Body Image Report - Parliament of Victoria

FAMILY AND COMMUNITY 

DEVELOPMENT COMMITTEE 

INQUIRY INTO ISSUES RELATING TO THE 

DEVELOPMENT OF BODY IMAGE AMONG 

YOUNG PEOPLE AND ASSOCIATED EFFECTS 

ON THEIR HEALTH AND WELLBEING 

Ordered to be Printed 

July 2005 

Parliamentary Paper No 142 - Session 2003-05

National Library of Australia 

Family and Community Development Committee (2005) 

Inquiry into Issues Relating to the Development of Body Image among Young People 

and Associated Effects on their Health and Wellbeing 

ISBN: 0-9752253-2-4 

Cover Design: 

Kate Simondson - Mongrel Creative 

http://www.mongrelcreative.com.au 

47 Cary Street 

Sunshine VIC 

0412 634 032 

Family and Community Development Committee 

Level 8, 35 Spring Street 

Melbourne, Victoria 3000 

Phone: (03) 9651 3526 

Fax: (03) 9651 3691 

Email: fcdc@parliament.vic.gov.au 

Website: http://www.parliament.vic.gov.au/fcdc 

© State of Victoria

M EMBERS 

Mr Robert Smith, MLC 

Chair 

Member for Chelsea Province 

Hon. David Davis, MLC 

Member for East Yarra Province 

Ms Lisa Neville, MLA 

Member for Bellarine 

Mr Dale Wilson, MLA 

Member for Narre Warren South 

Staff 

Mrs Jeanette Powell, MLA 

Deputy Chair 

Member for Shepparton 

Ms Heather McTaggart, MLA 

Member for Evelyn 

Mrs Helen Shardey, MLA 

Member for Caulfield 

Mr Paul Bourke Executive Officer 

Ms Lara Howe Office Manager 

Ms Iona Annett Research Officer

TABLE OF C ONTENTS 

• Committee Function i 

• Terms of Reference iii 

• Chairman’s Foreword v 

• Findings and Recommendations ix 

Chapter 1: Introduction 

• Body Image, Body Dissatisfaction. Eating Disorders 2 

• Understanding Body Image and Body Image Disturbance 3 

• The Links Between Body Image And Eating Disorders 4 

• An Integrated Approach to Addressing Negative Body Image 6 

Chapter 2: The Development of Body Image among Young 

People 

• What is Body Image? 9 

• Biological Factors 11 

• Social and Cultural Factors 13 

• Other Factors 24 

• Conclusion 29 

Chapter 3: Negative Effects of Problematic Body Image 

• The Effects of Negative Body Image 34 

• Eating disorders 51 

• Other Negative Effects 69 


Chapter 4: Treatment and Support Strategies 

• Eating Disorders 77 

• Treatment paths and access to services 85 

• Conclusion 102

Chapter 5: Health Promotion Strategies 

• Health promotion 107 

• Primary Prevention 113 

• Early Intervention 130 


Witnesses and Submissions 139

PARLIAMENTARY C OMMITTEES 

A CT 2003 

S.11. The functions of the Family and Community Development 

Committee are, if so required or permitted under this Act, to inquire 

into, consider and report to the Parliament on– 

(a) any proposal, matter or thing concerned with- 

(i) the family or the welfare of the family; 

(ii) community development or the welfare of the community; 

(b) the role of the Government in community development and 

welfare including the welfare of the family. 

i

INQUIRY INTO ISSUES RELATING TO THE DEVELOPMENT OF BODY IMAGE AMONG 

YOUNG PEOPLE AND ASSOCIATED EFFECTS ON THEIR HEALTH AND WELLBEING 

ii

T ERMS OF R EFERENCE 

The Governor in Council, under section 4F of the Parliamentary Committees 

Act 1968, requests that the: 

Family and Community Development Committee of Parliament inquire into, 

consider and report to Parliament on issues relating to the development of 

body image among young people and associated effects on their health and 

wellbeing. 

The Committee is requested to: 

1. Identify factors which contribute to the development of body image among 

young people; 

2. Consider: 

• the role of the media, family, the peer group and other potential 

factors in the development of body image; 

• other factors that impact on body image; 

• the associated health and other impacts of eating disorders, steroid 

use, and other manifestations of problematic body image, on young 

people; 

• gender differences in the development of problematic body image. 

3. Analyse available medical research on the linkages between mental health 

and problematic body imagery; 

4. Identify good practice in the promotion of positive body image among 

young people and how risk factors associated with negative body image can 

be combated; 

5. Identify possible improvements to health promotion campaigns aimed at 

young people, that promote positive body image and self esteem; 

6. Investigate the extent to which promoting positive body image and self 

esteem among young people can help to prevent associated health risks 

iii



such as potentially dangerous weight loss methods, eating disorders, steroid 

use, exercise dependence or avoidance, obesity and mental ill health; 

7. Consider whether further strategies are needed to enhance and promote 

positive body images among young people and, if so, what form the 

strategies should take (including non-legislative options) and whether these 

would be best developed by government agencies, the community sector or 

through partnership arrangements. 

The Committee is required to report to Parliament by 31 December 2004. 

Dated 18 November 2003 

Responsible Minister: HON STEVE BRACKS MP, Premier 

iv

CHAIRMAN’S FOREWORD 

I have great pleasure in presenting the Family and Community Development 

Committee’s Final Report on its Inquiry into Issues relating to the 

Development of Body Image among Young People and Associated Effects 

on their Health and Wellbeing. 

From the outset this Inquiry received a great deal of interest from both the 

media and the general public resulting in an extensive body of evidence and 

a large number of submissions. This reflects the level of concern which 

exists in the community around issues of body image and the associated 

medical and psychological effects which can occur where there is an 

imbalance. 

While it has been estimated that body image dissatisfaction can result in 

extreme dieting and eating disorders in 2- 4% of the population, it affects a 

far greater proportion of young people at a dangerous yet less acute level. 

The Committee has, therefore, placed stress on the development of 

strategies which promote self esteem and resilience, defences against the 

onset of body image dissatisfaction. In addition to prevention, the 

Committee has also examined Australian and international treatment and 

intervention models for acute eating disorders encouraging the development 

and trial of new models proven to be successful. 

In conducting this Inquiry the Committee has been aware that increases in 

the numbers of young people suffering eating disorders and body 

dissatisfaction has occurred at a time when obesity is also a serious 

problem in the community. Thus, the Committee has emphasised the 

importance of total health and lifestyle programs for young people -at home, 

v



school and community level- promoting the role of healthy eating and 

activity. 

In order to address the terms of reference in full the report has been divided 

into five chapters. The first chapter of this report provides an overview of 

the subject and illustrates the extent of the problem as well as highlighting 

issues of importance. 

The second chapter seeks to identify factors which contribute to the 

development of body image among young people. The family, media and 

peers are suggested in the Terms of Reference, however the Committee 

has investigated a range of additional factors which may determine an 

individuals body image in a both a positive and negative way. 

The third chapter examines the possible effects of negative body image on 

the health and well-being of young people. The first part of the chapter 

examines the possible linkages between negative body image and the 

development of medical and psychological problems among young people. 

The final section looks at these problems in more detail. 

The fourth chapter focuses on the treatments recommended and available 

in Victoria for those children and adolescents suffering the most severe 

impact of negative body image. The first section discusses the treatment 

options for eating disorders. The second section focuses on the treatment 

services available in Victoria, issues of accessibility and the experience of 

sufferers and their carers. 

The final chapter reviews the role of health promotion in preventing the 

development of body dissatisfaction in young people and ameliorating its 

effects. It begins by defining health promotion and describing its activities. 

The structure of health promotion in Victoria is then briefly described. The 

next section reviews how health promotion works to prevent the 

development of body dissatisfaction and eating disorders and examines 

vi

CHAIRMAN’S FOREWORD 

Victorian, interstate and overseas programs. The last section is concerned 

with early intervention and how Victorian, interstate and overseas programs 

work to treat emerging health issues and prevent the development of more 

serious mental and physical conditions. 

During the course of this Inquiry the Committee held hearings in both rural 

and metropolitan Victoria and received testimony and submissions from a 

wide range of people from health professionals to community workers, 

psychologists to concerned members of the public. The Committee also 

received submissions from interstate and overseas. The Committee would 

like to thank everyone for their participation. 

Although no one should be singled out for their contribution to this report, 

the Committee would like to recognise the bravery of the sufferers of eating 

disorders and their families who testified and sent submissions to the 

Committee stressing the urgent need for solutions. The Committee hopes 

that this report goes some way to addressing the issues they highlighted 

and contributing to further the health and well being of young Victorians. 

Mr Robert Smith, MLC 

Chairman 

vii



viii

F INDINGS AND 

R ECOMMENDATIONS 

Recommendation #1: That the State Government dedicate 

funding for the establishment of an Australian centre for research into 

body image and eating disorders. Funding should also be sought from 

the federal government, other state and territories and philanthropic 

organisations. Such a centre would consist of a board of recognised 

experts and a Victorian lead agency to coordinate the distribution of 

funds. A key principle of the centre would be to leverage greater 

research efforts into body image and eating disorders, with a particular 

emphasis on current gaps in knowledge and research including- 

• bullying and teasing; 

• sexual abuse; 

• family breakdown; 

• obsessive and compulsive behaviour; 

• peer influence; and 

• risk factors 

The Committee also believes that there needs to be more research 

conducted into male body image problems. 

Chapter 3 

ix



Recommendation #2: That the Centre for Excellence in Eating 

Disorders be assisted in its production of professional development 

and training programs for health and allied health professionals, and 

for counsellors working with youth. 

Chapter 3 

Recommendation #3: That a code of conduct for the media 

industry be developed, recognising the media’s social responsibility to 

display images that are representative of the community. The 

Committee further recommends that this be developed in consultation 

with advertisers, media owners and government; such consultation 

should involve discussions and negotiations between federal, state 

and territory governments and between the federal government and 

industry. 

Chapter 2 

Finding #1: That there is low-level cross-sectoral awareness of 

programmes and services focusing on body image and eating 

disorders. 

Chapter 4 

Finding #2: The Committee finds that services for eating disorders 

patients in Victoria vary widely in their accessibility, availability and 

type of care provided to patients and their carers. This variation is most 

pronounced for Victorians living in rural and regional areas. 

Chapter 4 

Recommendation #4: That Community Health Centres are utilised 

more effectively for the delivery of body image programs. 

Chapter 4 

x

FINDING AND RECOMMENDATIONS 

Recommendation #5: That the Department of Human Services 

undertake a state-wide mapping exercise of eating disorder services, 

including patterns of use and demand. The results should be 

disseminated to all service providers and inform future government 

policy and funding. 

Chapter 4 

Recommendation #6: The Committee recommends that a day 

centre proposal be developed as a community-based initiative 

designed to address a serious service gap in the public health 

treatment of young adolescents recovering from severe eating 

disorders. 

Chapter 4 

Recommendation #7: That dedicated funding be available to 

Child and Adolescent Mental Health Services for eating disorder 

specific programs. 

Chapter 4 

Finding #3: The Committee finds that a ‘one size fits all’ approach to 

the treatment of eating disorders does not adequately cater for the 

needs of all young sufferers of eating disorders. 

Chapter 4 

Recommendation #8: The Committee recommends that the 

Department of Human Services works together with the Department of 

Health and Ageing to establish a trial of the Karolinska Institute 

treatment method for eating disorders in Victoria. 

Chapter 4 

xi



Recommendation #9: The Committee recommends the formation 

of a standing Community Reference Group, easily accessible to the 

general community, with representation from health and allied health 

professionals, service providers, consumers and carers, to monitor, 

inform and make recommendations to the government on issues of 

body image and eating disorders. 

Chapter 4 

Finding #4: That whole-of-school programs that teach and promote 

physical wellness and self-esteem in primary students result in 

improvements in student wellbeing and learning. 

Chapter 5 

Recommendation #10: That the Department of Education, with the 

Department of Human Services and in partnership with schools, 

undertake a program of evaluation, monitoring and implementation of 

whole-of-school health promotion in primary schools. 

The Committee notes the success of programs such as those 

implemented at Clifton Springs Primary School and Karingal Primary 

School. It also notes the success of health promotion programs such 

as the Gatehouse Project in secondary schools in building resilience 

and self esteem. It therefore recommends particular programs that 

target the following areas be the focus of evaluation and 

implementation: 

• whole-of-school health promotion; 

• healthy eating; 

• physical activity; and 

• resilience and self-esteem. 

Chapter 5 

xii

FINDING AND RECOMMENDATIONS 

Recommendation #11: That Eating Disorder Awareness Week be 

part of a broader program of health promotion in body image. 

Chapter 5 

Recommendation #12: That the Department of Education consider 

the development and promotion of programs that develop skills in 

media literacy within the current English curriculum for primary and 

secondary school students. 

Chapter 5 

xiii



xiv

C HAPTER O NE – A N 

I NTRODUCTION AND O VERVIEW 

1.1 The issue of body image development and the effect of negative 

body image upon young people is of major importance to the Victorian 

community. As the following chapters of this report will show, a 

significant proportion of young people are affected to a significant 

degree and the Committee welcomes this Inquiry, in part, as an 

avenue to highlight an issue in the community which at times has been 

neglected. 

1.2 The Terms of Reference for this Inquiry require the identification 

of broad issues and the suggestion of possible solutions. The 

Committee is concerned about the growing discrepancy between the 

popularised “thin ideal” and increasing levels of overweight and obesity 

in Victoria. As such, this report focuses on the broader social 

determinants of body image development and raises issues relating to 

the prevention of body image dissatisfaction, making 

recommendations as to changes in service provision and early 

intervention. 

1.3 It is the Committee’s understanding that body image 

dissatisfaction occurs more commonly in young females than males, 

and is most severe between the ages 15-22 years. While it has been 

estimated that it can result in extreme dieting and eating disorders in 2- 

4% of the population, the Committee is particularly concerned with the 

1



sub-clinical presentations of poor body image, as it affects a greater 

proportion of young people. These include: 

2 

• Restrictive dieting behaviours and disordered eating patterns; 

• Weight cycling; 

• Inadvertent weight gain; 

• Lower participation in physical activity; 

• Low self esteem and feelings of worthlessness; and 

• Anxiety and depression. 

1.4 Major factors in the development of body image can be briefly 

stated as follows: 

• Peer influence & consumerism; 

• Mainstream media, the model industry, and fashion retailers; 

• Family characteristics; 

• Individual personality traits; 

• Body weight and stigmatisation; and 

• Health professionals and health messages. 

These issues will be dealt with in more detail in the second chapter of 

this report. 

Body Image, Body Dissatisfaction and Eating 

Disorders 

1.5 There is a distinction between body image and body 

dissatisfaction which involves a general concern with the appearance 

of the body. Eating disorders involve psychological aspects that have 

mental and physical implications which are different from problems 

associated with obesity. However, there are overlaps and links, and it 

has become clear in the Inquiry that body image involves self esteem, 

body esteem, and healthy eating. Eating disorders involve different

CHAPTER ONE - AN INTRODUCTION AND OVERVIEW 

issues and different solutions. The emotional elements of fear, 

sadness, and anger are critical. The risks factors for body image 

dissatisfaction can be summarised in the following diagram. 

Understanding Body Image and Body Image 

Disturbance 

1.6 There is a major focus on body image amongst young people. 1 

Further, with a higher proportion of the population overweight than 

before, there is an increasing emphasis on weight as well as shape. 

1.7 Body image encompasses feelings of body satisfaction, selfesteem 

and beliefs about appearance. From a clinical perspective, 

body image disturbance is more complex than just a fear of being 

overweight or a drive for thinness. There is overwhelming evidence 2, 3, 4, 

5 that body image is intrinsically linked with self-esteem and resilience. 

As previously stated, the factors that affect and shape it include the 

beliefs and modelling behaviours within families, peer groups and the 

media. 

3



The Links Between Body Image And Eating 

Disorders 

1.8 The third chapter of this report discusses the way in which body 

image disturbance relates to the manifestation of an eating disorder. 

The evidence is still inconclusive in relation to cause and effect. 

However, the emphasis a society places on appearance does seem to 

6, 7 

affect the way people feel about themselves. 

1.9 There is a clear relationship between high levels of disordered 

body image and development of eating disorders. By definition, body 

image disturbance is one criterion for the diagnosis of both bulimia and 

anorexia nervosa. What is unclear however is whether body image 

dissatisfaction leads to dieting and eating disordered behaviour or 

whether this results from dieting and a focus on one’s body. The 

following diagram illustrates what has become apparent from 

testimony to the Committee: 

1.10 As well as describing the development of body image and the 

conditions in which body image dissatisfaction can occur, this report 

attempts to identify areas of good practice in body image promotion 

4


programs and recommends that further initiatives in this area should 

address the following two problems: 

• the broader socio-cultural determinants of body image 

development, such as developing more size-accepting cultures in 

the media, fashion and retail arenas; and 

• the use of schools as a setting, targeting young peoples’ values, 

beliefs and attitudes; and promoting individual resilience and selfworth, 

as well as healthy eating. 

1.11 There are few broad level prevention programs that have 

measured changes in body image satisfaction. Evaluation of body 

image strategies will be an important requirement of any future work. 

TREATMENT TREATMENT 

1.12 The body image agenda should be framed within an obesity 

prevention strategy. Size acceptance issues can be infused into health 

messages about healthy weight, if relevant policy makers are 

sensitised to body image concerns. A policy mainstreaming approach 

reduces fragmentation and potential message conflicts. 

5



An Integrated Approach to Addressing Negative 

Body Image 

1.13 Within the framework of prevention, intervention and treatment, 

discussion has focused on how an integrated approach to dealing with 

body image issues is the best strategic approach. In particular, healthcentred 

rather than weight-centred disorders involve different issues 

and different solutions. The emotional elements of fear sadness and 

anger are critical. There is a need to be aware of labels, but overall 

body image is the major concern as it is dissatisfaction that causes 

problems. The final chapter of this report discusses health promotion 

strategies which address total lifestyle and healthy eating solutions. 

6

Endnotes 


1 Davis C Shuster B Blakemore E Fox J “Looking Good Family Focus on appearance and risk 

of Eating Disorders” International Journal of Eating Disorders 35 (2) 136-44 2004 March. 

2 Abraham S “Dieting, Body Weight, Body Image and Self Esteem in Young Women: Doctors 

Dilemmas” Medical Journal of Australia 178 607-11 2003. 

3 Joshi, R Herman CP Polivy J “Self Enhancing Effects of Exposure to thin body Images” 

International Journal of Eating Disorders 35(3) 333-41 2004 April. 

4 Mendelson B Mclaren L Gauvin L Steiger H “The relationship of Self Esteem and Body 

Esteem in Women with and without Eating Disorders” International Journal of Eating Disorders 

31(3) 318-23 2002 April. 

5 Wade T Lowes J “Variables associated with Disturbed Eating habits and Overvalued Ideas 

about the Personal Implications of Body Shape and Weight in a Female Adolescent 

Population” International Journal of Eating Disorders 39-45 2002 Nov. 

6 Abdollahi, P and Mann,T “ Eating Disorder Symptoms and Body Image Concerns in Iran: 

Comparisons between Iranian women in Iran and in America” International Journal of Eating 

Disorders 30(3) 259-68 2001 Nov. 

7 Waller G Barnes J “Preconscious processing of Body Image cues. Impact on body percept 

and concept” Journal of Psychosomatic Research 53 (5) 1037-41 2002 Nov. 

7



8

C HAPTER T WO – T HE 

D EVELOPMENT OF B ODY I MAGE 

A MONG Y OUNG P EOPLE 

2.1 The Terms of Reference for the Inquiry require the Committee 

to identify factors which contribute to the development of body image 

among young people. Family, the media and peer group are 

suggested, however the Committee is encouraged to investigate other 

potential factors. This chapter discusses a range of factors which can 

determine an individual’s body image in a both a positive and negative 

way, derived from the Committee’s consultation and submissions as 

well as the clinical research literature. 

What is Body Image? 

2.2 Simply defined, body image refers to a person’s self-perception 

and judgement about the size, shape and weight of their body. 1 

I think of body image as the very general way in which people 

view their bodies, but especially how they feel about them. 

There are different things that you can have views about, such 

as how large or tall you are. They may be important, but most 

important is how you feel about it. 2 

2.3 Body image is constructed over time and, until recently, it was 

accepted among health professionals that adolescence was the critical 

phase during which negative and positive factors had their strongest 

influence. Although adolescence remains a time of critical personal 

9



and physical development, recent research has indicated that body 

image formation begins at much younger age, even as young as 4 and 

5 years of age. 3 This was confirmed by research conducted by 

Professor Marita McCabe 

Preschool children are aware of the ideal body for their gender. 

The socio-cultural influences — that is, mums, friends and 

particularly the media — play a strong role in this. By late 

childhood for girls and by early adolescence for boys there is an 

association between body dissatisfaction and high levels of 

negative affect or depression and low levels of self-esteem. So 

the boys are a bit later in learning that association, but they are 

learning it, and the girls are already learning it in late childhood. 4 

2.4 A range of factors influence the development of body image, 

though the common denominator is the thin body ideal. Western 

socio-cultural standards of attractiveness for women and men equate 

thinness with beauty, and this is perpetuated through the mass media 

and may reinforce peer and family expectations of physical 

appearance. 5 Body image dissatisfaction is not, however, an automatic 

outcome for contemporary children and adolescents. Higher selfesteem 

and resilience protects against body dissatisfaction, as does 

the ability to interpret media messages about physical attractiveness 

and weight. Children and adolescents who receive positive and 

supportive feedback from peers and families about their health and 

appearance are less likely to develop body image dissatisfaction, as 

are those who are physically active. 6 

2.5 Body image dissatisfaction compromises physical and mental 

health. It leads to unnecessary and dangerous attempts to change 

body weight and shape. In girls and women, this often takes the form 

of a preoccupation with size and weight while in males the 

10

CHAPTER TWO - THE DEVELOPMENT OF BODY IMAGE AMONG YOUNG PEOPLE 

development of musculature. 7 Body dissatisfaction can be associated 

with depression, low self-esteem anxiety and lead to excessive dieting, 

a strong predictor for disordered eating (eating disorder not otherwise 

specified, anorexia nervosa, bulimia nervosa, binge-eating disorder) or 

conversely contribute to being overweight. 8 

Biological Factors 

2.6 Body features are largely determined by biological and genetic 

factors, thus biological and genetic characteristics may play an 

important role in the development of body image. Some neurological 

disorders or biological characteristics can affect the way an individual 

perceives their body. Research has provided rare examples of this 

process such as the neglect of a body part in some psychological 

disorders or instances where individuals’ perceive a surgically 

removed limb is still present. 9 Epilepsy and migraines can be 

associated with a number of types of body misperception, including 

confusion in distinguishing right-left orientation and or delusions about 

body size. 10 

2.7 A more common example of a biological factor in body 

perception is an overestimation of waist size during the premenstrual 

period. 11 In addition, discomfort or inconvenience may result in body 

dissatisfaction – examples of this include very large breasts, 12 a 

pregnant body, menstruation, 13 or specific physical disabilities. 

2.8 Some biologically determined characteristics can become 

influential when they depart from what the individual considers as 

socially accepted and are thus considered undesirable. Examples of 

these include male pattern hair loss, 14 height, skin characteristics, 

11



breast size, facial features, and disfigurement. 15 The Committee has 

found that the most commonly discussed body features among young 

people have been body size (overweight or underweight) and shape 

(relative proportions of waist, hips, etc.). 16 There seems to be a greater 

emphasis on body size and shape in Western cultures resulting in 

weight concerns and body dissatisfaction. Individuals with a high body 

mass index (BMI) are more likely to report body dissatisfaction than 

those in the normal or low weight range; among females, even normalweight 

individuals are often over concerned about their bodies. 17 The 

effects of social and cultural influences are discussed later in the 

chapter. 

2.9 An individual’s actual body size is also important in determining 

both body ideals and body perception. In research studies where 

individuals rate a series of figures to indicate which most closely 

resembles their current appearance and which is closest to their ideal 

size the images are often very similar. 18 This may even occur in women 

even with eating disorders. 19 Women who have increased their weight 

have also been shown to mirror this with an increase their ideal 

weight. 20 It has been argued that these findings suggest an individual’s 

body ideals are partially influenced by their actual body size; however, 

where large discrepancies remain or if this process leads to an ideal 

that is a unobtainable, a negative image could be the result. 21 

2.10 Research has also shown that in relation to body size 

influencing body image, smaller individuals are more likely to 

overestimate their body size. 22 Therefore, biologically determined body 

size and shape can influence an individual’s own understanding of 

their body influencing a variety of other factors that can potentially lead 

to negative body image. 

12


Social and Cultural Factors 

2.11 It is argued in social and cultural models of the development of 

body image that standards of beauty within society in general or in the 

individuals’ social environment, such as schools families and 

neighbourhoods, effect the development of opinions about an 

individuals’ own body image. In testimony given to the Committee it 

was clear that young people consider the beauty ideal found amongst 

their peers and within the schools they attend highly significant in the 

development of body image. 23 Often these social ideals are given 

undue importance and are difficult to attain and may produce a 

negative body image. There are a number of social and cultural 

factors which may influence an individuals’ body image and these are 

discussed below. 

Differences in Culture 

2.12 The importance of social and cultural factors can be examined 

in a number of ways including comparing the beauty ideals of various 

cultures across different regions both within one country and 

internationally. Research suggests that such ethnic and cultural 

differences do exist in preferred body features such as weight and 

shape24 or skin toning and breast size. 25 For example, numerous 

studies have found that, despite higher rates of obesity, black women 

in Western cultures are more satisfied with their weight and 

appearance than white women, and they accept a wider range of body 

weights including a larger body size as ideal. 26 Similarly, students 

originating from the US studying in Ghana chose thinner ideal figure 

13



sizes than those of Ghanaian origin, with the U.S. origin women the 

most likely to be dissatisfied with their bodies. 27 

2.13 Further evidence of the origin of these cultural differences 

comes from research examining the levels of cultural identity within a 

community. For example, stronger African American cultural identity 

within an African American community has been associated with less 

susceptibility to certain types of negative body image. 28 Similarly, 

immigrating to a Western culture at an early age has been shown to 

influence the ideal thinness for Hispanic American females. 29 

2.14 The age at which immigration occurs may be extremely 

important in this regard. Australian research has shown that young 

women from different cultural backgrounds who had been born in 

Australia hold very similar perceptions of what is constituted an ideal 

body size for themselves, for women in general and for young men. 30 

2.15 In its submission to the Committee, the Centre for Multicultural 

Youth Issues stressed the fact that the impact of the process of 

immigration and settlement was also a highly significant contributor to 

body image for young people from refugee and migrant backgrounds 

particularly where the cultural differences between the country of origin 

and settlement were substantial. 31 

The Beauty Ideal over Time 

2.16 Differences can occur within a culture over time as dramatically 

as they occur between cultures and as the current ideal shifts 

individuals whose body shape does not conform to the current ideal 

can be placed at risk. The widespread concern about dieting and 

eating disorders has resulted in a number of studies examining the 

14


differences in ideal body types over time particularly those pertaining 

to women. 

2.17 The differences illustrated between the ‘Rubenesque’ ideal of 

voluptuous female beauty at one time and the hour glass shaped 

forms illustrated in the art of another confirm that through the centuries 

differing forms have been preferred. 32 Even the course of the twentieth 

century has seen subtle shifts in the ideal female form, from the more 

curvaceous to the slim as the century progressed, as demonstrated by 

the decreased size of Studies of Playboy magazine models, Miss 

America beauty pageant contestants, London magazine models, ballet 

dancers, and fashion shop mannequins have illustrated this point. 33 

These icons of beauty are generally considered underweight when 

compared to individuals of healthy or standard weight, 34 as are other 

models of beauty, such as children’s Barbie and Ken dolls. 35 In the 

latter part of the twentieth century, changes have also been 

documented in preferences about male body shapes, particularly 

related to increases in musculature. 36 

2.18 These recent trends toward a thinner ideal of female beauty 

have been mirrored in the increase in media articles encouraging 

weight loss through dieting or, more recently, exercise. 37 While it may 

be argued that the evidence that cultural ideals influence body 

concerns is only coincidental, it does suggest that stereotypes of 

beauty can influence an individuals’ own body ideal and may provide 

conditions in which body image concerns develop when an individual 

can not match the ideal. 

15



Influence of Parents 

2.19 While body-related ideals may exist within a culture, an 

individual’s immediate social environment is likely to be more 

influential in influencing values and ideals directly. The most important 

influence for children and young people in this context is their parents. 

Both mothers and fathers play a role in communicating values about 

weight, shape, and body attributes. 38 

2.20 Research to date has focused on two main types of parental 

influence: children imitating parents concerns and behaviours about 

their own body; and parents being directly critical of their child’s body 

or indirectly encouraging a change in weight or shape. 

2.21 The latter research has generally found that there is consistent 

evidence that children who have body concerns and diet are more 

likely to have parents who encourage them to lose weight or who make 

negative comments about the child’s body. 39 Parents who suggest a 

child lose weight often do have heavier children. However, even when 

the child’s actual weight is taken into consideration, a significant 

though smaller relationship is often found between parent 

encouragement of a child to lose weight and children’s own dieting or 

weight concerns. 40 

2.22 Conversely, the Committee also heard of the positive role that 

parents can play in supporting children who have concerns about their 

bodies and influencing the development of self esteem, resilience and 

subsequently a healthy body image. 

2.23 Evidence is less clear about children imitating their parent’s 

attitudes and behaviours, with some studies finding similarities 

between parent and child; 41 others finding no relationship42 and still 

16


others finding a relationship in some behaviours but not in others. 43 In 

addition, girls’ menstrual status may be a contributor, with mother-child 

similarities in attention to thinness found only in menstrual girls. 44 

Interestingly, the Committee heard from a number of women whose 

daughters suffered from severe negative body image who had suffered 

similar dissatisfaction themselves. 

2.24 However these studies tend to suggest that parental concern 

about their own body weight are not always influential depending on 

the degree to which the parent attempts to directly influence the child 

to mirror their perceptions and behaviours or the parent displays 

obvious weight loss behaviours. 45 

2.25 In conclusion, the Committee is aware that families have a 

significant role to play in the development of a child’s healthy lifestyle, 

a factor which may not only be important in regard to body image but 

also in maintaining a healthy weight. 

Peer Group Influence 

2.26 As part of the National Body Image and Eating Disorders 

Awareness Week, the Minister for Youth Affairs, the Hon Jacinta Allen, 

circulated post cards encouraging parents and young people to make 

comment on and around these issues and send them back. 

Unsurprisingly one of the most often mentioned issues revolved 

around peers. Characteristic of such comments are the following: 

Body image has a large affect on the people in my 

school…people are always talking about how she put on weight 

or she’s lost weight. 

If you are fat you get teased a lot at school. 

Some of my friends think they are fatter than they are because 

they are not as skinny as others. 46 

17



2.27 As mentioned previously, the Committee also received a great 

deal of evidence that peers provide another important social 

environment which may affect an individual’s body satisfaction in a 

number of ways. As with parents, peers may play a role in setting and 

communicating values about weight and desirable body image, 

thereby dictating appearance norms and ideals. In addition, peers may 

actively reward or punish adherence to body image ideals punishing 

those who are less similar while rewarding those whose appearance 

conforms most closely. With popularity and social integration crucial to 

the establishment and maintenance of self esteem amongst young 

people any deviation from an accepted ideal can have devastating 

effects for both males and females. 47 As the Committee was informed 

“the prettiest girl is the leader”. 48 

2.28 Research has shown that groups of adolescent female friends 

have similar levels of body dissatisfaction, at least partially 

independent of weight, depression, and self-esteem. 49 While it can be 

argued that individuals in peer groups tend to assimilate and are also 

attracted to making friends with others of similar interests and 

attitudes, this finding of friendship group similarities does support the 

existence of a peer body ideal in friendship groups. Friendship groups 

exhibiting relatively high body dissatisfaction are also more likely to 

talk about weight, shape, and dieting. 50 

2.29 Research has also found that talk about body size and weight 

amongst female friends may determine what is acceptable about body 

shape and size, stress the importance of body shape, and encourage 

engaging in behaviours to maintain or achieve the ideal. 51 

2.30 An individual’s perception that peers consider weight and shape 

to be important has also been found to be a strong indicator of weight 

18


concerns and negative body image. 52 Talk among peers may 

communicate the importance of weight and shape and the initiator’s 

anxiety. An analysis of individuals’ responses to such talk suggests 

there may be a positive side of reassurance through the affirmation of 

friends but may also result in insecurity and body image concerns for 

others within the group. 53 

2.31 In a recent Australian study, body dissatisfaction in girls was 

found to emerge in junior primary school years between ages 5 and 7 

and appeared to be a function of shared peer ideals for thinness. 54 As 

the Committee heard: 

The most important findings of the present study were in relation 

to the peer influences. Basically girls as young as five years of 

age knew about the potential social consequences of weight - 

both negative in terms of being teased and positive in terms of 

being more liked, if you are a normal weight or a thinner figure. 

Also, the main finding was perhaps this peer norm for the thin 

ideal even in the five to eight-year-old age bracket… 55 

2.32 Comparing body shapes with friends and peers is a more subtle 

way of determining whether an individual conforms to the group’s 

ideal. Thus peers may serve as points of comparison so that 

individuals may determine their place within their social environment. 

Research supports peers as being major targets of body comparison. 56 

2.33 Peer groups may also actively promote a certain body type. As 

previously stated, popularity in adolescence may often be bound to a 

certain body type generally thin with girls57 and athletic and muscular 

for boys. Another significant contributor to negative body image is 

teasing, from both within and without peer groups. Research has 

shown that teasing about weight can be a contributor to body 

dissatisfaction independent of the individuals’ actual size. 58 Another 

19



long term study has shown weight-related teasing to be a predictor of 

later general body dissatisfaction after the individuals’ initial body 

dissatisfaction is taken into consideration. 59 However, it is argued that 

further long term and experimental research is required to confirm 

weight and shape teasing as directly related to body dissatisfaction. 60 

2.34 Peers may also play a positive role. There is a strong 

correlation between low peer group emphasis on body image and low 

levels of body dissatisfaction just as the opposite can be found. 61 

Although study of positive peer influence has concentrated more 

specifically to deterring extreme weight loss behaviours than 

determining body image, 62 the success of an American school-based 

peer support group intervention in improving weight and appearance 

esteem over a three- month period suggests that positive peer group 

can be a factor in minimising body dissatisfaction. 63 

Influence of the Media 

2.35 There is a predominance of images of thin glamorous women 

and muscular athletic men in the current media. These are presented 

as the aspiration and are associated with happiness and success. 

However, they are unrealistic and unrepresentative, often the product 

of a rare body shape, image manipulation or a combination of both. 64 

These body types are also difficult to attain for most people and the 

difference in the ideal and what is attainable is thought to be a 

significant source of body dissatisfaction. 

2.36 The National Body Image and Eating Disorders Awareness 

Week post card distribution also revealed the concern young people 

have with the type of body images presented in the media. 

Characteristic of the comments were: 

20


I think that the magazines with skinny blondes are just a put 

down to those who feel less attractive; 

We need less sticks (people) on TV or in the limelight; and 

I would like to see more overweight girls in magazines because 

all the girls that model in them are pretty and skinny and I think 

that it’s pretty hurtful to an overweight girl looking and seeing all 

these pretty girls. 65 

2.37 A constant feature of submissions and presentations made to 

the Committee was a concern from young people, psychologists and 

social workers with the influence of the media and the dominance of 

the body beautiful message. In a survey conducted by the Associated 

Independent Schools of Victoria designed to coincide with the 

Committee’s Inquiry respondents “painted the picture of an evil media 

that sets unrealistic expectations of beauty to vulnerable 

adolescents.” 66 

2.38 Research has shown, on the other hand, that there is a 

difference between perception of the media’s influence and the actual 

effect on body image satisfaction. There is a complexity in the manner 

in which individuals engage with media, leading to inconsistencies in 

research findings. 67 Studies have been conducted into the effect of 

long term media exposure on body image with some studies 

observing, associations between high media exposure and poor body 

image or disturbed eating. Others have not found any connection or 

only with association with some forms of media. 68 

2.39 Studies have been conducted to measure the short term effect 

on women’s body image of viewing slim model-type images. Again, 

findings have been mixed. 69 However, an analysis of a large number 

of studies found that body image was significantly more negative after 

viewing thin media images than after those which involved a different 

21



kind of image. This effect was stronger in studies of women under 19 

years old. 70 

2.40 There is evidence to suggest that the influence of media 

exposure many vary between individuals. Recent research has shown 

that if the individual is already conscious of the slim ideal, has 

compared their body shape with others and has already experienced 

some body dissatisfaction they are more likely to experience a 

negative impact when viewing idealised images, particularly in 

adolescent girls. 71 If the individual places a high emphasis on thinness 

and frequently compares themselves with idealised images, the result 

will generally be body dissatisfaction. 

2.41 While studies generally indicate short term negative effects on 

body image of exposure to idealised media images, the duration of the 

effect is not clear. The relationship between short term impact and 

long term body dissatisfaction is also unclear. It has been argued that 

repeated exposure in vulnerable individuals could have a cumulative 

impact, resulting in body dissatisfaction and that further research is 

required to explore this issue. 72 

2.42 While the research results remain inconclusive, the Committee 

believes that the media has a role to play in the responsible potrayal of 

body image. The Committee also a realises that there are difficulties 

involved. As Mia Fredman editor of Cosmopolitan and Dolly magazines 

– both of which have actively attempted to alter stereotypes - 

explained: 

22 

That is a difficult thing to do within the pages of magazines and 

within the media because, for example, you go to the beach and 

you see all shapes and sizes. You turn on the television, go to 

the movies or pick up a magazine and there is one type of 

woman. They are tall, skinny women in their 20s. That is all you


see. That makes the rest of us, the 90 per cent who do not fall 

into that very small demographic, feel inadequate. Magazines 

get bashed up a lot. I think we need to take responsibility for 

what we do, but it is a broader issue. 73 

2.43 However, the difficulties do not outweigh the possible benefits 

for the health and well being of young people. Oz Child submitted to 

the Committee suggested that advertising codes by enhanced to 

require the inclusion of a variety of body sizes, that media be 

encouraged to reduce the number of stories based around body size 

and shape, and to apply a warning system for digitally altered 

images. 74 These suggestions could provide a starting point for 

discussion. 

Recommendation #3 

That a code of conduct for the media industry be developed, 

recognising the media’s social responsibility to display images that are 

representative of the community. The Committee further recommends 

that this be developed in consultation with advertisers, media owners 

and government; such consultation should involve discussions and 

negotiations between federal, state and territory governments and 

between the federal government and industry. 

The Effect of Multiple Social and Cultural Factors 

2.44 Given the above, it could be assumed that individuals who live 

in an environment that includes a higher emphasis on idealised body 

images across the major sectors of social interaction such as family 

friends and the media would be at greatest risk of developing body 

image concerns. Cross-cultural studies and studies of special high risk 

23



environments, such as ballet schools, 75 have examined this issue 

Researchers have also studied individuals in the same culture to 

determine which types of social and cultural factors are seen as 

proving the most influential and whether the effects of these different 

types of agents compound. 

2.45 A number of studies have examined the effect on children and 

adolescents of the relationships between media, family, and peers and 

have found that the effects do combine. The research suggests that 

multiple agents all emphasising the thin ideal are associated with 

smaller thinness ideals amongst individuals and more body image 

concerns. 76 This research offers further support for the idea that body 

image concerns are most likely to emerge in a culture which is weight 

and shape conscious from childhood through to maturity. These 

findings have implications for prevention work, in which social 

environments may need to be changed. This is discussed further in 

Chapter Five of this Report. 

Other Factors 

Puberty 

2.46 As important as social and cultural factors in effecting the 

development of body image among children and adolescents are 

developmental stages. These may initiate psychological disturbances, 

including those associated with negative body image. The most 

important of these stages is puberty. Other stages have significance 

such as early childhood, as previously discussed, when body ideals 

24


and concerns are likely to start. However, puberty is the most 

discussed period, particularly in the development of body image. 77 

2.47 Children experience dramatic changes to their bodies during 

puberty and must make adjustments in a relatively short period of time. 

This can be compounded by the fact that individuals develop at 

different rates and concerns may arise when comparisons are made 

with friends and peers. Those who mature too quickly or slowly may 

experience anxieties about being different at a time when peer 

affirmation is highly important. 

2.48 Long term studies of puberty as a risk factor have had mixed 

results. For example, research has shown an association between the 

early onset of menstruation and greater body dissatisfaction. 78 The 

associated increase in body size at the same stage, however, makes it 

difficult to make a direct correlation. Dramatic body changes for girls 

during puberty including as pubic hair distribution and breast 

development can be associated with ‘chubbiness’ and greater body 

size. 79 Thus, during puberty, girls may find themselves moving away 

from the culturally preferred thinness ideal of beauty and slimness 

placing them at risk of body dissatisfaction. 

Sexual Abuse 

2.49 Traumatic life events and experiences also have the potential to 

increase the risk of body image concerns. One of the most researched 

experiences is sexual abuse. Several theories have been offered for 

how sexual abuse leads to body disturbances including 

• altering the meaning of the body; 

• increasing bodily shame; and 

25



• attempting to control the body and make it less vulnerable. 80 

2.50 Evidence for increased body self-consciousness in young 

children who have been sexually abused and for more weight 

concerns, body dissatisfaction, and dieting in adolescents with a 

history of sexual abuse have been found in a review of studies of 

sexual abuse and body image dissatisfaction. 81 There is inconsistency 

in the findings, however, in the form in which body image concerns 

arise and even whether there is an increased incidence in sexually 

abused groups. In addition the development of such disturbances is 

only beginning to be examined. 82 However numerous variables have 

been discussed, such general distress and psychological makeup, 

family support, general family dysfunction, early puberty, and how 

negatively the abuse was experienced at the time it occurred. 83 Effects 

on body image might also vary depending on the nature of abuse, for 

example, whether it involves overt sexual contact or more covert forms 

such as unwanted sexual attention. 84 

2.51 The Centre Against Sexual Assault (CASA) has suggested that 

victims/survivors of sexual assault (approximately 87% of whom are 

women) may experience one, but usually more occasions of violence 

during their lifetime, including child sexual assault, intra-familial sexual 

assault, sexual harassment, domestic violence and rape. From 

victim/survivors their experience is that: 

• fear of, consequences and impacts of the experience of sexual, 

family and domestic violence is a daily lived experience for many 

victim/survivors; 

• a disturbed or disrupted sense of self and wellbeing, and 

relationships with others, are, to some degree, often short and 

longer term impacts of intimate violence; 

26


• a disrupted body image along with other feelings such as low 

self-esteem may be consequences of traumatic and violent 

experiences, such as sexual assault; 

• weight preoccupation, eating disorders, self-harm, drug and 

alcohol misuse and compulsive exercise are consequences 

frequently associated with sexual assault; 

• a negative sense of self, including body image may be learned or 

confirmed through the experience of sexual assault; 

• behaviours that are assumed to be consistent with a negative 

sense of self, such as eating disorders and self harm may 

constitute a survival adaptation for a person who has been 

robbed of personal, bodily and sexual integrity, and safety 

through an act or repeated acts of sexual assault; 

• sexual assault may be experienced as absolute violation and 

overpowering of the self by another or others; and 

• sexual assault, may leave victim/survivors feeling powerless, take 

away their sense of control over themselves and their own lives, 

temporarily or longer term, partially or more completely. 85 

Gender 

2.52 Gender can be an important variable in understanding the risk 

factors related to body disturbances. While it is likely that the general 

types of risk factors discussed previously are similar across genders, 

the specific nature of these influences may differ for males and 

females. For example, both males and females are likely to be at risk 

if they live in an environment that devalues their particular body type. 

27



However, the specific nature of the ideal body and the relative 

importance placed on that ideal are likely to vary. 

2.53 Studies that have examined differences between individuals’ 

ratings of their actual body in comparison to their ideal size indicate 

that when dissatisfied with their current shape, the vast majority of 

females desire to be thinner. In contrast, when males are dissatisfied 

with their weight, more than half desire to gain weight, 86 particularly in 

the form of greater muscularity. 87 These differences are likely to derive 

from social and cultural ideals previously mentioned stressing different 

preferred body shapes for males and females. 

Sexual Orientation 

2.54 An individual’s sexual orientation may also be a determinant in 

the development of body dissatisfaction. There is an assumption that 

the cultural emphasis on physical attractiveness amongst gay men 

causes greater pressure and anxiety and as a consequence body 

concerns than occurs in heterosexual men. The assumption is 

reversed in regard to gay women who place less emphasis on physical 

attractiveness. 88 Studies have largely supported these conjectures in 

men, with homosexual men reporting greater body and weight 

dissatisfaction. 89 In research comparing gay and heterosexual women 

results have been inconsistent, with some studies indicating no 

differences and others indicating lesbian women to be more accepting 

of higher weights or less concerned about body size. 90 

28

Psychological Factors 


2.55 In addition to the physical factors listed above there are a 

number of potential psychological risk factors for body dissatisfaction 

that have been examined, including depression, anxiety, low selfesteem, 

and negative emotionality. It has been argued that these 

characteristics result in negative self-evaluations, including poor body 

image. 91 However, while depression and low self-esteem are generally 

found to be associated with body dissatisfaction, 92 there is little 

evidence of a causal relationship. 93 The research tends to suggest that 

the opposite is true with depression and other psychological 

characteristics arising from body dissatisfaction. 94 This is discussed 

again in the next chapter. 

Conclusion 

2.56 This chapter has identified many factors which may individually 

or in conjunction play a role in the development of body image. These 

factors may also be major determinants in the development of negative 

body image or body dissatisfaction. While submissions and evidence 

received by the Committee as well as the research evidence discussed 

tend to emphasise the negative influence of these factors, it must be 

remembered that family and friends are crucial in the development of 

health body image and can play a supportive and positive role when 

difficulties arise. The media can also provide responsible images and 

positive role models for adolescents. 

2.57 The next chapter examines the possible link between negative 

body image and physical and psychological illnesses and examines 

29



these illnesses and other possible effects of negative body image in 

detail. 

30

Endnotes 


1 

Howell, P. (1999). Relationship between body image and eating behaviour. Melbourne: 

Body Image & Health Inc., p. 1. 

2 

Professor S. Paxton, School of Psychological Science, La Trobe University, Public Hearings. 

3 

Birbeck, D.J., and Drummond, M.J.N. 2003. Body image and the pre-pubescent child. 

Journal of Educational Enquiry. 4(1): 117-27, Dohnt, H., and Tiggemann, M. 2005. Peer 

influences on body dissatisfaction and dieting awareness in young girls. British Journal of 

Developmental Psychology. 23: 103-16, Ricciardelli, L.A., and McCabe, M.P. 2001. 

Children's body image concerns and eating disturbance: a review of the literature. Clinical 

Psychology Review. 21(3): 325-44, Sands, E.R., and Wardle, J. 2003. Internalization of ideal 

body shapes in 9-12 year-old girls. International Journal of Eating Disorders. 33(2): 193-204, 

Sands, R., Tricker, J., Sherman, C., Armatas, C., and Maschette, W. 1997. Disordered eating 

patterns, body image, self-esteem and physical activity in preadolsescent children. 

International Journal of Eating Disorders. 21(2): 159-66. 

4 Professor Marita McCabe, School of Psychology, Deakin University, Public Hearings 

Melbourne 

5 

Howell, P. (1999). Relationship between body image and eating behaviour. Melbourne: 

Body Image & Health Inc, McCabe, M.P., Ricciardelli, L.A., and Ridge, D. 2004. "Who thinks I 

need a perfect body?" Perception and internal dialogue among adolescents about their body. 

6 

Paxton, S.J., and O'Connor, T. (2000). Body image and health - what are the links? 

Melbourne: Body Image & Health Inc, Ricciardelli, L.A. (2000). Children and body image. 

Melbourne: Body Image & Health Inc, Sands, R., Tricker, J., Sherman, C., Armatas, C., and 

Maschette, W. 1997. Disordered eating patterns, body image, self-esteem and physical 

activity in preadolsescent children. International Journal of Eating Disorders. 21(2): 159-66. 

7 Professor S. Paxton, School of Psychological Science, La Trobe University, Public Hearings. 

8 

Sawyer, S., Weigall, S., and Jones, S. (9 August 2004). Public Hearing. Melbourne: Family 

& Community Development Committee, Parliament of Victoria. 

9 

Cummings, W. J. K. (1988). The neurobiology of the body schema. British Journal of 

Psychiatry, 153(Suppl. 2), 7—11. 

10 

Braun, C. M. J., & Chouinard, M. (1992). Is anorexia nervosa a neurological disease? 

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11 Altabe, M., & Thompson, I. K. (1990). Menstrual cycle, body image, and eating 

disturbance. International Journal of Eating Disorders, 9,395—402. 

31



12 

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13 

Altabe, M., & Thompson, I. K. (1990). Menstrual cycle, body image, and eating 

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16 

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17 

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18 

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22 

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46 Taken from cards returned to Hon. Jacinta Allen, Minister for Youth Affairs. 

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48 Jennifer Klitzing, Public Hearings, Shepparton August 2004 

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43



44

C HAPTER T HREE - T HE E FFECTS 

OF N EGATIVE B ODY I MAGE 

3.1 The last chapter examined a number of factors which were 

influential in the development of body image. This Chapter examines 

the possible effects of negative body image on the health and wellbeing 

of young people. The first part of the chapter examines the 

possible linkages between negative body image and development of 

medical and psychological problems among young people. The final 

section looks at these problems in more detail. 

The Effects of Negative Body Image 

3.2 Discussion of the effects of negative body image can be split 

into three main areas: firstly, to discuss the idea of negative body 

image as a concept; secondly, to review the relevant literature, and 

thirdly, to examine the relationship of body image not only to eating 

disorders but mental illness in general. 

3.3 As was stated in the previous chapter that the idea of body 

image is essentially a very complex one. It is more than just body 

image, it is multifaceted. In the research there are many different ways 

in which body image is defined; for example, the use of the terms 

‘body dissatisfaction’, ‘body esteem’, ‘weight esteem’, ‘over concern 

with appearance’, ‘basing self-esteem on weight and shape’. These 

differences can be important when thinking about how body image 

45



affects young people and is very much intrinsically related to 

resilience. 

3.4 It is also important to point out that the idea of body image 

disturbance —specifically relating to eating disorders — is often 

thought to be a fear of being overweight or a drive for thinness, but 

may not even be related to weight rather appearance in general. 

3.5 The area of body image and its potential effects on general 

psychopathology, particularly eating disorders, is a huge area. 

Generally speaking, higher proportions than ever of the population in 

western society are overweight. Not surprisingly, therefore, body 

image disturbance and concern about weight and shape is very 

significant in our society. 

3.6 A review of the literature on body image suggests three areas of 

particular interest to this Inquiry—the association between body image 

disturbance and disordered eating, the association between body 

image disturbance and other psychopathology, and the ones that 

interrelate. Evidence to the Committee suggests that there is an 

association between the two but how one affects the other is still 

unclear. It was also suggested that that there are other risk factors 

that may be significant such us genetic make-up and heredity. 

3.7 It is well documented that there are high levels of body image 

disturbance as part of the eating disorders bulimia nervosa and 

anorexia nervosa. It is known that in individuals with high disturbance 

of body image — high levels of negative body image — this appears to 

be associated with later development of eating disorder behaviour and 

appears to be a risk factor. It is also apparent that body image 

disturbance is linked with levels of dieting generally. 

46

CHAPTER THREE - THE EFFECTS OF NEGATIVE BODY IMAGE 

3.8 There also is evidence suggest that an individual who displays 

body image dissatisfaction in childhood is likely to display the same 

dissatisfaction into adolescence and early adulthood. 1 

There are also associations between body image dissatisfaction and 

the development of depressive symptoms and disorders. 

3.9 Research, however, is yet to determine the exact nature of the 

relationship between negative body image and the problems amongst 

young people and the mechanisms that may allow appropriate 

interventions. It was suggested to the Committee that the relationship 

is likely to be linked with the concepts of resilience and self-esteem. 

However further research is required to determined these important 

links fully. 


That the State Government dedicate funding for the establishment of 

an Australian centre for research into body image and eating 

disorders. Funding should also be sought from the federal government, 

other state and territories and philanthropic organisations. Such a 

centre would consist of a board of recognised experts and a Victorian 

lead agency to coordinate the distribution of funds. A key principle of 

the centre would be to leverage greater research efforts into body 

image and eating disorders, with a particular emphasis on current gaps 

in knowledge and research including- 

• bullying and teasing; 

• sexual abuse; 

• family breakdown; 

47



48 

• obsessive and compulsive behaviour; 

• peer influence; and 

• risk factors 

The Committee also believes that there needs to be more research 

conducted into male body image problems. 

3.10 It was suggested to the Committee that the idea of negative 

body image may play a part in general mental illness. It has been 

found to present as one of the symptoms, in patients with early 

psychosis who may present with body image disturbance as part of a 

delusional belief for example. 

3.11 In the Association of Independent Schools Victoria (ASIV) 

survey mentioned previously respondents recognised that poor body 

image is usually accompanied by low self-esteem and that this can 

lead them on a dangerous road toward eating disorders. 

“Anxiety, depression and eating disorders frequently coexist and self-esteem 

is usually fragile.” 

“Many of these disorders develop from a perceived undesirable body image. 

Suffering from such a disorder only creates a vicious cycle of trying to attain 

the unattainable.” 

“Poor body image creates eating disorders – starting at primary school.” 

“Health impacts of eating disorders are severe and seem to be becoming more 

prevalent.” 2


One girls’ school also noted the academic implications of an eating 

disorder: 

“The girls tend to become very obsessive about studying if they are 

struggling with eating disorders.” 3 

3.12 Respondents did not make particular note of steroid use, other 

than to recognise that media personalities and sporting stars who use 

steroids are reinforcing unrealistic expectations for adolescent body 

image. 4 

3.13 AISV’s survey questioned respondents specifically on how 

different genders deal with body image and received responses to 

indicate that, while girls are more 

concerned by body image than boys, this difference is shrinking over 

time: 

“Girls are more aware of changes in their body that are not in line with the 

‘ideal’ and because puberty is hitting earlier, girls are more greatly affected 

by body image issues.” 

“We are tending to see boys becoming overweight more often than anorexic. 

Girls as young as seven are showing problems with both overeating and 

overdieting.” 

“Seems to be a bigger problem for adolescent girls in regard to negative 

comments and criticisms on body shape and self esteem … Boys sometimes 

inclined towards over eating…” 

“We have found boys and girls to be equally impacted.” 5 

3.14 Another school suggested that the differences between body 

image concerns for boys and girls are limited and stated that, “lots of 

boys are being encouraged by the media to get a ‘six pack’ and build 

49



up muscle”. One teacher who has worked in a boys’ school and a 

coeducational school noted that the presence of boys tends to make 

teenage girls more self-conscious. 6 

3.15 Respondents were acutely aware of the link between mental 

health, poor body image and eating disorders. Their experiences and 

observations of the relationship between poor body image and eating 

disorders are supported by research, which “has identified concurrent 

problems such as an association between low self-esteem and body 

image problems”. 7 

Dieting 

3.16 There is a dramatic correlation between body image 

dissatisfaction and the desire to diet. Australians spend about $1 

million a day on weight loss attempts with little success. 8 Nine out of 

ten weight-loss diets are unsuccessful. 9 This locks individuals into the 

cycle of guilt and failure, feelings of poor self-worth and even 

depression. 10 Compounding this problem body image dissatisfaction 

can also limit physical activity participation. Studies have shown that 

teenagers who feel self-conscious about their body are less likely to 

participate in physical activity for fear of exposing their body11 and if 

they do participate, they are more likely to drop out. 12 

3.17 Unfortunately most Australian women— young or otherwise— 

and an increasing number of men - fall into the dieting and chronic 

dieting categories. Left unaddressed these behaviours can quickly 

progress to subclinical eating disorder and then into a clinical eating 

disorder. 

3.18 Dieting is the greatest risk factor for the development of an 

eating disorder. Adolescent girls, who diet only moderately, are five 

50


times more likely to develop an eating disorder than those who don’t 

diet, and those who diet severely are 18 times more likely to develop 

an eating disorder. 13 Sixty-eight per cent (68%) of 15 year old females 

are on a diet, of these, 8% are severely dieting. A study involving 341 

female and 221 male high school students in Victoria, found that 48% 

of girls and 26% of boys occasionally used at least one extreme weight 

loss measure (such as vomiting, using laxatives or over-exercising) 

and 13.2% of girls and 8.8% of boys used such a measure weekly. 14 

Women who diet frequently (more than 5 times) are 75% more likely to 

experience depression. 15 

Eating Disorders 

3.19 Eating disorders are psychological disorders where eating and 

body weight/shape concerns become an unhealthy focus of someone’s 

life; often as a way of dealing with underlying psychological issues. 

Left unaddressed, the medical psychological and social consequences 

can be serious and long term. Once entrenched they are insidious, 

can impact on every component of an individual’s life and for some, 

are potentially life threatening. 16 Eating disorders and body image 

concerns occur across a spectrum of severity, from near-normal 

healthy eating through chronic dieting and a range of disordered eating 

behaviours, to the clinically diagnosable eating disorders as illustrated 

below. 

51



Source: CEED Submission 

3.20 Eating disorders affect a range of people extending from 

individual experiences through to their peers. Particularly these issues 

profoundly affect adolescent peer groups. These disorders are often 

carried well into adulthood. The effects of poor body image and 

associated eating behaviours are wide ranging and have the potential 

to impact on: 

• Individuals of all ages 

• Peers and friendship groups 

• Families: parents, partners, siblings, children 

• Workplaces and employers 

• The community at large 

3.21 The costs of eating disorders can be measured in a number of 

ways: 

• Unrealised individual potential of those who are directly affected 

52


• Consequent reduced social participation which has a negative on 

overall community wellbeing 

• Family breakdown and the impact on families and carers who are 

living with these conditions on a daily basis 

• Economic cost to the community through reduced capacity of 

individuals and families to maintain jobs and independence 

• Costs of providing acute treatment. 

Anorexia Nervosa 

3.22 Diagnostic criteria 

a. Refusal to maintain body weight at or above a minimally normal 

weight for age and height (e.g., weight loss leading to 

maintenance of body weight less than 85% of that expected; or 

failure to make expected weight gain during period of growth, 

leading to body weight less than 85% of that expected). 

b. Intense fear of gaining weight or becoming fat, even though 

underweight. 

c. Disturbance in the way in which one's body weight or shape is 

experienced, undue influence of body weight or shape on selfevaluation, 

or denial of the seriousness of the current low body 

weight. 

d. Amenorrhea in post-menarchal females, i.e., the absence of at 

least three consecutive menstrual cycles. 

3.23 There are two types of anorexia: 

• the restricting type in which during an episode of illness the 

person has not regularly engaged in binge eating or purge 

53



54 

behaviour (i.e., self-induced vomiting or the misuse of laxatives, 

diuretics, or enemas); and 

• the binge-eating/purging type in which during an episode of the 

illness the person has regularly engaged in a binge-eating or 

purging behaviour (i.e., self-induced vomiting or the misuse of 

laxatives, diuretics, or enemas). 

3.24 The Royal Australian and New Zealand College of Psychiatrists 

(RANZCP) cautions against a strict interpretation of these criteria due 

to the possibility of excluding patients who present in the early stages 

of the illness.17 

Clinical epidemiology 

3.25 The RANZCP describes anorexia nervosa as a low prevalence 

disorder with a lifetime risk for women of 0.2%-0.5%. It has the highest 

mortality rate of any psychiatric illness and a suicide rate higher than 

major depression. 18 Statistics compiled by the Eating Disorders 

Foundation of Victoria (EDFV) indicate that one in 100 adolescent girls 

develop anorexia nervosa and that it is the third most chronic illness 

for girls after obesity and asthma. In young adults, 10% of sufferers are 

male, though this increases to 25% when anorexia nervosa is 

diagnosed in children. 19 This is replicated in some American studies 

which suggest that in younger patient populations, some 19-30% of 

anorexia nervosa sufferers are male. 20 

Medical effects of Anorexia nervosa 

3.26 It is estimated that 50% of anorexics will return to a normal body 

weight within 6 months of treatment; 25% will have low but stable


weight, and the remaining 25% will be chronically ill or die with the 

condition. 21 The RANZCP provides a clinical description of outcomes: 

3.27 The body is deprived of the essential nutrients and energy it 

needs to function effectively, it is then forced to slow down all of its 

processes in order to conserve energy which results in serious medical 

consequences and sometimes death. 

Medical effects of anorexia nervosa include: 

• Abnormally slow heart rate and low blood pressure. 

• Risk for heart failure increases as the blood pressure and heart 

rate drops. 

• Reduction of bone density which results in dry and brittle bones 

(osteoporosis). 

• Muscle loss and weakness. 

• Severe dehydration (may result in kidney failure). 

• Dry hair and skin. 

• Hair loss. 

• Lanugo (growth of a fine downy hair layer to keep the body 

warm). 

• Severe sensitivity to the cold. 

• Problems conceiving and infertility. 

• Headaches. 

• Oedema (retention of fluid giving a "puffy" appearance) 

• Stunting of height and growth. 

55



• Loss of periods. 

• Anaemia (iron deficiency). 

• Hypoglycaemia. 

• Abdominal pain. 

• Constipation or diarrhoea. 

• Fainting. 

• Reduced ability to concentrate and think clearly. 

3.28 The physical health implications for anorexia nervosa are 

usually more profound than in bulimia nervosa, but occur less 

frequently than bulimia-related syndromes. It is generally estimated 

that in Australia 2-3% of adolescent and adult females satisfy the DSM 

IV diagnostic criteria for Anorexia Nervosa. 22 The overall mortality rate 

for anorexia is five times that of the same aged population in general, 

with death from natural causes being four times greater (i.e. cardiac 

arrhythmia, infection etc) and deaths from unnatural causes 11 times 

greater. The risk of suicide is high being, 32 times that expected of the 

comparison-aged population. 23 

56 

The Human Costs of Anorexia nervosa 

3.29 Eating disorders place a great deal stress on individuals and 

may have the following emotional and psychological consequences: 

• Depression 

• Anxiety 

• Shame and guilt 

• Mood swings

• Low self esteem 

• Impaired social and family relationships 

• Perfectionism 

• "all or nothing" thinking 

• Suicidal thoughts or behaviours 

• Obsessive behaviour 

• Impaired understanding of reality 

• Lack of assertiveness 


3.30 During the course of this Inquiry the Committee received 

devastating evidence from both courageous recovering sufferers and 

their equally courageous families. In order to stress the harrowing 

nature of this condition on both individuals and families, the Committee 

has decided to pick out one case of the many it became aware of 

through testimony and submissions as an illustration of the effects 

anorexia nervosa. 

If I can bring you the reality of being a chronic sufferer — chronic 

sufferer being anyone who has had an eating disorder for more than 

seven years. Originally it might start with body image, and body image 

always stays a part of it, but it becomes more and more complex. 

Living with an eating disorder is a bit like living with a third world war 

going on inside your body, and it never changes. It is very much like it 

is with you 24-7. If you can imagine living with your worst enemy, and it 

is not someone who you get any break from — ever. They are there 

the whole time. They are there when you get up in the morning, they 

are there when you go to the toilet, they are there when you get 

57



dressed, and they are there at the end of the day. There is no break 

from it. I think that is what makes it so difficult. It is learning the skills 

and taking on board the tools that will give them the added ability to be 

able to fight that war — and win. Some of it is medically based, 

undoubtedly, but a lot of it is just not really looked at all. The weekend 

before last my daughter had her fourth suicide attempt, and she ended 

up in hospital and in emergency. Five hours later they discharged her. 

She is too difficult. She is 19 years down the track; this is the start of 

our 20th year. What happens as they go along is that in their fight to 

overcome the eating disorder they look to taking on tools which are not 

necessarily useful to them, although they see it that way. So there is 

the drug and alcohol abuse. They want some way of being able to just 

deaden that voice inside them. It may be drug and alcohol abuse; it 

may be that they are exercise obsessive. There are many things that 

they look to, none of which we would consider as being productive and 

helpful. But for them it might give them some reprieve. They are not 

hopeless; they are not helpless. They are not useless, and that is what 

is so often reinforced with them. Once it becomes chronic they live in a 

world of their own, where they only have their eating disorder and 

themselves. That aloneness means that they really are so stigmatised. 

They might be stigmatised when they are young with an eating 

disorder, but the longer they have it the more they become isolated 

and rejected by society. It is a bit like when sometimes we look at 

survival of the fittest. These people are invariably some of the fittest 

people in our community — to be able to survive with what goes on in 

their heads and what goes on in their bodies. 

Mrs K. Johnson, Director, Positive Eating Australia 

58


3.31 One issue that became apparent during the course of the 

Inquiry was the lack of access to medical practitioners with experience 

in dealing with such cases. In rural and regional Victoria the issue was 

practical: 

I rang public and private hospitals. I was either not in the 

catchment area or, as I said, she was not sick enough. It dawned 

on me that it was like presenting my daughter with cancer at a 

hospital and people saying to me, ‘We are sorry. Your daughter 

is not sick enough. Come back when she has secondary-stage 

cancer and we might be able to do something about it’. Can you 

imagine the outrage? That is exactly what I was being told, but it 

was for an eating disorder. There are no services. With the 

community centre that I had rung and where I had been put on 

the list, the three to four-month wait turned out to be an 

eight-month wait. She got to the top of the list last month, but by 

that stage I had already been travelling backwards and forwards 

to Melbourne since about January, once a week. At one stage 

we were travelling twice a week.. 24 

3.32 In metropolitan areas there was a perception that some medical 

practitioners were not adequately trained in identifying and caring for 

sufferers of anorexia: 

The question becomes: what does the GP do now? Many GPs 

recognise that there is a problem, but they might not feel quite so 

comfortable about how to address it, because as I said, it is still a 

relatively uncommon condition in our society. The GP, if he or 

she has had some specialist training — maybe has attended 

some training through CEED, maybe has attended the 

commonwealth Better Outcomes in Mental Health Care Initiative 

training — might be comfortable to continue to see her for a 

couple of visits. But I tell you what, if this kid has had significant 

weight loss, the most average and reasonably good GP in our 

59



60 

society very quickly becomes very uncomfortable and needs 

additional help. 25 

3.34 The perception that general practitioners were inadequately 

equipped was also expressed by members of rural and regional 

communities: 

Honestly, when you go and see a doctor and you are told this, 

you walk out and you do not hear what the doctor says because 

it is a bit like being hit with a brick, to be honest. If only you could 

have literature or something to go home and read once it has all 

died down or to tell your partner or whatever. You walk away 

with no information. You need to be told that you need your GP, 

your psychologist, your dietician, your social worker at least to go 

and see what financial assistance there is, family therapy — 

everything. At GP level there is nothing — absolutely nothing. 

That has been our story so far. 26 

3.35 From this evidence it would appear that General Practitioners 

may require some assistance in their ability to handle patients who 

present with symptoms of anorexia nervosa, whether it be additional 

training or printed information available for distribution to patients and 

their families. 

Recently, the Centre for Excellence in Eating Disorders 

launched its new short course for health professionals in the 

management of eating disorders. This course includes the Eating 

Disorder Resource for Health Professionals and two modules, 

“Introductory Training in the Management of Eating Disorders” and 

“Specialised Training in the Management of Eating Disorders”. The 

first module covers understanding eating disorders, early recognition 

and assessment and management plans and referral. The latter 

module is designed so that it caters to the needs of different groups of


health professionals: dieticians and nutritionists, medical professionals, 

and health workers receive training and information specific to their 

field. 27 


That the Centre for Excellence in Eating Disorders be assisted in its 

production of professional development and training programs for 

health and allied health professionals, and for counsellors working with 

youth. 

Bulimia Nervosa 


a. Recurrent episodes of binge eating. An episode of binge eating 

is characterized by both of the following: 

b. Eating, in a discrete period of time (e.g., within any 2-hour 

period) an amount of food that is definitely larger than most 

people would eat during a similar period of time and under 

similar circumstances. 

c. A sense of lack of control over eating during the episode (e.g., a 

feeling that one cannot stop eating or control what or how much 

one is eating). 

d. Recurrent inappropriate compensatory behaviour in order to 

prevent weight gain, such as self-induced vomiting, misuse of 

laxatives, diuretics, enemas or other medications, fasting, or 

excessive exercise. 

e. The binge eating and inappropriate compensatory behaviours 

both occur, on average, at least twice a week for 3 months. 

f. Self-evaluation is unduly influenced by body shape and weight. 

61



62 

g. The disturbance does not occur exclusively during episodes of 

Anorexia Nervosa. 

3.37 There are also two types of bulimia: 

• the purging type in which during an episode the person has 

regularly engaged in self-induced vomiting or the misuse of 

laxatives, diuretics, or enemas; and 

• the non-purging type in which during an episode the person has 

used other inappropriate compensatory behaviours, such as 

fasting or excessive exercise, but has not regularly engaged in 

self-induced vomiting or the misuse of laxatives, diuretics, or 

enemas. 


3.38 Statistics compiled by the Eating Disorders Foundation of 

Victoria indicate the prevalence of bulimia nervosa in the general 

community at a rate of 5 in 100, though there suggestions that bulimia 

nervosa tends to be under-reported. It is estimated that the rate of 

bulimia nervosa rises to 1 in 5 in the student population. The onset of 

bulimia nervosa is more likely to be in older adolescence or early 

adulthood and an Australian study has indicated that 77% of women 

with bulimia nervosa or binge eating disorder were over the age of 25. 

Most sufferers of bulimia nervosa hide their disorder for between 8 and 

10 years.28 The American Psychiatric Association reports lifetime 

prevalence in women of 1.1% to 4.2%. 

3.39 Prevalence studies in North America suggest that males are 

more likely to suffer from bulimia nervosa than anorexia nervosa. 

Where males do present with eating disorders they are more likely


than females to have co-morbid substance abuse disorders and 

antisocial personality disorders. Sexual orientation has been 

hypothesized as a factor in male eating disorders though this has not 

been confirmed in epidemiological studies. 29 

Medical effects of bulimia nervosa 

3.40 Bulimia nervosa is considered a periodic disorder and it is 

suggested that patients benefit from a prolonged follow-up, with 

approximately half of the patients becoming free of any eating disorder 

symptoms. 30 Australian data suggests that 70% of patients reports a 

significant improvement in their symptoms after treatment. 31 The 

American Psychiatric Association reports that the short term success 

rate for patients receiving psychosocial treatment or medication is 

between 50-70%. In the period 6 months to 6 years after successful 

treatment, relapse rates of between 30-50% have been reported. One 

large study of the long-term course of bulimia nervosa after intensive 

treatment reported good outcomes for 60% of patients, intermediate 

success for 29%, poor results for 10% and a mortality rate of 1%. 

Developing patient motivation before commencing other treatments 

has been seen to increase the rapidity of response to care. 32 This is 

reflected in the National Institute of Health’s recommendation to 

engage patients in a self-help programme as a first step. 33 

Recurrent bingeing and purging can place a great deal of stress on the 

body and can lead to electrolyte and chemical imbalances that may 

effect the heart and other major organs. 

3.41 Effects of vomiting: 

• Tooth decay, erosion of enamel and staining due to exposure to 

stomach acid. 

63



• Enlarged or swollen salivary glands. 

• Abdominal pain. 

• Sore throat. 

• Indigestion and heartburn. 

• Electrolyte imbalances that can lead to irregular heartbeat and in 

rare cases heart failure or death. Dehydration and loss of sodium 

and potassium cause electrolyte imbalance. 

• There is a slim chance of gastric rupture from excessive vomiting. 

3.42 Effects of laxative abuse: 

• Chronic irregular bowel movements. 

• Dehydration which may lead to an electrolyte imbalance. 

• Bowel disease. 

• Bleeding (may lead to anaemia). 

• Constipation. 

3.43 Effects of syrup of ipecac abuse: 

• Syrup of ipecac is very dangerous and can lead to major damage 

to the nervous system and heart. 

3.44 Effects of diuretic abuse: 

• Abuse of diuretics may lead to a serious condition called 

hypokalemia where the body loses too much potassium. This 

may cause disturbances in the heart's rhythm and may even 

cause it to stop. 

• Dehydration. 

64

3.45 Effects of diet pill abuse: 


• May lead to heart rhythm disturbances and changes in blood 

pressure and pulse. 

3.46 Effects of excessive exercise: 

• May lead to stress fractures. 

• May lead to menstrual cycle abnormalities. 

Other Effects 

3.47 People with bulimia may have had one or several suicide 

attempts and there is a high incidence of depression amongst bulimia 

sufferers. 34 It is common for people suffering from bulimia to keep their 

disorder hidden for 8-10 years, at great cost to their physical and 

psychological health. 35 

Binge Eating Disorder 


a. Recurrent episodes of binge eating. An episode of binge eating 

is characterized by both of the following: 

b. Eating in a discrete period of time (e.g., within any 2-hour 

period) an amount of food that is definitely larger than most 

people would eat during a similar period of time and under 

similar circumstances. 

c. A sense of lack of control over eating during the episode (e.g., a 

feeling that one cannot stop eating or control what or how much 

one is eating). 

65



66 

d. The binge-eating episodes are associated with three (or more) 

of the following: 

i. Eating much more rapidly than normal. 

ii. Eating until feeling uncomfortably full. 

iii. Eating large amounts of food when not feeling physically 

hungry. 

iv. Eating alone because of being embarrassed by how 

much one is eating. 

v. Feeling disgusted with oneself, depressed, or very guilty 

after overeating. 

vi. Marked distress regarding binge eating is present. 

e. The binge eating occurs, on average, at least 2 days a week for 

6 months. Note: the method of determining frequency differs 

from that used for Bulimia Nervosa; future research should 

address whether the preferred method of setting a frequency 

threshold is counting the number of days on which binges occur 

or counting the number of episodes of binge eating. 

f. The binge eating is not associated with the regular use of 

inappropriate compensatory behaviours (e.g., purging, fasting, 

excessive exercise) and does not occur exclusively during the 

course of Anorexia Nervosa or Bulimia Nervosa. 


3.49 As with bulimia nervosa, binge eating disorder (BED) usually 

has its onset in late adolescence or early adulthood. Prevalence is 

suggested at 2% in the community in North American studies, though it 

is common amongst patients seeking treatment for obesity in hospitalaffiliated 

weight programs. One-third of these patients are male. 36


Australian data suggests that community prevalence is 4% and that 

the incidence among males and females is almost equal. 37 

Health effects of binge eating disorder 

3.50 Binge eating disorder may lead to obesity, which has many 

health risks. Health risks of obesity include: 

• High blood pressure. 

• High cholesterol. 

• Heart disease. 

• Type 2 diabetes. 

• Gallbladder disease. 

Other Effects 

3.55 There has been a dramatic increase in the incidence of binge 

eating type syndromes in recent years, which correlates not only to the 

thin ideal messages, but also to the rising obesity levels witnessed 

over the past few decades. This trend is estimated to escalate with 

predictions of further increases in obesity rates. Studies suggest that 

bulimic type syndromes outnumber bulimia nervosa by a factor of 2:1. 

Whilst the prevalence of binge eating disorder in the general 

population is approximately 4%, in young women the rates are 

significantly higher. A study of 15,000 18-22 year old Australian 

women found that 20% had symptoms of Binge Eating Disorder. 38 

67



Eating Disorder Not Otherwise Specified 

68 

Diagnostic criteria 

3.56 The Eating Disorder Not Otherwise Specified category is for 

disorders of eating that do not meet the criteria for any specific eating 

disorder. Examples include the following: 

a. For females, all of the criteria for Anorexia Nervosa are met 

except that the individual has regular menses. 

b. All of the criteria for Anorexia Nervosa are met except that, 

despite significant weight loss, the individual's current weight is 

in the normal range. 

c. All of the criteria for Bulimia Nervosa are met except that the 

binge eating and inappropriate compensatory mechanisms 

occur at a frequency of less than twice a week or for duration of 

fewer than 3 months. 

d. The regular use of inappropriate compensatory behaviour by an 

individual of normal body weight after eating small amounts of 

food (e.g., self-induced vomiting after the consumption of 2 

biscuits). 

e. Repeatedly chewing and spitting out, but not swallowing, large 

amounts of food. 

f. Binge eating disorder, recurrent episodes of binge eating in the 

absence of the regular use of inappropriate compensatory 

behaviours characteristic of Bulimia Nervosa. 


3.57 There is evidence to suggest that the community prevalence of 

EDNOS- bulimic type syndrome in Australia is 4%-5.5% among


females. 39 In a briefing to the Committee Ms Stephanie Jones, 

Coordinator of the Centre for Excellence in Eating Disorders noted 

that: 

Indeed, the largest group we see presenting in adolescence 

would be the partial syndrome disorders – some features of 

eating disorders without necessarily reaching the full hand of 

eating disorders, but they are still really pretty important. 40 

Other Negative Effects 

Steroid Abuse 

3.58 Recent research indicates that men too can be dissatisfied and 

preoccupied with their bodies. Of note is that the nature of this 

dissatisfaction is not usually a desire to be thin, as is the case with 

women, but to be more muscular and one study of men in Austria, 

France and USA has reported a desired increase in muscle mass of 

12kgs. 41 The desire for muscularity has been found to be related to 

frequency of weight training and weight training programmes can, of 

course, improve body satisfaction in both women and men. However, 

the research is showing indications that in young men, the desire for 

muscularity can lead to exercise addiction, the abuse of anabolic 

steroids, human growth hormone and the over use of nutritional 

supplements. 

3.59 In addition, a new body image disorder that primarily afflicts 

men has been identified, called Muscle Dysmorphia (MD), this disorder 

is likened to reverse anorexia (which afflicts primarily women); 

sufferers are pathologically concerned that their bodies are not 

sufficiently muscular when they are in fact usually very muscular. 42 

69



3.60 The condition may be both disabling and distressing as the 

sufferer characteristically avoids situations where his body might be 

seen (for example, going to the beach with friends) and if such 

situations cannot be avoided, goes to great lengths to cover up his 

body (wearing many layers of clothing in very hot weather). Training in 

the gym becomes all consuming with little time left for relationships, 

family and work. However the research in this area is still at an early 

stage. 

70 


That there be further resources provided for the study of the 

development of body image and eating disorders among young males. 

3.61 Information about the extent of anabolic steroid use is difficult to 

obtain due to the fact that it is an illegal substance. Statistics provided 

by the Australian Institute of Health and Welfare (2003) indicate that 

less than 3% of adolescents between the ages of 12-17 had used 

anabolic steroids. This compares to 35% of 15-17 year olds and 15% 

of 12-14 year olds having used cannabis. 43 

3.62 The Committee received evidence during the course of the 

Inquiry that steroid use is prevalent amongst a small section of young 

males as a response to the desire to add musculature and bulk: 

For the males, I am sure you have heard a lot of stats, it is now a 

case of 1 in 10 teenage males is taking steroids and over half of 

them for non-athletic reasons — purely aesthetic. That concerns 

me as much as the anorexic concerns of the female gender. For 

that reason males cannot be left out of any discussion to do with 

body image. 44


3.63 For the health and fitness industry this is a major concern and 

steps have been taken through the industry association to minimise 

the contact of members to steroids and the trade in steroids. The 

Committee has received the Fitness Australia guidelines, Identifying 

and Managing Members with Eating Disorders and/or Problems with 

Excessive Exercise. Fitness Australia is the peak body of the health 

and fitness industry. However it was argued that a section of the 

industry still caters to steroid use: 

The people who are taking steroids in the health industry I would 

suggest are all within a few select sites. The majority of the 

industry will not tolerate it in any way, shape or form. The police 

are called very quickly. When I took over a gym eight years ago 

it was rife, and I had the police in uniform there regularly for four 

weeks. 

Then you get about 100 members who cancel, and the whole 

thing changes. 45 

3.64 It was also suggested that older students at more exclusive 

schools, where pressure to achieve in sport is more intense are often 

targeted by the steroid trade. 46 

Excessive exercise 

3.65 Although the Committee has not received personal accounts of 

excessive exercise as a response to disordered body image. The 

guidelines of Fitness Australia, previously mentioned were developed 

in conjunction with the Centre for Eating and Dieting Disorders 

(Sydney). 

3.66 The guidelines provide information on eating disorder and 

issues relating to exercise such excessive amounts of exercise, 

71



overtraining, exercise dependence, athletic menstrual dysfunction and 

the female athlete triad (the conjunction of three disorders: disordered 

eating, amenorrhea and osteoporosis). 

3.67 In order to assist fitness instructor in managing clients with 

these problems, the guidelines provide management strategies and 

discussion guidelines. It is recommended that instructors proceed 

through a four step process, which includes the initial approach to the 

client, program review, secondary review and taking further action 

(such as referring to a GP, limiting access to the gym and suspension 

from the gym). Forms and sample letters are also included as aids to 

instructors. 

Conclusion 

3.68 This chapter has briefly discussed the link between negative 

body image and a number of medical, psychological and behavioural 

problems that may arise if body dissatisfaction is not addressed. In 

order to proceed to the development of interventions it is important to 

try to understand this link and also to stress the importance of 

resilience and self esteem in overcoming these problems. 

The next chapter examines a number of treatments for the disorders 

examined above and provides an overview of the existing provision of 

these services in Victoria. 

72

Endnotes 


1 Dohnt, H., and Tiggemann, M. 2005. Peer influences on body dissatisfaction and dieting 

awareness in young girls. British Journal of Developmental Psychology. 23: 103-16, 






7 Ford, S. “Understanding and treating eating disorders,” InPsych, December 2003, page 24 

8 VicHealth Submission. 

9 VicHealth Submission. 

10 

Body Image and Health Inc 1999. Body Image Research summaries, BI & HI, Melbourne 

(Body Image and Health Inc, 1999) 

11 Owen N, and Bauman A (1992) The descriptive epidemiology of a sedentary lifestyle in 

adult Australians. International Journal of Epidemiology. 21, 305-10 

12 Shaw SM and Kemeny L (1989) Fitness Promotion for Adolescent Girls: The Impact and 

Effectiveness of Promotional Material Which Emphasises the Slim Ideal. Adolescence 24 (95), 

677-687 

13 Patton, G.C., Selzer, R., Coffey, C., Carlin, J.B., & R Wolfe, R. (1999). Onset of adolescent 

eating disorders: population based cohort study over 3 years. British Medical Journal, 318, 

765-768 

14 Paxton, S., Wertheim, E., Gibbons, K., Szmukler, G., Hillier, L., and Petrovich, J. (1991). 

Body image satisfaction, dieting beliefs, and weight loss behaviours in adolescent girls and 

boys. Journal of Youth and Adolescence, 20, 361-379. 

15 Kenardy, J., Brown, W.J., & Vogt, E. (2001). Dieting and health in young Australian women. 

European Eating Disorders Review, 9(4) 242-254. 

16 NEEDS submission, CEED submission. 

17 Beumont, P., Hay, P., and Beumont, R. 2003. Summary: Australian and New Zealand 

clinical practice guidlines for the management of anorexia nervosa. Australian Psychiatry. 

11(2): 129-133., p. 129. 

18 Ibid., p. 130. 

19 Eating Disorders Foundation of Victoria. (2004). Eating Disorders: statistics: 

http://eatingdisorders.org.au/fact_sheets/statistics.shtml. 

20 American Psychiatric Association. (2000). Practice Guideline for theTreatment of Patients 

with Eating Disorders. Arlington, VA: American Psychiatric Association., p. 26. 



22 Clayer, J. McFArlabe, A., Bookless. Air, T., Wright, G., & Czechowicz, A (1995). Prevalence 

of psychiatric disorders in rural South Australia The Medical Journal of Australia. 163 pp 124- 

73



19.Cited in the encultured body p 6 School of Nursing Queensland University of Technology 

2000 

23 Beaumont, P. (2000). Anorexia Nervosa as a mental and physical illness – the medical 

perspective. In D. Gaskill and F. Sanders (Eds.). The Encultured Body – Policy Implications for 

Healthy Body Image and Distorted Eating Behaviours. (pp80-94): Queensland University of 

Technology, Brisbane 

24 Ms D. Cuman, Private Citizen, Public Hearings, Melbourne 2004 

25 Associate Professor S. Sawyer, acting director, Centre for Adolescent Health, Royal 

Children’s Hospital, Public Hearings, Melbourne 2004 

26 Ms D. Cuman, Private Citizen, Public Hearings, Melbourne 2004 

27 Centre for Excellence in Eating Disorders, Royal Children’s Hospital, Melbourne: 

http://www.rch.org.au/ceed/edu.cfm?doc_id=2967 Viewed June 2005. 

28 Ibid. 


with Eating Disorders. Arlington, VA: American Psychiatric Association., p 53. 

30 Ebeling, H., Tapanainen, P., Joutsenoja, A., Koskinen, M., Morin-Papunen, L., Järvi, L., 

Hassinen, R., Keski-Rahkonen, A., Rissanen, A., and Wahlbeck, K. 2003. A practice guideline 

for treatment of eating disorders in children and adolescents. Annals of Medicine. 35: 488- 

501., p 35. 





33 National Collaborating Centre for Mental Health. (2004). Eating Disorders: Core 

interventions in the treatment and management of anorexia nervosa, bulimia nervosa and 

related eating disorders. London: National Institute for Clinical Excellence., p 16. 

34 

Edelstein, C., Haskew, P., & Kramer, J. (1989). Early cues to Anorexia Nervosa and Bulimia 

Nervosa. Patient Care, 23, 155-175. 

35 Women’s Health Queensland Wide Inc. (1997). Understanding Eating Disorders. 

Queensland: Women’s Health Queensland Wide Inc. and The Eating Disorders Association 

Resource Centre. 

36 American Psychiatric Association. (2000). Practice Guideline for the Treatment of Patients 




38 

Wilfley et al (1993) in Howell, P. 1999 and The Australian Longitudinal Study on Women’s 

Health 2001 



40 (2004). Family & Community Development Committee, Briefing: Inquiry into Issues relating 

to the Development of Body Image among Young People and Associated Effects on their 

Health and Wellbeing. Melbourne: FCDC., p 656. 

74


41 Dr Murray Drummond, Senior Lecturer in the School of Health Sciences, University of 

South Australia, A/Professor Precilla Y L Choi, School of Human Movement, Recreation & 

Performance, Victoria University , Submission. 

42 Choi, P Y L. Pope Jr, H G. Olivardia, R. Muscle dysmorphia: a new syndrome in 

weightlifters, British Journal of Sports Medicine 2002, vol 36 pp 375-377 

43 Australian Institute of Health and Welfare. (2003). Australia's Young People: their health and 

wellbeing, 2003. Canberra: AIHW., p. 206. 

44 Mr P. Bourke, Valley Sport, Public Hearings, Shepparton, 2004 

45 Mr J. Clift, president, Fitness Victoria, Public Hearings, Melbourne 2005 

46 Mr J. Clift, president, Fitness Victoria, Public Hearings, Melbourne 2005 

75



76

C HAPTER F OUR – T REATMENT 

AND S UPPORT S TRATEGIES 

4.1 This chapter focuses on the treatments recommended and 

available in Victoria for those children and adolescents suffering the 

most severe impact of negative body image. The first section 

discusses the treatment options for eating disorders. The second 

section focuses on the treatment services available in Victoria, issues 

of accessibility and the experience of sufferers and their carers. 

Eating Disorders 

4.2 As previously mentioned eating disorders are a range of 

psychiatric illnesses whose symptoms are ordered in the Diagnostic 

and Statistics Manual, Edition 4 (DSM-IV). They are: anorexia nervosa, 

bulimia nervosa, binge eating disorder, and the sub-clinical diagnosis 

of eating disorder not otherwise specified. In the following paragraphs, 

the treatment for each of these illnesses is described. A new form of 

treatment practised by the Karolinska Institute, Sweden, is also 

described. To conclude the section on eating disorders, current and 

proposed treatment programs in Victoria are described. 

77



Anorexia Nervosa 

78 

Clinical practice guidelines 

4.3 All clinical practice guidelines agree that the first step in the 

treatment of anorexia nervosa is to assess the medical stability of the 

patient in order to select the most appropriate setting for the 

commencement of treatment. 1 The guidelines also agree that a 

multidisciplinary care team most appropriately addresses the complex 

issues of anorexia nervosa. As the RANZCP states, 

“There is general consensus that a multiskilled and multidisciplinary 

approach is optimal utilizing cognitive, behavioural, and motivational 

enhancement therapies (psychologists), nutritional supervision and 

counselling (dieticians), family and individual therapy 

(psychotherapists), skilled nursing care, and adequately trained 

family doctors (and in some circumstances, paediatricians and 

physicians).” 2 

4.4 The American Psychiatric Association suggests different levels 

and settings of care according to the characteristics of the patient. 

Taking into account a range of factors (including medical 

complications, suicidality, weight as a percentage of healthy body 

weight, psychiatric comorbidity and treatment availability), the setting 

for treatment may be outpatient, partial hospitalisation, a residential 

treatment centre or inpatient hospitalisation. 3

CHAPTER FOUR - TREATMENT AND SUPPORT STRATEGIES 

4.5 Prof. Susan Sawyer, (then) Acting Director of the Centre for 

Excellence in Eating Disorders at the Royal Children’s Hospital, 

described the possible clinical pathways for children and adolescents 

presenting at the Healthy Eating Clinic located at the hospital: 

“Our approach is case management of complex cases with a 

multidisciplinary focus, if required. So that if it is relatively 

straightforward, with a young person seen in the early stages, 

then an adolescent physician such as myself alone will be able 

to maintain and deal with the complexity and the issues at hand. 

On the other hand, if it is a more severe condition and there are 

broader family-related issues and hospitalisation is also required, 

then we are highly likely to put in a team of people around that 

young person and the family with case management led by an 

adolescent physician; with mental health, either at the Centre for 

Adolescent Health but more likely, because we do not have 

funding, with community-based mental health and also with 

nutrition…But the importance of expert case management — of 

communication, of holding the anxiety within the family, within 

the other health professionals — is, we believe, a fairly important 

part of what we provide. And in particular it is the integration of 

not only community with hospital-based care but within 

hospital-based care the integration of inpatient and outpatient 

services.” 

4.6 The services provided by the Healthy Eating Clinic are in line 

with the multidisciplinary case management approaches advocated by 

clinical practice guidelines. 

79



4.7 The following diagram represents the usual treatment process 

for anorexia nervosa: 

Figure 1. Some goals of psychological treatment and the treatment process 4 

80 

Treatment types and evaluation 

4.8 The pursuit of evidenced-based medicine in the treatment of 

eating disorders generally, and anorexia nervosa particularly, is 

complicated by the overall poor quality of data, small sample sizes and 

poor reporting of results. 5


4.9 The RANZCP provides the following guidelines in selecting 

treatment for patients with anorexia nervosa. These guidelines are 

based on a review of 41 identified randomised controlled trials. 

Where to treat For patients with anorexia nervosa which is not so 

severe as to require inpatient treatment (e.g. 

where the risk of death from suicide or physical 

effects is high), out patient or day-patient 

treatment may be suitable, but this decision will 

depend on availability of appropriate services. 

Psychological 

treatments 

The consensus is that family therapy is a valuable 

part of treatment, particularly in the case of 

children and adolescents, but no specific 

approach emerges as superior to any other. 

Dietary advice should be included in all treatment 

programs. Cognitive behaviour therapy (CBT) or 

other therapies are likely to be helpful. 

Drug treatments Evidence for antidepressant and antipsychotic 

efficacy is insufficient. However, the consensus is 

that antidepressants have a role in patients with 

marked depressive symptoms and olanzapine 

helps to attenuate hyperactivity. Cyproheptadine, 

zinc supplements, lithium and naltrexone warrant 

further study. 

Related treatment 

issues 

Naso-gastric vs ‘ordinary’ food in weight 

restoration: Weight restoration is essential in 

treatment but evidence is lacking to recommend a 

specific approach. 

Discharge at normal vs below normal weight: A 

consensus prevails that, particularly where after- 

81



Outcomes of anorexia nervosa 

care may be inadequate or unavailable, patients 

should achieve close to normal weight as an 

inpatient. 

Lenient vs stricter programs: A lenient approach 

is likely to be more acceptable to patients than a 

punitive one and less likely to impair self-esteem. 

Osteoporosis: Assessment of bone density 

should be routine. Evidence is lacking to 

recommend a specific approach to treat 

osteopaenia. Specialist referral is recommended. 

4.10 It is estimated that 50% of anorexics will return to a normal body 

weight within 6 months of treatment; 25% will have low but stable 

weight, and the remaining 25% will be chronically ill or die with the 

condition. 6 The RANZCP provides a clinical description of outcomes: 

Good outcome: 

• BMI in excess of 17.5 

• absence of severe medical complications 

• strong motivation to change behaviour 

• supportive family & friends who do not condone abnormal 

behaviour 

Poor outcome: 

• vomiting in very malnourished patients 

• onset in adulthood rather than adolescence 

• comorbid psychiatric or personality disorder 

82

• disturbed family relationships 

• long duration of illness 

Bulimia Nervosa 



4.11 Both the American Psychiatric Association and the United 

Kingdom’s National Institute for Health have released clinical practice 

guidelines for bulimia nervosa. 7 The main goal in treating bulimia 

nervosa is a reduction in bingeing and purging practices. Since one of 

the characteristics of bulimia nervosa is weight within the normal 

range, weight restoration is not usually a part of nutritional therapy. 

However, purging behaviour may result in electrolyte imbalance and in 

some cases this may require therapy. 

4.12 The National Institute of Health recommends that the majority of 

bulimia nervosa patients can be treated as outpatients. Inpatient 

treatment is only indicated with the management of suicide risk or selfharm. 

8 Pharmacotherapy is more often utilised in the treatment of 

bulimia nervosa than in anorexia nervosa. Antidepressants are used to 

reduce bingeing and purging behaviours and to alleviate other 

psychiatric symptoms such as depression, anxiety, obsessions or 

certain impulse disorder symptoms. 9 

4.13 An evidence-based self-help programme may be sufficient 

treatment for a subset of bulimia nervosa patients. Cognitive behaviour 

therapy for bulimia nervosa (CBT-BN) is a specifically adapted form of 

CBT and should be offered to adults with bulimia nervosa. 

Interpersonal psychotherapy may be offered but it takes longer to 

achieve the same results as CBT-BN. 10 

83



84 

Treatment types and evaluation 

4.14 Evaluation of CBT-BN and types of individual psychotherapy 

(interpersonal, psychodynamically oriented or psychoanalytic) indicate 

that all are equally effective in reducing binge eating symptoms over 

the long term. However, CBT-BN is associated with a shorter 

treatment time to recovery and with greater improvement in disturbed 

attitudes toward shape and weight and restrictive dieting. Family 

therapy is strongly recommended for adolescents. 11 The National 

Institute of Health recommends suitably adapted CBT-BN for 

adolescents, including the family as appropriate. 12 

Outcomes of bulimia nervosa 

4.15 Bulimia nervosa is considered a periodic disorder and it is 

suggested that patients benefit from a prolonged follow-up, with 

approximately half of the patients becoming free of any eating disorder 

symptoms. 13 Australian data suggests that 70% of patients report a 

significant improvement in their symptoms after treatment. 14 The 

American Psychiatric Association reports that the short term success 

rate for patients receiving psychosocial treatment or medication is 

between 50-70%. In the period 6 months to 6 years after successful 

treatment, relapse rates of between 30-50% have been reported. One 

large study of the long-term course of bulimia nervosa after intensive 

treatment reported good outcomes for 60% of patients, intermediate 

success for 29%, poor results for 10% and a mortality rate of 1%. 

Developing patient motivation before commencing other treatments 

has been seen to increase the rapidity of response to care. 15 This is 

reflected in the National Institute of Health’s recommendation to 

engage patients in a self-help programme as a first step. 16

Binge Eating Disorder 



4.16 Psychological treatments are recommended for BED, with the 

first step being an evidenced-based self help program. As with bulimia 

nervosa, this type of intervention may be sufficient for a particular 

subset of patients. 

4.17 The National Institute of Health recommends that clinicians offer 

CBT-BED (a modified version of cognitive behaviour therapy) to adults. 

Other forms of psychological treatment, such as interpersonal 

psychotherapy and modified dialectical behaviour therapy, are suitable 

for adults with persistent BED. Adapted versions of these therapies are 

suitable for adolescents with persistent BED. There is a role for certain 

antidepressants in the treatment of BED as they act to alter satiety 

perceptions and suppress psychological symptoms associated with 

BED. 17 

Eating Disorder Not Otherwise Specified 


4.18 There is a consensus view that the treatment of EDNOS should 

follow practice guidelines for the eating disorder that most closely 

resembles the individual patient’s eating problem. 18 

Treatment paths and access to services 

4.19 The previous section reviewed clinically recommended 

treatments for a range of eating disorders. A significant issue raised in 

submissions to the Committee was gaining access to treatments in a 

85



timely manner, in the patient’s local area and treatment that 

recognised the entwined elements of mental and physical health. 

Relevant excerpts from the accounts of sufferers and their carers are 

included in this review of treatment services. 

4.20 Treatment for eating disorders in Victoria is available through 

public and private providers. Publicly provided services are available 

on inpatient or outpatient basis, with medical severity or complexity 

determining whether treatment is delivered though hospital inpatient 

services. Public outpatient services may be provided by the Child and 

Adolescent Mental Health Service, paediatric clinics or dedicated 

eating disorder units, though treatment by General Practitioners (GPs) 

or dieticians in community settings is common. Referral to such 

services is usually made through a GP, though some community 

health services accept and encourage self-referral. Private providers 

usually operate day treatment programs on an outpatient basis, though 

some provide inpatient treatment as private hospitals. 

4.21 Child and Adolescent Mental Health Services (CAMHS) provide 

intensive youth support, continuing and clinical care, and acute 

inpatient services to all health services areas. In some areas, day 

programs and conduct disorder programs are also available. 19 Access 

to services is primarily determined by geography as each CAMHS has 

a ‘catchment area’ population to which its services are delivered. 

CAMHS services are provided to children and youth up to the age of 

18; in the Orygen and Barwon services children are between the ages 

of 0-14 and youth between 15-24. In other services, youth between the 

ages of 16-18 may be treated by the Adult Mental Health Service, 

depending on their needs. 

86

The CAMHS metropolitan areas are: 

• North Western Metropolitan (ORYGEN) 

• Inner Southern 

• North Eastern Metropolitan 

• Eastern 

• South Eastern 

The CAMHS rural areas are: 

• Barwon 

• Gippsland 

• Glenelg (South Western) 

• Goulburn and Southern 

• Grampians 

• Loddon 

• North Eastern Hume 

• Northern Mallee 


4.22 Specialist inpatient and community based eating disorders 

services are based at Austin Health (Mood and Eating Disorders Unit, 

Austin Hospital), Melbourne Health (ORYGEN – youth specific, Eating 

Disorders Program – 16 years and over, Royal Melbourne Hospital), 

and Southern Health (Monash Medical Centre). The Royal Children’s 

Hospital provides inpatient treatment to sufferers of eating disorders 

where necessary as part of the treatment provided by its Healthy 

Eating Clinic. 

87



4.23 Ms Freida Andrews, Manager of the West Hume Primary Mental 

Health Team (part of the Goulburn Valley Area Mental Health Service), 

described the type of treatment usually encountered by an eating 

disorder sufferer across the West Hume rural area and the North 

Eastern metropolitan area: 

88 

Treatment was most likely to be provided by specialist services, 

such as child and adolescent mental health services, paediatric 

services, and Banksia House, Austin Health. However, the 

treatment was only provided when the eating disorder became 

severe. As access to these services is limited, it is not unusual 

for treatment interventions…to be provided by general 

practitioners and dieticians in community settings. Publicly 

funded adult mental health services do provide some treatment 

but this is usually in the context of treatment for a psychotic 

disorder, and the eating disorder is not usually the focus of 

attention. 20 

4.24 The first step in the treatment path for an eating disorder is 

usually the sufferer’s GP. Based on evidence before the Committee, 

the course of treatment beyond that initial contact will depend on the 

GP’s level of expertise in eating disorders and their awareness of 

treatments and service providers. 21 In one case reported to the 

Committee, the GP did not refer and left further treatment to the 

initiative of the adolescent sufferer. 22 More usually, the GP will refer to 

the local Child and Adolescent Mental Health Services (CAMHS), 

psychiatrist, psychologist or specific eating disorders clinic if they are 

aware of it. 23 If the patient’s condition is medically unstable they will be 

admitted to a hospital for stablisation and treatment. 

4.25 From this point, access to the required services may become 

difficult to access depending on whether the patient is in a rural or


regional area, the waiting list of the mental health service, restricted 

access to some services based on severity of the illness, and the 

capacity of the family to access private treatment. These difficulties 

were described by Ms D Kuman, based in Wonthaggi and whose 

daughter has been treated for anorexia nervosa: 

I rang public and private hospitals. I was either not in the 

catchment area or…she was not sick enough. It dawned on me 

that it was like presenting my daughter with cancer at a hospital 

and people saying to me, “We are sorry. Your daughter is not 

sick enough. Come back when she has secondary-stage cancer 

and we might be able to do something about it” Can you imagine 

the outrage? That is exactly what I was being told, but it was for 

an eating disorder. There are no services. With the Community 

centre that I had rung and where I had been put on the list, the 

three to four-month wait turned out to be an eight-month wait. 

She got to the tope of the list last month, but by that stage I had 

already been travelling backwards and forwards to Melbourne 

since about January, once a week. At one stage we were 

travelling twice a week. Medicare helps us with the psychiatrist 

because the psychiatrist has a provider number, but had my 

daughter been seeing a psychologist – I have private health 

cover – it would have run out. I get a little bit of money from 

Human Services for travelling…but that is very limited as well. 

While we are seeing the psychiatrist we get the travelling 

money, but once I do not see the psychiatrist…and see someone 

else, that is gone as well. There has got to be a better way. Your 

GP is the first person you go to, but sometimes they cannot help 

you or they hand you a business card. 24 

4.26 Prof. Susan Sawyer described to the Committee a typical 

presentation to the Royal Children’s Healthy Eating Clinic, from the 

moment of family concern to ultimate referral to the Clinic: 

89



90 

I want to frame this around what would be a very typical 

presentation. Here we have a 14 year old previously well girl 

from a loving family whose family has become concerned that 

she has started dieting. It has become increasingly severe. She 

is now losing weight and is increasingly withdrawn. The family 

sensibly has had some discussion with the school, which shares 

the concern. They are worried. Perhaps they have had some 

recent professional development and the new schools resource 

from CEED [Centre for Excellence in Eating Disorders], and they 

know that they need to get this kid into care. The girl herself, not 

at all surprising in terms of anorexia nervosa, is unconcerned, 

but the family is able to arrange for her to see her GP who 

confirms, as a good GP, that she does have…‘diagnosable’ 

features of anorexia. So he confirms she has anorexia, she does 

have significant weight loss, and it is quite significant in that she 

now has loss of menstruation; that is a mark of diagnosis and of 

severity…She has been growing nicely here on her flow chart 

over her earlier years — her GP said ‘Very good’ — but she has 

started now to have some drop off of her weight. Indeed, she has 

further drop off of her weight by the time she is seen on a second 

occasion by the GP. 

The question becomes: what does the GP do now? Many GPs 

recognise that there is a problem, but they might not feel quite so 

comfortable about how to address it, because as I said, it is still a 

relatively uncommon condition in our society. The GP, if he or 

she has had some specialist training — maybe has attended 

some training through CEED, maybe has attended the 

Commonwealth Better Outcomes in Mental Health Care Initiative 

training — might be comfortable to continue to see her for a 

couple of visits. But I tell you what, if this kid has had significant 

weight loss, the most average and reasonably good GP in our 

society very quickly becomes very uncomfortable and needs 

additional help. The GP is likely to refer to any one of these sorts


of resources — mental health interventions in terms of CAMHS 

services, private mental health services, physical assessments 

by perhaps a paediatrician or maybe through a dietician. Any 

options would be perhaps reasonable for starters. But this kid 

then continues to lose further weight and becomes more 

withdrawn, and the family becomes even more concerned. And 

sadly, because of lack of training, often lack of confidence, lack 

of expertise, lack of time — within privatised services in 

particular — and lack of support for integration of services the 

end result is that many of those existing services are unable to 

put in place an appropriately integrated treatment plan for a 

young person like this. I have highlighted that as being ‘panic!’ — 

a common sort of result. We need to send her somewhere else. 

4.27 At this point, a dedicated eating disorder clinic is necessary for 

the recovery of the patient. As Prof. Sawyer noted to the Committee, 

the earlier such a referral is made, the better: 

I started the healthy eating clinic with the whole idea of it being 

an early intervention service, trying to be a site that young 

people and their families could come to before all of the severity 

of anorexia nervosa in its full hand came into being. I think it is 

really ironic that we spent the first six years of running this 

service absolutely at the hard end — we never saw anyone with 

a mild eating disorder; we only ever saw the most extreme cases 

of anorexia nervosa. Now that we are so well known for the 

service that we run, the really good news now is that in the last 

few years we have started to see much more exactly the sorts of 

cases that I had established the clinic to see. We still see all of 

the hard end, but in addition we see a number of young people 

at really the right time to be seeing them. 

4.28 The ORYGEN Youth Health runs a dedicated eating disorders 

clinic and, similarly to the Healthy Eating Clinic, is conducted with a 

case management approach. ORYGEN is a specialist mental health 

91



service for young people with a primary focus on early intervention. 

The service caters for 15-25 year olds living in the western and northwestern 

metropolitan area. Dr Andrew Court described to the 

Committee the work of the Clinic: 

92 

Our aim is to assess and manage all referred young people in 

our catchment area with an eating disorder…We provide 

intensive psychological input, both individual therapy and family 

work; we also provide medical review and assessment on site or 

in liaison with other services; and…we provide a dietician to 

provide dietary advice. We also liaise with and provide 

secondary consultation to referral sources – GPs, schools and 

parents, as well as other specialist services working in the area. 

Finally, we have a significant component of research. We are 

currently in the middle of a trial looking at the use of a specific 

medication in anorexia nervosa. We are developing a program 

for multifamily groups, working with eating disorder patients and 

their families, and we are trying to evolve a specific therapy 

technique for these people. 25 

4.29 The Barwon CAMHS runs a Disordered Eating Service, which 

received funding from the Department of Human Services for a trial of 

coordinated referral and care between a consortium comprised of 

Barwon Health, the GP Association of Geelong and The Geelong 

Clinic (a private psychiatric hospital). In contrast to most clinics, the 

Disordered Eating Service takes self-referrals. 26 Ms Cornett, 

coordinator of the Service, provided the following information to the 

Committee: 

Our service is predominantly an assessment and referral service. 

We do a multidisciplinary assessment of people who front up to 

our service, and we take self-referrals as well as referrals from 

health professionals and other interested people. We offer them


multidisciplinary assessment; mental health assessment offered 

either by a psychiatry registrar, family therapist or psychologist; 

and I do the nutritional assessment. We try to tie that 

assessment in with a person’s GP to maintain contact with their 

supports in the community. After we do an assessment in 

conjunction with the person who is presented to us we would 

make recommendations about therapy in the community. We do 

some short-term case management of people who are either 

acutely ill and need to be kept an eye on or who fall through the 

cracks of being able to access services in the community. We 

access both public and private services — about half and half. 

We call ourselves the Disordered Eating Service to try to 

encourage as many people as possible with eating problems to 

come. We take all ages and anyone from the very underweight, 

restricting anorexic-type person right through to people who have 

had problems of years of chronic dieting and issues around that. 

We try to take the whole lot. To give you some idea, about 

18 per cent of people who front to our service would have a 

diagnosis of anorexia nervosa, about 18 per cent would have a 

diagnosis of binge eating or compulsive overeating and about 

30 per cent would have bulimia nervosa. That is a good range of 

people. The youngest we have seen presenting to our service 

would be 9 or 10. Whether or not a diagnosis of an eating 

disorder is something that you could make at that age is 

controversial, but we certainly have seen people of that age right 

up through to people in their 60s. 27 

4.30 Butterfly Foundation, a not-for-profit organisation, has identified 

the need for a public health service which fills the gap between early 

diagnosis and acute care. Together with Southern Health, the Butterfly 

Foundation has conducted a feasibility study (Stage 1 of the project) 

into a day centre, which would be embedded within a continuum of 

care and provide a place of treatment for those ill enough to require 

93



constant care and support but still able to live in the community and 

maintain crucial family, school and community networks. Such a day 

centre would provide less intensive care than acute care on inpatient 

basis (such as a re-feeding episode) and provide more support and 

therapy in the recovery phase than is currently provided on an 

outpatient basis. Stage 2 of the project envisions a pilot program 

running for 3 years and based in Southern Health; a fundraising 

program is in place to enable Stage 2 to proceed. 28 

4.31 The Bronte Foundation was established by Ms Jan Cullis, the 

mother of Bronte Cullis, who suffered from anorexia nervosa and 

whose search for appropriate treatment for her daughter led her to 

Canada. The Bronte Foundation has treatment centres in Brisbane 

and Melbourne and also runs professional development and early 

intervention programs in schools. The following information provided 

by Ms Cullis indicates both the scope of the problem and the type of 

treatment offered by the Bronte Foundation: 

94 

We now have more than 100 families in both centres and we 

have just this week located another premises for us to move to in 

Melbourne so we can triple our size over the next three months. 

We have 25 people waiting for an initial appointment and all of 

them have really seriously ill children and nowhere to take them. 

The approach the foundation takes is we enter into a contract 

with the family to share the responsibility. We educate the family, 

we support, we provide respite, we do all of that. We provide the 

expertise, the counselling, the dietetic management, but they 

undertake the care outside of the clinic hours. It is a partnership 

between family and practitioners. We run an immense amount of 

support programs for our families and the siblings because it 

affects every single person. 29


4.32 As a result of the evidence and submissions provided to the 

Inquiry, the Committee makes the following findings and 

recommendations on the provision of eating disorder services for 

Victorian youth, across a range of health services: 

Finding #1 

That there is low-level cross-sectoral awareness of programmes and 

services focusing on body image and eating disorders. 

Finding #2 

The Committee finds that services for eating disorders patients in 

Victoria vary widely in their accessibility, availability and type of care 

provided to patients and their carers. This variation is most 

pronounced for Victorians living in rural and regional areas. 

Recommendation 4# 

That Community Health Centres are utilised more effectively for the 

delivery of body image programs. 

95



96 


That the Department of Human Services undertake a state-wide 

mapping exercise of eating disorder services, including patterns of use 

and demand. The results should be disseminated to all service 

providers and inform future government policy and funding. 


The Committee recommends that a day centre proposal be developed 

as a community-based initiative designed to address a serious service 

gap in the public health treatment of young adolescents recovering 

from severe eating disorders. 


That dedicated funding be available to Child and Adolescent Mental 

Health Services for eating disorder specific programs. 

Karolinska Institute 

4.33 The Karolinska Institute treatment method was first described in 

1996 and it is based on the thesis that self-starvation and excessive 

physical activity produce a stress reward which then leads the patient


to anorectic behaviours. 30 The basis for treatment is then predicated on 

this physiological response to starvation rather than on the basis that 

the illness is a psychiatric disorder. 

4.34 The Karolinska method focuses on treating the following 

symptoms: 

1. disordered eating and perceptions of satiety; 

2. hypothermia; 

3. physical hyperactivity; and 

4. the social consequences of the disorder. 31 

4.35 The treatment involves the following steps: 

1. Training of eating: “The patients eat from a plate placed on a 

balance and the weight loss of the plate is recorded by computer. 

At 1 min intervals a scale from none (0) to maximum (10) 

appears on a monitor and the patient records her perception of 

satiety. This device, Mandometer, determines eating rate and 

satiety. A linear curve, steeper than that generated by the patient 

is then displayed on the monitor and the patient adapts her rate 

of eating, which emerges on the monitor during a meal, to the 

curve. Successive 20% increases in meal size and curve slope 

are presented. Similarly, the patient adapts her perception of 

satiety to less steep linear curves.” 32 

2. Supply of external heat: Patients rest in warm rooms, which may 

be heated up to 40º, for one hour after each meal. 

3. Reduction of physical activity: patients are monitored and their 

physical activity restricted in the first months of treatment. 

97



4. Social restoration: A combination of short- and long-term goals 

are determined for each patient. Examples include getting a 

haircut, joining friends in a café, returning to education or work 

98 

settings. 33 

4.36 The Karolinska method is based on a neurobiological, rather 

than a psycho-pathological, understanding of eating disorders. That is, 

anorexia nervosa starts with a reduction in food intake and the 

consequent anorectic behaviours are a function of neuroendocrinal 

responses to the starvation state and increased physical activity. 

Bergh et al describe their understanding of anorexia thus: 

“The lack of effective treatment may be because there are 

relatively few physiologically plausible hypotheses of how eating 

disorders develop and how they are maintained. In an attempt to 

improve this situation, we pointed out that there are two known 

risk factors for anorexia: dieting and increased physical activity. 

Experiments on animals have shown that both these risk factors 

activate the mesolimbic dopaminergic reward and the locus 

coeruleus noradrenergic attention pathways in the brain. It might 

be hypothesized, therefore, that anorexia develops because it is 

initially rewarding to eat less and move more, and that 

subsequently anorexic behavior becomes conditioned to the 

stimuli that originally provided the reward because the brain’s 

network for attention has been activated…From our perspective, 

psychopathology is considered a consequence, not a cause, of 

starvation. Similarly, hypothermia and a further increase in 

physical activity emerge in the state of starvation.” 34 

4.37 This differs from the consensus clinical view of eating disorders 

as psychopathologies where certain activities (such as dieting) or 

circumstances (bullying, abnormal family relationships, exposure to the


thin body ideal) trigger the development of eating disorders in 

susceptible personalities (perfectionist, obsessive-compulsive, anxiety 

or genetic predisposition). It is this difference and the success rates 

claimed for the Karolinska method that make it controversial. 

4.38 The professional arguments over the Karolinska method centre 

on the evidence for good clinical outcomes for patients. The clinical 

practice guidelines discussed earlier are based on a consensus view 

from clinicians and assessments of the quality of evidence supporting 

different treatment programs. This evidence base is disputed by the 

Karolinska Institute. 35 

4.39 Bergh et al claim a rate of remission of approximately 75%, with 

an additional 12% improving significantly, although they do not meet all 

the requirements for remission. The remaining 12% do not respond to 

treatment. The average time of treatment to remission is 14 months. 

These figures are based on a RCT conducted at the Mandometer 

Clinic. 

4.40 However, caution is required in interpreting its findings. It is 

difficult to determine, based on the report evidence and the manner in 

which they have reported their data, how the researchers have arrived 

at an overall success rate of 75%. Additionally, their criteria for 

remission seems broader than those adopted by clinical practice 

guidelines. 36 This makes direct comparison of success rate and health 

outcomes difficult, though the Committee believes that the Karolinska 

Institute’s treatment method warrants further investigation. 

4.41 The Committee received evidence from Ms Margaret Payne 

whose daughter received treatment at the Karolinska Institute. Ms 

Payne’s daughter was admitted to the clinic after treatment in 

Melbourne with a physician and adolescent psychiatrist failed to arrest 

99



her daughter’s symptoms. Ms Payne described her daughter’s 

experience: 

100 

It was quite clear to me after a stay in hospital that the ad hoc 

kind of medical care you get is just not enough. That is not the 

fault of the system. People were trying their best, but a system 

is simply not in place. Off we went to Sweden. My daughter 

went in as an inpatient, round-the-clock care with a case 

manager who looks after two or three patients. She had to do a 

test to be admitted, and it was interesting that Cecilia said her 

symptoms are exactly the same as any Swedish girl with 

anorexia, so there were no cultural differences, which is 

interesting. She was an inpatient for five and a half weeks; had 

to do a psychological test at the start and the end. 

After five weeks, when the exercise was cut down – which 

seemed to be a key factor – she was eating small amounts, not a 

lot at that stage, but being trained on the Mandometer. 

Food was coming in regularly, and she had warmth and was 

starting to get some kind of motivation back. At the end of that 

five-and-a-half-week period, she did the psychological test again, 

and she was almost back to normal scale on the test, which I 

think monitored things like depression, anxiety, suicidal thoughts, 

having been right off the scale at the start. So there was my first 

proof – and I could see it myself anyhow – that her psychological 

condition had stabilised, her weight had probably not gone up 

hugely but it had slowly gone up, food was coming in regularly, 

warmth was being applied, and along with the physical 

improvement came this extraordinary emotional improvement. 

Halleluiah! I knew then that we had a chance. She kept going 

through that system. 

Cecilia [Dr Cecilia Bergh] offered motivation at various points for 

her to increase her food. In response she could do things like


perhaps take a side trip somewhere else. There were all kinds 

of ways of tapping into what would help her get through the 

rough stages. At one point she said to me it was the only time I 

was very frightened she said, “Mum, I have something to tell 

you” and I thought, “Whoa!” And she said, “I think it is easier 

than it should be”. So somewhere at the two thirds mark in that 

program she was over the hurdle, and she could look forward 

and manage. She finished her treatment I think in 108 days, and 

she returned to Melbourne. Of course, we were all full of 

anxiety: how would she manage the next stage; would she go 

backwards? Because we know that is a very common 

occurrence with people with this sort of disorder. She has not at 

all. 37 

4.42 The Committee acknowledges that the methods of the 

Karolinska Institute are subject to some professional controversy. 

However, the Committee is also interested in the development of more 

treatment options for the sufferers of eating disorders. 

4.43 There has been strong public interest in the Karolinska method, 

as witnessed by the response to the Sunday program’s report. 38 The 

Committee also has a strong interest in the serious consideration of 

this method, given the evidence and material submitted to it. Sufficient 

evidence has been provided to the Committee to indicate that different 

treatments suit different patients and successes have been observed 

across different treatment programs. What may be an appropriate 

model of treatment for one young person may not be appropriate for 

another. The Committee has been encouraged by Health Minister 

Abbott’s comments on an Australian trial of the Karolinska Institute’s 

treatment method. 39 

101



102 

Finding #3 

The Committee finds that a ‘one size fits all’ approach to the treatment 

of eating disorders does not adequately cater for the needs of all 

young sufferers of eating disorders. 


The Committee recommends that the Department of Human Services 

works together with the Department of Health and Ageing to establish 

a trial of the Karolinska Institute method for eating disorders in Victoria. 

Conclusion 

4.44 Although the treatment guidelines for eating disorders are 

generally accepted, their practical implementation is made difficult by 

the necessity for complex case management and the need for a variety 

of treatment settings. The Committee has received evidence from a 

number of organisations who provide high quality case managed care. 

Evidence from consumers has indicated that such care is not always 

easily available, particularly in the case of rural and regional patients. 

Organisations such as the Centre for Excellence in Eating Disorders 

are working to improve the knowledge and capacity of health workers 

to treat eating disorders; others, such as the Butterfly Foundation, the 

Bronte Foundation and the Karolinska Institute, are working to provide 

alternative locations for care.



The Committee recommends the formation of a standing Community 

Reference Group, easily accessible to the general community, with 

representation from health and allied health professionals, service 

providers, consumers and careers, to monitor, inform and make 

recommendations to the government on issues of body image and 

eating disorders. 

103



Endnotes 

1 Ibid, Beumont, P., Hay, P., and Beumont, R. 2003. Summary: Australian and New Zealand 

clinical practice guidlines for the management of anorexia nervosa. Australian Psychiatry. 

11(2): 129-133, Ebeling, H., Tapanainen, P., Joutsenoja, A., Koskinen, M., Morin-Papunen, L., 

Järvi, L., Hassinen, R., Keski-Rahkonen, A., Rissanen, A., and Wahlbeck, K. 2003. A practice 

guideline for treatment of eating disorders in children and adolescents. Annals of Medicine. 35: 

488-501, Hay, P. 1998. Eating disorders: anorexia nervosa, bulimia nervosa and related 

syndromes - an overview of assessment and management. Australian Prescriber. 21(4): 100- 

03, National Collaborating Centre for Mental Health. (2004). Eating Disorders: Core 


related eating disorders. London: National Institute for Clinical Excellence, The Royal 

Australian and New Zealand College of Psychiatrists. (2003). Anorexia Nervosa: Treatment 

Guide for Consumers and Carers: RANZCP. 

2 Beumont, P., Hay, P., and Beumont, R. 2003. Summary: Australian and New Zealand clinical 

practice guidlines for the management of anorexia nervosa. Australian Psychiatry. 11(2): 129- 

133., p. 130. 


with Eating Disorders. Arlington, VA: American Psychiatric Association., pp 6-7. 

4 The Royal Australian and New Zealand College of Psychiatrists. (2003). Anorexia Nervosa: 

Treatment Guide for Consumers and Carers: RANZCP., p 7. 

5 Royal Australian and New Zealand College of Psychiatrists Clincial Practice Guidelines 

Team for Anorexia Nervosa. (2004). Australian and New Zealand clinical practice guidelines 

for the treatment of anorexia nervosa: RANZCP., p 664. 



7 Ibid, National Collaborating Centre for Mental Health. (2004). Eating Disorders: Core 


related eating disorders. London: National Institute for Clinical Excellence. The RANZCP have 

not published clinical practice guidelines for bulimia nervosa. 

8 National Collaborating Centre for Mental Health. (2004). Eating Disorders: Core interventions 

in the treatment and management of anorexia nervosa, bulimia nervosa and related eating 

disorders. London: National Institute for Clinical Excellence., p 16. 











104


13 Ebeling, H., Tapanainen, P., Joutsenoja, A., Koskinen, M., Morin-Papunen, L., Järvi, L., 

Hassinen, R., Keski-Rahkonen, A., Rissanen, A., and Wahlbeck, K. 2003. A practice guideline 

for treatment of eating disorders in children and adolescents. Annals of Medicine. 35: 488- 

501., p 35. 










related eating disorders. London: National Institute for Clinical Excellence., pp 20-21. 


with Eating Disorders. Arlington, VA: American Psychiatric Association, National Collaborating 

Centre for Mental Health. (2004). Eating Disorders: Core interventions in the treatment and 

management of anorexia nervosa, bulimia nervosa and related eating disorders. London: 

National Institute for Clinical Excellence. 

19 Department of Human Services. (2005). Flow Chart of Victorian Mental Health System. Vol. 

http://www.health.vic.gov.au/mentalhealth/services/mhsystem.pdf. Melbourne: State 

Government of Victoria. 

20 Andrews, F., Adams, R., Maskell, M., and Makell, R. (2004). Public Hearing: 4 August 2004. 

Melbourne: Family & Community Development Committee, Parliament of Victoria., p. 3-4. 

21 Ibid, Cornett, M. (2004). Public Hearing: 28 July 2004. Melbourne: Family & Community 

Development Committee, Parliament of Victoria, Elford, K., Freeman, R., and Coleman, J. 

(2004). Public Hearing: 8 September 2004. Melbourne: Family & Community Development 

Committee, Parliament of Victoria, Kuman, D. (2004). Public Hearing: 8 September 2004. 

Melbourne: Family & Community Development Committee, Parliament of Victoria, Munt, J. 

(2004). Public Hearing: 9 September 2004. Melbourne: Family & Community Development 

Committee, Parliament of Victoria, Vickery, C. (2004). Public Hearing: 8 September 2004. 

Melbourne: Family & Community Development Committee, Parliament of Victoria. 

22 Kuman, D. (2004). Public Hearing: 8 September 2004. Melbourne: Family & Community 

Development Committee, Parliament of Victoria., p. 2. 

23 Ibid, Munt, J. (2004). Public Hearing: 9 September 2004. Melbourne: Family & Community 

Development Committee, Parliament of Victoria, Sawyer, S., Weigall, S., and Jones, S. 

(2004). Public Hearing: 9 August 2004. Melbourne: Family & Community Development 

Committee, Parliament of Victoria. 

24 Kuman, D. (2004). Public Hearing: 8 September 2004. Melbourne: Family & Community 


25 ORYGEN Youth Health. (2004). Public Hearing: 9 September 2004. Melbourne: Family & 

Community Development Committee, Parliament of Victoria., p. 3. 

26 Barwon Disordered Eating Service. (2004). Public Hearing: 28 July 2004. Melbourne: Family 

& Community Development Committee, Parliament of Victoria., p. 5. 

105



27 Ibid., p. 2. 

28 

Butterfly Foundation, and Southern Health. (2004). Submission to the Family & Community 

Development Committee. Melbourne. 

29 Bronte Foundation. (2004). Public Hearing: 8 September 2004. Melbourne: Family & 

Community Development Committee, Parliament of Victoria., pp. 3-4. 

30 Bergh, C., Eklund, S., Mats, E., Lindberg, G., and Södersten, P. 1996. A new treatment of 

anorexia nervosa (letter to the editor). The Lancet. 348(9027): 611-612, Bergh, C., and 

Södersten, P. 1996. Anorexia nervosa, self-starvation and the reward of stress. Nature 

Medicine. 2: 21-22. 

31 Bergh, C., Brodin, U., Lindberg, G., and Södersten, P. 2002. Randomized controlled trial of 

a treatment for anorexia and bulimia nervosa. Proceedings of the National Academy of 

Sciences of the United States of America. 99(4): 9486-9491., p 71. 

32 Bergh, C., Eklund, S., Mats, E., Lindberg, G., and Södersten, P. 1996. A new treatment of 

anorexia nervosa (letter to the editor). The Lancet. 348(9027): 611-612., p 611. 



Sciences of the United States of America. 99(4): 9486-9491, Bergh, C., Eklund, S., Mats, E., 

Lindberg, G., and Södersten, P. 1996. A new treatment of anorexia nervosa (letter to the 

editor). The Lancet. 348(9027): 611-612, Bergh, C., and Södersten, P. 1996. Anorexia 

nervosa, self-starvation and the reward of stress. Nature Medicine. 2: 21-22. 



Sciences of the United States of America. 99(4): 9486-9491., p 9486. 

35 Bergh, C., Ejderhamn, J., and Södersten, P. 2003. What is the evidence basis for existing 

treatments of eating disorders? Pediatrics. 15(2003): 344-345. 

36 

Schmidt, J. 2003. Mandometer musings. European Eating Disorders Review. 11(1): 1-6., pp. 

3-5. 

37 Karolinska Institute. (2004). Public Hearing: 14 December 2004. Melbourne: Family & 

Community Development Committee, Parliament of Victoria., pp 3-4. 

38 “The Stockholm Solution”, Sunday, reporter Ross Coulthart, broadcast October 31 2004. A 

transcript of the program is available at 

http://sunday.ninemsn.com.au/sunday/cover_stories/transcript_1676.asp. 

39 Ibid. 

106

C HAPTER F IVE – H EALTH 

P ROMOTION S TRATEGIES 

5.1 This chapter reviews the role of health promotion in preventing 

the development of body dissatisfaction in young people and 

ameliorating its effects. It begins by defining health promotion and 

describing its activities. The structure of health promotion in Victoria is 

then briefly described. The next section reviews how health promotion 

works to prevent the development of body dissatisfaction and eating 

disorders and examines Victorian, interstate and overseas programs. 

The last section is concerned with early intervention and how Victorian, 

interstate and overseas programs work to treat emerging health issues 

and prevent the development of more serious mental and physical 

conditions. 

Health promotion 

5.2 Health promotion is concerned with the determinants of health – 

what makes us unhealthy, why we stay healthy and what can be done 

to protect and promote good health. In this context, health is 

understood as 

“…a state of complete physical, mental and social wellbeing and 

not merely the absence of disease or infirmity” 1 

5.3 This idea of health importantly combines physical and mental 

health, as well as acknowledging the importance of social setting in 

shaping overall health. Health promotion therefore focuses on both the 

107



individual and their environment when acting and advocating for good 

health. 

5.4 Health promotion is defined as action and advocacy “to address 

the full range of potentially modifiable determinants of health” 2 . These 

determinants of health may enhance or undermine an individual or 

community’s health status and may be a matter of individual choice 

(such as smoking) or beyond the control of the individual (such as 

gender etc). The Ottawa Charter of Health Promotion (1986) focuses 

on those determinants of health which require societal action. It 

describes five action strategies as a blueprint for health promotion: 

1. Building healthy public policy; 

2. Creating supportive environments; 

3. Strengthen community action; 

4. Develop personal skills; and 

5. Reorient health services. 3 

Australia is a signatory to the Ottawa Charter, and national and state 

health promotion strategies are aligned with its philosophy. 

The spectrum of interventions 

5.5 Successful health promotion activities are based on an 

understanding of the disease or behaviour they seek to prevent. Risk 

and protective factors must be known, the progress of the disease or 

the consequences of the behaviour understood, as must the support or 

ongoing treatment required to prevent or minimise the risk of relapse. 

This knowledge of the progress of disease or health-endangering 

behaviour shapes the health promotion and treatment options 

expressed in the ‘spectrum of interventions’. In Australian practice, the 

spectrum covers primary prevention; early intervention; intervention; 

postvention. 

108

CHAPTER FIVE – HEALTH PROMOTION STRATEGIES 

5.6 Primary prevention is concerned with preventing the 

development of risk factors and reinforcing protective factors. 

Universal primary prevention programs target whole populations and 

carry messages that are generally applicable and healthy for all groups 

of people. For example, a universal primary mental health promotion 

campaign may emphasise resilience, social skills and optimism; a 

universal primary physical health promotion campaign may focus on 

the benefits of healthy eating and moderate exercise. Selective 

primary prevention programs target subgroups of the population that 

have a higher than average risk of developing disease or damaging 

behaviour. 4 In the area of body image and eating disorders there may 

be a variety of subgroups – children and adolescents with low selfesteem, 

prepubescent girls etc. 

5.7 Early intervention focuses on those individuals or groups who 

are developing problems that place them at high risk of developing a 

disease or progressing to damaging behaviour. Early intervention 

involves strategies for the early identification of individuals at risk so 

that they may be directed to appropriate support. The focus of early 

intervention strategies is early identification or diagnosis so that prompt 

treatment may “prevent the further development or reduce the 

intensity, severity and duration of the predisposing problem”. 5 

5.8 Intervention means the provision of support or treatment to 

people suffering acute or chronic problems. Treatment may last for a 

relatively short period of time (particularly when early intervention 

activities have been effective) or it may be long-term (this outcome 

may be expected in chronic sufferers). 

The spectrum of interventions concludes with postvention. These 

programs or activities support the individual in their long-term recovery 

from an episode of care and are intended to reduce the risk of relapse. 

109



It is common for postvention to include other individuals and groups 

affected by the illness or behaviour, such as families, friendship and 

peer groups, as these groups are at higher risk of developing similar 

problems. 

Integrated health promotion in Victoria 

5.9 In Victoria, the Department of Human Services acknowledges 

that effective health promotion requires partnerships across sectors 

and agencies, including non-government organisations and community 

groups. These partnerships are based on health service catchment 

areas so that local knowledge and resources are used. 6 The 

Department of Human Services has published a guide for service 

providers in health promotion to assist in the development and delivery 

of targeted health promotion programs integrated across services (for 

example, health services, community and local government services). 7 

5.10 Primary and secondary schools are locations of much health 

promotion activity. Both the Departments of Education and Human 

Services recognise the benefits of targeted health promotion activities 

across physical and mental health. The Department of Human 

Services provides a resource for planning adolescent health promotion 

activities. 8 The Department also has a school nurse program in primary 

and secondary schools. Currently, there are 75.8 effective full time 

nurses in Victorian primary schools and 100 effective full time nurses 

across 199 secondary colleges. In primary schools, nurses respond to 

referrals from school staff regarding identified health issues. In 

secondary schools, nurses manage health promotion activities and 

provide individual health counselling for students. Ms J Parkinson, the 

student welfare co-ordinator at Wanganui Park Secondary College, 

praised the efforts of their school nurse: 

110


One of the best things that has happened to us is the school 

nurse program. We have a male school nurse, which is 

particularly good. We have him for only three days a week and 

he has made a huge change in health promotion in the 

classroom. 9 

5.11 School nurses may coordinate health promotion programs and 

activities such anti-bullying, safe partying, breakfast clubs, and girlsonly 

internet chat rooms. 10 The purpose of each of these programs is to 

respond to local issues in a relevant and meaningful way. 

5.12 The Department of Education has a Student Wellbeing Unit 

whose role is to support schools in the provision of drug education, 

students with disabilities, student welfare the development of 

community and school partnerships. The School Focused Youth 

Service (SFYS) is a collaboration between the Departments of 

Education and Human Services to support links between primary 

prevention work in schools and early intervention services provided in 

the community sector, in response to the recommendations of the 

Suicide Prevention Taskforce. The SFYS works across the 

government and non-government education sectors. 

5.13 The Framework for Student Support Services in Government 

Schools is provided by the Department of Education to guide schools 

in the selection and implementation of activities to support student 

health and wellbeing. It has a particular focus on bullying, emotional 

wellbeing and resilience through primary prevention and early 

intervention activities. It also provides guidance on intervention and 

postvention. 

The Victorian Health Promotion Foundation (VicHealth) is a State 

government agency and is the peak body for health promotion in 

Victoria. For the period 2003-2006, VicHealth has defined the following 

major programs: 

111



Table 1 VicHealth: Major Programs, 2003-2006 11 

112 

Mental Health & 

Wellbeing 

• Increase the evidence base 

for promoting mental health. 

• Develop the skill base and 

resources of communities, 

organisations and individuals 

to sustain mental health 

promotion activity. 

• Consolidate mental health 

promotion within policies 

across a range of sectors. 

• Increase the broader 

community understanding of 

the importance of obtaining 

and 

health. 

maintaining mental 

Physical activity Healthy eating 

• Contribute to increasing the 

proportion of Victorians 

participating in sufficient 

physical activity for physical 

and mental health 

improvements. 

• Increase the community 

capacity across different 

sectors at state, regional and 

local levels to increase 

opportunities for participation 

in physical activity. 

• Strengthen the evidence 

base for, and contribute to 

the creation of, organisational 

policies and social and 

physical environments that 

facilitate physical activity. 

• Increase the understanding 

of social, environmental and 

cultural factors that influence 

eating patterns. 

• Contribute to reversing the 

trends in obesity in the 

population over the next 10 

years. 

5.14 Its Physical Activity programs include the Out of School Hours 

Sports program (in conjunction with the Australian Sports 

Commission), Partnerships for Health, and the Participation in 

Community Sport and Active Recreation Scheme. The Mental Health 

Promotion Framework 2005-2007 nominates young people as priority 

population group and a focus for health promotion activity and 

research. 12 More details about these programs are provided in the 

following section on primary prevention.

Primary Prevention 


5.15 Primary prevention programs and activities focus on health 

messages that are of benefit to whole population groups. These 

activities are intended to educate people about their health and 

encourage healthy choices about physical activity, nutrition and mental 

health. Primary prevention can occur in a number of settings: at 

schools, in workplaces, community centres, health centres, in general 

practice and through mass communication. 

5.16 Primary prevention activities in the area of body image are 

necessarily broad-ranging, given the complex nature of body 

dissatisfaction. The most important element is nutrition and physical 

activity, and ensuring that population groups are well-informed about 

how to maintain good health through appropriate dietary intake and 

patterns of physical activity. In the case of children and youth, 

evidence demonstrates that this needs to be supplemented by 

programs focusing on self-esteem and resilience, mental health and 

media literacy. In this way, children and young people are not only 

informed about what constitutes healthy eating and activity, they are 

also given the tools to interpret contrary messages and make 

decisions for their own health. 

5.17 Each component of primary prevention in body image and 

dissatisfaction is reviewed in more detail below (nutrition and physical 

activity, self-esteem and resilience, media literacy and mental health). 

Examples of beneficial primary prevention activities in the following 

areas are provided, drawn from Victoria and elsewhere. 

113



Nutrition and physical activity 

5.18 The importance of healthy nutrition and levels of physical 

activity are generally acknowledged. For children and adolescents, a 

healthy diet and physical activity lay the foundation for adult health. 

There are a number of policies and programs which provide a 

framework for the design and delivery of consistent information on 

nutrition and physical activity for good health. National guidelines exist 

for diet and physical activity for children and adolescents; and 

framework policies provide information and strategies for 

implementation of programs by states and territories, community 

groups and schools. 

114 

Commonwealth Policies and Programs 

5.19 The dietary guidelines published by the National Health & 

Medical Research Council form the basis of nutrition advice provided 

by all Australian health departments and agencies. Recently revised 

(2003), the issues covered by the Guidelines are considered ‘key to 

optimal health’. 13 The Guidelines for children and adolescents are 

presented below. 

Dietary Guidelines for Children & Adolescents 14 

Encourage and support breastfeeding 

Children and adolescents need sufficient nutritious foods to grow and develop 

normally 

• Growth should be checked regularly for young children 

• Physical activity is important for all children and adolescents 

Enjoy a wide variety of nutritious foods 

Children and adolescents should be encouraged to: 

• Eat plenty of vegetables, legumes and fruits 

• Eat plenty of cereals (including breads, rice, pasta and noodles), preferably 

wholegrain 

• Include lean meat, fish, poultry and/or alternatives 

• Include milks, yoghurts, cheese and/or alternatives 

– Reduced-fat milks are not suitable for young children under 2 years, because of 

their high energy needs, but reduced-fat varieties should be encouraged for older 

children and adolescents


• Choose water as a drink 

– Alcohol is not recommended for children 

and care should be taken to: 

• Limit saturated fat and moderate total fat intake 

– Low-fat diets are not suitable for infants 

• Choose foods low in salt 

• Consume only moderate amounts of sugars and foods containing added sugars 

Care for your child’s food: prepare and store it safely 

Eat Well Australia, 2000-2010 

5.20 This public health nutrition strategy was developed by the 

Strategic Inter-Governmental Nutrition Alliance which is the nutrition 

arm of the National Public Health Partnership. Eat Well Australia was 

endorsed by Australian Health Minsters, in August 2001. 

5.21 The strategy focuses on 4 key nutrition priority areas: 

• prevention of overweight and obesity; 

• increasing the consumption of vegetables and fruit; 

• promotion of optimal nutrition for women, infants and children; 

and 

• improving nutrition for vulnerable groups. 15 

5.22 Programs and action under the Eat Well Australia strategy are 

intended as cross-sectoral projects involving government 

(Commonwealth and State), industry, health, education, professional 

associations and non-government organisations. 16 

Healthy Weight 2008 

5.23 The National Obesity Taskforce reported to the Australian 

Health Ministers in November 2003. Healthy Weight 2008 - Australia's 

Future - The National Action Agenda for Children and Young People 

and their Families recommended actions across a range of settings 

such as child care, schools, primary care, maternal and infant health 

care, neighbourhoods, workplaces, food supply, family and community 

115



services, media and marketing. In November 2003, the National 

Obesity Taskforce was asked to lead and coordinate the 

implementation of Healthy Weight 2008 and to develop further advice 

on strategies to address obesity in adults and older Australians. 

116 

Building a Healthy, Active Australia 

5.24 This four-year Commonwealth initiative was announced in 2004 

to promote good nutrition and increased levels of physical activity 

among school children. There are three elements to this program 

currently operating. 

Active After-School Communities – to assist in the establishment of 

after school physical activity programmes in schools and approved 

after school hours care services. In Victoria, this program is coordinated 

by VicHealth in conjunction with the Australian Sports 

Commission. 

Healthy School Communities – This fund enables community 

organisations linked with schools (such as parents and citizens 

associations) to initiate activities to promote healthy eating. 

Healthy Eating and Regular Physical Activity – Information for 

Australian Families – This is a communication activity to provide 

families with information about healthy eating and physical activity. The 

first stage, Go for 2 Fruit and 5 Veg, was launched on 28 April 2005. It 

involves television, radio, print and public advertisements. 

National Physical Activity Recommendations 

for Children & Young People 

5.25 The recommendations cover 5-12 year olds and young people 

between the ages of 12 and 18. Physical activity is recommended a 

minimum of 60 minutes a day, though several hours per day may be 

possible (and should be encourage) for young children. The activity


level should be moderate to vigorous and passive time spent in front of 

the television, computer etc should be kept as low as possible, with no 

more than two hours per day. 17 

State policies and programs 

Active for Life and Consumer Stuff! 

5.26 The Victorian Government has a “Healthy and Active Victoria” 

strategy to identify areas for collaborative investment, opportunities for 

building on existing activities and integrated stakeholder engagement. 

This strategy is based on the understanding that action at all 

community levels to realise the benefits of increased physical activity, 

healthy eating and community involvement. Given this, multisectoral/multi-intervention 

approaches, which are responsive to the 

broad physical, social, cultural and economic environments, have been 

adopted. 

5.27 The “Go for Your Life” health promotion campaign is intended to 

provide a clear and encompassing health message to effect longer 

term attitudinal and behavioural change. There are three strands to the 

Go for Your Life campaign: healthy eating (nutrition), active living 

(physical activity for wellbeing) and active communities (community 

involvement and volunteering). While each strand has messages and 

activities targeted at specific population groups (families, youth etc) 

there is a particular emphasis on senior Victorians and those from 

culturally and linguistically diverse communities. 18 

5.28 Recently the Department of Consumer Affairs released a 

complementary initiative called the “Consumer Stuff!” resource. 

Written by home economics teachers for teachers the program aims to 

encourage students to make healthier lifestyle choices while also 

emphasising spending behaviours. 

117



118 

Public Health Nutrition 

5.29 The Department of Human Services (DHS) established the Eat 

Well Victoria Partnership in 2001. Its Terms of Reference are based on 

the national strategic framework, Eat Well Australia. It is a strategic 

advisory group with the following membership: 

• DHS; 

• Dieticians Association of Australia; 

• Nutrition Australia; 

• National Heart Foundation; 

• Diabetes Australia – Victoria; 

• Vic Health; 

• Deakin University; 

• Monash University; and 

• The Cancer Council Victoria 

5.30 DHS also conducts a number of nutrition projects and resources 

that seek to support agencies, services and consumers in making 

healthy food choices. 

5.31 VicHealth conducts the Partnerships for Health Scheme, which 

is a 3-year (2003-2006) partnership with state sporting associations. 

The partnership enables the associations to increase their participation 

rates as either players or officials and/or create a healthy and 

welcoming sporting environment. It is intended that changes to the 

sporting environment will: 

1. help people to feel included and valued; 

2. promote practices which prevent sport related injury; 

3. promote responsible alcohol management; 

4. support smoke-free environments; 

5. promote the provision of healthy eating choices;


6. promote practices which prevent sun burn. 

5.32 Six agencies have been nominated to assist sporting 

associations in making these changes: VicSport, Australian Drug 

Foundation, Sports Medicine Australia – Victorian branch, Cancer 

Council Victoria and the International Diabetes Institute. 

5.33 Fifty-one associations covering 49 sports are involved. 

VicHealth notes the following statistics regarding the program: 

More than half of the sports focus on primary (50%) and 

secondary school aged students (60%). 45% of sports target 18- 

35 and 36-55 year olds. 10% of sports target those over the age 

of 55, whilst 12% of sports are specifically focusing on women. 

80% of sports have elected to run participation programs which 

focus on gaining new participants, whilst 40% are focusing on 

retaining current participants. 6% of sports are trying to reengage 

former participants. 75% of sports are working in 

metropolitan areas, whilst regional (55%) and rural areas (31%) 

receive significant support also. 19 

5.34 VicHealth also manages the Participation in Community Sport 

and Active Recreation Scheme, which is assists local government and 

community groups in delivering programs designed to increase levels 

of participation in sport and active recreation among population groups 

that are currently inactive or may encounter barriers to participation. 

These programs are co-ordinated through VicHealth’s Regional Sports 

Assemblies. 20 

Health promotion in schools 

5.35 The decision to undertake health promotion activities outside of 

the designated curriculum is one taken by individual schools. 

Generally, health promotion activities centre around the themes of 

nutrition and physical activity, and media literacy (this is less common). 

119



Discussion of self-esteem and resilience programs is held over to the 

section on early intervention, given the strongly combined elements of 

primary prevention and early intervention in such programmes. 

5.36 Victorian schools may choose to develop a framework on their 

own initiative or may choose to use implementing frameworks as a 

support. As noted above, schools have access to the Department of 

Education’s Student Wellbeing Unit, school nurse program and the 

School Focussed Youth Service. Schools may also choose to adopt a 

Health Promoting Schools framework, one that has been developed by 

the World Health Organisation in support of the Ottawa Charter on 

Health Promotion. 

5.37 Another framework has been designed by the Centre for 

Adolescent Health at the Royal Children’s Hospital, known as the 

Gatehouse Project. This Project, designed for use and implementation 

in secondary schools, has developed a standardised process of 

intervention which incorporates three elements: a survey of the school 

environment from the students’ perspective; the creation of a schoolbased 

action team as a coordinating structure; and consultation with a 

member of the Gatehouse Project team to manage implementation 

strategies. 21 Using this framework, schools may choose the type and 

extent of health promotion that best suits their needs and intentions. 

5.38 This section reviews the type of, and need for, of health 

promotion activities in schools. 

120 

Nutrition and physical activity 

5.39 Health promotion activities in schools are particularly important 

given that dieting and disordered eating tend to emerge around the 

time of puberty. The Victorian Adolescent Health Cohort Study Report 

found that in a cohort of Year 9 students selected from across Victoria,


3.3% of females and 0.3% of males were classified as having eating 

disorders. The Report noted that during follow-up, extreme dieters 

were 18 times as likely to develop an eating problem than non-dieters, 

and moderate dieters five times more likely. 22 

5.40 A number of Victorian primary and secondary schools have 

adopted different strategies to improve students’ nutrition. Karingal 

Primary School was offered the opportunity to host a 3-day seminar on 

healthy lifestyles by the charity Oz Child. As an incentive for their 

attendance, parents were offered a $50 voucher to a local 

supermarket. The seminar informed parents about the benefits of a 

healthy food and lifestyle on their children’s health and academic 

performance. As a result of the seminar, a Healthy Lifestyles parent 

group was established at the school. The principal, Mr Russell 

Gascoigne, provided the Committee with a detailed description of the 

program: 

We set up a special parents room where the parents are able to 

meet under any aspect they want, be it for full fundraising or this 

Healthy Lifestyles program. It was a place that they could come 

during the day with their children and talk about issues affecting 

them as a normal family group…This was done totally from the 

parents’ point of view — encouraged by the school but we 

wanted the parents to take ownership of this program. 

From that we have had huge changes in the approaches that we 

are having in the school. The parents took a more active role in 

what the children were eating at school. They had input into how 

our classroom set ups were arranged. They learned about the 

value of hydration and continuing hydration for children’s 

learning and also the Healthy Lifestyles programs within their 

own family groups. We were able to set a few school policies, as 

in that we would always have the water available on children’s 

tables so that that could continue right across the board. We 

121



122 

introduced fruit into the grades so that when teachers were 

reading a story, a serial novel, the children were able to eat fruit. 

Some teachers have big platters of fruit set up — almost like a 

kindergarten set up, where you have fruit and milk, that type of 

thing. We want to continue that aspect, along with our teaching. 

We have two 2 hour blocks in the morning dedicated to literacy 

and numeracy. They are lengthy periods of time for the children 

to go without some kind of break and food. We want to 

encourage this healthy program and also help with their ability in 

their learning. 

As part of this group, parents also come in and take cooking 

classes in the grades on a rotation. We have one grade a week 

that has a full meal cooked for that grade. The children take part 

in preparing the fruit and cooking it. It is parents, not teachers, 

out the front, talking about the preparation and their own 

experiences at home with their kids and what they do with kids’ 

hygiene. The whole works is covered by the parents. The kids 

see this as something special. They do not necessarily see it as 

part of their education. You could have teachers out in front of 

the children, talking about the Healthy Lifestyles program — and 

we do as part of the curriculum standards framework, which has 

health components within it — and kids drawing the food 

pyramid over and over again. We all know that children learn by 

doing. To have this going on is just a hands on learning 

experience for the children. 23 

5.41 The Karingal program successfully combines family and school 

settings for the promotion and modelling of healthy food choices. 

5.42 Other schools, such as Collingwood College (P-12), have 

started school gardens, where the children are able to grow vegetables 

and learn to cook healthy meals using fresh ingredients. The choice of 

foods available at a school tuckshop has also been a topic of concern. 

The Department of Education offers guidelines to schools on offering 

healthy choices, Guidelines For School Canteens And Other School


Food Services. 24 The guidelines encourage a whole-of-school 

approach to healthy eating, recommending that a healthy food services 

combines the following elements: 

• makes it easy for students to choose healthy snacks and meals 

• offers a variety of nutritious food and snacks 

• promotes food that is consistent with current best knowledge in 

the provision of nutritious food for students 

• can be an avenue for consistent and continual health education 

• complements the diverse elements of the school curriculum 

• involves students and parents 

• is an integral part of the entire healthy school environment. 

5.43 It recommends that schools carefully consider the items 

available to students in vending machines and that there be limitations 

in the quantity and/or frequency with which the following foods are 

served: 

• deep-fried food (e.g. chips, dim sims, potato cakes) 

• pastry items (e.g. pies, sausage rolls, croissants, vanilla slices) 

• hot dogs and sausages 

• cakes, biscuits and doughnuts 

• confectionery (sweets, lollies, liquorice and chocolate) 

• high sugar soft drinks, sports/electrolyte drinks and caffeine 

drinks. 

5.44 The New South Wales Government has adopted a “Fresh 

Tastes @ School Canteen Strategy”. It is a step beyond nutrition 

guidelines and is a government-endorsed strategy to make it easier for 

school canteens to change their menus to reflect dietary guidelines. 

Foods on a canteen menu are colour coded green, amber or red to 

reflect whether they should dominate the menu (green); be selected 

123



carefully and served in smaller portion (amber); and served only 

occasionally (red – served not more than twice in one term). 25 

5.45 Clifton Springs primary school, on the Bellarine Peninsula, has 

adopted a comprehensive approach to healthy body image, selfesteem 

and learning. The school year begins with a 6-week ‘learning 

to learn’ program which lays the foundation for school’s culture of 

learning. Ms Anne Hollander, the principal, explained that 

124 

We work with the girls and boys on learning together, so 

cooperative group work, team work, values, rights and 

responsibilities, and we work with community connectedness. 

We also work with the girls and boys on optimum learning 

conditions. 26 

5.46 The whole school participates in a 20-minute fitness program 

each morning. A key part of the program is brain food and brain gym. 

The children have available to them fresh fruit, dried fruit or unsalted 

nuts (provided by parents) and water in the classroom, and they are 

encouraged to ‘graze’ throughout the school day. The children also do 

gentle exercises during the day as part of ‘brain gym’. These exercises 

are designed to stimulate the brain and improve concentration. The 

effect that this program has on the children is best described by the 

children themselves: 

Stephanie Harper – Brain food and water help me concentrate. I 

have noticed a big change since I started. We only started 

it…last year, and I have really noticed a difference…Each person 

at our school received a drink bottle, and each time new preps 

come we get sent more. Our teachers encourage us to bring our 

water bottles and our brain food. Even our teachers are 

participating in these routines. It has also helped a lot of the 

naughty kids to settle down so they have become better in their 

work and they are concentrating more.


Hayden O’Keefe – Brain gym is exercise to help switch on the 

brain. It helps me learn better. Brain gym relaxes your brain and 

body. At the same time it stops you from getting confused or 

wriggling in your seat…Brain music is a calm relaxing music. 

Some slow, dreamy music can help with thinking up ideas for 

creative work…Music that has 60 beats per minute is perfect for 

reading quietly and finding information. We have brain music in 

our classrooms. 27 

The following comment was provided by a parent: 

Karen Saw – I am a parent of an eight-year-old, grade 3 child at 

Clifton Springs. I would just like to pass on some positive 

feedback on what we have found with our daughter, in particular, 

the idea of allowing the child to graze on healthy and nutritious 

snacks throughout their day, which includes fruit, rice crackers 

and nuts, and the presence of personal water bottles on their 

desks help to both encourage their eating habits and assist the 

children in their daily intake of water. Both of these initiatives in 

the case of my daughter help to maintain the level of 

concentration required to work consistently throughout the day. 

As a consequence, when she does come home she look for a 

healthy snack first and sees processed foods as just a treat for a 

one-off occasion. It has also given her the opportunity to try 

different foods…My daughter said to me when I asked her what 

she thought about it, that she concentrated on class all day now 

instead of thinking, “When is lunch? I’m hungry”. 28 

5.47 It has been argued that the most important element in the 

primary prevention or early intervention programs for self-esteem and 

bullying is a whole-of-school approach, where teachers are convinced 

of the need for change and committed to bringing that change about. 29 

Clifton Springs Primary School is an excellent case in point and is the 

most comprehensive program brought to the attention of the 

Committee. 

125



5.48 The Committee fully supports the type of whole-of-school 

programs implemented by the Karingal and Clifton Springs primary 

schools. These programs focus on positive behaviour change in the 

areas of eating and physical activity without the use of negative food 

messages. Importantly, these programs have the active involvement of 

the children and the support of their parents. 

126 

Finding #4 

That whole-of-school programs that teach and promote physical 

wellness and self-esteem in primary students result in improvements in 

student wellbeing and learning. 


That the Department of Education, with the Department of Human 

Services and in partnership with schools, undertake a program of 

evaluation, monitoring and implementation of whole-of-school health 

promotion in primary schools. 

The Committee notes the success of programs such as those 

implemented at Clifton Springs Primary School and Karingal Primary 

School. It also notes the success of health promotion programs such 

as the Gatehouse Project in secondary schools in building resilience 

and self esteem. It therefore recommends particular programs that 

target the following areas be the focus of evaluation and 

implementation: 

• whole-of-school health promotion; 

• healthy eating; 

• physical activity; and 

• resilience and self-esteem.


5.49 Patterns of food consumption have changed in recent years. 

The increased availability of processed foods, their lowered cost, and 

time constraints for many families has seen consumption of these 

foods increase at the cost of fresh fruit and vegetables. Although 

schools cannot take full responsibility for remedying this situation, they 

are an excellent location for programs that encourage healthy eating 

choices, whether in the school canteen, during classes or in before 

and after school care programs. 

5.50 Primary responsibility for the nutrition of children and 

adolescents lies with their parents: for this reason, it has been 

suggested to the Committee that parenting classes need to address 

healthy eating, body shape and exercise. 30 This also highlights the 

need for health promotion across school, community and family 

settings so that all those involved in child and adolescent nutrition 

receive consistent messages. 


That Eating Disorder Awareness Week be part of a broader program of 

health promotion in body image. 

Media literacy 

5.51 Media literacy is a tool that enables children and adolescents to 

decode the messages they receive from the media; to understand the 

source of these messages and how these messages are constructed 

to persuade. These skills are increasingly important as studies 

demonstrate the effect the media may have on young people’s selfperception 

and body acceptance. 

127



5.52 The impact of the media on children and adolescents has been 

the subject of ongoing debate. Studies suggest that long-term 

exposure to the thing body ideal has a cumulative effect on body 

dissatisfaction and drive for thinness. 31 The impact on adolescents 

does not vary significantly across cultures, indicating the strong 

influence of the media. 32 Not all adolescents, female or male, are 

affected equally; internalisation of, and self-comparison with, the thin 

body ideal will particularly affect certain vulnerable groups. 33 In her 

summary of the literature on the relationship between body image and 

the mass media, Sarah Durkin argued that 

The evidence is unclear whether media exposure causes body 

dissatisfaction in all women. However, there is compelling 

evidence to suggest that exposure to idealised pictures of 

slender women is more likely to harm the body satisfaction of 

certain groups of females and those who have certain individual 

vulnerabilities [low self-esteem, identity confusion and high 

comparison tendency]. 34 

5.53 An understanding of the age at which exposure to the thin body 

ideal begins to shape perceptions of self and others, and awareness of 

dieting is crucial to the formation of appropriate media literacy 

materials. A recent Australian study has indicated that dieting 

awareness may occur as early as five years of age. 35 

5.54 To date, there has been less research on the impact of 

idealised body image on young men. Studies that have been 

conducted indicate an increasing sensitivity to a physical ideal though 

the effect is not as pronounced as it is on females. 36 Although thinness 

is promoted as a media ideal for young men, the most common ideal 

and prompt for body dissatisfaction is the muscular ideal. 37 

5.55 McCabe, Ricciardelli and Ridge have studied the messages 

received by adolescent girls and boys from a variety of sources (self, 

128


parents, siblings, peers, media) and how these messages were 

interpreted. This type of study is necessary in order to construct the 

most effective programs for the prevention and amelioration of body 

dissatisfaction, as argued by the authors: 

Overall, the boys and girls in this study seemed to use the 

messages that they received about their bodies to develop a 

relatively positive body image. This was particularly the case for 

boys. A large proportion of both boys and girls engaged in social 

comparisons, but this frequently seemed to assist them to 

confirm the positive view they had of their body. Even if they 

perceived that their body did no conform to the media ideal, or 

was not as good as that of their friends, many appeared to 

accept this difference, and not regret the body that they had. The 

level of resiliency among boys and girls picked up in this study is 

encouraging and has not been highlighted in past studies. The 

findings also provide insights into how future body image 

programs could be shaped. Programs need to build on 

adolescents’ current awareness of media messages and provide 

skills to assist young people interpret feedback from others and 

the media in a more positive light. Additional work needs to focus 

on teaching young girls cognitive behavioural strategies that 

place less importance on social comparisons. 38 

This also suggests a link between media literacy activities and 

programs that develop resilience and promote positive self-esteem. 

5.56 The impact of the media is not restricted to promotion and 

dissemination of the thin-body or muscular ideal. The correlation 

between levels of television viewing and obesity is not a simple causal 

relationship between viewing and physical activity. The relationship 

exists between high exposure to advertisements for junk/fast food and 

obesity. Children who are regularly exposed to these advertisements 

consume higher quantities of foods high in fat and sugar and this 

contributes to obesity. 

129 

39 The Royal Australasian College of Physicians’



policy document supports regulation of food advertising during 

designated children’s viewing times. 40 

5.57 Although the evidence considered by the Committee suggests 

that health promotion activities targeting media literacy would be 

beneficial for children and adolescents, examples of such activities 

have not been readily available. The Committee considers media 

literacy to be only one aspect of the issue of the media’s role in body 

image perceptions. It makes the following recommendation in 

recognition of the media’s societal influence. 

130 


That the Department of Education consider the development and 

promotion of programs that develop skills in media literacy within the 

current English curriculum for primary and secondary school students. 

Early Intervention 

5.58 Early intervention often works in tandem with primary 

prevention. It seeks to identify vulnerable groups or individuals who 

have begun to display early symptoms (such as frequent dieting, 

depressed mood, dramatically increased physical exercise) and offer 

remedial treatment. Since health promotion activities in schools tend to 

be large scale projects, they often combine both primary prevention 

and early intervention strategies. This is particularly so with mental 

health and resilience health promotion. This section briefly discusses 

mental health promotion and resources available to schools for early 

intervention in the area of eating disorders.

Self-esteem, resilience and mental health 


5.59 The importance of self-esteem and resilience in developing and 

maintaining positive body image should not be understated. It is a part 

of positive self-perception that accepts one’s body for its abilities and 

difference, and is able to minimise the impact of unhealthy messages. 41 

The most common strategies implemented in schools are the 

MindMatters program and BullyBusters. 

5.60 MindMatters is conducted across all school sectors, is managed 

by the Australian Principals’ Association Professional Development 

Council and the Curriculum Corporation. It is funded by the 

Commonwealth Government. MindMatters may be taken as 

professional development for teachers or as a whole-of-school 

approach. In Victoria, MindMatters reports the following usage 

statistics: 

Government secondary settings There is a total of 476 

Government secondary settings in Victoria. Of these 376 (79%) 

accessed MindMatters training. Of the 100 not trained 62 are 

from special schools and 11 are from alternative settings. 

Catholic secondary settings There is a total of 124 in Victoria. Of 

these 101 (81%) accessed MindMatters training, and 23 are not 

trained. 

Independent secondary settings Of the total of 181 (65%), 119 

accessed MindMatters training, leaving 62 not trained. 

Of the 597 school settings in Victoria that have accessed training 

only 60 (10%) have had a whole school staff in-school training 

session (8% of total schools), 352 (59%) school settings have 

been involved in sending school representatives to 2-day 

MindMatters training (45% of total schools), 427 (71%) school 

settings have sent representatives to 1-day MindMatters training 

131



(54% of total schools) and 513 (85%) have been represented at 

introductory or other type of training sessions. 42 

5.61 Some of the resources and training offered by MindMatters are: 

SchoolMatters: Mapping and Managing Mental Health in Schools 

provides schools with planning tools and a framework to assist them 

adopting a whole school approach to mental health promotion; 

CommunityMatters: Working with diversity for well-being shifts the 

focus from mental health to a more holistic social and emotional wellbeing, 

exploring the interrelationship between community, culture, 

identity and resilience; 

Enhancing Resilience 1: Communication, Changes and Challenges is 

designed to enhance resilience via the promotion of communication, 

participation, positive self-regard, teamwork and a sense of belonging 

and connectedness to the school (junior years of secondary school); 

Enhancing Resilience 2: Stress and Coping deals with creating a 

positive school culture. It addresses issues of coping with stress and 

challenge, help-seeking, peer support, stress management, and goal 

setting (middle to senior years of secondary school); and 

A Whole School Approach to Dealing with Bullying and Harassment 

provides a basis from which to deal with bullying and harassment, 

including a checklist to guide policy and practice as well as curriculum 

units suitable for junior secondary students. 43 

5.62 BullyBusters is a commercial program that offers schools 

teacher in-service training, workshops with children, and parent 

information sessions. Where MindMatters work with secondary 

students, BullyBusters deals predominantly with primary schools and 

the junior years of secondary school. 

5.63 The Department of Education offers a comprehensive resource 

for addressing bullying within schools, covering the spectrum of 

132


interventions. 44 This resource is placed within the Department’s 

Framework for Student Support Services. Schools may also develop 

their own programs to suit the needs of their students and community. 

The Association of Independent Schools Victoria has allocated 

‘resiliency funding’ to its schools, and projects must focus on primary 

prevention. Its report on the programs funded through this allocation 

demonstrate a variety of strategies, ranging from ‘health festivals’, to 

development of inter-personal skills, to parent information on 

adolescent health issues. 45 

Body dissatisfaction and Eating Disorders 

5.64 The Centre for Excellence in Eating Disorders, in conjunction 

with the Eating Disorders Foundation of Victoria, has developed a 

comprehensive eating disorders resource for secondary schools. The 

aim of the project was to develop an eating disorders resource that 

• assisted teachers, coaches and other members of the school 

community in the prevention and intervention of eating disorders; 

• provides accurate information to respond to immediate situations; 

and 

• encourages school communities to develop a whole school 

approach to the prevention of eating disorders, by focusing on 

building resilience in students and reducing risk factors within the 

school community. 

5.65 The resource was developed in consultation with school staff 

from all education sectors, with students and parents of students 

experiencing an eating disorder and with those working in the field of 

prevention/early intervention in eating disorders. The resources tackles 

myths about eating disorders, discusses how to create a positive 

school environment, and the characteristics of successful eating 

133



disorder prevention programs. It offers strategies and information for 

teachers when approaching a student for whom they have concern, 

managing a student diagnosed with an eating disorders, and the 

restoration to wellbeing of students. 

Conclusion 

5.66 This chapter has reviewed a number of policies, programs and 

activities that seek to improve the overall health of children and 

adolescents. Each activity promotes healthy choices and 

acknowledges that changes must occur in multiple settings – family, 

school, community – in order to sustain long-term changes. The most 

well-developed aspect of public health promotion is in the area of 

nutrition and physical activity. Self-esteem and mental health also 

receive a great deal of attention, particularly in secondary schools. 

However, one area that attracts criticism from health professionals and 

from adolescents – the media – apparently receives very little 

attention. 

134

Endnotes 


1 World Health Organisation. (2001). Basic documents. Geneva: World Health Organisation. 

2 

World Health Organisation. (1998). Health promotion glossary. Geneva: World Health 

Organisation. 

3 

World Health Organisation. (1986). The Ottawa Charter for Health Promotion. Geneva: World 

Health Organisation. 

4 

Silburn, S. 1999. Frameworks for conceptualising youth suicide prevention. Youth Suicide 

Prevention Bulletin. 2: 21-24., 24. 

5 Ibid., 24. 

6 Primary & Community Health Branch, Department of Human Services. Source: 

http://www.health.vic.gov.au/healthpromotion/what is/index.htm, viewed April 2005. 

7 Primary & Community Health Branch. (2003). Integrated Health Promotion: a practice guide 

for service providers. Melbourne: Department of Humans Services Victoria., pp 1-6. 

8 Department of Human Services. (2000). Evidence-based Health Promotion: resources for 

planning - No. 2 Adolescent Health. Melbourne: DHS. 

9 Klitzing, D. (2004). Public Hearing: 4 August 2004. Melbourne: Family & Community 


10 Source of information: http://www.health.vic.gov.au/schoolnursing/ Viewed May 2005. 

11 

VicHealth. (2003). Strategic Directions, 2003-2006: Victorian Health Promotion Foundation. 

Melbourne: VicHealth., p. 9. 

12 VicHealth. (2005). A Plan for Action 2005-2007: Promoting Mental Health and Wellbeing. 

Melbourne: Victorian Health Promotion Foundation., p. 26. 

13 National Health & Medical Research Council. (2003). Dietary Guidelines for Australian 

Adults. Canberra: National Health & Medical Research Council, National Health & Medical 

Research Council. (2003). Dietary Guidelines for Children and Adolescents in Australia 

incorporating the Infant Feeding Guidelines for Health Workers. Canberra: National Health & 

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14 National Health & Medical Research Council. (2003). Dietary Guidelines for Children and 

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Canberra: National Health & Medical Research Council., xvii. 

15 http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-food- 

nphp.htm Viewed March 2005 

16 National Public Health Partnership. (2001). Eat Well Australia: a strategic framework for 

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17 Department of Health & Ageing. (2004). Healthy and Active School Communities: a 

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18 

Go For Your Life. (2004). What 'Go for your life' is all about. Melbourne: Government of 

Victoria. 

19 Information obtained from VicHealth at 

http://www.vichealth.vic.gov.au/default.asp?tid=479&level=1 Viewed May 2005. 

135



20 

VicHealth. (2003). PICSAR: A quick guide to the Community Sport and Active Recreation 

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21 Patton, G., Butler, H., and Glover, S. 2003. Changing schools, changing health? Design and 

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23 Gascoigne, R. (2004). Public Hearing: 9 September 2004. Melbourne: Family & Community 

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24 Department of Education, Executive Memorandum 2003/017. 

25 NSW Department of Health & Ageing, and NSW Department of Education. (2004). Canteen 

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26 Clifton Springs Primary School. (2004). Public Hearing: 21 March 2004. Melbourne: Family 

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27 Ibid., p 10. 

28 Ibid., p 11. 

29 

Piran, N. 2004. Teachers: on 'being' (rather than 'doing') prevention. Eating Disorders. 12: 1- 

9. 

30 Lehman, K. (2004). Public Hearing: 4 August 2004. Melbourne: Family & Community 


31 Champion, H., and Furnham, A. 1999. The Effect of the Media on Body Satisfaction in 

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Tiggemann, M. 2003. Longer-Term Implications of Responsiveness to 'Thin-Ideal' Television: 

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32 Becker, A.E., Burwell, R.A., Gilman, S.E., Herzog, D.G., and Hamburg, P. 2002. Eating 

behaviours and attitudes following prolonged exposure to television among ethnic Fijian 

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2001. A cross-cultural comparison of body dissatisfaction in Estonian and Australian young 

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736-742. 

33 Posavac, S.S., and Posavac, H.D. 2002. Predictors of women's concerns with body weight: 

the roles of perceived self-media ideal discrepancies and self-esteem. Eating Disorders. 10: 

153-160. 

34 Durkin, S. (1999). Relationship between females' body image and the mass media, 

Research Summaries. Body Image & Health Inc: Melbourne., pp 3-4. 

35 Dohnt, H., and Tiggemann, M. 2005. Peer influences on body dissatisfaction and dieting 

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36 McCabe, M.P., Ricciardelli, L.A., and Ridge, D. 2004. "Who thinks I need a perfect body?" 

Perception and internal dialogue among adolescents about their body., p. 4-5. 

37 Durkin, S. (1999). Relationship between females' body image and the mass media, 

Research Summaries. Body Image & Health Inc: Melbourne., p. 4. 

136


38 McCabe, M.P., Ricciardelli, L.A., and Ridge, D. 2004. "Who thinks I need a perfect body?" 

Perception and internal dialogue among adolescents about their body., p. 23. 

39 Carter, O. (2004). The weighty issue of childhood obesity and television food advertising in 

Australia, CBRCC Report. Vol. 040406. Curtin University: Perth. 

40 

Royal Australasian College of Physicians. (2004). Children and the media: advocating for 

the future. Melbourne: RAGP. 

41 McGee, R., and Williams, S. 2000. Does low self-esteem predict health compromising 

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42 http://cms.curriculum.edu.au/mindmatters/vic/vic.htm, viewed May 2005. 

43 http://cms.curriculum.edu.au/mindmatters/about/about.htm, viewed May 2005. 

44 http://www.eduweb.vic.gov.au/bullying/index.htm, viewed May 2005. 

45 

Association of Independent Schools Victoria. (2004). Report of AISV Resiliency Programs. 

Melbourne: AISV. 

137



138

SUBMISSIONS 

Submission 

No 

Organisation Position Name 

01 Private Citizen Ms Emma J Lions 

02 Private Citizen Mr Rubi Johnson 

03 Western 

Young 

People's 

Independent 

Network 

04 Master of 

Applied 

Psychology 

(candidates) 

Youth 

Coordinator 

School of 

Psychology, 

Victoria 

University 

Kavitha Chandra- 

Shekeran 

E.Lee/C.McKersie 

/H.Radermacher/ 

C.Wallace/T.Whit 

e 

05 Private Citizen Miss Connie 

Boglis 

06 Austin Health, 

Child & 

Adolescent 

Mental Health 

Service 

07 National 

Council of 

Women 


08 Family 

Planning 

Victoria Inc 

Associate 

Nurse Unit 

Manager 

Ms Kristy Young 

Youth Advisor Ms Gabrielle 

Buzatu 

Chief 

Executive 

Officer 

09 readMylips Project Coordinator 

Ms Lynne Jordan 

Ms Georgia Van 

Cuylenburg 

139



140 

Submission 

No 

10 Private 

Citizens 


11 VicHealth Acting Chief 

Executive 

Officer 

12 Dance 

Movement 

Therapist 

13 Association of 

Independent 

Schools of 


14 Eating 

Disorders 

Foundation of 


15 Victorian 

YMCA 

16 Women's 

Health Victoria 

Chief 

Executive 

Manager, 

Access and 

Participation 

Policy & 

Research 

Officer 

Mr Bernie D'Arcy 

& Mrs Pat D'Arcy 

Ms Barbera Mouy 

Ms Natalie Will 

Ms Michelle 

Green 

Ms Shona Eland 

Ms Kerrilie Rice 

17 Ms Gladys E. 

Miller 

18 NEEDS Jacinta Agostinelli 

19 Inner City 

Regional Youth 

Affairs Network 

(ICRYAN) 

Convenor Mr Jack 

Melbourne

Submission 

No 


20 Private Citizen Ms Julie Viney 

21 CASA House - 

Centre Against 

Sexual Assault 

22 Western 

District Health 

Service 

Acting 

Manager 

Community 

Dietician 

SUBMISSIONS 

Ms Maggie Innes 

Ms Bianca 

Gazzola 

23 Private Citizen Social Worker Ms Sabine 

Beecher 

24 Loddon 

Campaspe 

Regional Youth 

Affairs Network 

(LC RYAN) 

25 Swan Hill 

District 

Hospital 

26 Disordered 

Eating Service, 

c/o GP 

Association of 

Geelong 

27 South West 

Community 

Health 

Convenor Mr Gavan 

Thomson 

Head of 

Dietetics & 

Health 

Promotion 

Coordinator & 

Dietitian 

Womens 

Health 

Resource 

Worker 

Ms Gayle Taylor 

Ms Marion Cornett 

APD 

Ms Rochelle 

Campbell 

28 Private Citizen Ms Darlene 

Cuman 

141



142 

Submission 

No 


29 Northwestern 

Mental Health, 

Eating 

Disorders 

Program 

30 Toorak College Head of 

Health & PE 

Director Dr Sue Weigall 

Ms Lee-Anne 

Marsh 

31 Private Citizen Ms Kathleen 

Mitakakis 

32 The Butterfly 

Foundation 

33 Southern 

Health & The 

Butterfly 

Foundation 

Founder/CEO Ms Claire Vickory 

CAMHS 

Director 

Dr Paul Lee 

34 Nip & Tuck Off Spokesperson Ms Christine Craik 

35 The Oak 

House 

36 Centre for 

Multicultural 

Youth Issues 

37 School of 

Psychological 

Science 

38 Australian 

Drug 

Foundation 

Dietitian & 

Director 

Ms Belinda Dalton 

Director Ms Carmel Guerra 

Professor & 

Director of 

Postgraduate 

Programs 

Youth 

Resource 

Worker 

Professor Susan 

J. Paxton 

Ms Daria Healy- 

Aarons

Submission 

No 

39 ORYGEN 

Research 

Center 

40 Victorian 

Centre of 

Excellence in 

Eating 

Disorders 

41 Eating 

Disorders 

Foundation of 

Victoria Inc. 


Advocate & 

Policy Analyst 

Mr Matthew 

Hamilton 

Director Ms Stephanie 

Jones 

Executive 

Officer 

SUBMISSIONS 

Ms Karen Elford 

42 Private Citizen Dr Rick Kausman 

43 Banyule City 

Council 

44 Greater 

Dandenong 

Community 

Health Service 

Youth Program 

45 Goulburn 

Valley Area 

Mental Health 

Service 

46 Oz Child- 

Children 

Australia 

Director, 

Community 

Programs 

Youth Health 

Worker 

Manager, 

West Hume 

PMH&EI 

Team 

School 

Focused 

Youth Service 

Coordinator 

Sauro Antonelli 

Ms Julie Thomson 

Ms Freida 

Andrews 

Ms Jenny O'Neill 

143



144 

Submission 

No 


47 Private Citizen Ms Sofie Gregory 

48 Body Image & 

Health Inc. 

49 The Royal 

Women's 

Hospital, 

Melbourne 

50 Warrnambool 

Neighbourhood 

& Community 

Centre 

51 Eating 

Disorders 

Professional 

Network 

52 Ministerial 

Body Image 

Reference 

Group 

53 Dr Murray 

Drummond & 

Professor 

Precilla Choi 

54 Ms Stacey 

Kennedy 

Chair Dr Rick Kausman 

Chief 

Executive 

Officer 

Eating 

Disorders 

Coordinator- 

Grampians 

Region 

Minister for 

Educational 

Services and 

Youth Affairs 

University of 

South 

Australia & 


University 

Correspondence 

and 

Briefing 

Manager 

Mr Dale Fisher 

Ms Simone 

Favelle 

Ms Toula Filiadis 

Hon. Jacinta 

Allen, MLA 

Office of the 

Minister for Health 

Department of 

Human Services

WITNESSES 

Geelong 28th July 2004 

Dr Chris Gore 

Clockwork Young People’s Health Service 

Marion Cornett 

Disordered Eating Service – Barwon Region 

Colin Bell, Senior Research Fellow 

School of Exercise & Nutrition Sciences, Deakin University 

Emma Jayne Lions 

Think Healthy, Be Healthy Body Image Workshop Presenter 

Marian Manainveldt 

Barwon Youth Taskforce 

Shepparton 4th August 2004 

Peter Bourke & Susan Nabbs 

Valley Sport 

Kelly Lehman 

Team Manager: Primary Health & Families, Goulburn Valley 

Community Health Service 

Freida Andrews 

Manager-West Hume Primary Mental Health & Early 

Intervention Team 

Dr Rachel Adams 

General Practitioner, Princess Park Clinic, Shepparton 

Mrs Shelly Maskell & Kelly Maskell 

Private Citizens 

Jan Parkinson 

Welfare Co-ordinator – Wanganui Park Secondary College 

145



146 

Jenny Klitzing 

Private Citizen 

Melbourne 8th September 2004 

Professor Susan Paxton 

School of Psychological Science, La Trobe University 

Fiona Lange 

Absolutely Women’s Health 

Karen Elford, Executive Officer 

Rosalie Freeman, President 

Jacinta Coleman, Board Member & Paediatrician 

Michelle Roberton, Board Member & Dietitian 

Eating Disorders Foundation of Victoria 

Claire Vickery 

Executive Director, Butterfly Foundation 

Louise Wigg 

Senior Partner, Corporeal Workplace Wellbeing 

Meg Gulbin 

Manager Absolutely Women's Health 

Associate Professor Susan Sawyer 

Acting Director, Centre for Adolescent Health 

Ian Kett, Executive Director 

Rachel Whiffen, Health Promotion Officer 

VicFit 

Darlene Kuman 


Professor Marita McCabe 

School of Psychology, Deakin University 

Jan Cullis 

Executive Director, Bronte Foundation

Melbourne 9th September 2004 

Gabriele Buzatu 

Psychologist 

WITNESSES 

Dianna Cordingley, Teacher 

Ms. Sabrina Basic, Yr 9 student in Girls Leadership program 

Ms. Anita Budai, Yr 9 student in Girls Leadership program 

Ms. Hamida Zekiroski, Yr. 9 student in Girls Leadership 

program 

Carwatha Prep-Yr 12 College 

Dr Claudia Mulder 

Senior Clinician, ORYGEN Youth Health 

Kim Johnson 

Positive Eating Victoria 

Jacqui Law 


Janice Munt 

Member of Parliament 

Russell Gascoigne 

Principal, Karingal Primary School 

Ass Prof Michael Carr-Gregg 

Adolescent Psychologist 

Melbourne, 14th December 2004 

Dr Cecilia Bergh 

Director of the Mandometer Clinic – Karolinska Institute, 

Stockholm 

Professor Per Sodersten 

Section of Applied Neuroendocrinology – Karolinska Institute, 

Stockholm 

Mrs Margaret Jane Payne, Parent 

147



Melbourne 21st March 2005 

148 

Mia Freedman 

Group Editor in Chief, Cosmopolitan, Cleo and Dolly 

Anne Hollander, Principal 

Ms J. Graham, Assistant Principal 

Ms Karen Saw; 

Mr Hayden O’Keefe; and 

Ms Stephanie Harper 

Clifton Springs Primary School. 

Johanna de Wever, Marketing/Somazone Manager 

Daria Healy-Aarons, Youth Resource Worker 

Australian Drug Foundation 

Mr Jehrom Clift, President 

Fitness Victoria 

Hayley Dohnt, Clinical PhD student 

School of Psychology, Flinders University 

Melbourne 11th April 2005 

Dr Rob Moodie, Chief Executive Officer 

Ms J. A. Potter, Senior Project Officer 

VicHealth

Body Image Report - Parliament of Victoria

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