Eating disorder





Summarize the articla below 150 or more words


ISSN: 0963-8237 (print), 1360-0567 (electronic)


J Ment Health, 2014; 23(2): 51–54


! 2014 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2014.889286




Eating disorders ‘‘mental health literacy’’: an introduction


Jonathan M. Mond 1,2


1 Department of Psychology, Macquarie University, Sydney, Australia and 2 Research School of Psychology, The Australian National University,


Canberra, Australia




No doubt there are many things that readers of this journal


would not agree upon. What constitutes ‘‘evidence-based


treatment’’, how best to revise classification schemes, and the


priority given to prevention, early intervention and treatment


approaches to mental health improvement, are some examples.


One thing that I hope all readers can agree upon,


however, is that community knowledge and understanding


of mental health problems is not as good as it should be.


Community knowledge and understanding of eatingdisordered


behavior may be particularly poor. Reasons for


this likely include the fact that certain eating disorders, such


as binge eating disorder, are relatively new to the psychiatric


nomenclature and the fact that certain eating disorder


behaviors, such as extreme dietary restriction and excessive


exercise, have strongly ego-syntonic properties . The goal of


this contribution is to introduce readers to a field of research


that I believe has promise in redressing this situation, namely,


‘‘mental health literacy’’ . After outlining the origins of the


mental health literacy paradigm, I shall do my best to explain


why its application to eating-disordered behavior has merit


and how research in this field might be progressed.


The mental health literacy paradigm


Jorm et al. (1997) introduced the term ‘‘mental health


literacy’’ (MHL), in the mid-1990s, to refer to ‘‘knowledge


and beliefs about mental disorders which aid their recognition,


management or prevention’’(p.182). The rationale was


that improving community awareness and understanding of


the nature and treatment of mental health problems was not, at


this time, a priority for government health agencies. As a


consequence, members of the public were unsure of the


symptoms of different mental health problems and of how to


respond to, or prevent, the occurrence of those symptoms in


themselves or others. This situation contrasted with that for


physical health problems, where it was accepted that the


public would benefit by knowing what actions they could take


to prevent disease, how to recognize warning signs and assist


others in the event of emergencies, and the likely benefits of


available treatments (Jorm, 2012).


The research methodology could not be simpler – a vignette


of a fictional person suffering from a given mental health


problems is presented and questions about that problem are


posed to study participants. This is the MHL paradigm.


Aspects of MHL examined by Jorm (2012) and others thus far


include: beliefs about the nature and causes of, and risk factors


for, mental health problems; recognition of the symptoms that


constitute a mental disorder; knowledge of and beliefs about


treatment options and their availability; attitudes and beliefs


that may be conducive to stigma and discrimination; and


knowledge and understanding of how to assist others who may


be developing or experiencing a mental disorder.


The use of large, general population surveys in MHL


research has permitted stratification of the data by participants’


demographic characteristics and symptom levels (Jorm,


2012; Jorm et al., 2000). Demographic differences in MHL


are important because they indicate specific targets for health


promotion efforts, for example, a need to improve MHL


relating to depression among young people in rural and


remote communities. MHL differences between individuals


with and without symptoms, on the other hand, might inform


early intervention efforts. Improving community MHL should


also facilitate early intervention efforts on the part of family


members, friends and others who share information with


and interact with symptomatic individuals (Jorm, 2012;


Jorm et al., 2000).


As I am sure Jorm and colleagues would acknowledge, the


concept of MHL was neither radical nor new. Researchers had


recognized the need to study the knowledge and beliefs of the


public concerning mental health problems for decades


(Hayward & Bright, 1997). The early literature included


studies of knowledge and beliefs about eating disorders


(Branch & Eurman, 1980). What was novel, however, was the


rationale provided for the systematic investigation of knowledge


and beliefs concerning mental health problems, particularly


the view that poor MHL may be a major factor in


low or inappropriate help-seeking among individuals with


symptoms (Andrews et al., 2000; Meltzer et al., 2000). It is a


testament to the efforts of Jorm and colleagues that governments


in many countries now incorporate the assessment of


Correspondence: Jonathan M. Mond, PhD, MPH, Department of


Psychology, C3A 411, Macquarie University, Sydney, NSW 2109,


Australia. E-mail: [email protected]


MHL in their mental health plans and use this information to


inform their health promotion agendas.


What is known about ‘‘eating disorders mental


health literacy’’?


Whereas much has been learned about MHL relating to the


‘‘more common mental disorders’’, and to schizophrenia,


‘‘eating disorders mental health literacy’’ (ED-MHL) has not,


thus far, been a priority for researchers or policy makers.


It has therefore not been systematically investigated in the


same way as other mental health problems and the detailed


information required to inform health promotion and early


intervention programs is lacking. Further, it is difficult to


determine what is known because there exists a disparate,


but substantial, body of research that has examined


ED-MHL-related knowledge and beliefs but which has


employed an alternative methodology and/or not used the


term ‘‘mental health literacy’’ (Crisp et al., 2000; Davidson &


Connery, 2003). A systematic review of all relevant research


would be beneficial.


Nevertheless, perusal of the recent literature suggests a


small number of key ‘‘problem areas’’ (Mond et al., 2006b,


2008, 2010a). First, it is apparent that awareness and


understanding of the spectrum of disordered eating that


occurs at the population level is poor (Mond et al., 2006b). To


give just one example, ‘‘eating disorders’’ may be associated,


in the public mind, with anorexia nervosa and the purging


form of bulimia nervosa, whereas binge eating disorder and


the non-purging form of bulimia nervosa may tend to be seen


as ‘‘normative’’ (Gratwick-Sarll et al., 2013). Second, there


appears to be a pervasive belief that eating disorders are either


serious but uncommon or common but trivial when the reality


is that they are both serious and common (Mond et al., 2006a;


Palmer, 2003). Third, attitudes and beliefs likely to be


conducive to stigma, such as the beliefs that individuals with


eating disorders only have themselves to blame and that these


individuals are vain, self-obsessed or weak, are not uncommon


(Crisp et al., 2000; Mond et al., 2006b). In addition,


ED-MHL has been found to vary as a function of individuals’


demographic characteristics and symptom levels. Thus, young


men may consider eating disorders to be less serious than


do young women (Mond & Arrighi, 2011) and individuals


with eating disorder symptoms may be particularly likely to


believe that eating-disordered behavior is acceptable or even


desirable (Mond et al., 2010a).


In terms of whose ED-MHL might be most worthy of


attention, research addressing attitudes and beliefs likely to


be conducive to low or inappropriate help-seeking among


men with disordered eating would be especially welcome,


for several reasons (Mond et al., 2013b). First, men may be


particularly unlikely to seek advice or treatment for an


eating problem. Second, the prevalence of disordered eating


and its impact on quality of life are increasing in men.


Third, much of the existing ED-MHL research has been


confined to the ‘‘high-risk’’ populations of adolescent and


young adult women. Moreover, research addressing the


ED-MHL of men is important because their knowledge,


beliefs and behaviors influence the knowledge, beliefs and


behaviors of the individuals with whom they interact,


including adolescent and young adult women (Mond et al.,


2010a, 2013b).


Efforts will also be needed to identify attitudes and beliefs


on the part of primary care practitioners and other nonspecialist


treatment providers that may undermine effective


care delivery. For example, there is good evidence that


primary care practitioners are diffident in their ability to


recognize and/or screen for the presence of eating disorder


psychopathology (Linville et al., 2012; Mond et al., 2010b).


Primary care practitioners may also be unsure as to the


comparative benefits of different possible treatment


approaches and/or treatment providers and, in turn, appropriate


referral of their patients. However, the issue of what


constitutes ‘‘evidence-based treatment’’ is relevant for both


primary care and specialist treatment providers and is not


straightforward (Mond, 2012).


Perhaps most importantly, efforts will be needed to change


the way that eating disorders are viewed by researchers in


other fields of academia and by those who are in a position to


influence public knowledge, beliefs and policy more generally.


The author’s experience, in Australia and the USA, is


that eating-disordered behavior is not taken seriously as a


public health problem, or, worse still, viewed with contempt,


in public health research and policy circles. Certainly this


would help to explain why eating disorders research is so


rarely featured in leading public health journals (Austin,




If institutionalized stigma towards eating disorders


research and clinical practice exists, then there is a need to


identify the source of this and do something about it. For


example, if there is a lingering perception that eating


disorders are associated with affluence and privilege and,


therefore, not worthy of public policy attention, then this


misconception needs to be dispelled (Striegel-Moore &


Franko, 2003). The misconception that eating disorders are


either serious but uncommon or common but trivial also


seems to be stubbornly resistant to change, perhaps because


this perception is reinforced by adherence to a dichotomous,


medical-model approach to classification and treatment


(Mond et al., 2009). Recent changes to the DSM diagnostic


criteria for eating disorders, including less stringent criteria


for anorexia nervosa and bulimia nervosa and the inclusion of


binge eating disorder as a formal diagnosis, should go some


way to redressing this problem (Mond, 2013).


Eating disorders mental health literacy and the


‘‘obesity epidemic’’


As I have argued elsewhere (Mond et al., 2009, 2013a), the


way in which body dissatisfaction and disordered eating are


conceptualized in obesity prevention research, namely, as


variables that may need to be assessed as secondary outcomes


– as opposed to variables worthy of attention in their own


right – is particularly unfortunate, given the conspicuous links


between body weight, body dissatisfaction, eating-disordered


behavior and mental health. Body-weight-centric obesity


prevention messages should be of concern to all those with


an interest in the reciprocal relations between physical health


and mental health and efforts to improve ED-MHL need to be


accompanied by efforts to inculcate a more balanced view of


52 J. M. Mond J Ment Health, 2014; 23(2): 51–54


the ‘‘obesity epidemic’’ (Bacon & Aphramor, 2011;


Campos et al., 2006). In the author’s view, the latter would


entail information to the effect that adverse physical and


psychosocial consequences are far more likely to occur for


moderate and severe obesity than for overweight and mild


obesity, that the prevalence of moderate and severe obesity is


relatively low, and that moderate degrees of overweight may


in fact be associated with better physical and mental health


outcomes (Mond et al., 2009).


Why is improving ED-MHL important?


A potential criticism of the MHL paradigm is that changing


knowledge and beliefs does not necessarily lead to behavior


change (Stice et al., 2000). Thus, findings from the first


generation of ED prevention research were seen to be


‘‘disappointing’’ because change in knowledge and beliefs


about eating disorders was associated with little or no


change in eating-disordered behavior (Stice et al., 2000).


However, this argument misses the point (Cowen, 1998;


Mond et al., 2013b). The focus of efforts to improve EDMHL


is on reducing the individual and community health


burden of eating-disordered behavior by reducing stigma and


otherwise changing public knowledge and beliefs in ways


that promote the importance of early, appropriate helpseeking


where this is needed (Cowen, 1998; Mond et al.,


2010a, 2013b). Improving ED-MHL may also serve to


prevent the occurrence of eating-disordered behavior among


individuals at risk or potentially at risk. But that is not the


primary objective.


Of course, the relative merits of different possible


approaches to reducing the health burden of eating-disordered


behavior and other mental health problems – health promotion/


universal prevention, selective prevention and indicated


prevention/early intervention – warrant careful consideration


(Munoz et al., 1996). But it also needs to be remembered that


these different approaches are not mutually exclusive (Mond


et al., 2013b). Efforts to improve ED-MHL at the population


level would complement the current focus of eating disorders


prevention research on selective interventions in high-risk


populations (Stice et al., 2013) and would potentially have


multiple benefits, including: (i) greater willingness to seek


treatment among individuals with symptoms, (ii) improved


uptake of empirically supported treatments, (iii) improved


willingness and ability to intervene on the part of family and


friends, (iv) improved detection and management of eating disordered


behavior in primary care and (v) reduced stigma


associated with eating-disordered behavior and mental health

problems more generally

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