Eating disorders are serious psychiatric conditions affecting up to 5% of the population over the life-course and bearing some of the highest mortality rates of all psychiatric disorders (Treasure et al, 2010). Yet, it is not uncommon that in public discourse they are trivialised as disorders of volition; the result of media and peer pressures on young girls to achieve unattainable beauty standards. A case in point is last year’s comment by Baroness Joan Bakewell (who afterwards apologised for her remark) suggesting that to suffer from anorexia nervosa is a “sign of the overindulgence of our society, over-introspection, narcissism”.
Far from being lifestyle choices, eating disorders, much like any other psychiatric condition, are the result of a complex interaction between genetic, neurobiological and social factors, albeit ones that are not yet fully understood. Moreover, though they have a typical onset in adolescence and are more frequent among women, eating disorders are not confined to young girls. Recent studies have shown that older women and men might suffer from these conditions more frequently than was previously thought. One of the reasons why little is known about eating disorders in these groups, besides the lack of large scale epidemiological data, is that many people might fear disclosing their eating disorder due to the stigma that is attached to these diagnoses.
In this context, a new systematic review on the effectiveness of different types of interventions to reduce stigma towards eating disorders by Doley and colleagues is a much-needed piece of research in an area lacking evidence (Doley et al, 2017).
Background and aims
The authors systematically reviewed the literature on interventions to reduce different types of stigma towards people with eating disorders:
- Attitudinal stigma: beliefs about people with eating disorders
- Affective stigma: emotional reactions to people with eating disorders
- Behavioural stigma: actual or intended behaviours towards people with eating disorders
The main types of interventions evaluated were:
- The use of aetiological explanations aiming to reduce stigma by shifting the focus from blaming the person for their eating disorder to explaining what contributed to the diagnosis
And interventions relying on:
- Education: tackling stigma by providing evidence-based information on eating disorders in order to address publicly held stereotypes
- Contact: inviting people to connect with others with eating disorders, with the aim of encouraging empathy.
The authors searched a number of databases for relevant studies, screened them, and extracted data using a structured coding strategy. They further meta-analysed (i.e., they jointly analysed the results from multiple studies) the effect of using biological vs. socio-cultural aetiological explanations on reducing stigma. In this analysis, they also assessed the risk of publication bias (i.e., that only studies showing a certain type of result, usually those showing a positive effect, are published).
Eighteen studies were included in the review and, of these, 4 were included in the meta-analysis.
In general, interventions employing biological explanations (as opposed to socio-cultural, environmental, and multifactorial explanations) resulted in fewer levels of attitudinal stigma and so did environmental explanations, whereas socio-cultural explanations were associated with greater stigma. Of these studies only 2 employed control groups, compared to which, any type of aetiological explanation appeared to reduce attitudinal stigma.
The authors further explored the effectiveness of biological versus socio-cultural explanations of eating disorders on reducing of stigma using a meta-analytic approach, which confirmed the findings from the review suggesting a superiority of biological explanations in reducing attitudinal stigma, with no evidence of publication bias or heterogeneity between studies.
The review found no type of aetiological explanation impacted on affective measures of stigma, but that biological explanations reduced behavioural stigma towards people with eating disorders.
A combination of educational and contact approaches was the most effective approach at reducing attitudinal, affective, and behavioural measures of stigma. No studies directly compared educational and contact approaches, but, overall, studies evaluating the impact of these two approaches individually did not observe improvements in attitudinal stigma after the intervention or found small improvement in behavioural stigma that, however, did not persist at follow-up.
Other factors to consider
Mental health literacy
Some studies found that interventions to reduce stigma improved mental health literacy relating to eating disorders, although there was little evidence that this translated to reduced levels of stigma.
Eating disorder diagnosis
The majority of the reviewed studies focused on anorexia and bulimia nervosa and found that the interventions employed reduced stigma towards both conditions. Studies focusing on eating disorders in general (i.e., regardless of diagnoses) did not find any improvement in measures of stigma. No studies directly targeted stigma towards individuals with binge eating disorder or other specified feeding and eating disorders (i.e., atypical and sub-threshold eating disorder presentations).
Most studies employed samples drawn from student populations (primarily psychology and medicine undergraduates), who were female and identified as white Caucasian. Only one study was community-based.
Risk of bias
Though most studies used well-established measures of stigma, the majority were rated as having a number of methodological limitations, such as small sample sizes, and lack of control groups and adjustment for potential confounding factors. Thus, as the authors note, these results ought to be taken with caution.
Overall, this review suggests that interventions using aetiological explanations focusing on biological risk factors for eating disorders, and a combination of education and contact strategies, might be successful in reducing the stigma attached to these conditions. The authors do warn, however, that reliance on biological explanations could contribute to a deterministic view of eating disorders, as ‘biologically-based and unchangeable’ which might thwart treatment efforts. They therefore suggest that these unintended consequences be measured in future studies. One reason for the observed superiority of biological explanations might have to do with the populations (psychology and medical students) in which these interventions were tested, something that the authors also acknowledge.
Interestingly, the only study that was conducted in a community sample did not show any improvements in stigmatising beliefs (e.g.: that people with eating disorders are to blame for their conditions and unlikely to recover). Although the authors were not able to identify which anti-stigma framework this intervention employed, to me this finding stresses the importance of moving beyond convenience sampling in eating disorder research and including the general population. This is likely to reduce bias and produce results that are more relevant for service planners and, ultimately, service users.
The review also highlights that studies so far have largely ignored stigma towards people with binge eating disorder. Research on binge eating disorder is urgently needed for several reasons: it might be often undiagnosed, given its comorbidity with overweight and obesity. For the same reason, people who suffer from it are also likely to be stigmatised as weight stigma is widespread. Furthermore, it would be worth considering, given that there is some evidence that binge eating disorder might be more common than other diagnoses in men and older women, whether increasing eating disorders mental health literacy around this condition, and thus showing that eating disorders are not limited to young girls, could have knock-on effects on reducing stigma for other diagnoses too.
In conclusion, robust general population research investigating the effectiveness of interventions to reduce stigma using large samples is urgently needed. Stigma might prevent many individuals with eating disorders from receiving timely and appropriate treatment, the most effective gateway to successful and sustained recovery.
Doley JR, Hart LM, Stukas AA, et al. (2017) Interventions to reduce the stigma of eating disorders: A systematic review and meta-analysis. International Journal of Eating Disorders, 50(3), pp.210–230. https://doi.org/10.1002/eat.22691
Micali N, Martini MG, Thomas JJ, et al. (2017) Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors. BMC Medicine. 2017;15:12. doi:10.1186/s12916-016-0766-4.
Raevuori A, Keski-Rahkonen A, Hoek HW. (2014) A review of eating disorders in males. Current Opinion in Psychiatry, 27(6), pp.426–430. [PubMed abstract]
Treasure J, Claudino AM, Zucker N, (2010) Eating disorders. The Lancet, 375(9714), pp.583–93. [Abstract]
- By Fernwer (Own work) [GFDL or CC BY-SA 3.0], via Wikimedia Commons
- Challiyil Eswaramangalath Pavithran Vipin CC BY 2.0
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