] The United Kingdom
ASA took action in 2011 to investigate and discipline doctored
images.[136] Two celebrity
advertisements were investigated for being misleading: Lancôme’s
“Teint Miracle” and Maybelline’s
“The Eraser”. The
ASA concluded the advertisement did not accurately illustrate the effect that
could be achieved by
the
product.[137]
While the
ASA’s intervention was seen as a sea change for digitally altered images,
“misleading” has since proven
a high threshold to meet, as
advertisers can mitigate their liability by using “actual product results
may vary” disclaimers.
Furthermore, ASA action for
“misleading” advertisements is confined to industries where a
product is presented as having
a certain effect, such as cosmetics. Thus, the
possibility of being subject to ASA intervention for “misleading”
advertising
does not necessarily stop companies from using unrealistic bodies.
It is misguided to believe the industry alone can successfully achieve
reform of advertising ethics. Yet there is a powerful counterexample:
Australia’s ASA equivalent—The Australian Association of National
Advertisers (AANA)—upheld its first complaint
relating to unrealistic body
ideals in early 2019.[138] Rule
2.6 of the AANA’s Code of Ethics states: “Advertising shall not
depict material contrary to Prevailing Community
Standards on health and
safety.”[139] The
AANA’s Code of Ethics Practice Note, a guide to interpretation of the Code
of Ethics, states that r 2.6 should be interpreted
to include the following
prohibition: “Advertising must not portray an unrealistic ideal body image
by portraying body shapes
or features that are unrealistic or unattainable
through healthy
practices.”[140] The
Community Panel, tasked with reviewing complaints from the community about
advertisements, stated that while it could not judge
whether the female model in
a Calvin Klein underwear advertisement was healthy or not, it was deemed
irresponsible due to the model’s
significant thigh gap, visibility of her
ribs and collarbones, and the thinness of her upper arms and wrists. Calvin
Klein responded
by changing the image, evidencing that it is not impossible to
formulate policies that target advertisements which contribute to
the
“thin-ideal” for women or the “muscular-ideal” for
men.
AANA’s Code of Ethics has been more successful in regulating the
advertising industry than the Australian government-led Voluntary
Industry Code
of Conduct on Body Image, introduced in
2009.[141]
Guidelines include the hiring of models in the fashion industry who are
“clearly of a healthy weight” and over 16 years
old. The Code also
states images should not be digitally altered to the point that bodies look
“unrealistic or unattainable
through healthy practices”. The Code
has been criticised as there is no entity empowered to encourage or enforce
compliance.[142] A one-off study
found that only one of seven Australian magazines complied with the Code
fully.[143] Baffsky has suggested
a mandatory code ought to be adopted which also prohibits journalists from using
derogatory language when reporting
on eating
disorders.[144]
Critics argue
self-regulation is a slow-moving, unreliable option as there are no specific
sanctions or enforcement
means.[145] While the 2019 Calvin
Klein AANA decision is an example of a business responding to an adverse
finding, businesses can choose not
to comply. Unfortunately, without the
publicity of an investigation and determination, businesses will continue using
unrealistic
body imagery as the perceived economic benefit of potentially
harmful business practices currently outweighs the public health
costs.[146] This is supported by a
2021 study that found that switching to more authentic and realistic
advertisements is not necessary for a
brand’s
success.[147] Brands are unlikely
to change the use of harmful body imagery of their own accord and
self-regulation has had very limited success.
Several authors have proposed a voluntary
certification scheme to recognise businesses that comply with practices to
reduce body dissatisfaction,
such as not using digitally manipulated images and
using a realistic and diverse range of models in
advertising.[148]
B Corp is a
notable example of a voluntary certification scheme. To receive B Corp
Certification, a business has to meet high standards
of social and environmental
performance, exhibit transparency about their performance and legally commit to
a corporate governance
structure that requires accountability to both
shareholders and
stakeholders.[149] The
certification has grown in popularity since its 2007 launch—for example,
Sir Richard Branson launched the “B Team”
in 2013 to shift his
corporation’s focus away from short-term
profit.[150]
A study found there were two key reasons for seeking B Corp status: proving a
business is a genuine advocate for stakeholder benefits
within the
“greenwash revolution”, and the fact that “the major crises of
our time are a result of the way we conduct
business”.[151] While B Corp
status is not contingent on an entity avoiding use of altered images or
idealised body types, the concept illustrates
how voluntary certification
schemes can influence businesses to adopt more socially conscious practices.
The launch of a new “badge” to certify that a brand takes
measures in its advertising to prevent body dissatisfaction
would take time to
gain traction. B Corp was launched in 2006 and took over a decade to gain
increased recognition.[152] New
Zealand’s eating disorder crisis necessitates consideration of swifter
alternatives to producing a novel “badge”.
For example, policymakers
could work with B Corp to amend their standards to require brands to refrain
from digitally altering images
which contribute to unrealistic body ideals. In a
survey on social responsibility, 81 per cent of respondents stated it
is important
for them to purchase from brands that align with their social
values.[153] The invisibility of
eating disorders has hindered the inclusion of image altering in the context of
corporate social responsibility.
Including this in a B Corp certification will
influence broader social values and raise awareness of the harms caused by
advertisements
that contribute to body dissatisfaction.
In summary, regulation of diet pills and clothing size availability are not useful approaches to targeting the causes of body dissatisfaction in the New Zealand context, due to sufficient extant regulation and a more inclusive sizing culture. A ban on advertising slimming products or aesthetics treatments is also unnecessary given the ASA already enforces its stringent guidelines, with high compliance across the advertising industry. Adopting a minimum BMI for models has been criticised due to contention that BMI is a poor measure of health. Taxation of social media outlets faces a myriad of issues, most notably the global nature of social media which complicates enforcement. Further, voluntary industry codes will not have a significant impact as there is no economic incentive for brands to change their approach to advertising. Notwithstanding this, voluntary certification may prove particularly effective to influence broader social values and give socially conscious consumers a way to support brands which do not alter images. Further, warning labels and media literacy can be criticised for shifting the onus onto the audience to understand they are being manipulated. However, there is a case for more overt action to be taken as effective prevention measures, such as banning manipulated images and educating young New Zealanders on eating disorder symptoms.
The final part of this article draws from the discussion in Part VI to devise an approach to eating disorder prevention policies tailored to the New Zealand context. While a critical first step is to fund research to remedy the lack of data on the efficacy of different policies, this part discusses various other initiatives which should be implemented.
First and foremost, the New Zealand
government must clarify how it will tackle eating disorders. In 2018, Rodgers
and Sonneville pointed
out the lack of substantial research aimed at informing
strategies for regulating risks associated with eating disorders, as well
as
research into the influence of legislative efforts on eating disorder cognitions
and behaviours.[154] Scientific
research informs policymaking too infrequently. This is likely due to
researchers not being trained with the goal of influencing
policy and engagement
with policymakers not being encouraged or rewarded in academic
settings.[155] Furthermore,
researchers do not always receive input from change agents, such as politicians,
to shape their research focus. Consequently,
a substantial proportion of the
laws and regulations targeting social eating disorders lack evidential
foundation. As discussed in
Part V.B, research funding in Australia per person
with autism is around AUD 32 and for eating disorders it is just over AUD 1,
despite
eating disorders having a much higher social
cost.[156] The 2012 Butterfly
Report estimated the annual socioeconomic cost of eating disorders to the
Australian economy at AUD 69.7
billion.[157] A 2011 report
estimated the annual socioeconomic cost of autism between AUD 8.1 billion to
11.2 billion.[158] Although the
reports are 10 and 15 years old, respectively, the disparity is
eye-opening.
However, eating disorder funding should not be increased merely
for the sake of achieving parity with autism funding—it must
serve a
purpose. Specifically, funding needs to support research to provide an evidence
base to inform policy. Australia is an example
of a country that has implemented
such an approach in its Australian Eating Disorders Research &
Translation Strategy 2021–2031. Released in September 2021, the
strategy has been cited as a “significant turning point” in the
country’s policy
approach to eating
disorders.[159] The
transdisciplinary strategy was co-designed with eating disorder researchers,
clinicians and people with lived experiences with
eating disorders—drawing
on the expertise and experience of over 480 individuals. With the Australian
government’s support,
the University of Sydney’s InsideOut Institute
led the strategy’s development. Ten priority areas for research were
identified:
stigma, health promotion, risk and protective factors, prevention,
early identification, equity of access, early intervention, support
families,
individual’s medicine, and treatment outcomes. By recognising eating
disorders as a nationwide crisis, Australia
has become a world leader in the
area. The Australian government has committed AUD 268 million to eating disorder
initiatives since
2012,[160]
and announced an additional AUD 24.3 million in funding in March
2022.[161] Furthermore, AUD 13
million was granted to the University of Sydney to establish the Australian
Eating Disorders Research and Translation
Centre.[162] Concurrent to the
Centre’s establishment, a rapid literature review was undertaken to
categorise existing research into each
of the ten priority areas to identify
deficits.[163] Interestingly,
research on risk factors constituted the highest proportion of extant literature
at 20 per cent, whilst prevention
and early intervention were the
fourth lowest at nine per cent
each.[164] The need for a national
“Research & Translation Strategy” is credited to the vital role
that research can play in
preventing
illness.[165]
The strategy acknowledges that eating disorder research has been hampered by
insufficient resourcing and a lack of coherent vision,
resulting in
“intermittent discoveries and limited uptake of the
evidence”.[166]
The
development of a New Zealand national strategy need not be in isolation. The
close relationship with Australia presents an opportunity
to leverage learnings
and exchange knowledge between the two countries. Further, the mere act of
implementing a strategy is a significant
first step to show New Zealanders that
the prevalence of eating disorders is a serious issue whose stigma has
exacerbated the harms
it has caused to individuals and communities. New Zealand
ought to follow Australia’s lead with respect to co-designing a strategy
with relevant stakeholders such as researchers, healthcare providers and the
affected population. The Māori Health Authority
is an obvious stakeholder
for engagement to ensure alignment with the Pae Ora (Healthy Futures) Act which
places importance on improving
Māori health outcomes to ensure everyone has
the same access to adequate health
outcomes.[167]
Co-design of an
eating disorder prevention policy and strategy with indigenous peoples is of the
utmost importance. This imperative
has been recognised in Australia, with the
new Centre currently developing an “Aboriginal and Torres Strait Islanders
Eating
Disorders Research Strategy” to ensure the experience of First
Nations peoples with eating disorders is better understood through
research.[168] Determination of
the scope and direction of the strategy is an ongoing collaborative effort
between consultancy firm First Nations
Co and the Centre. In the New Zealand
context, partnership with Māori is fundamental given that Māori are
disproportionately
affected by eating disorders. The University of Otago
exercised partnership with Māori by working with its own Māori
Indigenous
Health Institute in a study that affirmed rates of eating disorders
are higher in Māori
communities.[169] In addition to
the University of Otago, the University of Auckland has Tōmaiora—the
Māori Health Research Group—which
endeavours to find solutions
through quality evidence-based Māori health
research.[170] Genuine
consideration of Māori interests and perspectives is essential to ensure
the processes to formulate the strategy are
transparent to the Māori
community.
Australia’s eating disorder strategy co-development with
Aboriginal and Torres Strait Islanders is a model that New Zealand
must follow.
Authentic engagement and cultural oversight will increase the likelihood that
Māori will be positively impacted
by the strategy as well as subsequent
research outcomes.
Overall, the New Zealand government’s first step in
a preventative approach to eating disorders should be to establish a national
strategy. Much can be learned from the Australian approach, which has provided
sufficient funding, established a targeted research
centre, and co-designed
strategic goals with indigenous peoples. Furthermore, New Zealand should
collaborate with the Australian
Centre to share learnings to contribute to a
more informed preventative policy approach.
While research is necessary to support a comprehensive eating disorder prevention policy response in the long-term, the New Zealand government should introduce two valuable initiatives in the meantime: restrictions on the distortion of bodies in advertising and targeted eating disorder education for primary school children. As an alternative to advertising restrictions, this section also considers third party certification for companies which practice the portrayal of realistic body image and inclusive representation in advertising.
The first proposed
prevention initiative is a ban on the distortion of bodies in advertising, as
less restrictive initiatives have
failed in other jurisdictions. As discussed in
Part VII, “warning labels” on photoshopped images produce a
“backfire”
effect, as they simply highlight the idea that even the
models’ bodies are not “ideal” enough for the purposes
of the
company’s advertisement. Furthermore, media literacy to build resilience
to image distortion places the burden on those
receiving the education to be
aware of companies’ advertising practices in the hopes of minimising body
dissatisfaction.
Given that the use of “idealised” models is a
key driver of sales, companies are unlikely to voluntarily shift away from
their
current practices. Therefore, a more robust intervention, such as enforcing a
prohibition on digitally altered and distorted
bodies in advertising visuals, is
imperative. Such a prohibition has precedent. In 2017, Getty Images banned
images from its libraries
that were photoshopped to make female models look
thinner and male models more
muscular.[171] In 2016, the Mayor
of London, Sadiq Khan, banned advertisements that pressure people to conform to
“unrealistic body images”
on London’s tube and bus network,
collaborating with the network to implement a steering group to monitor
advertisements.[172] In 2018, CVS
Pharmacy announced it would no longer feature images where a person’s
shape, size, proportion, wrinkle or skin
colour had been altered, and urged
brands to do the same.[173] If the
world’s largest stock image library, the largest city in the United
Kingdom and the largest pharmacy chain in the United
States can prohibit body
distortion, why not the New Zealand government?
One approach to implementing
such a prohibition would be to amend s 9 of the Fair Trading Act 1986.
Section 9 states that “no
person shall, in trade, engage in conduct that
is misleading or deceptive or is likely to mislead or deceive”. The Fair
Trading
Act defines “advertisement”
as:[174]
... any form of communication made to the public or a section of the public
for the purpose of promoting the supply of goods or services
or the sale or
granting of an interest in land
Thus, an advertisement constitutes conduct
“in trade”. As discussed in the context of the United Kingdom
ASA’s finding
that several cosmetic advertisements were
“misleading”, the ability to make a “misleading” finding
has so
far been confined to promoting specific product outcomes, which has since
been mitigated through actual product result disclaimers.
However, the
definition of “misleading or deceptive” should be broadened beyond
the product to focus on the models used
in an image to sell and promote the
product. Currently, the Commerce Commission is responsible for upholding fair
trading standards.
A potential enhancement could involve empowering a dedicated
committee within the Commission to enforce a prohibition on distorted
bodies
with investigatory and declaratory powers.
Opponents may challenge a
prohibition on body distortion in advertising as an infringement on freedom of
expression. However, while
Parliament may enact contrary to the New Zealand Bill
of Rights Act 1990, there is nevertheless a strong argument that such a
prohibition
on distorted images would be a justifiable limitation of freedom of
expression, given the impetus for prevention policy action to
address New
Zealand’s eating disorder crisis. A prohibition on photoshopping also
avoids complex questions like what is “health”
and discrimination
arguments which could arise if a prevention policy’s focus was on ensuring
the use of a diverse range of
healthy models in advertising.
The second proposal is an eating disorder education
initiative targeting primary school students. As mentioned in the
“Protective
factor programmes” section above, studies have shown
that five to nine year old girls and boys were already significantly invested
in
thin and muscular ideals.[175]
These studies reiterate that preadolescence is an important age for prevention
initiatives, before weight-loss behaviours and cognitions
become entrenched.
While media literacy and body image workshops are useful to build resilience
when it comes to consuming content,
it is a roundabout way to prevent eating
disorders. The stigma of eating disorders has been highlighted as an immense
barrier to
accessing aid, as well as a lack of symptom awareness in the general
population—education could curtail this stigma.
Health education in
New Zealand has expanded beyond physical to now include mental health and could
be easily expanded to cover eating
disorders. However, until 2018, guidelines
only recommended mental health education for students in Year 7 and above,
neglecting
the reality that poor mental health does not have a starting
age.[176] Positively, an updated
mental health education guide was issued in 2022, which is applicable to Years
1–13.[177] However, the
guidelines state: “Eating disorders should not be a focus of learning
programmes. Rather, learning experiences
should focus on thinking critically
about societal pressures, taking action, and promoting
self-acceptance.”[178]
Unfortunately, this sentiment only exacerbates the stigma that surrounds eating
disorders and contributes to poor early intervention
outcomes.
To the extent
that measures are recommended to school staff to address body image issues,
these also avoid acknowledgement of eating
disorders. For example, the
guidelines state that schools should review their uniform design, focus on the
benefits of physical activity,
use diverse body sizes in school publications,
and that staff should not discuss
weight.[179] Advising against
direct discussion about eating disorders is a regressive step. This advice is in
stark contrast with the guidelines’
approach to alcohol and drug
education, which advise teachers to explain the effects of consumption, the
effect of media representations,
and ways of seeking help personally and amongst
peers.[180] Overall, the New
Zealand health curriculum has made commendable progress by integrating mental
health education from Year 1. Yet,
it is essential that curriculum guidelines
avoid perpetuating the taboo nature of eating disorders. Addressing these issues
openly
can empower adolescents to seek help and recognise symptoms amongst their
friends. The causes and consequences of eating disorders
should be discussed in
New Zealand classrooms.
The third initiative is endorsement of
third-party certification which presents a less interventionist approach to
prohibiting body
alterations in advertising. A New Zealand government agency
could be tasked with certifying companies which market their products
in a
manner that prevents the promotion of idealised body types. The agency could
certify companies that exercise practices consistent
with the prevention of
eating disorders, such as including diverse body sizes, body types and
ethnicities in their advertising.
Nonetheless, the efficacy of a
government-led certification may be less effective than other well-recognised
certifications such as
the aforementioned B Corp which certifies that a business
has met high standards of corporate social responsibility. With this in
mind, a
more compelling approach for the New Zealand government could be to engage with
B Corp to expand its criteria to include
companies that practice eating disorder
prevention in their marketing and advertising. B Corp entities are subject to
“Impact
Assessments” where brands must certify that they are, for
example, creating inclusive
workplaces.[181] An
“inclusive” workplace is not a well-defined inquiry, as is the case
for other standards that must be met to achieve
certification. Consequently,
criteria relating to eating disorder prevention practices would conform with the
discretionary nature
of B Corp certification, which states lofty expectations
and requires companies to provide documentary proof that they meet those
expectations. New criteria could mirror the Australian government’s
Voluntary Industry Code of Conduct, developed by the National
Advisory Group on
Body Image.[182] For example, the
following criterion, reflecting clause one of the Code, could be added:
“Use positive content and messaging
to support the development of a
positive body image and realistic and healthy physical goals and aspirations
among consumers.”
Prospective B Corps could submit their advertising
campaigns to prove that they do not solely portray idealised bodies, but also
promote healthy body image. This approach is preferable to a government-led
certification as B Corp took over a decade to gain increased
recognition and New
Zealand’s eating disorder crisis necessitates consideration of a swifter
alternative.
Evidence-based
policymaking is a formidable tool to address both health and social issues.
Nonetheless, the chronic underfunding of
eating disorder treatment, prevention,
early intervention initiatives and research has resulted in a lack of evidence
necessary for
a nuanced understanding of these issues for policymakers.
Nonetheless, this article has proposed a trio of actions for prevention
that the
literature supports. Firstly, a prohibition on altering bodies in advertising to
reduce the negative impact of body dissatisfaction,
which emerges due to
discrepancies between what society portrays as an ideal body and a
person’s real body. Secondly, improved
education on eating disorders to
reduce the stigma around eating disorders, with such stigma preventing New
Zealanders from seeking
help before disordered eating behaviours are entrenched.
Excluding eating disorders from mental health education prevents young New
Zealanders from being aware of the signs and effects of eating disorders.
Education can empower adolescents to seek help and support
their peers. Thirdly
and finally, third-party certification for entities whose advertising practices
do not contribute to unrealistic
body image idealisation. Such a certification
would make it clear to consumers which companies are and are not cognisant of,
or responding,
to the New Zealand eating disorder crisis, and, ideally,
incentivise companies to factor eating disorder prevention into their strategic
decisions.
These measures can be monitored by a new or existing government
body, such as Te Whatu Ora (Health New Zealand) and Te Aka Whai Ora
(the
Māori Health Authority), established pursuant to a national eating disorder
prevention policy and strategy and subject
to future studies to examine their
efficacy. To facilitate this research, funding should come from a national
strategy for eating
disorders and New Zealand should follow in Australia’s
wake to establish a comprehensive strategy to combat eating disorders.
A formal
strategy would recognise eating disorders as the serious issue it is, which
demands a deliberate and categorical preventative
response. In conjunction with
formulating such a strategy to allocate funding for policy efficacy research,
the three initiatives
proposed provide a strong foundation for the proactive
management of eating disorders in New Zealand.
[*] LLB(Hons), BCom Auck. Solicitor, Russell McVeagh. The author wishes to acknowledge Professor Jaime King for generously sharing her wisdom and guidance; her family and friends for their unconditional support throughout her studies; and her partner, Jordan Stevenson, for his incredible patience.
[2] See American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (5th ed, Arlington (Va), 2013).
[3] At 345 and 350.
[5] Brittany Mulders-Jones and others “Socioeconomic Correlates of Eating Disorder Symptoms in an Australian Population-Based Sample” (2017) 12 PLoS One 1 at 1.
[6] At 1.
[7] Cameron Lacey and others “Eating disorders in New Zealand: Implications for Māori and health service delivery” (2020) 53 Int J Eat Disord 1974 at 1975.
[9] Rachel Baffsky “Eating disorders in Australia: a commentary on the need to address stigma” (2020) 8 J Eat Disord at 1.
[10] See generally Davene R Wright and others “The Cost-Effectiveness of School-Based Eating Disorder Screening” (2014) 104 Am J Public Health 1774.
[14] Vanessa Wolter and others “Prevention of eating disorders—Efficacy and cost-benefit of a school-based program (‘MaiStep’) in a randomized controlled trial (RCT)” (2021) 54 Int J Eat Disord 1855 at 1856.
[15] Wright and others, above n 10.
[16] Culbert, Racine and Klump, above n 4.
[17] At 1143.
[18] At 1145.
[19] Pilar Aparicio-Martinez and others “Social Media, Thin-Ideal, Body Dissatisfaction and Disordered Eating Attitudes: An Exploratory Analysis” (2019) 16 Int J Environ Res Public Health 4177 at 1.
[20] Culbert, Racine and Klump, above n 4, at 1145.
[21] Aparicio-Martinez and others, above n 19, at 3.
[22] Anne E Becker and others “Eating behaviours and attitudes following prolonged exposure to television among ethnic Fijian adolescent girls” (2002) 180 Br J Psychiatry 509.
[23] At 510.
[24] At 513.
[25] At 512.
[26] Aparicio-Martinez and others, above n 19.
[27] Jaime E Sidani and others “The Association between Social Media Use and Eating Concerns among US Young Adults” (2016) 116 J Acad Nutr Diet 1465 at 1466.
[28] Simon M Wilksch and others “The relationship between social media use and disordered eating in young adolescents” (2020) 53 Int J Eat Disord 96 at 96.
[29] At 97.
[30] Culbert, Racine and Klump, above n 4, at 1147.
[31] Pamela K Keel and K Jean Forney “Psychosocial Risk Factors for Eating Disorders” (2013) 46 Int J Eat Disord 433 at 437.
[32] At 437.
[33] Culbert, Racine and Klump, above n 4, at 1150.
[34] Emily Davis “Unlocking the Genetics of Eating Disorders” (18 August 2020) University of North Carolina Research <www.endeavors.unc.edu>.
[35] Aparicio-Martinez and others, above n 19, at 2.
[36] Hay and others, above n 1, at 979.
[37] Aparicio-Martinez and others, above n 19, at 2.
[38] Sonja Swanson and others “Prevalence and Correlates of Eating Disorders in Adolescents. Results from the National Comorbidity Survey Replication Adolescent Supplement” (2011) 68 Arch Gen Psychiatry 714 at 718.
[39] Baffsky, above n 9, at 1.
[40] Elizabeth Rowe “Early detection of eating disorders in general practice” (2017) 46 AFP 833 at 833.
[42] The National Eating Disorders Collaboration Eating Disorders: The Way Forward – An Australian National Framework (The Butterfly Foundation, Sydney, 2010) at 36.
[43] P Knightsmith, J Treasure and U Schmidt “Spotting and supporting eating disorders in school: recommendations from school staff” (2013) 28 Health Educ Res 1004 at 1005.
[44] At 1004.
[46] Sara J Hansen, Alice Stephan and David B Menkes “The impact of COVID-19 on eating disorder referrals and admissions in Waikato, New Zealand” (2021) 9 J Eat Disord 1 at 7.
[48] Eating Disorder Association New Zealand “About Us” <www.ed.org.nz>.
[49] Eating Disorder Association New Zealand “Submission to the New Zealand Government Mental Health Inquiry” at 22.
[54] Letter from Philip Grady (Acting Deputy Director-General, Mental Health and Addiction, Ministry of Health) to Britney Clasper regarding request for documentation relating to government policy concerning the prevention of eating disorders (14 February 2022) at 3 (Obtained under Official Information Act 1982 Request to the Ministry of Health) [document held by author, available upon request].
[55] Philip Grady “Response to Select Committee Submission 2020/83: Rebecca Toms” Health Report: 20211827 at 2 (Obtained under Official Information Act 1982 Request to the Ministry of Health, Document 3) [document held by author, available upon request].
[56] Robyn Shearer “Eating disorders health promotion and prevention initiatives” (3 September 2021) Briefing HR20211781 at 4 (Obtained under Official Information Act 1982 Request to the Ministry of Health, Document 4) [document held by author, available upon request].
[57] Shearer, above n 56, at [12]–[13].
[58] At [15].
[59] At [23]–[25].
[60] Ministry of Health “Background and talking points regarding Rebecca Tom’s petition and oral hearing at Health Committee 8/12/21” at 3 (Obtained under Official Information Act 1982 Request to the Ministry of Health, Document 6) [document held by author, available upon request].
[61] Shearer, above n 56, at 7.
[62] Ministry of Health “Talking points for eating disorders health promotion and prevention initiatives 6/9/2021” (6 September 2021) at 1 (Obtained under Official Information Act 1982 request to the Ministry of Health, Document 5) [document held by author, available upon request].
[63] Eating Disorders Genetics Initiative “The great underfunding of eating disorders research” (22 December 2021) <www.edgi.nz>.
[64] Stuart B Murray and others “When illness severity and research dollars do not align: are we overlooking eating disorders?” (2017) 16 World Psychiatry 321 at 321.
[65] Joseph Boniface Ajefu and Faith Barde “Market Efficiency and Government Intervention Revisited: What Do recent Evidence Tell Us?” (2015) 3 Int J Bus Econ 20 at 21.
[66] Mrinal Datta-Chaudhuri “Market Failure and Government Failure” (1990) 4 JEP 25 at 25.
[67] Murray Laugesen and Boyd Swinburn “New Zealand’s tobacco control programme 1985-1998” (2000) 9 Tobacco Control 155 at 156.
[68] At 155.
[69] At 156.
[70] Māori Affairs Committee Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori (November 2010) at 12.
[71] Ministry of Health “History of Smokefree Aotearoa 2025: Progress to Smokefree 2025” <www.health.govt.nz>.
[72] Department of the Prime Minister and Cabinet “Te Aka Whai Ora / Māori Health Authority” Future of Health <www.futureofhealth.govt.nz>.
[73] Section 7(1)(e)(i).
[74] Section 7(2).
[75] Anthony D Moulton and others “The Scientific Basis for Law as a Public Health Tool” (2009) 99 Am J Public Health 17.
[76] Supporting Eating disorders Recovery through Vital Expansion Act 2019, HR 2767, 116th Cong, § 6.
[77] “S.2673 - SERVE Act” (23 October 2019) Congress.gov <www.congress.gov>.
[78] An Act amending the act of March 10, 1949 (PL30, No 14), known as the Public School of Code of 1949, in school health services, providing for parent educational information regarding eating disorders 2021, HB 2158, RS 2021–2022 (Penn). The Bill was referred to the Education Committee on 13 December 2021.
[79] Behavioral Healthcare Executive “Virginia becomes first state to enact eating disorder education law” (29 March 2013) HMP Global Learning Network <www.hmpgloballearningnetwork.com>.
[80] An Act to amend the Code of Virginia by adding a section numbered 22.1-273.2, relating to parent educational information; eating disorders, HB 1406, S 2013 (Va), which was enacted as Va Code Ann § 22.1-273.2.
[81] Virginia Department of Planning and Budget “2013 Fiscal Impact Statement” (Bill No HB1406, 18 December 2013).
[82] Scott County Schools “Eating Disorders: Scott County School Policy” <www.scottschools.com>.
[83] Eating Disorder Prevention in Schools Act of 2020, HR 6703, 116th Cong.
[84] Richard B Russell National School Lunch Act 1946 79 Pub L No 396, 60 Stat 230.
[85] Email from Richa Patel (Legislative Correspondent for North Carolina Congresswoman Alma Adams) to Britney Clasper regarding the Eating Disorder Prevention in Schools Act of 2020 (28 March 2022) [document held by author, available upon request].
[86] Ellen E Fitzsimmons-Craft and others “Results of disseminating an online screen for eating disorders across the U.S.: Reach, respondent characteristics, and unmet treatment need” (2019) 52 Int J Eat Disord 721 at 721.
[87] Kathleen Rindahl “A Systematic Review of Literature on School Screening for Eating Disorders” (2017) 5 Int J Health Sci 1 at 2.
[88] At 3. See also John F Morgan, Fiona Reid and J Hubert Lacey “The SCOFF questionnaire: a new screening tool for eating disorders” (2000) 173 WJM 164 for the article that first proposed the SCOFF questionnaire.
[89] Jason Nagata and S Bryn Austin “Diet pills are incredible dangerous for teens. California needs to regulate them like cigarettes” San Francisco Chronicle (online ed, San Francisco, 12 January 2022).
[90] An act to add Section 110423.7 to the Health and Safety Code, relating to public health 2021, AB 1341, RS 2021–2022 (Calif). The Bill was passed by the California legislature but vetoed by Governor Gavin Newsom.
[91] Nearly six times more likely than peers who did not use these products to be diagnosed with an eating disorder within one to three years of beginning use of these products.
[92] Health Navigator “Common questions about weight loss medicines” Healthify <www.healthify.nz>.
[93] Therapeutic Products Act 2023, pt 11 sub-pt 4.
[94] Vanessa Rivera de la Fuente “Argentine Legislators Consider Law to Regulate Clothing Sizes, Advocates Promote Positive Body Image” (28 November 2012) Global Press Journal <www.globalpressjournal.com>.
[95] Marilyn Krawitz “Beauty is only photoshop deep: Legislating models’ BMIs and photoshopping images” (2014) 21 J Law Med 859 at 869.
[96] This law, which covers the Buenos Aires province, was followed in 2019 by a state-level law along the same lines in 2019: see Sistema Único Normalizado de Identificación de Talles de Indumentaria (Single Standardized Clothing Size Identification System) Law No 27,521, 20 December 2019.
[97] Ann Robin Tucker “Body Modification and Body Image Among Argentines: The Prevalence of Plastic Surgery and Eating Disorders in Buenos Aires” (BA Thesis, University of Mississippi, 2010) at 45.
[98] Kirsty Lawrence “Ruby releases clothing line with larger size range, and zero waste” (30 September 2021) Stuff <www.stuff.co.nz>.
[99] Giles Tremlett “Spain curbs ‘body image’ ads on television” The Guardian (online ed, London, 18 January 2010).
[100] “Legislación Consolidada: General de la Comunicación Audiovisual (Consolidated Legislation: General Law of Audiovisual Communication)” (1 April 2010) Boletín Oficial Del Estado BOE-A-2010-5292.
[101] Article 124(1)(g).
[102] Article 2.
[103] Article 3.
[104] Article 155.
[105] Advertising Standards Authority “Therapeutic and Health Advertising Code” <www.asa.co.nz>.
[106] Advertising Standards Authority “What happens if an advertisement is found to be in breach of a Code?” <www.asa.co.nz>.
[108] Nirav R Shah and Eric R Braverman “Measuring Adiposity in Patients: The Utility of Body Mass Index (BMI), Percent Body Fat, and Leptin” (2012) 7 PLoS ONE 1 at 1.
[109] Marilyn Bromberg and Cindy Halliwell “‘All About That Bass’ and Photoshopping a Model’s Waist: Introducing Body Image Law” (2016) 18 UNDALR 1 at 12.
[110] Jake Linardon “Positive body image, intuitive eating, and self-compassion protect against the onset of the core symptoms of eating disorders: A prospective study” (2021) 54 Int J Eat Disord 1967 at 1968.
[111] Kirrilly M Pursey and others “Disordered eating, body image concerns, and weight control behaviours in primary school aged children: A systematic review and meta-analysis of universal-selective prevention interventions” (2021) 54 Int J Eat Disord 1730 at 1730.
[112] At 1732.
[113] At 1762.
[114] Shearer, above n 56, at 6.
[116] The Law Restricting Weight in the Modelling Industry, 5772–2023, SH 2347 229 (Israel).
[118] The Law Restricting Weight in the Modelling Industry, s 1.
[119] Section 3.
[120] Krawitz, above n 95, at 868.
[121] Eran Swissa “Israel’s Ministerial Committee for Legislation approves upgraded ‘Photoshop Law’” Jewish News Syndicate (online ed, Tel Aviv, 7 February 2022).
[122] Mun Yee Kwan and others “Warning labels on fashion images: Short- and longer-term effects on body dissatisfaction, eating disorder symptoms, and eating behaviour” (2018) 51 Int J Eat Disord 1153 at 1154. The five studies which concluded there was little support for the use of media warning labels were Rheanna N Ata, J Kevin Thomspon and Brent J Small “Effects of exposure to thin-ideal media images on body dissatisfaction: Testing the inclusion of a disclaimer versus warning label” (2013) 10 Body Image 472; Belinda Bury, Marika Tiggemann and Amy Slater “Disclaimer labels on fashion magazine advertisements: Impact on visual attention and relationship with body dissatisfaction” (2016) 16 Body Image 1; Belinda Bury, Marika Tiggemann and Amy Slater “The effect of digital alteration disclaimer labels on social comparison and body image: Instructions and individual differences” (2016) 17 Body Image 136; David A Frederick and others “Reducing the negative effects of media exposure on body image: Testing the effectiveness of subvertising and disclaimer labels” (2016) 17 Body Image 171; and Marika Tiggemann and others “Disclaimer labels on fashion magazine advertisement: Effects on social comparison and body dissatisfaction” (2013) 10 Body Image 45.
[123] Kwan and others, above n 122, at 1154. For the study that concluded that warning labels prevented an increase in body dissatisfaction, see Amy Slater and others “Reality Check: An Experimental Investigation of the Addition of Warning Labels to Fashion Magazine Images on Women’s Mood and Body Dissatisfaction” (2012) 31 J Soc Clin Psychol 105.
[124] Kwan and others, above n 122, at 1154.
[127] An Act relative to mental health promotion through realistic advertising images 2020, H 3892, S 191 (Mass) § 1; and see Tessa Yannone “This New Bill Incentivizes Companies to Use Unedited Images of Models” Boston Magazine (online ed, Boston, 31 May 2019).
[128] See the Bill’s progress on the Massachusetts legislature website: “Bill H.3892” Commonwealth of Massachusetts <malegislature.gov/191/H3892>.
[129] Bernadka Dubicka and Louise Theodosiou Technology use and the mental health of children and young people (Royal College of Psychiatrists, College Report CR225, January 2020) at 6.
[130] Josh Kallmer “Digital Tax: The Critical Importance of a Multilateral Approach” (14 December 2017) German Marshall Fund of the United States <www.gmfus.org>.
[131] Leigh Thomas “France orders tech giants to pay digital tax” (26 November 2020) Reuters <www.reuters.com>.
[132] Pinsent Masons “France to resume collection of digital tax” (4 December 2020) <www.pinsentmasons.com>.
[134] See for example Advertising Standards Authority “About Complaints: Why are there no fines to make advertisers take down the advertisement if the complaint is upheld?” <www.asa.co.nz>.
[135] McBride, Costello and Ambwani, above n 125, at 17.
[137] Mark Sweney “L’Oréal’s Julia Roberts and Christy Turlington ad campaigns banned” The Guardian (online ed, London, 27 July 2011).
[138] Australian Association of National Advertisers “AANA’s Body Image Rules in action” (17 September 2020) <www.aana.com.au>.
[139] Australian Association of National Advertisers Code of Ethics (February 2021) at 3.
[140] Australian Association of National Advertisers Code of Ethics - Practice Note (February 2021) at 12.
[141] Australian Government Voluntary Industry Code of Conduct on Body Image (A10-0361, 2016).
[142] Bromberg and Halliwell, above n 109, at 9.
[143] Elizabeth Reid Boyd and Jessica Moncrieff-Boyd “Swimsuit issues: promoting positive body image in young women’s magazines” (2011) 22 Health Promot J Aust 102 at 102.
[144] Baffsky, above n 9, at 2.
[145] Ian Ayres and John Braithwaite Responsive Regulation: Transcending the Deregulation Debate (Oxford University Press, New York, 1992) at 44.
[147] Allyssa Compton “Does Body Positivity Yield Positive Attitudes? The Effects of Female Empowerment in Advertisements on Consumer Perceptions” (Senior Honors Project, University of Lynchburg, 2021).
[148] McBride, Costello and Ambwani, above n 125, at 22.
[149] B Corporation “About B Corp Certification: Measuring a company’s entire social and environmental impact” <www.bcorporation.net>.
[150] Suntae Kim and others “Why Companies are Becoming B Corporations” (17 June 2016) Harvard Business Review <www.hbr.org>.
[151] Kim and others, above n 150.
[152] B Corporation “How did the B Corp movement start?” <www.bcorporation.net>.
[153] Shelley E Kohan “Customers Seek Purpose Driven Companies Creating A Rise in B Corps” Forbes (online ed, Jersey City, 28 March 2021).
[156] Eating Disorder Genetics Initiative, above n 63.
[157] The Butterfly Foundation, above n 8, at 9.
[158] Synergies Economic Consulting “Economic Costs of Autism Spectrum Disorder in Australia” (April 2011) <www.synergies.com.au> at 11.
[159] University of Sydney “Australia’s first national strategy for eating disorders released” (21 September 2021) <www.sydney.edu.au>.
[160] Australian Department of Health and Aged Care “More support for Australians with eating disorders” (media release, 31 March 2022).
[161] Australian Department of Health and Aged Care, above n 160.
[162] InsideOut Institute “Australian Eating Disorders Research and Translation Centre webinar: four-year plan” (18 March 2022) <www.insideoutinstitute.org.au>.
[163] Philip Aouad and others “Informing the development of Australia’s National Eating Disorders Research and Translation Strategy: a rapid review methodology” (2022) 10(31) J Eat Disord 1 at 1.
[164] At 9.
[165] InsideOut Institute “Australian Eating Disorders Research & Translation Strategy 2021-2031” (23 March 2023) <www.insideoutinstitute.org.au>.
[166] InsideOut Institute, above n 165.
[167] Department of the Prime Minister and Cabinet, above n 72.
[168] InsideOut Institute “The Australian Eating Disorders Research & Translation Centre: building a national effort” (10 August 2022) <www.insideoutinstitute.org.au>.
[169] Māori Indigenous Health Institute and University of Otago Christchurch “Tangata Kōmuramura: Māori Experiences of Eating Disorders?” <www.otago.ac.nz>.
[170] Tōmaiora – Māori Health Research Group “Home” <www.tomaiora-research-group.blogs.auckland.ac.nz>.
[171] Steve Dent “Getty bans images photoshopped to make models look thinner” (27 September 2017) Engadget <www.engadget.com>.
[172] Robert Cookson “Sadiq Khan bans body-shaming ads on London transport” Financial Times (online ed, London, 14 June 2016).
[173] Danielle Selby “CVS is Banning Photoshopped Photos for Product Promotion” (19 January 2018) Global Citizen <www.globalcitizen.org>.
[174] Section 2 definition of “advertisement”.
[175] See Part VII.C.5; and Pursey and others, above n 111.
[176] New Zealand Council for Educational Research “Mental health education and hauora: Teaching interpersonal skills, resilience, and wellbeing” (2016) <www.nzcer.org.nz>.
[177] Ministry of Education Mental Health Education Years 1–13: A Guide for Teachers, Leaders, and School Boards (28 September 2022).
[178] At 55.
[179] At 44.
[180] At 64.
[181] B Corporation “B Impact Assessment” <www.bcorporation.net>.
[182] Australian Government, above n 141.
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