Eating Disorders

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Optimizing prevention programs and maximizing

public health impact are not the same thing

Jonathan M. Mond

To cite this article: Jonathan M. Mond (2016) Optimizing prevention programs and
maximizing public health impact are not the same thing, Eating Disorders, 24:1, 20-28, DOI:
10.1080/10640266.2015.1113824

To link to this article: http://dx.doi.org/10.1080/10640266.2015.1113824

Published online: 07 Dec 2015.

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EATING DISORDERS
2016, VOL. 24, NO. 1, 20–28
http://dx.doi.org/10.1080/10640266.2015.1113824

THE LAST WORD

Optimizing prevention programs and maximizing public

health impact are not the same thing
Jonathan M. Monda,b,c
a
Department of Psychology, Macquarie University, Sydney, New South Wales, Australia; bResearch
School of Psychology, The Australian National University, Canberra, Australian Capital Territory,
Australia; cSchool of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia

Overview
Call me pessimistic, but I am concerned that current approaches to reducing
the public health burden of body dissatisfaction (BD) and eating disordered
behaviour (EDB), in which efforts are focused on prevention of new cases of
the most severe disorders, are unlikely to achieve the large-scale impact that
we all agree is needed. The article by Austin (Austin, 2015), which I had the
opportunity to review prior to writing the current piece, exemplifies such a
focus and I shall use it in the current contribution to highlight my concerns,
while also outlining my thoughts about the sort of alternative approach that I
believe will be needed to achieve such impact.

The problem of conflation

The key contention made in Austin’s piece is that eating disorder (ED)
prevention, as a field, needs to effect a shift in priorities to more policy-
translation oriented research and research training. A shift of this kind will, it
is argued, permit the field to have the public health impact that has, thus far,
proved elusive. A framework that the author believes has promise in guiding
such a shift is outlined and examples of the author’s and colleagues’ efforts in
applying this framework to guide ED prevention research and training efforts
are described.
While I find myself in agreement with much of what the author says, in all
sections of the manuscript, there is, in my view, a key problem that runs through
Austin’s piece that limits its potential to take the “bigger-picture” perspective
that the author intends. That problem is the conflation of “prevention efforts”
with “public health efforts” and/or efforts to “advance population health.” Thus,
in the opening sentences of the abstract, the author states that:
The public health burden of eating disorders is well documented, and over the past
several decades, researchers have made important advances in the prevention of eating

CONTACT Jonathan M. Mond Jonathan.Mond@mq.edu.au Department of Psychology, Macquarie

University, C3A 513, Sydney, NSW 2109, Australia.
© 2016 Taylor & Francis
 EATING DISORDERS 21

disorders and related problems with body image. Despite these advances, however,
several critical limitations to the approaches developed to date leave the field far from
achieving the large-scale impact that is needed. This commentary provides a brief
review of what achievements in prevention have been made and identifies the gaps
that limit the potential for greater impact on population health.

The conflation is thereby established a priori. It is repeated throughout the

manuscript, including in the concluding section:
Through a shift in the field’s priorities to policy translation research and training
with an emphasis on macro-environmental influences, the pace of progress in
prevention can be accelerated and the potential for large-scale impact on population
health substantially improved . . .

Addressing this conflation, as it applies to each section of the manuscript,

would have made for a more valuable and impactful contribution in my view.
Using terms such as “progress in prevention” and “public health impact” inter-
changeably gives the impression that addressing the limitations of prevention
efforts alone will give rise to initiatives with greater public health impact.
However, this ignores the role of other points on the spectrum of possible
interventions to reduce health burden, namely, health promotion, early inter-
vention, and clinical management (Institute of Medicine [IOM], 1994, National
Research Council [NRC] & IOM, 2009). Once this concept—of prevention being
just one point on a spectrum of possible interventions to reduce health burden—
is grasped, priorities change. In particular, the need to consider how these
different approaches might be integrated with each other and with efforts to
reduce the health burden of related health problems, at the population level,
becomes paramount.

The rise and rise of selective prevention

Other sections of the manuscript have a similarly narrow focus. Thus, in the
Background section, there is no reference to the fact that, for much of past two
decades, efforts to reduce the public health burden of BD and EDB have been
largely confined to selective-targeted prevention programs in adolescent and
young adult females (cf. Stice, Becker, & Yokum, 2013). This is despite the
need, as stated by the author, for the field to move away from “an exclusive
focus on individual and interpersonal-level determinants and behavior-change
strategies.” While a focus of this kind may have been appropriate at one time,
it certainly isn’t now. Rather, as evidence for increases in the prevalence and
adverse impact of BD and EDB—in women and men of all ages—mounts,
prioritising selective prevention programs in adolescent and young adult
women appears increasingly anachronistic (Mitchison & Mond, 2015;
Mitchison, Hay, Slewa-Younan, & Mond, 2014; Mond, Mitchison, & Hay,
2013a). Arguably, a focus on research of this kind has detracted from greater
22 J. M. MOND

consideration being given to the sort of macro-level determinants that the

author argues—and that I agree—have been neglected. My concern is that in
the absence of a new, more comprehensive approach, the individual and
community health burden of BD and EDB will merely continue to increase.
It might be added that the “notable successes” in prevention efforts alluded to
in the Background section, while important, are less impressive when these
efforts are seen as just one component of overall efforts to reduce public health
burden.

Problems of perspective
The fact that ED prevention programs have typically emanated from the field
of clinical psychology, rather than public health, warrants consideration in
this regard and also when considering the difficulty of integrating ED and
obesity prevention programs (Austin, 2000; Hill, 2007). Clinical psychology,
like psychiatry, favors a medical-model approach in which the focus is on
preventing “disease” by targeting “risk factors,” i.e., a focus on individual-
level determinants of behavior. Concerns with this approach are well known
in the health promotion and sociology literatures (Antonovsky, 1996;
Bunton, Nettleton, & Burrows, 1995), and the ED field needs to be careful
to avoid uncritical acceptance of it. Regrettably, adherence to a medical-
model approach to improving population health tends to be proselytized—in
much the same way that the use of so-called “evidence-based treatments” is
proselytized—such that anyone expressing reservations about the merits of
this approach runs the risk of being labelled unscientific or, worse, negligent
(Pilgrim, 2011; Robison & Kline, 2002).
At the same time, it needs to be recognized that efforts to move towards a
greater focus on macro-level determinants of behavior in the obesity prevention
field have, thus far, not been particularly encouraging, perhaps because of a shift
too far in the opposite direction, namely, a focus on macro-level determinants to
the exclusion of individual-level factors (Roberto et al., 2015). Importantly, the
need for integrated approaches to reducing the health burden of EDB and
obesity is, for the first time, being given serious consideration in leading public
health journals (e.g., Macpherson-Sánchez, 2015). It will be important for the
ED field to capitalise on these developments moving forward. For this to
happen, there needs to be greater awareness of the different conceptual
approaches underpinning prevention efforts in the different disciplines and
genuine collaboration in seeking to develop programs that reconcile these
differences, while also recognising that neither approach is likely to succeed if
implemented in isolation (Neumark-Sztainer et al., 2006; Roberto et al., 2015).
Developing, conducting, and evaluating whole-of-community interventions
poses formidable methodological and logistical challenges, and this is the case
for interventions confined to one point on the spectrum of possible
 EATING DISORDERS 23

interventions, let alone those designed to integrate all points on the spectrum in
the one community at the one time. However, methods for complex interven-
tions of this kind are now well advanced in the field of public health (Bauman &
Nutbeam, 2014; Sorensen, Emmons, & Hunt, 1998). This includes whole-of-
community obesity prevention trials (e.g, Sanigorski, Bell, Kremer, Cuttler, &
Swinburn, 2008) and in this regard alone, collaboration between obesity and ED
researchers would be welcome. Further, while whole-of-community interven-
tions for BD and EDB are largely uncharted territory, some tentative steps in this
direction have been made (McVey et al., 2005; Wilfley, Agras, & Taylor, 2013).
Through collaboration between researchers in different disciplines, progress in
developing novel approaches to reducing the health burden of BD and EDB can
be expedited (Austin, 2000; Mond, 2014).
Along similar lines, and while I agree with each of the key limitations of
current ED prevention efforts referred to in the discussion section of Austin’s
article, I was surprised that there is no mention of the complete absence of
trials of programs seeking to integrate different possible approaches to redu-
cing burden with each other and with efforts to reduce the burden of obesity
and mental health more generally in whole populations. Arguably, compre-
hensive, integrated, initiatives of this kind are most likely to achieve the sort of
substantial public health impact that has been lacking thus far. While pro-
grams seeking to integrate universal and selective ED prevention approaches
(e.g., Abascal, Bruning-Brown, Winzelberg, Dev, & Barr Taylor, 2004), ED
prevention and treatment approaches (e.g., Wilfley et al., 2013), and ED and
obesity prevention programs (e.g., Stock et al., 2007), have been developed—
envisioned at least—to my knowledge, only the work of McVey and colleagues
in Canada approximates the more ambitious ideal referred to above (e.g.,
McVey et al., 2005, 2013). Further, and while better funding of more research-
policy-oriented prevention trials is no doubt needed, the field needs to be
careful that this does not come at the cost of diminished resources for efforts
along other points of the intervention spectrum and for the development and
testing of programs that seek to integrate the different possible approaches.
As I have also outlined elsewhere (Mond, Hay, Rodgers, & Owen, 2009),
there needs to be a clearer separation of the public health problem of
reducing health burden and the more clinical problem of treating—and
preventing—the most severe disorders. The vast majority of the individual
and community health burden of EDB is accounted for by conditions that do
not meet diagnostic for a specific eating disorder diagnosis and/or that entail
high levels of BD that may or may not occur in conjunction with one or
more EDBs at any given point in time. This is by virtue of the fact that these
conditions are common but still associated with substantial distress and
disability (Mond, 2015; Mond et al., 2009, 2013b). A truly public health
approach would recognise this reality and seek to develop interventions
that maximize reduction in this burden.
24 J. M. MOND

Whatever happened to health promotion?

Health promotion efforts seem to me to be a particularly neglected component of
overall efforts to reduce the public health burden of BD and EDB and of mental
health problems more generally (Mond, 2014; NRC & IOM, 2009). Indeed, the
much-cited and highly influential Institute of Medicine report “Reducing Risks
for Mental Disorders” (IOM, 1994) specifically excludes health promotion efforts
from the “spectrum of interventions for mental disorders,” the latter comprising:
prevention (universal, selective, indicated); treatment (case identification, stan-
dard treatment for known disorders); and maintenance (compliance with long-
term treatment, aftercare). The rationale provided for this decision was that:
“Health promotion is not driven by an emphasis on illness, but rather by a focus
on the enhancement of well-being . . . This focus on health, rather than illness, is
what distinguishes health promotion activities from the enhancement of protec-
tive factors within a risk reduction model . . .” (p. 27). This distinction has been
reiterated in subsequent key prevention documents (e.g., World Health
Organization, 2004).
While it may be helpful to distinguish between health promotion and
disease prevention for conceptual purposes, in practice there is no clear
separation between these or any other points on the spectrum of interventions
potentially employed to reduce the adverse impact of poor mental health (NRC
& IOM, 2009; Peterson, Barry, Lund, & Bhana, 2013). The separation between
health promotion and universal prevention is particularly tenuous (Albee,
1996; NRC & IOM, 2009) and, while there has been renewed interest in
universal ED prevention programs in recent years (e.g., McVey, Tweed, &
Blackmore, 2007), health promotion efforts for BD and EDB have, thus far,
been sporadic and piecemeal (Paxton, 2012). Efforts to refine selective preven-
tion research are of course welcome, but if the contribution of selective
prevention to reducing the overall burden of BD and EDB is relatively small,
then these efforts will have a relatively small public health impact. Arguably,
health promotion and early intervention efforts would engender a more sub-
stantial reduction in the health burden of BD and EDB than selective preven-
tion and clinical management approaches. Although the need to include health
promotion in the spectrum of interventions for mental disorders—and to
integrate promotion and prevention approaches—has since been recognized
(NRC & IOM, 2009), trials of mental health promotion interventions remain
under-developed when compared with prevention and treatment trials
(Peterson et al., 2013).

“Mental health literacy” as a framework for health promotion

As I have argued elsewhere (Mond, 2014, 2015; Mond et al., 2010), the
“mental health literacy” (MHL) framework developed by Jorm (2012) may
 EATING DISORDERS 25

be helpful in facilitating the incorporation of health promotion efforts into

overall efforts to reduce the health burden of BD and EDB. A key aspect of
this framework is that it recognizes the importance of both “bottom-up” and
“top-down” approaches to policy development and, indeed, clinical practice.
That is, policy development needs to solicit and take into account public
opinion rather than being dictated by “experts” in a proscriptive fashion
(Huang et al., 2015). It is apparent that key aspects of ED-MHL are deficient
and that effecting change in this regard would have substantial benefits in
terms of key aspects of health burden, such as stigma towards sufferers and
awareness of the importance of early, appropriate intervention among suf-
ferers and those with whom they interact. Improving community ED-MHL
would serve both health promotion and early intervention functions, while
complementing endeavours in prevention and clinical management. It would
also be consistent with a greater focus on macro-level determinants of
behavior and would facilitate the integration of ED and obesity prevention
programs. Improving community awareness of the spectrum of BD and EDB
that occurs at the population level would be a good start, as such awareness
obviously impacts the willingness to fund interventions on the part of policy
makers. As the government of many countries now include the need to
improve MHL in their mental health plans, it is important to ensure that
the ED field does not miss out on developments in this regard, as has
happened with various national mental health surveys and health promotion
campaigns (Jorm, 2012; Mond, 2015).

A broader approach to accelerating progress and triggering action

With reference to Austin’s section on “Keys to Accelerating Progress,” I agree
entirely that a shift in research towards the use of study designs and methods
more likely to result in policy or practice improvement is needed and that
each of the four specific shifts mentioned (rapid translation, effectiveness and
dissemination studies rather than RCTs, simulation modeling, and economic
evaluations) is important. As suggested above, however, there also needs to
be shift towards trials that seek to integrate prevention efforts with efforts to
reduce health burden along other points of the intervention spectrum and
with efforts to reduce the health burden of related health problems. With
time and resources perennially constrained, and given the conspicuous links
among BD, EDB, body weight, and mental health, it simply doesn’t make
sense to conduct ED prevention efforts in isolation.
The outline of the “triggers-to-action” framework provided in the final
section of Austin’s paper is instructive and the efforts of the author and her
team to implement this framework (within the STRIPED Program) are
impressive. However, the “pragmatic value” of the framework would be better
illustrated if the author were to consider, for each trigger, how the framework
26 J. M. MOND

might accommodate and inform the sort of larger-scale shift referred to above.
For example, with reference to “Trigger 1a, (Does the scientific evidence
link the exposure in question to long-term health problems?),” I would argue
that, along with greater consideration of macro-level determinants of
behavior, there needs to be better communication to the public and other
key stakeholders as to strong links between BD and EBD and a broad range of
adverse health outcomes.
With reference to “Trigger 1b (Do economic costs favor prevention?),”
economic evaluations of the relative merits of different possible approaches
to reducing health burden and of their integration in whole populations would
be particularly welcome. With reference to “Trigger 2 (Practical considerations
as to how preventive approaches can be operationalized into law and policy),”
how might the framework be adapted to guide research training and policy as
this relates to the integration of different intervention approaches in whole
populations, and what practical and policy considerations are likely to be faced
in developing and trialling initiatives of this kind? With reference to “Trigger 3
(Political will among decision makers and the public to support action),”
I would argue that improving awareness and understanding of the costs and
consequences of the spectrum of BD and EDB that occurs at the population
levels will be a key component of improving political will and public support
for interventions likely to reduce these costs and consequences.

Conclusion
In sum, efforts to refine ED prevention programs can only go so far in achieving
the sort of wide-ranging public health impact that has, thus far, proved elusive.
There is no doubt that a change of strategy is needed in order to effect a
meaningful reduction in the individual and community health burden of BD
and EDB. But this shift needs to come in the form of a move beyond prevention
and clinical management to the development and implementation of programs
that seek to integrate these approaches, along with health promotion and early
intervention, in whole populations. This would by a truly public health
approach.

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