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Eating Disorders: Current Knowledge and Treatment Update

• B. Timothy Walsh , M.D.

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Although relatively uncommon, eating disorders remain an important concern for clinicians and researchers as well as the general public, as highlighted by the recent depiction of Princess Diana’s struggles with bulimia in “The Crown.” This brief review will examine recent findings regarding the diagnosis, epidemiology, neurobiology, and treatment of eating disorders.

Eight years ago, DSM-5 made major changes to the diagnostic criteria for eating disorders. A major problem in DSM-IV ’s criteria was that only two eating disorders, anorexia nervosa and bulimia nervosa, were officially recognized. Therefore, many patients presenting for treatment received the nonspecific diagnostic label of eating disorder not otherwise specified (EDNOS), which provided little information about the nature of the patient’s difficulties. This problem was addressed in several ways in DSM-5 (see DSM-5 Feeding and Eating Disorder list). The diagnostic criteria for anorexia nervosa and bulimia nervosa were slightly expanded to capture a few more patients in each category. But two other changes had a greater impact in reducing the use of nonspecific diagnoses.

The first of these was the addition of binge eating disorder (BED), which had previously been described in an appendix of DSM-IV . BED is the most common eating disorder in the United States, so its official recognition in DSM-5 led to a substantial reduction in the need for nonspecific diagnoses.

DSM-5 Feeding and Eating Disorder

Rumination Disorder

Avoidant/restrictive food intake disorder

Anorexia nervosa

Bulimia nervosa

Binge-eating disorder

Other specified feeding or eating disorder

Unspecified feeding or eating disorder

The second important change was the combination of the DSM-IV section titled “Feeding and Eating Disorders of Infancy or Early Childhood” with “Eating Disorders” to form an expanded section, “Feeding and Eating Disorders.” This change thereby included three diagnostic categories: pica, rumination disorder, and feeding disorder of infancy or early childhood. Pica and rumination disorder are infrequently diagnosed.

The other category, feeding disorder of infancy or early childhood, was rarely used and had been the subject of virtually no research since its inclusion in DSM-IV . The Eating Disorders Work Group responsible for reviewing the criteria for eating disorders for DSM-5 realized that there was a substantial number of individuals, many of them children, who severely restricted their food intake but did not have anorexia nervosa. For example, after a severe bout of vomiting after eating, some individuals attempt to prevent a recurrence by no longer eating at all, leading to potentially serious nutritional disturbances. No diagnostic category in DSM-IV existed for such individuals. Therefore, the DSM-IV category, feeding disorder of infancy or early childhood, was expanded and retitled “avoidant/restrictive food intake disorder” (ARFID). Combined, these changes led to a substantial reduction in the need for nonspecific diagnostic categories for eating disorders.

In the course of assessing the impact of the recommended changes in the diagnostic criteria for eating disorders, the Eating Disorders Work Group became aware of another group of individuals presenting for clinical care whose symptoms did not quite fit any of the existing or proposed categories. These were individuals, many of them previously overweight or obese, who had lost a substantial amount of weight and developed many of the signs and symptoms characteristic of anorexia nervosa. However, at the time of presentation, their weights remained within or above the normal range, therefore not satisfying the first diagnostic criterion for anorexia nervosa. The work group recommended that a brief description of such individuals be included in the DSM-5 diagnostic category that replaced DSM-IV ’s EDNOS: “other specified feeding and eating disorders” (OSFED); this description was labeled atypical anorexia nervosa. The degree to which the symptoms, complications, and course of individuals with atypical anorexia nervosa resemble and differ from those of individuals with typical anorexia nervosa remains an important focus of current research.

Epidemiology

Although eating disorders contribute significantly to the global burden of disease, they remain relatively uncommon. A study published in September 2018 by Tomoko Udo, Ph.D., and Carlos M. Grilo, Ph.D., in Biological Psychiatry examined data from a large, nationally representative sample of over 36,000 U.S. adults 18 years of age and older surveyed using a lay-administered diagnostic interview in 2012-2013. The 12-month prevalence estimates for anorexia nervosa, bulimia nervosa, and BED were 0.05%, 0.14%, and 0.44%, respectively. Although the relative frequencies of these disorders were similar to those described in prior studies, the absolute estimates were somewhat lower for unclear reasons. Consistent with clinical experience and prior reports, the eating disorders, especially anorexia nervosa and bulimia nervosa, were more prevalent among women (though men are also affected). Although eating disorders occurred across all ethnic and racial groups, there were fewer cases of anorexia nervosa among non-Hispanic and Hispanic Black respondents than among non-Hispanic White respondents. Consistent with long-standing clinical impression, individuals with lifetime anorexia nervosa reported higher incomes.

Finally, when BED was under consideration for official recognition in DSM-5 , some critics suggested that, since virtually everyone occasionally overeats, BED was an example of the misguided tendency of DSM to pathologize normal behavior. The low prevalence of BED reported in the study by Udo and Grilo documents that, when carefully assessed, BED affects only a minority of individuals and is therefore distinct from normality.

A subject of some debate and substantial uncertainty is whether the incidence of eating disorders (the number of new cases a year) is increasing. Some studies, such as that of Udo and Grilo, have found that the lifetime rates of eating disorders among older individuals are lower than those among younger individuals, suggesting that the frequency of eating disorders may be increasing. However, this might also reflect more recent awareness and knowledge of eating disorders. Other studies that conducted multiple examinations of the frequency of eating disorders in the same settings over time appear to suggest that, in the last several decades, the incidence of anorexia nervosa has remained roughly stable, whereas the incidence of bulimia nervosa has decreased. Presumably, this reflects changes in the sociocultural environment such as an increased acceptance of being overweight and reduced pressure to engage in inappropriate compensatory measures such as self-induced vomiting after binge eating.

The COVID-19 pandemic has impacted virtually every facet of life across the world and has produced severe financial, medical, and psychological stresses. Preliminary research suggests that such stresses have exacerbated the symptoms of individuals with preexisting eating disorders and have led to increased binge eating in the general population. Hopefully, these trends will improve with successful control of the pandemic.

Neurobiology

Much recent research on the mechanisms underlying the development and persistence of eating disorders has focused on the processing of rewarding and nonrewarding/punishing stimuli. Several studies have suggested that individuals with anorexia nervosa are less able to distinguish among stimuli with varying probabilities of obtaining a reward. Other studies suggest that, when viewing images of food during MRI scanning, individuals with anorexia nervosa tend to show less activation of brain reward areas than do controls. Such deficits may be related to disturbances in dopamine function in areas of the brain known to be involved in reward processing. Research based on emerging methods in computational psychiatry suggests that individuals with anorexia nervosa may be particularly sensitive to learning from punishment; for example, they may be very quick to learn what stimuli lead to a decrease in the amount of a reward. Conceivably, they may learn that eating high-fat foods prevents weight loss and produces undesirable weight gain, and they begin to avoid such foods. These studies, and a range of others, focus on probing basic brain mechanisms and how they may be disrupted in anorexia nervosa. A challenge for this “bottom-up” approach is to determine how exactly disturbances in such mechanisms are related to the eating disturbances characteristic of anorexia nervosa.

Other recent studies take a “top-down” approach, focusing on the neural circuitry underlying the persistent maladaptive choices made by individuals with anorexia nervosa when they decide what foods to eat. Such research successfully captures the well-established avoidance of high-fat foods by individuals with anorexia nervosa and has documented that such individuals utilize different neural circuits in making decisions about what to eat than do healthy individuals. These results are consistent with suggestions that the impressive persistence of anorexia nervosa in many individuals may be due to the establishment of automatic, stereotyped, and habitual behavior surrounding food choice. A challenge for such top-down research strategies is to determine how these maladaptive patterns develop so rapidly and become so ingrained.

Research on the neurobiology underlying bulimia nervosa is broadly similar. Although the results are complex, individuals with bulimia nervosa appear to find food stimuli more rewarding, and there are indications of disturbances in reward responsiveness to sweet tastes. Several studies have documented impairments in impulse control assessed using behavioral paradigms such as the Stroop Task. In this task, individuals are presented with a word naming a color (for example, “red”) but asked to name the color of the letters spelling the word (for example, the letters r, e, and d are green). Increased difficulties in performing such tasks have been described in individuals with bulimia nervosa and linked to reduced prefrontal cortical thickness.

It has long been known that eating disorders tend to run in families, and there has been strong evidence that this in part reflects the genes that individuals inherit from their parents. In recent decades, it has become clear that the risk of developing most complex human diseases, including obesity, hypertension, and eating disorders is related to many genes, each one of which contributes a small amount to the risk. Because the contribution of a single gene is so small, the DNA from a very large number of individuals with and without the disorder needs to be examined. For instance, genomewide association studies (GWAS) in schizophrenia have examined tens of thousands of individuals with schizophrenia and over 100,000 controls and identified well over 100 genetic loci that contribute to the risk of developing schizophrenia.

GWAS examining the genetic risk for eating disorders are under way but to date have focused primarily on anorexia nervosa. The Psychiatric Genetics Consortium has collected information from 10,000 to 20,000 individuals with anorexia nervosa and over 50,000 controls and has, so far, identified eight loci that contribute to the genetic risk for this disorder. In addition, this work has identified genetic correlations between anorexia nervosa and a range of other disorders known to be comorbid with anorexia nervosa such as anxiety disorders as well as a negative genetic correlation with obesity. These data suggest that the genetic risk for anorexia nervosa is based on a complex interplay between loci associated with a range of psychological and metabolic/anthropometric traits.

Although there have been no dramatic developments in our knowledge of how best to treat individuals with eating disorders, there have been some significant and useful advances in recent years.

For anorexia nervosa, arguably the most significant advance in treatment in the last quarter century has been family-based treatment for adolescents. In this approach, sometimes referred to as the “Maudsley method,” the family, guided by the therapist, becomes the primary agent of change and responsible for ensuring that eating behavior normalizes and weight increases. This approach differs markedly from prior treatment strategies that assumed parental involvement was not helpful or even detrimental. Family-based treatment is now widely viewed as a treatment of first choice for adolescents with anorexia nervosa and has also been adapted to treat bulimia nervosa.

Family-based treatment can be quite challenging for parents. The entire family is asked to attend treatment sessions, and one session early in treatment includes a family meal during which the parents are charged with the difficult task of persuading the adolescent to consume more food than he/she had intended. An alternative but related model, termed “parent-focused treatment,” has recently been explored in a few studies. In this approach, parents meet with a therapist without the affected adolescent or other members of the family and receive guidance regarding how to help the adolescent to alter his or her behavior following techniques virtually identical to those provided in traditional family-based treatment. Several small studies have examined this approach, and results suggest similar effectiveness. Although more research is needed, these findings suggest that parent-focused treatment may be an attractive alternative to family-based treatment for many parents and practitioners.

The COVID-19 pandemic has led to a dramatic acceleration in the provision of psychiatric care remotely, including family-based treatment. Work on providing family-based treatment via videoconference had begun prior to the arrival of COVID-19, as this specialized form of care is not widely available, and its provision via HIPAA-compliant video links would offer a substantial increase in accessibility. Several small studies suggested that remote provision of family-based treatment is feasible and likely to be efficacious. The restrictions imposed by COVID-19 on face-to-face contact have accelerated the remote delivery of family-based treatment; hopefully, new research will document its effectiveness. It should be noted, however, that, in most cases, local contact with a medical professional who can directly measure weight and oversee the patient’s physical state is required.

The treatment of adults with anorexia nervosa, who typically developed the disorder as teenagers and have been ill for five or more years, remains challenging. Structured behavioral interventions, such as those available in specialized inpatient, day program, or residential centers, typically lead to significant weight restoration and psychological and physiological improvement. However, the rate of relapse following acute care remains substantial. Furthermore, most adult patients with anorexia nervosa are very reluctant to accept treatment in such structured programs. A recent helpful development is evidence that olanzapine, at a dose of 5 mg/day to 10 mg/day, assists modestly with weight gain in adult outpatients with anorexia nervosa and is associated with few significant side effects. Unfortunately, it does not address core psychological symptoms and must be viewed as adjunctive to standard care.

There have been fewer recent developments in the treatment of patients with bulimia nervosa and of BED. For bulimia nervosa, cognitive-behavioral therapy remains the mainstay psychological treatment, and SSRIs continue to be the first-choice class of medication. For BED, multiple forms of psychological treatment are associated with substantial improvement in binge eating, and, in 2015, the FDA approved the use of the stimulant lisdexamfetamine (Vyvanse) for individuals with BED. Unlike most psychological treatments, lisdexamfetamine is associated with modest weight loss but has effects on pulse and blood pressure that may be of concern, especially for older individuals.

Also noteworthy are the development and application of new forms of psychological treatment for individuals with eating disorders. These include dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), and integrative cognitive-affective therapy (ICAT). Although only a few controlled studies have examined the effectiveness of these treatments, anecdotal information and the results of these studies suggest that such methods may be useful alternatives to more established interventions.

Conclusions

Eating disorders remain uncommon but clinically important problems characterized by persistent disturbances in eating or eating-related behavior. Cutting-edge research focuses on neurobiology and genetics, utilizing novel and rapidly evolving methodology. There have been modest advances in treatment approaches, including the COVID-19 pandemic’s acceleration of treatment delivery via video-link. Future studies will hopefully clarify the nature of ARFID and of atypical anorexia nervosa and lead to the development of more effective interventions, especially for individuals with long-standing eating disorders. ■

Additional Resources

Walsh BT. Diagnostic Categories for Eating Disorders: Current Status and What Lies Ahead. Psychiatr Clin North Am . 2019; 42(1):1-10.

Udo T, Grilo CM. Prevalence and Correlates of DSM-5 -Defined Eating Disorders in a Nationally Representative Sample of U.S. Adults. Biol Psychiatry . 2018; 84(5):345-354.

Van Hoeken D, Hoek HW. Review of the Burden of Eating Disorders: Mortality, Disability, Costs, Quality of Life, and Family Burden. Curr Opin Psychiatry . 2020; 33(6):521-527.

Bernardoni F, Geisler D, King JA, et al. Altered Medial Frontal Feedback Learning Signals in Anorexia Nervosa. Biol Psychiatry . 2018; 83(3):235-243.

Frank GKW, Shott ME, DeGuzman MC. The Neurobiology of Eating Disorders. Child Adolesc Psychiatr Clin N Am . 2019; 28(4):629-640.

Steinglass JE, Berner LA, Attia E. Cognitive Neuroscience of Eating Disorders. Psychiatr Clin North Am . 2019; 42(1):75-91.

Bulik CM, Blake L, Austin J. Genetics of Eating Disorders: What the Clinician Needs to Know. Psychiatr Clin North Am . 2019; 42(1):59-73.

Attia E, Steinglass JE, Walsh BT, et al. Olanzapine Versus Placebo in Adult Outpatients With Anorexia Nervosa: A Randomized Clinical Trial. Am J Psychiatry . 2019; 176(6):449-456.

Le Grange D, Hughes EK, Court A, et al. Randomized Clinical Trial of Parent-Focused Treatment and Family-Based Treatment for Adolescent Anorexia Nervosa. J Am Acad Child Adolesc Psychiatry . 2016; 55(8):683-92.

Pisetsky EM, Schaefer LM, Wonderlich SA, et al. Emerging Psychological Treatments in Eating Disorders. Psychiatr Clin North Am . 2019; 42:219-229.

B. Timothy Walsh, M.D., is a professor of psychiatry at the Columbia University Irving Medical Center and the founding director of the Columbia Center for Eating Disorders at the New York State Psychiatric Institute. He is the co-editor of the Handbook of Assessment and Treatment of Eating Disorders from APA Publishing.

Dr. Walsh reports receiving royalties or honoraria from UpToDate, McGraw-Hill, the Oxford University Press, the British Medical Journal, the Johns Hopkins Press, and Guidepoint Global

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Current discoveries and future implications of eating disorders.

1. Introduction

3. current discoveries of eating disorders, 3.1. anorexia nervosa (an), 3.2. bulimia nervosa (bn), 3.3. binge eating disorder (bed), 3.4. treatments of eating disorders, 4. discussion, 4.1. limitations of the current eating disorders research, 4.2. future direction of eating disorder research, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• Diaz-Marsa, M.; Alberdi-Paramo, I.; Niell-Galmes, L. Nutritional supplements in eating disorders. Actas Esp. Psiquiatr. 2017 , 45 , 26–36. [ Google Scholar ]
• Zipfel, S.; Schmidt, U.; Giel, K.E. The hidden burden of eating disorders during the COVID-19 pandemic. Lancet Psychiatry 2022 , 9 , 9–11. [ Google Scholar ] [ CrossRef ]
• Azzeh, M.; Peachey, G.; Loney, T. Prevalence of High-Risk Disordered Eating Amongst Adolescents and Young Adults in the Middle East: A Scoping Review. Int. J. Env. Res. Public. Health 2022 , 19 , 5234. [ Google Scholar ] [ CrossRef ]
• Rantala, M.J.; Luoto, S.; Krama, T.; Krams, I. Eating Disorders: An Evolutionary Psychoneuroimmunological Approach. Front. Psychol. 2019 , 10 , 2200. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• van Eeden, A.E.; van Hoeken, D.; Hoek, H.W. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Curr. Opin. Psychiatry 2021 , 34 , 515–524. [ Google Scholar ] [ CrossRef ]
• Hotzy, F.; Risch, L.; Motteli, S. Nutritional Needs in Mental Healthcare: Study Protocol of a Prospective Analytic Observational Study Assessing Nutritional Status, Eating Behavior and Barriers to Healthy Eating in Psychiatric Inpatients and Outpatients Compared to Healthy Adults. Front. Psychiatry 2022 , 13 , 906234. [ Google Scholar ] [ CrossRef ]
• Coelho, J.S.; Lee, T.; Karnabi, P.; Burns, A.; Marshall, S.; Geller, J.; Lam, P.Y. Eating disorders in biological males: Clinical presentation and consideration of sex differences in a pediatric sample. J. Eat. Disord. 2018 , 6 , 40. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Ragnhildstveit, A.; Slayton, M.; Jackson, L.K.; Brendle, M.; Ahuja, S.; Holle, W.; Moore, C.; Sollars, K.; Seli, P.; Robison, R. Ketamine as a Novel Psychopharmacotherapy for Eating Disorders: Evidence and Future Directions. Brain Sci. 2022 , 12 , 382. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Petropoulou, A.; Bakounaki, G.; Grammatikopoulou, M.G.; Bogdanos, D.P.; Goulis, D.G.; Vassilakou, T. Eating Disorders and Disordered Eating Behaviors in Cystic Fibrosis: A Neglected Issue. Children 2022 , 9 , 915. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Olguin, P.; Fuentes, M.; Gabler, G.; Guerdjikova, A.I.; Keck, P.E., Jr.; McElroy, S.L. Medical comorbidity of binge eating disorder. Eat. Weight. Disord. 2017 , 22 , 13–26. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Cena, H.; Vandoni, M.; Magenes, V.C.; Di Napoli, I.; Marin, L.; Baldassarre, P.; Luzzi, A.; De Pasquale, F.; Zuccotti, G.; Calcaterra, V. Benefits of Exercise in Multidisciplinary Treatment of Binge Eating Disorder in Adolescents with Obesity. Int. J. Env. Res. Public. Health 2022 , 19 , 8300. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Rendina-Ruedy, E.; Smith, B.J. Common Dietary Modifications in Preclinical Models to Study Skeletal Health. Front. Endocrinol 2022 , 13 , 932343. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Fontana, L.; Garzia, E.; Marfia, G.; Galiano, V.; Miozzo, M. Epigenetics of functional hypothalamic amenorrhea. Front. Endocrinol 2022 , 13 , 953431. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Frostad, S. Are the Effects of Malnutrition on the Gut Microbiota-Brain Axis the Core Pathologies of Anorexia Nervosa? Microorganisms 2022 , 10 , 1486. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Freizinger, M.; Recto, M.; Jhe, G.; Lin, J. Atypical Anorexia in Youth: Cautiously Bridging the Treatment Gap. Children 2022 , 9 , 837. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Pedreira, C.C.; Maya, J.; Misra, M. Functional hypothalamic amenorrhea: Impact on bone and neuropsychiatric outcomes. Front. Endocrinol 2022 , 13 , 953180. [ Google Scholar ] [ CrossRef ]
• Keeler, J.L.; Patsalos, O.; Chung, R.; Schmidt, U.; Breen, G.; Treasure, J.; Hubertus, H.; Dalton, B. Short communication: Serum levels of brain-derived neurotrophic factor and association with pro-inflammatory cytokines in acute and recovered anorexia nervosa. J. Psychiatr. Res. 2022 , 150 , 34–39. [ Google Scholar ] [ CrossRef ]
• Reyes-Haro, D. Glial cells in anorexia. Front. Cell Neurosci. 2022 , 16 , 983577. [ Google Scholar ] [ CrossRef ]
• Djogo, T.; Robins, S.C.; Schneider, S.; Kryzskaya, D.; Liu, X.; Mingay, A.; Gillon, C.J.; Kim, J.H.; Storch, K.F.; Boehm, U.; et al. Adult NG2-Glia Are Required for Median Eminence-Mediated Leptin Sensing and Body Weight Control. Cell Metab. 2016 , 23 , 797–810. [ Google Scholar ] [ CrossRef ]
• Frintrop, L.; Liesbrock, J.; Paulukat, L.; Johann, S.; Kas, M.J.; Tolba, R.; Heussen, N.; Neulen, J.; Konrad, K.; Herpertz-Dahlmann, B.; et al. Reduced astrocyte density underlying brain volume reduction in activity-based anorexia rats. World J. Biol. Psychiatry 2018 , 19 , 225–235. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Giel, K.; Zipfel, S.; Hallschmid, M. Oxytocin and Eating Disorders: A Narrative Review on Emerging Findings and Perspectives. Curr. Neuropharmacol. 2018 , 16 , 1111–1121. [ Google Scholar ] [ CrossRef ]
• Lafrance, V.; Inoue, W.; Kan, B.; Luheshi, G.N. Leptin modulates cell morphology and cytokine release in microglia. Brain Behav. Immun. 2010 , 24 , 358–365. [ Google Scholar ] [ CrossRef ]
• Cai, X.; Liu, H.; Feng, B.; Yu, M.; He, Y.; Liu, H.; Liang, C.; Yang, Y.; Tu, L.; Zhang, N.; et al. A D2 to D1 shift in dopaminergic inputs to midbrain 5-HT neurons causes anorexia in mice. Nat. Neurosci. 2022 , 25 , 646–658. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Sutton Hickey, A.K.; Duane, S.C.; Mickelsen, L.E.; Karolczak, E.O.; Shamma, A.M.; Skillings, A.; Li, C.; Krashes, M.J. AgRP neurons coordinate the mitigation of activity-based anorexia. Mol. Psychiatry 2022 , 28 , 1622–1635. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Plata-Salaman, C.R.; Sonti, G.; Borkoski, J.P.; Wilson, C.D.; French-Mullen, J.M. Anorexia induced by chronic central administration of cytokines at estimated pathophysiological concentrations. Physiol. Behav. 1996 , 60 , 867–875. [ Google Scholar ] [ CrossRef ]
• Casper, R.C. Restlessness and an Increased Urge to Move (Drive for Activity) in Anorexia Nervosa May Strengthen Personal Motivation to Maintain Caloric Restriction and May Augment Body Awareness and Proprioception: A Lesson From Leptin Administration in Anorexia Nervosa. Front. Psychol. 2022 , 13 , 885274. [ Google Scholar ] [ PubMed ]
• Hebebrand, J.; Hildebrandt, T.; Schlogl, H.; Seitz, J.; Denecke, S.; Vieira, D.; Gradl-Dietsch, G.; Peters, T.; Antel, J.; Lau, D.; et al. The role of hypoleptinemia in the psychological and behavioral adaptation to starvation: Implications for anorexia nervosa. Neurosci. Biobehav. Rev. 2022 , 141 , 104807. [ Google Scholar ] [ CrossRef ]
• Shobeiri, P.; Kalantari, A.; Teixeira, A.L.; Rezaei, N. Shedding light on biological sex differences and microbiota-gut-brain axis: A comprehensive review of its roles in neuropsychiatric disorders. Biol. Sex. Differ. 2022 , 13 , 12. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Russell, G. Bulimia nervosa: An ominous variant of anorexia nervosa. Psychol. Med. 1979 , 9 , 429–448. [ Google Scholar ] [ CrossRef ]
• Castillo, M.; Weiselberg, E. Bulimia Nervosa/Purging Disorder. Curr. Probl. Pediatr. Adolesc. Health Care 2017 , 47 , 85–94. [ Google Scholar ] [ CrossRef ]
• Wang, H.R.; Hu, S.W.; Zhang, S.; Song, Y.; Wang, X.Y.; Wang, L.; Li, Y.Y.; Yu, Y.M.; Liu, H.; Liu, D.; et al. KCNQ Channels in the Mesolimbic Reward Circuit Regulate Nociception in Chronic Pain in Mice. Neurosci. Bull. 2021 , 37 , 597–610. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Wang, L.; Bi, K.; An, J.; Li, M.; Li, K.; Kong, Q.M.; Li, X.N.; Lu, Q.; Si, T.M. Abnormal structural brain network and hemisphere-specific changes in bulimia nervosa. Transl. Psychiatry 2019 , 9 , 206. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Berner, L.A.; Simmons, A.N.; Wierenga, C.E.; Bischoff-Grethe, A.; Paulus, M.P.; Bailer, U.F.; Kaye, W.H. Altered anticipation and processing of aversive interoceptive experience among women remitted from bulimia nervosa. Neuropsychopharmacology 2019 , 44 , 1265–1273. [ Google Scholar ] [ CrossRef ]
• Monteleone, P.; Martiadis, V.; Colurcio, B.; Maj, M. Leptin secretion is related to chronicity and severity of the illness in bulimia nervosa. Psychosom. Med. 2002 , 64 , 874–879. [ Google Scholar ] [ PubMed ]
• Brewerton, T.D.; Lesem, M.D.; Kennedy, A.; Garvey, W.T. Reduced plasma leptin concentrations in bulimia nervosa. Psychoneuroendocrinology 2000 , 25 , 649–658. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Jimerson, D.C.; Mantzoros, C.; Wolfe, B.E.; Metzger, E.D. Decreased serum leptin in bulimia nervosa. J. Clin. Endocrinol. Metab. 2000 , 85 , 4511–4514. [ Google Scholar ] [ CrossRef ]
• Hu, Y.; Kang, Q.; Chen, C.; Guo, L.; Chen, J. Increased plasma asprosin levels are associated with overeating and loss of control in drug-free bulimia nervosa. Eat. Weight. Disord. 2022 , 27 , 2783–2789. [ Google Scholar ] [ CrossRef ]
• Mihov, Y.; Treyer, V.; Akkus, F.; Toman, E.; Milos, G.; Ametamey, S.M.; Johayem, A.; Hasler, G. Metabotropic glutamate receptor 5 in bulimia nervosa. Sci. Rep. 2020 , 10 , 6374. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Qiu, A.; Adler, M.; Crocetti, D.; Miller, M.I.; Mostofsky, S.H. Basal ganglia shapes predict social, communication, and motor dysfunctions in boys with autism spectrum disorder. J. Am. Acad. Child. Adolesc. Psychiatry 2010 , 49 , 539–551, 551.e1-4. [ Google Scholar ]
• Berner, L.A.; Wang, Z.; Stefan, M.; Lee, S.; Huo, Z.; Cyr, M.; Marsh, R. Subcortical Shape Abnormalities in Bulimia Nervosa. Biol. Psychiatry Cogn. Neurosci. Neuroimaging 2019 , 4 , 1070–1079. [ Google Scholar ] [ CrossRef ]
• Lecomte, A.; Zerrouk, A.; Sibeoni, J.; Khan, S.; Revah-Levy, A.; Lachal, J. The role of food in family relationships amongst adolescents with bulimia nervosa: A qualitative study using photo-elicitation. Appetite 2019 , 141 , 104305. [ Google Scholar ] [ CrossRef ]
• Hudson, J.I.; Hiripi, E.; Pope, H.G., Jr.; Kessler, R.C. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol. Psychiatry 2007 , 61 , 348–358. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• di Giacomo, E.; Aliberti, F.; Pescatore, F.; Santorelli, M.; Pessina, R.; Placenti, V.; Colmegna, F.; Clerici, M. Disentangling binge eating disorder and food addiction: A systematic review and meta-analysis. Eat. Weight. Disord. 2022 , 27 , 1963–1970. [ Google Scholar ] [ CrossRef ]
• Hilker, I.; Sanchez, I.; Steward, T.; Jimenez-Murcia, S.; Granero, R.; Gearhardt, A.N.; Rodriguez-Munoz, R.C.; Dieguez, C.; Crujeiras, A.B.; Tolosa-Sola, I.; et al. Food Addiction in Bulimia Nervosa: Clinical Correlates and Association with Response to a Brief Psychoeducational Intervention. Eur. Eat. Disord. Rev. 2016 , 24 , 482–488. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Imperatori, C.; Fabbricatore, M.; Vumbaca, V.; Innamorati, M.; Contardi, A.; Farina, B. Food Addiction: Definition, measurement and prevalence in healthy subjects and in patients with eating disorders. Riv. Psichiatr. 2016 , 51 , 60–65. [ Google Scholar ] [ PubMed ]
• Cao, X.; Xu, P.; Oyola, M.G.; Xia, Y.; Yan, X.; Saito, K.; Zou, F.; Wang, C.; Yang, Y.; Hinton, A., Jr.; et al. Estrogens stimulate serotonin neurons to inhibit binge-like eating in mice. J. Clin. Investig. 2014 , 124 , 4351–4362. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Val-Laillet, D.; Aarts, E.; Weber, B.; Ferrari, M.; Quaresima, V.; Stoeckel, L.E.; Alonso-Alonso, M.; Audette, M.; Malbert, C.H.; Stice, E. Neuroimaging and neuromodulation approaches to study eating behavior and prevent and treat eating disorders and obesity. Neuroimage Clin. 2015 , 8 , 1–31. [ Google Scholar ] [ CrossRef ]
• Xu, P.; He, Y.; Cao, X.; Valencia-Torres, L.; Yan, X.; Saito, K.; Wang, C.; Yang, Y.; Hinton, A., Jr.; Zhu, L.; et al. Activation of Serotonin 2C Receptors in Dopamine Neurons Inhibits Binge-like Eating in Mice. Biol. Psychiatry 2017 , 81 , 737–747. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Zhang, X.; van den Pol, A.N. Rapid binge-like eating and body weight gain driven by zona incerta GABA neuron activation. Science 2017 , 356 , 853–859. [ Google Scholar ] [ CrossRef ]
• Hildebrandt, B.A.; Ahmari, S.E. Breaking It Down: Investigation of Binge Eating Components in Animal Models to Enhance Translation. Front. Psychiatry 2021 , 12 , 728535. [ Google Scholar ] [ CrossRef ]
• Mineo, D.; Cacace, F.; Mancini, M.; Vannelli, A.; Campanelli, F.; Natale, G.; Marino, G.; Cardinale, A.; Calabresi, P.; Picconi, B.; et al. Dopamine drives binge-like consumption of a palatable food in experimental Parkinsonism. Mov. Disord. 2019 , 34 , 821–831. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Prins, K.; Huisman, M.; McLuskey, A.; Mies, R.; Karels, B.; Delhanty, P.J.D.; Visser, J.A. Ghrelin deficiency sex-dependently affects food intake, locomotor activity, and adipose and hepatic gene expression in a binge-eating mouse model. Am. J. Physiol. Endocrinol. Metab. 2022 , 322 , E494–E507. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Micioni Di Bonaventura, E.; Botticelli, L.; Del Bello, F.; Giorgioni, G.; Piergentili, A.; Quaglia, W.; Cifani, C.; Micioni Di Bonaventura, M.V. Assessing the role of ghrelin and the enzyme ghrelin O-acyltransferase (GOAT) system in food reward, food motivation, and binge eating behavior. Pharmacol. Res. 2021 , 172 , 105847. [ Google Scholar ] [ CrossRef ]
• Burmester, V.; Graham, E.; Nicholls, D. Physiological, emotional and neural responses to visual stimuli in eating disorders: A review. J. Eat. Disord. 2021 , 9 , 23. [ Google Scholar ] [ CrossRef ]
• Yu, Y.; Miller, R.; Groth, S.W. A literature review of dopamine in binge eating. J. Eat. Disord. 2022 , 10 , 11. [ Google Scholar ] [ CrossRef ]
• Alboni, S.; Micioni Di Bonaventura, M.V.; Benatti, C.; Giusepponi, M.E.; Brunello, N.; Cifani, C. Hypothalamic expression of inflammatory mediators in an animal model of binge eating. Behav. Brain Res. 2017 , 320 , 420–430. [ Google Scholar ] [ CrossRef ]
• Abbott, S.; Dindol, N.; Tahrani, A.A.; Piya, M.K. Binge eating disorder and night eating syndrome in adults with type 2 diabetes: A systematic review. J. Eat. Disord. 2018 , 6 , 36. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Harris, S.R.; Carrillo, M.; Fujioka, K. Binge-Eating Disorder and Type 2 Diabetes: A Review. Endocr. Pract. 2021 , 27 , 158–164. [ Google Scholar ] [ CrossRef ]
• Bryant, E.; Spielman, K.; Le, A.; Marks, P.; Touyz, S.; Maguire, S. Screening, assessment and diagnosis in the eating disorders: Findings from a rapid review. J. Eat. Disord. 2022 , 10 , 78. [ Google Scholar ] [ CrossRef ]
• Riva, G.; Malighetti, C.; Serino, S. Virtual reality in the treatment of eating disorders. Clin. Psychol. Psychother. 2021 , 28 , 477–488. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Quansah Amissah, R.; Basha, D.; Bukhtiyarova, O.; Timofeeva, E.; Timofeev, I. Neuronal activities during palatable food consumption in the reward system of binge-like eating female rats. Physiol. Behav. 2021 , 242 , 113604. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Abdelaal, M.; le Roux, C.W.; Docherty, N.G. Morbidity and mortality associated with obesity. Ann. Transl. Med. 2017 , 5 , 161. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Boye, K.S.; Ford, J.H.; Thieu, V.T.; Lage, M.J.; Terrell, K.A. The Association Between Obesity and the 5-Year Prevalence of Morbidity and Mortality Among Adults with Type 2 Diabetes. Diabetes Ther. 2023 , 14 , 709–721. [ Google Scholar ] [ CrossRef ]
• Lenz, M.; Richter, T.; Muhlhauser, I. The morbidity and mortality associated with overweight and obesity in adulthood: A systematic review. Dtsch. Arztebl. Int. 2009 , 106 , 641–648. [ Google Scholar ]
• Sambandam, S.; Bokhari, S.; Tsai, S.; Nathan, V.S.; Senthil, T.; Lanier, H.; Huerta, S. Morbidity and Mortality in Non-Obese Compared to Different Classes of Obesity in Patients Undergoing Transtibial Amputations. J. Clin. Med. 2022 , 12 , 267. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Rekkers, M.E.; Aardenburg, L.; Scheffers, M.; van Elburg, A.A.; van Busschbach, J.T. Shifting the Focus: A Pilot Study on the Effects of Positive Body Exposure on Body Satisfaction, Body Attitude, Eating Pathology and Depressive Symptoms in Female Patients with Eating Disorders. Int. J. Env. Res. Public. Health 2022 , 19 , 11794. [ Google Scholar ] [ CrossRef ]
• Navarro-Tapia, E.; Almeida-Toledano, L.; Sebastiani, G.; Serra-Delgado, M.; Garcia-Algar, O.; Andreu-Fernandez, V. Effects of Microbiota Imbalance in Anxiety and Eating Disorders: Probiotics as Novel Therapeutic Approaches. Int. J. Mol. Sci. 2021 , 22 , 2351. [ Google Scholar ] [ CrossRef ]
• Palmieri, S.; Mansueto, G.; Scaini, S.; Caselli, G.; Sapuppo, W.; Spada, M.M.; Sassaroli, S.; Ruggiero, G.M. Repetitive Negative Thinking and Eating Disorders: A Meta-Analysis of the Role of Worry and Rumination. J. Clin. Med. 2021 , 10 , 2448. [ Google Scholar ] [ CrossRef ]
• Barnes, R.D.; Ivezaj, V.; Martino, S.; Pittman, B.P.; Paris, M.; Grilo, C.M. Examining motivational interviewing plus nutrition psychoeducation for weight loss in primary care. J. Psychosom. Res. 2018 , 104 , 101–107. [ Google Scholar ] [ CrossRef ]
• Yohn, S.E.; Galbraith, J.; Calipari, E.S.; Conn, P.J. Shared Behavioral and Neurocircuitry Disruptions in Drug Addiction, Obesity, and Binge Eating Disorder: Focus on Group I mGluRs in the Mesolimbic Dopamine Pathway. ACS Chem. Neurosci. 2019 , 10 , 2125–2143. [ Google Scholar ] [ CrossRef ]
• Manasse, S.M.; Espel, H.M.; Forman, E.M.; Ruocco, A.C.; Juarascio, A.S.; Butryn, M.L.; Zhang, F.; Lowe, M.R. The independent and interacting effects of hedonic hunger and executive function on binge eating. Appetite 2015 , 89 , 16–21. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Sultson, H.; Kreegipuu, K.; Akkermann, K. Exploring the role of momentary positive and negative affect in overeating and binge eating: Evidence for different associations among men and women. Appetite 2022 , 168 , 105758. [ Google Scholar ] [ CrossRef ]
• Guerdjikova, A.I.; Mori, N.; Casuto, L.S.; McElroy, S.L. Novel pharmacologic treatment in acute binge eating disorder-role of lisdexamfetamine. Neuropsychiatr. Dis. Treat. 2016 , 12 , 833–841. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Schneider, E.; Martin, E.; Rotshtein, P.; Qureshi, K.L.; Chamberlain, S.R.; Spetter, M.S.; Dourish, C.T.; Higgs, S. The effects of lisdexamfetamine dimesylate on eating behaviour and homeostatic, reward and cognitive processes in women with binge-eating symptoms: An experimental medicine study. Transl. Psychiatry 2022 , 12 , 9. [ Google Scholar ] [ CrossRef ]
• Heal, D.J.; Gosden, J. What pharmacological interventions are effective in binge-eating disorder? Insights from a critical evaluation of the evidence from clinical trials. Int. J. Obes. 2022 , 46 , 677–695. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Heal, D.J.; Smith, S.L. Prospects for new drugs to treat binge-eating disorder: Insights from psychopathology and neuropharmacology. J. Psychopharmacol. 2022 , 36 , 680–703. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Romano, A.; Micioni Di Bonaventura, M.V.; Gallelli, C.A.; Koczwara, J.B.; Smeets, D.; Giusepponi, M.E.; De Ceglia, M.; Friuli, M.; Micioni Di Bonaventura, E.; Scuderi, C.; et al. Oleoylethanolamide decreases frustration stress-induced binge-like eating in female rats: A novel potential treatment for binge eating disorder. Neuropsychopharmacology 2020 , 45 , 1931–1941. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Dakanalis, A.; Clerici, M.; Stice, E. Prevention of eating disorders: Current evidence-base for dissonance-based programmes and future directions. Eat. Weight. Disord. 2019 , 24 , 597–603. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Touyz, S.; Hay, P. The future of eating disorders research: An editorial. J. Eat. Disord. 2022 , 10 , 10. [ Google Scholar ] [ CrossRef ]
• Jagielska, G.; Kacperska, I. Outcome, comorbidity and prognosis in anorexia nervosa. Psychiatr. Pol. 2017 , 51 , 205–218. [ Google Scholar ] [ CrossRef ]
• Chatelet, S.; Wang, J.; Gjoertz, M.; Lier, F.; Monney Chaubert, C.; Ambresin, A.E. Factors associated with weight gain in anorexia nervosa inpatients. Eat. Weight. Disord. 2020 , 25 , 939–950. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Van Huysse, J.L.; Smith, K.; Mammel, K.A.; Prohaska, N.; Rienecke, R.D. Early weight gain predicts treatment response in adolescents with anorexia nervosa enrolled in a family-based partial hospitalization program. Int. J. Eat. Disord. 2020 , 53 , 606–610. [ Google Scholar ] [ CrossRef ]
• Loomes, R.; Bryant-Waugh, R. Widening the reach of family-based interventions for Anorexia Nervosa: Autism-adaptations for children and adolescents. J. Eat. Disord. 2021 , 9 , 157. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Monteleone, A.M.; Pellegrino, F.; Croatto, G.; Carfagno, M.; Hilbert, A.; Treasure, J.; Wade, T.; Bulik, C.M.; Zipfel, S.; Hay, P.; et al. Treatment of eating disorders: A systematic meta-review of meta-analyses and network meta-analyses. Neurosci. Biobehav. Rev. 2022 , 142 , 104857. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Leppanen, J.; Cardi, V.; Ng, K.W.; Paloyelis, Y.; Stein, D.; Tchanturia, K.; Treasure, J. The effects of intranasal oxytocin on smoothie intake, cortisol and attentional bias in anorexia nervosa. Psychoneuroendocrinology 2017 , 79 , 167–174. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Schwenzer, C.; Voelz, C.; Kogel, V.; Schlosser, A.; Herpertz-Dahlmann, B.; Beyer, C.; Seitz, J.; Trinh, S. Fear and food: Anxiety-like behavior and the susceptibility to weight loss in an activity-based anorexia rat model. Clin. Transl. Sci. 2022 , 15 , 889–898. [ Google Scholar ] [ CrossRef ]
• Sorrentino, D.; Mucci, A.; Merlotti, E.; Galderisi, S.; Maj, M. Modified nutritional counselling to increase motivation to treatment in anorexia nervosa. Eur. Psychiatry 2005 , 20 , 186–187. [ Google Scholar ] [ CrossRef ]
• Gruber, M.; Konig, D.; Holzhauser, J.; Castillo, D.M.; Bluml, V.; Jahn, R.; Leser, C.; Werneck-Rohrer, S.; Werneck, H. Parental feeding practices and the relationship with parents in female adolescents and young adults with eating disorders: A case control study. PLoS ONE 2020 , 15 , e0242518. [ Google Scholar ] [ CrossRef ]
• Cassioli, E.; Rossi, E.; Vizzotto, C.; Malinconi, V.; Vignozzi, L.; Ricca, V.; Castellini, G. Avoidant Attachment Style Moderates the Recovery of Healthy Sexuality in Women With Anorexia Nervosa Treated With Enhanced Cognitive Behavior Therapy (CBT-E): A 2-Year Follow-Up Study. J. Sex. Med. 2022 , 19 , 347–355. [ Google Scholar ] [ CrossRef ]
• Catone, G.; Salerno, F.; Muzzo, G.; Lanzara, V.; Gritti, A. Association between anorexia nervosa and other specified eating or feeding disorders and paranoia in adolescents: What factors are involved? Riv. Psichiatr. 2021 , 56 , 100–106. [ Google Scholar ]
• Powers, P.S.; Bruty, H. Pharmacotherapy for eating disorders and obesity. Child. Adolesc. Psychiatr. Clin. N. Am. 2009 , 18 , 175–187. [ Google Scholar ] [ CrossRef ]
• Dalle Grave, R.; El Ghoch, M.; Sartirana, M.; Calugi, S. Cognitive Behavioral Therapy for Anorexia Nervosa: An Update. Curr. Psychiatry Rep. 2016 , 18 , 2. [ Google Scholar ] [ CrossRef ]
• Kaa, B.S.; Bunemann, J.M.N.; Clausen, L. A benchmark study of a combined individual and group anorexia nervosa therapy program. Nord. J. Psychiatry 2022 , 77 , 447–454. [ Google Scholar ] [ CrossRef ]
• de Vos, J.; Houtzager, L.; Katsaragaki, G.; van de Berg, E.; Cuijpers, P.; Dekker, J. Meta analysis on the efficacy of pharmacotherapy versus placebo on anorexia nervosa. J. Eat. Disord. 2014 , 2 , 27. [ Google Scholar ] [ CrossRef ]
• Berner, L.A.; Brown, T.A.; Lavender, J.M.; Lopez, E.; Wierenga, C.E.; Kaye, W.H. Neuroendocrinology of reward in anorexia nervosa and bulimia nervosa: Beyond leptin and ghrelin. Mol. Cell Endocrinol. 2019 , 497 , 110320. [ Google Scholar ] [ CrossRef ]
• Harrington, B.C.; Jimerson, M.; Haxton, C.; Jimerson, D.C. Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. Am. Fam. Physician 2015 , 91 , 46–52. [ Google Scholar ] [ PubMed ]
• Agras, W.S.; Bohon, C. Cognitive Behavioral Therapy for the Eating Disorders. Annu. Rev. Clin. Psychol. 2021 , 17 , 417–438. [ Google Scholar ] [ CrossRef ]
• Stabouli, S.; Erdine, S.; Suurorg, L.; Jankauskiene, A.; Lurbe, E. Obesity and Eating Disorders in Children and Adolescents: The Bidirectional Link. Nutrients 2021 , 13 , 4321. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Bello, N.T.; Yeomans, B.L. Safety of pharmacotherapy options for bulimia nervosa and binge eating disorder. Expert. Opin. Drug Saf. 2018 , 17 , 17–23. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Crow, S.J. Pharmacologic Treatment of Eating Disorders. Psychiatr. Clin. North. Am. 2019 , 42 , 253–262. [ Google Scholar ] [ CrossRef ]
• Klein, D.A.; Sylvester, J.E.; Schvey, N.A. Eating Disorders in Primary Care: Diagnosis and Management. Am. Fam. Physician 2021 , 103 , 22–32. [ Google Scholar ]
• Denman, E.; Parker, E.K.; Ashley, M.A.; Harris, D.M.; Halaki, M.; Flood, V.; Stefoska-Needham, A. Understanding training needs in eating disorders of graduating and new graduate dietitians in Australia: An online survey. J. Eat. Disord. 2021 , 9 , 27. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Hay, P.; Palavras, M.A.; da Luz, F.Q.; Dos Anjos Garnes, S.; Sainsbury, A.; Touyz, S.; Appolinario, J.C.; Claudino, A.M. Physical and mental health outcomes of an integrated cognitive behavioural and weight management therapy for people with an eating disorder characterized by binge eating and a high body mass index: A randomized controlled trial. BMC Psychiatry 2022 , 22 , 355. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Brownley, K.A.; Berkman, N.D.; Peat, C.M.; Lohr, K.N.; Cullen, K.E.; Bann, C.M.; Bulik, C.M. Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis. Ann. Intern. Med. 2016 , 165 , 409–420. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Mathisen, T.F.; Rosenvinge, J.H.; Friborg, O.; Vrabel, K.; Bratland-Sanda, S.; Pettersen, G.; Sundgot-Borgen, J. Is physical exercise and dietary therapy a feasible alternative to cognitive behavior therapy in treatment of eating disorders? A randomized controlled trial of two group therapies. Int. J. Eat. Disord. 2020 , 53 , 574–585. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Walenda, A.; Bogusz, K.; Kopera, M.; Jakubczyk, A.; Wojnar, M.; Kucharska, K. Emotion regulation in binge eating disorder. Psychiatr. Pol. 2021 , 55 , 1433–1448. [ Google Scholar ] [ CrossRef ]
• Schneider, E.; Higgs, S.; Dourish, C.T. Lisdexamfetamine and binge-eating disorder: A systematic review and meta-analysis of the preclinical and clinical data with a focus on mechanism of drug action in treating the disorder. Eur. Neuropsychopharmacol. 2021 , 53 , 49–78. [ Google Scholar ] [ CrossRef ]
• Costa, M.B.; Melnik, T. Effectiveness of psychosocial interventions in eating disorders: An overview of Cochrane systematic reviews. Einstein 2016 , 14 , 235–277. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Karam, A.M.; Fitzsimmons-Craft, E.E.; Tanofsky-Kraff, M.; Wilfley, D.E. Interpersonal Psychotherapy and the Treatment of Eating Disorders. Psychiatr. Clin. 2019 , 42 , 205–218. [ Google Scholar ] [ CrossRef ]
• Forrest, L.N.; Franko, D.L.; Thompson-Brenner, H.; Grilo, C.M. Examining changes in binge-eating disorder network centrality and structure in patients treated with cognitive-behavioral therapy versus interpersonal psychotherapy. Int. J. Eat. Disord. 2022 , 56 , 944–955. [ Google Scholar ] [ CrossRef ]
• Grilo, C.M.; Reas, D.L.; Mitchell, J.E. Combining Pharmacological and Psychological Treatments for Binge Eating Disorder: Current Status, Limitations, and Future Directions. Curr. Psychiatry Rep. 2016 , 18 , 55. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Garvey, W.T.; Mechanick, J.I.; Brett, E.M.; Garber, A.J.; Hurley, D.L.; Jastreboff, A.M.; Nadolsky, K.; Pessah-Pollack, R.; Plodkowski, R. Reviewers of the AACEOCPG American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr. Pract. 2016 , 22 (Suppl. S3), 1–203. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Safer, D.L.; Adler, S.; Dalai, S.S.; Bentley, J.P.; Toyama, H.; Pajarito, S.; Najarian, T. A randomized, placebo-controlled crossover trial of phentermine-topiramate ER in patients with binge-eating disorder and bulimia nervosa. Int. J. Eat. Disord. 2020 , 53 , 266–277. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Adams, G.; Turner, H.; Hoskins, J.; Robinson, A.; Waller, G. Effectiveness of a brief form of group dialectical behavior therapy for binge-eating disorder: Case series in a routine clinical setting. Int. J. Eat. Disord. 2021 , 54 , 615–620. [ Google Scholar ] [ CrossRef ]
• Carter, J.C.; Kenny, T.E.; Singleton, C.; Van Wijk, M.; Heath, O. Dialectical behavior therapy self-help for binge-eating disorder: A randomized controlled study. Int. J. Eat. Disord. 2020 , 53 , 451–460. [ Google Scholar ] [ CrossRef ]
• Lammers, M.W.; Vroling, M.S.; Crosby, R.D.; van Strien, T. Dialectical behavior therapy compared to cognitive behavior therapy in binge-eating disorder: An effectiveness study with 6-month follow-up. Int. J. Eat. Disord. 2022 , 55 , 902–913. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Duan, H.; Zhu, L.; Li, M.; Zhang, X.; Zhang, B.; Fang, S. Comparative efficacy and acceptability of selective serotonin reuptake inhibitor antidepressants for binge eating disorder: A network meta-analysis. Front. Pharmacol. 2022 , 13 , 949823. [ Google Scholar ] [ CrossRef ]
• Amodeo, G.; Cuomo, A.; Bolognesi, S.; Goracci, A.; Trusso, M.A.; Piccinni, A.; Neal, S.M.; Baldini, I.; Federico, E.; Taddeucci, C.; et al. Pharmacotherapeutic strategies for treating binge eating disorder. Evidence from clinical trials and implications for clinical practice. Expert Opin. Pharmacother. 2019 , 20 , 679–690. [ Google Scholar ] [ CrossRef ]
• Spalding, W.M.; Bertoia, M.L.; Bulik, C.M.; Seeger, J.D. Treatment characteristics among patients with binge-eating disorder: An electronic health records analysis. Postgrad. Med. 2022 , 135 , 254–264. [ Google Scholar ] [ CrossRef ]
• Guerdjikova, A.I.; Williams, S.; Blom, T.J.; Mori, N.; McElroy, S.L. Combination Phentermine-Topiramate Extended Release for the Treatment of Binge Eating Disorder: An Open-Label, Prospective Study. Innov. Clin. Neurosci. 2018 , 15 , 17–21. [ Google Scholar ]
• Fardouly, J.; Crosby, R.D.; Sukunesan, S. Potential benefits and limitations of machine learning in the field of eating disorders: Current research and future directions. J. Eat. Disord. 2022 , 10 , 66. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Haghshomar, M.; Shobeiri, P.; Brand, S.; Rossell, S.L.; Akhavan Malayeri, A.; Rezaei, N. Changes of symptoms of eating disorders (ED) and their related psychological health issues during the COVID-19 pandemic: A systematic review and meta-analysis. J. Eat. Disord. 2022 , 10 , 51. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Gorrell, S.; Reilly, E.E.; Brosof, L.; Le Grange, D. Use of Telehealth in the Management of Adolescent Eating Disorders: Patient Perspectives and Future Directions Suggested from the COVID-19 Pandemic. Adolesc. Health Med. Ther. 2022 , 13 , 45–53. [ Google Scholar ] [ CrossRef ] [ PubMed ]

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Feng, B.; Harms, J.; Chen, E.; Gao, P.; Xu, P.; He, Y. Current Discoveries and Future Implications of Eating Disorders. Int. J. Environ. Res. Public Health 2023 , 20 , 6325. https://doi.org/10.3390/ijerph20146325

Feng B, Harms J, Chen E, Gao P, Xu P, He Y. Current Discoveries and Future Implications of Eating Disorders. International Journal of Environmental Research and Public Health . 2023; 20(14):6325. https://doi.org/10.3390/ijerph20146325

Feng, Bing, Jerney Harms, Emily Chen, Peiyu Gao, Pingwen Xu, and Yanlin He. 2023. "Current Discoveries and Future Implications of Eating Disorders" International Journal of Environmental Research and Public Health 20, no. 14: 6325. https://doi.org/10.3390/ijerph20146325

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Peer-reviewed

Research Article

40 years of research on eating disorders in domain-specific journals: Bibliometrics, network analysis, and topic modeling

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Perú

• Carlos A. Almenara

• Published: December 15, 2022
• https://doi.org/10.1371/journal.pone.0278981
• Peer Review
• Reader Comments

Previous studies have used a query-based approach to search and gather scientific literature. Instead, the current study focused on domain-specific journals in the field of eating disorders. A total of 8651 documents (since 1981 to 2020), from which 7899 had an abstract, were retrieved from: International Journal of Eating Disorders (n = 4185, 48.38%), Eating and Weight Disorders (n = 1540, 17.80%), European Eating Disorders Review (n = 1461, 16.88%), Eating Disorders (n = 1072, 12.39%), and Journal of Eating Disorders (n = 393, 4.54%). To analyze these data, diverse methodologies were employed: bibliometrics (to identify top cited documents), network analysis (to identify the most representative scholars and collaboration networks), and topic modeling (to retrieve major topics using text mining, natural language processing, and machine learning algorithms). The results showed that the most cited documents were related to instruments used for the screening and evaluation of eating disorders, followed by review articles related to the epidemiology, course and outcome of eating disorders. Network analysis identified well-known scholars in the field, as well as their collaboration networks. Finally, topic modeling identified 10 major topics whereas a time series analysis of these topics identified relevant historical shifts. This study discusses the results in terms of future opportunities in the field of eating disorders.

Citation: Almenara CA (2022) 40 years of research on eating disorders in domain-specific journals: Bibliometrics, network analysis, and topic modeling. PLoS ONE 17(12): e0278981. https://doi.org/10.1371/journal.pone.0278981

Editor: Alberto Baccini, University of Siena, Italy, ITALY

Received: February 5, 2021; Accepted: November 27, 2022; Published: December 15, 2022

Copyright: © 2022 Carlos A. Almenara. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data that support the findings of this study are publicly available from the OSF repository: https://osf.io/5yzvd/ (DOI: 10.17605/OSF.IO/5YZVD ).

Funding: Funding for this study was obtained from Universidad Peruana de Ciencias Aplicadas (A-006-2021).

Competing interests: The author has no competing interest to declare.

Introduction

There are a large and growing number of scientific publications on eating disorders (ED) [ 1 – 3 ]. ED are mental disorders characterized by a continuous disturbance in eating behavior, such as Anorexia Nervosa [ 4 ]. ED are usually defined according to manuals like the Diagnostic and Statistical Manual of Mental Disorders (DSM) [ 4 ]. The spectrum of ED can share some symptoms (e.g., fear of fatness ), and these symptoms negatively impact psychosocial functioning and physical health. Due to the complexity of ED like Anorexia Nervosa, scholar literature about them covers different disciplines, such as ED related to: visual arts (e.g., art history) [ 5 ], sociology (e.g., social history) [ 6 ] and even dentistry (e.g., oral health) [ 7 ]. Thus, ED literature has a broad diversity.

Previous bibliometric studies about ED have focused on: identifying the distribution by language, region and country, as well as topics and their trends [ 1 ], productivity trends and collaboration patterns [ 2 ], most cited works in Anorexia Nervosa research [ 8 ], cross-cultural aspects of ED [ 3 ], comparison of citations between types of journals [ 9 ], female authorship [ 10 ], secular trends in the scientific terminology [ 11 , 12 ], the gap between scientific research and clinical practice [ 13 ], the use of keywords [ 14 ], and network analyses of common terms used in the field [ 15 ]. In particular, the current study complements the work by He et al. [ 1 ].

A standard practice of these studies is to retrieve the literature by performing a systematic search in databases like Web of Science or Scopus (i.e., employing a query-based approach), although there are some caveats worth mentioning. As noted elsewhere [ 16 , 17 ], those two databases differ in journal coverage and their use can introduce bias favoring science publications (e.g., biomedicine) in detriment of arts and humanities, other than overrepresenting English-language journals. Second, databases in general (including others like PubMed, Dimensions, JSTOR), differ in their search engine functionality and information retrieval capabilities.

For example, some databases offer a controlled vocabulary like a thesaurus or taxonomy from which to choose the search terms (e.g., the Medical Subject Headings [MeSH] in PubMed), whereas others offer a full text search. Regarding the latter, indexing scanned documents to offer a full text search, requires pre-processing methods like optical character recognition (OCR), known to include typos, and post-OCR processing, both affecting information retrieval accuracy [ 18 – 23 ].

In other words, a query-based approach, although widely used, can be affected by several factors, including: domain expertise to design the most appropriate search strategy, the characteristics of the selected database(s), including indexation accuracy (e.g., due to OCR typos). The former is particularly important because scholars are not always consistent in using the terminology [ 24 ]. In fact, their selection of keywords is not systematic, but rather influenced by factors like their background knowledge and previous experience [ 25 ]. In this regard, within the field of ED, scholars are encouraged to use appropriate terminology [ 26 , 27 ], usually a controlled vocabulary such as the Thesaurus of Psychological Index Terms. This helps to optimize the Knowledge Organization Systems (KOS) of journals and databases, such as a controlled vocabulary for information retrieval [ 14 , 28 ].

In sum, most previous studies have employed a query-based search, being compelled to choose among different databases, search terms, and search strategies [ 29 ]. Nevertheless, this approach not necessarily recognizes the boundaries and limitations of both databases and we as humans interacting with machines, using diverse information retrieval strategies, and dealing with information overload [ 30 , 31 ].

An alternative to the query-based approach is the one proposed in this study: to select a set of specialty journals exclusively devoted to the study of ED. Although this sampling could seem arbitrary, it was adopted: (1) to complement the findings of previous studies [ 1 , 2 ] and (2) because it has in fact a sound base: the intellectual and social structure of knowledge [ 32 – 36 ]. We must recognize that documents need to be understood with regard to "the broader contexts in which they are produced, used, and cited" [ 37 , p. 42]. Thus, the following sections will explain how domain-specific journals are tightly tied to an organized social and disciplinary structure. Moreover, I will explain how this approach does not necessarily exclude all ED literature from non-domain-specific journals, but rather incorporates part of it into their citations. Finally, from a complex systems perspective, I will show how domain-specific journals can be conceived as a specialized subset from the larger and more complex network comprising all ED literature.

Domain-specific journals and its social structure

From a scientometric perspective, science, metaphorically conceived as a knowledge space or knowledge landscapes , can be defined in terms of a network of scholars that produce a network of knowledge [ 35 ]. In the former case, the social function of science has long been recognized (e.g., by Thomas Kuhn): scholars produce and communicate scientific knowledge and this organized activity has the characteristics of a social process [ 36 , 38 ]. More importantly, the patterns of interactions and communication within this social organization are tightly tied, rather than isolated, to the knowledge they produce [ 36 ].

An exemplary case is the role of journal editors as gatekeepers, with studies identifying editorial gatekeeping patterns [ 39 , 40 ]. According with the Network Gatekeeping Theory, inspired by the work of Kurt Lewin, gatekeeping refers to the control in the flow of information [ 41 , 42 ]. In the field of ED, this intellectual and social organization of knowledge can be seen in professional societies like the Academy of Eating Disorder, which since 1981 publishes the most renowned scientific journal: The International Journal of Eating Disorders. Within its editorial board, there are distinguished scholars that can act as gatekeepers to ensure quality control and that manuscripts published by the journal are in line with the aims and scope of it.

In sum, domain-specific journals have the goal of publishing information within the boundaries of their aims and scope, allowing the diffusion of specialized knowledge.

Domain-specific journals and its disciplinary organization

From a network perspective, specialty journals are also indicators of disciplinary organization [ 43 ], which exerts a non-trivial influence at both the global and local level of the network. To be more precise, if we visualize a network [e.g., 2 , 44 , 45 ], the local density of specialty journals evidence emerging patterns such as citation patterns by articles from the same journal or group of journals [ 43 ]. At the author level, these patterns reflect the local influence of specialty journals on scholars who adhere to their research tradition and their contributions help to advance a research agenda [ 46 ].

For example, domain-specific journals on ED often publish curated information from conferences [e.g., 47 ] or special issues about a specialized topic [e.g., 48 ], which commonly include a research agenda [ 48 ], setting the stage for future research. As we mentioned above, similar literature, such as special issues about ED published in other journals [e.g., 49 ], is not necessarily excluded in the analysis of domain-specific journals. Rather, such literature is commonly cited in documents from domain-specific journals and can be included in a citation analysis. Importantly, these citation patterns suggest that the former intellectual and social structure of knowledge constrains what is being studied in the future [ 46 ]. Thus, in the upcoming years, most of this specialized literature is expected to become an active research front [ 32 ], as evidenced by its high number of citations.

Finally, it is worth mentioning that the analysis of these patterns can reveal latent hierarchies and topological properties of journal networks. In fact, domain-specific journals can be identified through the study of the hierarchical organization of journal networks. When hierarchical network analysis is used to identify the capability of journals to spread scientific ideas, multidisciplinary journals are found at the top of the hierarchy, whereas more specialized journals are found at the bottom [ 50 , 51 ]. Similarly, significant articles from a specific domain have unique topological properties that can affect the dynamic evolution of the network [ 52 ]. In sum, it is important to recognize the topological properties of networks and their latent hierarchies, both at the journal level and document level. In our case, focusing on domain-specific journals, it would be like zooming into the most central part (core) of the network topology to analyze its organization and distinctive features. Indeed, this approach is commonly employed, for example, when studying network subsets such as niches or communities in complex systems.

Domain-specific journals and complex adaptive systems

Domain-specific journals can also be comprehended from a complex systems standpoint, as the aggregation of the intellectual, social, and citation patterns outlined above. According to the Structural Variation Theory [ 53 ], the body of scientific knowledge can be conceived as a complex adaptive system (CAS). As such, it can be described and studied as a complex network with a series of characteristics like non-linearity, emergence, and self-organization; and a series of social, conceptual, and material elements that evolve over time [ 46 ]. Ideally, we must study CAS holistically to understand the properties of the system at the macrolevel [ 54 ]. In our case, this would require including all scholar literature on ED, which could be attempted using a query-based approach and employing ad hoc methodologies (e.g., iterative citation expansion) [ 45 ]. However, complex systems emerge from rules and behavior of lower-level components, and there is growing interest in understanding complexity from its simplest and fundamental elements and patterns [ 55 , 56 ]. In our case, this can be accomplished by zooming into domain-specific patterns that emerge from the relational structure and organization of journals and papers [ 46 ], rather than focusing on the whole system which comprises all the scientific literature on ED.

This approach can be described in terms of modularity , a structural property of systems: the local density of specialty journals is indicative of a structural module or subsystem [ 57 ]. This property of complex systems is important because it recognizes, as we did above, the existence of subsets within networks. Indeed, scientometric studies usually attempt to detect communities based on the principle of modularity by grouping similar literature (i.e., clustering) [ 44 , 58 ]. However, in the approach used in this study, rather than using bibliographic connections (e.g., through co-citation analysis) to detect domain-specific literature, we can use logical connections [ 59 ], to identify modules that operate as domain-specific representations [ 60 ]. In other words, domain-specific journals can be seen as clusters of articles that are logically linked because they all pertain to a given domain, which is explicitly stated in the aims and scope of the journals.

This modular organization has some advantages over others such as a hierarchy (e.g., Scimago categorization of journals) or a cluster obtained by literature partitioning algorithms. First, it has the advantage of reducing both complexity bias and hierarchical bias . The former is the tendency to assume and adopt a more complex system (the opposite to Occam’s Razor: prefer the simplest explanation), which means to analyze all ED literature. The latter assumes that behavior is directed in a hierarchical fashion, where a central authority passes instructions to all agents in the system [ 54 ]. Second, although it still recognizes a hierarchical structure composed by diverse classes of subsystems, it assumes heterarchy [ 43 , 61 ], which means that both hierarchical and nonhierarchical elements can be present in a system; holarchy , which means that systems are composed of components that can be recognized as subsystems [ 62 ]; and glocal control , which means that local and global phenomena in a system are achieved by local actions [ 63 ]. In simple words, sampling a set of domain-specific journals reduces complexity without affecting assumptions such as a categorical hierarchy of journals.

The current study

To expand on previous studies [ 1 , 2 ], the current study aims to answer the following research questions:

Which are the most cited documents in this domain-specific corpus of articles?

Which are the most important authors and their collaboration networks?

Which are the most relevant topics in this domain-specific corpus of articles?

How have the identified topics evolved over time (since 1981 to 2020)?

To answer these questions, this study employs a hybrid methodology. First, basic bibliometrics will be performed to identify the most cited documents. Second, network analysis will be employed to identify the most important authors and their networks of collaboration. Third, text mining, natural language processing, and machine learning algorithms will be used to identify the most relevant topics (i.e., topic modeling). Finally, a simple time series analysis will be performed to examine the evolution of these topics over time. The procedure employed for the analyses is detailed in the methods section below (and S5 File ), whereas the dataset and the code to perform the analyses are shared in a public repository ( https://doi.org/10.17605/OSF.IO/5YZVD ), allowing the reproducibility of results [ 64 ].

Data collection

The methodology workflow is presented in Fig 1 .

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https://doi.org/10.1371/journal.pone.0278981.g001

First, in May 2020, a search of journals was performed in Scimago Journal Reports (SJR, https://www.scimagojr.com/ ), using the term “eating disorders”. In this step, the following five journals were identified: International Journal of Eating Disorders (ISSNs: 0276–3478, 1098-108X), European Eating Disorders Review (ISSNs: 1072–4133, 1099–0968), Eating Disorders (ISSNs: 1064–0266, 1532-530X), Eating and Weight Disorders (ISSNs: 1124–4909, 1590–1262), and Journal of Eating Disorders (ISSN: 2050-2974). The official website of each journal was then visited to confirm that the scope of the journal specifically includes the publication of research articles on eating disorders. It should be noted that the journal Advances in Eating Disorders (ISSNs: 2166–2630, 2166–2649) was not included because it was not found in SJR, it was published only between 2013 and 2016, it was incorporated into the journal Eating Disorders , and by the time of writing this article, it was not indexed neither in Scopus ( https://www.scopus.com ) nor in Web of Science ( https://www.webofknowledge.com ).

Next, also in May 2020, the Scopus database was chosen to retrieve the document records from the aforementioned journals. The election was made for no other reason than the capability of Scopus to retrieve several structured information (metadata, such as the abstract), and the file types for download are easy to manage, such as comma-separated values (CSV). Therefore, all document records published by these journals were searched in Scopus using the ISSN as the search term (e.g., ISSN (0276–3478) OR ISSN (02763478) OR ISSN (1098-108X) OR ISSN (1098108X) ). A total of 8651 documents between 1981 and 2020 were retrieved (of which 7899 had an abstract): 4185 (48.38%) from the International Journal of Eating Disorders, 1540 (17.80%) from Eating and Weight Disorders, 1461 (16.88%) from the European Eating Disorders Review, 1072 (12.39%) from Eating Disorders, and 393 (4.54%) from the Journal of Eating Disorders. These 8651 documents included a total of 213,744 references. It should be noted that the International Journal of Eating Disorders is the oldest of these journals, established in 1981. The S7 and S8 Files provide the number of documents per year and per journal. The document records were downloaded from Scopus both as comma separated values (CSV) and as BibTex ( http://www.bibtex.org/ ), and selecting all fields available (i.e., title, author, abstract, etc.). Due to copyright, the full text of all documents was not retrieved but rather their metadata (i.e, title, author, date, abstract), whilst the dataset shared online ( https://doi.org/10.17605/OSF.IO/5YZVD ) is the one obtained after the preprocessing procedures detailed below.

Analyses were performed using open software: R Statistical Software 4.0.3 (Bunny-Wunnies Freak Out) [ 65 ], and Python programming language version 3.9.1 ( https://www.python.org/ ).

Bibliometric analysis and network analysis in R

The biblioshiny application from the R package bibliometrix [ 66 ] was used to preprocess the CSV file. Next, it was used to identify the most cited documents. Local citations (i.e., citations only from documents whithin the dataset), and global citations (i.e., citations made by any document from the whole Scopus database), were computed. Biblioshiny was also used for network analysis as described by Batagelj & Cerinšek [ 67 ], and Aria & Cuccurullo [ 66 ]. Regarding the network, it is defined as a pair of sets: a set of nodes or vertices and a set of edges (link between nodes) [ 68 ]. In this study, when authors were treated as nodes, a link would represent co-authorship or collaboration [see 69 ]. More precisely, the Louvain algorithm for community detection [ 70 ] was used to identify communities within the collaboration network. This algorithm identifies densely connected nodes within the network (i.e., communities) [e.g., 71 ]. It works unconstrained to automatically extract a number of clusters although it requires basic network parameters as input. These network parameters were: up to 100 nodes, a minimum of two edges by node, and the removal of isolated nodes. For network layout visualization, the Fruchterman & Reingold [ 72 ] algorithm was chosen. Finally, common centrality measures were calculated: betweenness, closeness, and PageRank. Betweenness centrality refers to “the frequency that a node is located in the shortest path between other nodes” [ 73 , p. 772]. Closeness centrality refers to nodes that can easily reach others in the network, whilst PageRank , originally created to rank websites [ 74 ], has been used to rank authors because it takes into account the weight of influential nodes [ 75 ].

Topic modeling: Dimensionality reduction and matrix factorization

As can be seen in the workflow ( Fig 1 ), once network analysis was finished, a series of steps (detailed in S5 File ) were necessary to preprocess the dataset prior to topic modeling. Topic modeling refers to applying machine learning techniques to find topics by extracting semantic information from unstructured text in a corpus [ 76 ]. As we explain in S5 File , to this point we end up with a high-dimensional and sparse document-term matrix. In other words, we have many features (columns) each corresponding to a term in our corpus, and for a given document (rows) we have many columns with zero values meaning the term of that column is not in the given document. To deal with sparsity, we can perform dimensionality reduction to obtain a representation that effectively captures the variability in the data. In summary, dimensionality reduction can be categorized in feature extraction and feature selection ; the former combines the original feature space into a new one, whereas the latter selects a subset of features [ 77 ].

As explained in S5 File , the term frequency (TF) and the term frequency-inverse document frequency (TF-IDF) were used as feature extraction for vectorization. Then, the following machine learning algorithms were applied for topic modeling: Latent Dirichlet Allocation (LDA) [ 78 ], Latent Semantic Analysis (LSA or Latent Semantic Indexing) [ 79 ], Hierarchical Dirichlet Process (HDP) [ 80 ], and Non-negative Matrix Factorization (NMF) [ 81 ]. LDA is a generative probabilistic model that decomposes the document-term matrix into a topic-term matrix and a document-topic matrix, and it is commonly used for topic discovering from a corpus [e.g., 82 ]. LSA utilizes a truncated Singular Value Decomposition for decomposition and can work efficiently on TF or TF-IDF sparse matrices. In a fully unsupervised framework, the HDP model is characterized by inferring the number of topics on its own. Finally, NMF is an alternative approach that implements the Nonnegative Double Singular Value Decomposition, an algorithm suitable for sparse factorization [ 83 ].

First, the GENSIM library [ 84 ] was used for topic modeling because it provides a way to calculate topic coherence , an index to compare models based on measures of segmentation, probability estimation, confirmation measure, and aggregation [see 85 ]. Therefore, based on a TF matrix, HDP, LSA, NMF, and LDA were performed in GENSIM and compared in topic coherence. Once identified the topic modeling algorithms with the highest topic coherence, scikit-learn [ 86 ] was used because it provides an Exhaustive Grid Search option for ensemble learning the models (i.e., automatically fine-tuning the parameters to find the most optimal). Finally, once the topics were extracted, a simple time series analysis was performed to visualize the changes over time in the topics found. This analysis consisted of simply plotting the number of documents for each topic across years, from 1981 to 2020.

First, bibliometric analyses were performed to identify the most cited documents. Local citations are presented in Table 1 (and the S1 File ), whereas global citations are in Table 2 (and the S2 File ).

https://doi.org/10.1371/journal.pone.0278981.t001

https://doi.org/10.1371/journal.pone.0278981.t002

Next, a network analysis was performed to identify the most important authors ( Table 3 ) and their collaboration networks ( Fig 2 , see also S3 File , a dataset, and S4 File , an interactive visualization in HTML and JavaScript, also available online: https://osf.io/5yzvd/ ). This collaboration network analysis identified eight clusters with 96 authors: (1) red color, 4 authors; (2) blue, 15 authors; (3) green, 17 authors; (4) purple 21 authors; (5) orange, 2 authors; (6) brown, 18 authors; (7) pink, 2 authors; (8) grey, 17 authors.

https://doi.org/10.1371/journal.pone.0278981.g002

https://doi.org/10.1371/journal.pone.0278981.t003

Regarding the most relevant topics, LDA and NMF were superior to HDP and LSA in topic coherence. Then, when ensemble learning was used for LDA (based on TF) and NMF (based on TF-IDF), NMF provided the most meaningful results, and 10 topics were identified ( Table 4 ).

https://doi.org/10.1371/journal.pone.0278981.t004

The labels for the topics were manually added based on the top 10 keywords and their respective weights. Thus, each topic was manually labeled as follows: (1) risk factors for eating disorders, (2) body image dissatisfaction, (3) Binge Eating Disorder diagnosis, (4) weight loss, weight control, and diet, (5) clinical groups, (6) treatment outcome, (7) family and parent-child, (8) binge and purge episodes, (9) gender and subgroups, (10) EDNOS.

To examine how these topics have evolved over time, a simple time series analysis plot was created ( Fig 3 and S6 File ).

Note . Values in the y-axis are the sum of the weight values from the NMF analysis for topic dominance, per year and per topic. Values go from minimum 0 to maximum 11.2 (see S6 File ).

https://doi.org/10.1371/journal.pone.0278981.g003

This study analyzed 8651 documents between 1981 and 2020 from domain-specific journals in the field of eating disorders. The aims were: to identify the most cited documents, the most important authors and their collaboration networks, and the most relevant topics and their evolution over time. The results expand previous findings of studies that employed a query-based approach and included articles dating back as far as 1900 [ 13 ]. In particular the results expand the studies by Jinbo He et al. (2022) and Juan-Carlos Valderrama-Zurián, et al. (2017), which employed a similar methodology [ 1 , 2 ]. For example, He et al. (2022) created a collaboration network, although it was based on countries rather than authors [ 1 ]. Therefore, the results obtained here (e.g., author centrality measures, author clusters) provide a more fine grained understanding of the relevance and contribution of individual authors and their collaboration networks. Furthermore, He et al. (2022) [ 1 ] identified top authors based on traditional performance metrics (e.g., h-index), and it should be noted that there is some criticism towards their use and a claim to shift towards more responsible metrics of research excellence [ 87 ]. Then, He et al. (2022) [ 1 ] employed LDA for topic modeling, whilst this study employed NMF. Although LDA is largely used, in this study NMF outperformed LDA in interpretability, reproducibility, and as we said above, it suits better for short texts, as is the case of article abstracts used here. Finally, the top journals identified by He et al. (2022) confirmed that the five journals selected for this study are in fact among the most important in the field of eating disorders [ 1 ]. In the case of Valderrama-Zurián, et al. (2017) [ 2 ], they also focused on authors’ productivity trends whereas their social network analysis was focused on network metrics such as the number of nodes and edges over time, which precludes to inspect the social network at the author level. Therefore, this study also expands on the findings of Valderrama-Zurián, et al. (2017) [ 2 ].

Below, we discuss in more detail the results of the analysis employed to answer the four research questions outlined in the introduction.

Bibliometric analysis

The top cited documents were all from the International Journal of Eating Disorders. As noted above, this journal is the oldest one (it started in 1981), and it has the largest number of articles per year, with the exception of the year 2019 when it was outperformed by the Eating and Weight Disorders journal (see S7 and S8 Files). The majority of top cited documents were related to the development of instruments for the assessment of eating disorders or the course and outcome of eating disorders. For example, we can see in the results the most common instruments used for the screening of eating disorders, as well as the evaluation of its core symptoms: Eating Disorder Inventory (EDI), Body Shape Questionnaire (BSQ), Dutch Eating Behavior Questionnaire (DEBQ), and Eating Disorder Examination Questionnaire (EDE-Q). These instruments are widely used to screen the general population, as well as in clinical settings, together with more recent instruments [ 88 ]. It should be noted, however, that in clinical practice settings the use of instruments for the diagnosis and the different phases of the treatment process is not necessarily widespread [ 89 , 90 ]. To reduce this gap, some authors suggest to provide assessment training and/or assessment guidelines for mental health professionals and general practitioners in primary health care [ 91 , 92 ]. This can help obtain a comprehensive clinical assessment, particularly of individuals with higher risk such as young adolescents with restrictive Anorexia Nervosa [ 93 ]. The instruments mentioned above are reliable measures, and they could be used online for a quick screening or session by session for ongoing monitoring, although further research is necessary [e.g., 94 – 96 ].

The rest of most cited documents include important review articles on epidemiology (Hoek & van Hoeken, 2003, in Table 1 ); the course and outcome of eating disorders (Berkman, Lohr & Bulik, 2007; Strober, Freeman & Morrell, 1997; in Table 1 ); and the diagnosis of Binge Eating Disorder (Spitzer et al., 1992, 1993, in Table 1 ). These results are similar to previous studies in which measurement methods (including instrument development), epidemiology, and review articles were the most common type of document [ 8 , 9 ].

Finally, the large number of articles on the diagnosis of Binge Eating Disorder, which was not fully recognized as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fifth edition [ 4 ], reveal that the recognition of Binge Eating Disorder as an own disorder took several years. To reach expert consensus in a shorter time, eating disorder professionals should pay special attention to emerging eating problems, such as Orthorexia Nervosa [ 97 ].

Network analysis

The network analysis identified eight clusters with 96 authors. Previous studies have examined the network of authors in the field in terms of network statistics such as number of edges or network density [ 2 ]. By contrast, this study provides a more fine-grained network analysis, identifying experts and group of experts in the field of eating disorders. As seen in the results section, the majority are distinguished authors with contributions dating back to the early 1980s.

The author with the largest betweenness centrality was Ross D Crosby (Sanford Center for Biobehavioral Research, United States), followed by James E Mitchell (University of North Dakota, United States) which has the largest value in PageRank. Authors with high betweenness centrality can act as both enablers and gatekeepers of information flow between communities [ 75 ]. Moreover, it has been found that authors with high betweenness centrality establish more collaborations than those high in closeness centrality [ 75 ]. In summary, the results of centrality measures can help to identify experts in the field of eating disorders, particularly authors that can quickly reach other authors in the network (high in closeness), act as gatekeepers (high in betweenness), or relate to influential others (high in PageRank).

Regarding the clusters identified by the network analysis, in the same cluster of Ross D Crosby and James E Mitchell are found other renowned authors like Daniel Le Grange (University of California, San Francisco, United States), Stephen A Wonderlich (Sanford Center for Biobehavioral Research, United States), and Carol B Peterson (University of Minnesota, United States). Among the most relevant results of collaboration of this cluster we can find studies on the ecological momentary assessment of eating disorders [ 98 ], the psychometric properties of the EDE-Q [ 99 ], and the diagnosis of Binge Eating Disorder [ 100 ].

The second largest cluster includes authors like Cynthia M Bulik (University of North Carolina at Chapel Hill, United States), Walter H Kaye (University of California, San Diego, United States), and Katherine A Halmi (Weill Cornell Medical College, United States). The results of their collaboration include studies related to the phenotypic characterization of eating disorders, such as the International Price Foundation Genetic Study, a multisite study that included a large sample of patients with eating disorders and their families [e.g., 101 ].

Finally, the third largest cluster includes authors like Janet Treasure (King’s College London, England), Ulrike Schmidt (King’s College London, England), and Tracey D Wade (Flinders University, Australia), which are widely recognized by the Maudsley Model for Treatment of Adults with Anorexia Nervosa (MANTRA) [ 102 , 103 ]. Interestingly, this is the only cluster that includes collaborations with authors from non-English speaking countries, more specifically from Spain. Examples of these collaborations include studies resulting from the Wellcome Trust Case Control Consortium 3 (WTCCC3) and the Genetic Consortium for AN (GCAN) [ 104 ], and other studies with clinical samples in Spain [e.g., 105 ].

On the other hand, the results reveal the importance of multisite studies that strengthen collaboration and originate in relevant outcomes for the prevention and treatment of eating disorders. Research groups could look for opportunities to collaborate in multisite studies and strengthen both their interdisciplinary and transdisciplinary collaboration, and their collaboration with less common partners such as stakeholders and policy makers [ 106 , 107 ]. By establishing these integrative and strategic collaborations we can promote translational research, and thus helping to reach broader public health goals [ 108 ].

Topic modeling

The combination of TF-IDF and NMF provided meaningful results, identifying 10 topics. After labeling these topics based on the first 10 keywords and their respective weights, we can see that most of the research on eating disorders done in the past 40 years has focused on their prevention and treatment. Interestingly, the time trend analysis of these topics revealed a noticeable change in the first lustrum of the 1990s. Whereas during the early 1980s the study of clinical groups (topic 5) was the most dominant topic, from the mid-1990s, this topic was surpassed by the study of risk factors of eating disorders (topic 1). This indicates an increasing interest for the prevention rather than solely the treatment of eating disorders. This result is consistent with the historical shift that occurred in the United States when in 1992 the Institute of Medicine (IOM) Committee on Prevention of Mental Disorders was created [ 109 ]. Then two years later, a report on reducing risk factors for mental disorders and promoting a preventive approach in research was published [ 110 ]. As expected, this shift had echo in several scholars at the time, became a research front, and relevant publications started to include more information on the prevention of eating disorders, including a special issue [ 111 ], book chapters [ 112 ], and progressively entire books [ 113 ]. It is important to note that this historical shift, as well as later others like in 2017 [ 114 ], were favorable, because in other cases like obesity, it took more time to focus on its prevention due to different issues, including the pressure of the weight loss industry and its commercial interest [ 115 ].

Another interesting finding was that the outcome of the treatment of eating disorders (topic 6), is the second most important topic of 2013, and this finding has important aspects to discuss. First, the surge of state-of-the-art machine learning algorithms provide several opportunities to build intelligent systems for precision medicine. Thus, the treatment course and outcome of eating disorders can be more personalized, guided, and enhanced with the help of predictive technologies and intelligent systems [e.g., 116 ]. Second, as suggested elsewhere [ 117 ], the advantages of technology can be particularly relevant for certain age groups like adolescents, and when a digital intervention is employed [ 118 ]. In summary, treatment outcome is currently an important topic, and future studies can deploy digital interventions and machine learning algorithms for a more precise treatment planning.

Limitations and conclusions

Although this study has strengths, such as using data and code that allows the reproducibility of the results, readers should consider some limitations. First, the analysis of most cited documents is for all the time span, and more recent highly cited documents are underrepresented. Moreover, the journal Advances in Eating Disorders was not included due to indexing issues. Nevertheless, this study provides the code and a detailed procedure to allow researcher to perform further analyses, such as document co-citation analysis. Future studies can also evaluate the Mexican Journal of Eating Disorders ( Revista Mexicana de Trastornos Alimentarios , ISSN 2007-1523), which has published articles primarily in Spanish [ 119 ]. Second, the network analysis included close to 100 scholars mostly with a long trajectory in the field, and this can be a limitation in representing more younger scientists or newcomers [ 2 ]. Future studies can focus on a larger number of scholars and apply different techniques in network analysis, such as other community detection techniques [e.g., 120 ]. Finally, the results of topic modeling suggested a solution of 10 topics out of up to 30 topics solution models tested. Although there is not a universally accepted approach to establish the number of topics, this study relied on several strategies, including ensemble learning, to automatically fine-tune the parameters of the machine learning algorithms, stability, and heuristic approaches [ 121 ]. Future studies can try other machine learning algorithms and techniques to retrieve topics [ 121 ].

In conclusion, this study analyzed 40 years of research on eating disorders, identified the most cited articles, networks of collaboration, experts in the field, and the 10 major topics in the field.

Supporting information

S1 file. most local cited documents..

https://doi.org/10.1371/journal.pone.0278981.s001

S2 File. Most global cited documents.

https://doi.org/10.1371/journal.pone.0278981.s002

S3 File. Network statistics.

https://doi.org/10.1371/journal.pone.0278981.s003

S4 File. Network of collaboration including close to one hundred authors.

https://doi.org/10.1371/journal.pone.0278981.s004

S5 File. Data preprocessing and text representation in Python.

https://doi.org/10.1371/journal.pone.0278981.s005

S6 File. Sum of NMF results for topic dominance per year and per topic.

https://doi.org/10.1371/journal.pone.0278981.s006

S7 File. Number of documents per year and per journal.

https://doi.org/10.1371/journal.pone.0278981.s007

S8 File. Trends over time in number of documents per journal.

https://doi.org/10.1371/journal.pone.0278981.s008

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• PubMed/NCBI
• Google Scholar
• 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
• 6. Mennell S. All manners of food: Eating and taste in England and France from the Middle Ages to the present. Oxford, UK: Basil Blackwell; 1985.
• 21. Savoy J, Naji N. Comparative information retrieval evaluation for scanned documents. In: Proceedings of the 15th WSEAS International Conference on Computers. Stevens Point, Wisconsin, USA: World Scientific and Engineering Academy and Society (WSEAS); 2011. p. 527–534. https://doi.org/10.5555/2028299.2028394
• 23. De S, Stanley RJ, Cheng B, Antani S, Long R, Thoma G. Automated text detection and recognition in annotated biomedical publication images. Information Resources Management Association, editor. Medical Imaging: Concepts, Methodologies, Tools, and Applications. Hershey, PA: IGI Global; 2017. p. 457–489. https://doi.org/10.4018/978-1-5225-0571-6.ch018
• 28. Hlava MMK. The taxobook: Principles and practices of building taxonomies. Morgan & Claypool; 2015. (Synthesis Lectures on Information Concepts, Retrieval, and Services). https://doi.org/10.2200/S00603ED1V02Y201410ICR036
• 33. Crane D. Invisible colleges: Diffusion of knowledge in scientific communities. University of Chicago Press; 1972.
• 34. Merton RK. The sociology of science: Theoretical and empirical investigations. University of Chicago Press; 1973.
• 35. Börner K, Boyack KW, Milojević S, Morris S. An introduction to modeling science: Basic model types, key definitions, and a general framework for the comparison of process models. In: Scharnhorst A, Börner K, van den Besselaar P, editors. Models of science dynamics: Encounters between complexity theory and information sciences. Berlin: Springer; 2012. p. 3–22. (Understanding Complex Systems). https://doi.org/10.1007/978-3-642-23068-4
• 36. Whitley R. The intellectual and social organization of the sciences. 2nd ed. Oxford University Press; 2000.
• 37. Hjørland B. Informetrics needs a foundation in the theory of science. In: Sugimoto CR, editor. Theories of informetrics and scholarly communication. De Gruyter; 2016. p. 20–46. https://doi.org/10.1515/9783110308464-005
• 38. Vitanov NK. Science and society: Assessment of research. In: Vitanov NK, editor. Science dynamics and research production: Qualitative and quantitative analysis of scientific and scholarly communication. Cham: Springer International Publishing; 2016. p. 3–52. (Qualitative and Quantitative Analysis of Scientific and Scholarly Communication). https://doi.org/10.1007/978-3-319-41631-1_1
• 40. McGinty S. Gatekeepers of knowledge: Journal editors in the sciences and the social sciences. Westport, CT: Bergin & Garvey; 1999.
• 53. Chen C, Song M. Representing scientific knowledge: The role of uncertainty. New York, NY:Springer; 2017. https://doi.org/10.1007/978-3-319-62543-0
• 54. Carmichael T, Hadžikadić M. The fundamentals of complex adaptive systems. In: Carmichael T, Collins AJ, Hadžikadić M, editors. Complex adaptive systems: Views from the physical, natural, and social sciences. New York, NY: Springer; 2019. p. 1–16. (Understanding Complex Systems). https://doi.org/10.1007/978-3-030-20309-2_1
• 55. Wolfram S. Complex systems theory. In: Pines D, editor. Emerging syntheses in science: Proceeding of the founding workshops of the Santa Fe Institute. Santa Fe, NM: Santa Fe Institute; 2019. p. 299–307. https://doi.org/10.1201/9780429492594-18
• 56. Wolfram S. A project to find the fundamental theory of physics. Manitoba, Canada: Wolfram Media, Inc.; 2020.
• 57. Northrop RB. Introduction to complexity and complex systems. Boca Raton, FL: CRC Press; 2011. https://doi.org/10.1201/9781439894989
• 62. Mobus GE, Kalton MC. Principles of systems science. Springer; 2015. (Understanding Complex Systems). https://doi.org/10.1007/978-1-4939-1920-8
• 63. Hara S, Imura J, Tsumura K, Ishizaki T, Sadamoto T. Glocal (global/local) control synthesis for hierarchical networked systems. In: 2015 IEEE Conference on Control Applications (CCA). Sydney, Australia: IEEE; 2015. p. 107–12. https://doi.org/10.1109/CCA.2015.7320618
• 65. R Core Team. R: A language and environment for statistical computing. Vienna, Austria; 2020.
• 68. Menche J, Barabási A-L. Introduction to network analysis. In: Loscalzo J, Barabási A-L, Silverman EK, editors. Network medicine: Complex systems in human disease and therapeutics. Cambridge, MA: Harvard University Press; 2017. p. 17–43. https://doi.org/10.4159/9780674545533-003
• 75. Milojević S. Network analysis and indicators. In: Ding Y, Rousseau R, Wolfram D, editors. Measuring scholarly impact: Methods and practice. Cham: Springer International Publishing; 2014. p. 57–82. https://doi.org/10.1007/978-3-319-10377-8_3
• 76. Chen Z, Liu B. Topic models for NLP applications. In: Sammut C, Webb GI, editors. Encyclopedia of machine learning and data mining. 2nd ed. New York, NY: Springer; 2017. p. 1276–80. https://doi.org/10.1007/978-1-4899-7687-1_906
• 77. Alelyani S, Tang J, Liu H. Feature selection for clustering: A review. In: Aggarwal CC, Reddy CK, editors. Data clustering: Algorithms and applications. Boca Raton, FL: CRC Press; 2014. p. 29–60. (Data Mining and Knowledge Discovery Series). https://doi.org/10.1201/9781315373515-2
• 79. Landauer TK. LSA as a theory of meaning. In: Landauer TK, McNamara DS, Dennis S, Kintsch W, editors. Handbook of latent semantic analysis. Mahwah, NJ: Lawrence Erlbaum Associates; 2011. p. 3–34. https://doi.org/10.4324/9780203936399-5
• 80. Wang C, Paisley J, Blei DM. Online variational inference for the Hierarchical Dirichlet Process. In: Gordon G, Dunson D, Dudík M, editors. Proceedings of the Fourteenth International Conference on Artificial Intelligence and Statistics (PMLR). PMLR; 2011. p. 752–60.
• 84. Řehůřek R, Sojka P. Software framework for topic modelling with large corpora. In: Proceedings of the LREC 2010 Workshop on New Challenges for NLP Frameworks. Valletta, Malta: ELRA; 2010. p. 45–50. Available from: http://www.fi.muni.cz/usr/sojka/presentations/lrec2010-poster-rehurek-sojka.pdf
• 85. Röder M, Both A, Hinneburg A. Exploring the space of topic coherence measures. In: Proceedings of the Eighth ACM International Conference on Web Search and Data Mining. New York, NY, USA: Association for Computing Machinery; 2015. p. 399–408. (WSDM ‘15). https://doi.org/10.1145/2684822.2685324
• 87. Tijssen R. Re-valuing research excellence: From excellentism to responsible assessment. In: Kraemer-Mbula E, Tijssen R, Wallace ML, McLean R, editors. Transforming research excellence: New ideas from the global south. Cape Town, South Africa: African Minds; 2020. pp. 59–78.
• 88. Thomas JJ, Roberto CA, Berg KC. Assessment measures, then and now: A look back at seminal measures and a look forward to the brave new world. In: Walsh BT, Attia E, Glasofer DR, Sysko R, editors. Handbook of assessment and treatment of eating disorders. Arlington, VA: American Psychiatric Publishing; 2016.
• 109. Levine MP, Smolak L. Introduction to prevention. In: Levine MP, Smolak L, editors. The prevention of eating problems and eating disorders: Theories, research, and applications. 2nd ed. New York, NY: Routledge; 2020. p. 3–16. https://doi.org/10.4324/9781315401065-2
• 110. Mrazek PJ, Haggerty RJ. Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press; 1994.
• 111. Piran N, Levine MP. Introduction. Eat Disord. 1996 Dec 1;4(4):291–3. https://doi.org/10.1080/10640269608249189
• 112. Smolak L, Levine MP, Striegel-Moore RH. The developmental psychopathology of eating disorders: Implications for research, prevention, and treatment. Mahwah, NJ: Lawrence Erlbaum Associates; 1996. https://doi.org/10.4324/9780203763506
• 113. Piran N, Levine MP, Steiner-Adair C. Preventing eating disorders: A handbook of interventions and special challenges. Ann Arbor, MI: Brunner/Mazel; 1999. https://doi.org/10.4324/9780203778081
• 115. Ulijaszek SJ. Models of obesity: From ecology to complexity in science and policy. Cambridge, UK: Cambridge University Press; 2017. https://doi.org/10.1017/9781316338650
• 117. Attia E, Becker AE, Bulik CM, Field AE, Golden NH, Kreipe RE, et al. Research agenda for eating disorders. In: Evans DL, Foa EB, Gur RE, Hendin H, O’Brien CP, Romer D, et al., editors. Treating and preventing adolescent mental health disorders: What we know and what we don’t know. 2nd ed. New York, NY: Oxford University Press; 2017. p. 363–7. https://doi.org/10.1093/med-psych/9780199928163.003.0016
• 121. Greene D, O’Callaghan D, Cunningham P. How many topics? Stability analysis for topic models. In: Calders T, Esposito F, Hüllermeier E, Meo R, editors. Machine learning and knowledge discovery in databases. Berlin, Heidelberg: Springer Berlin Heidelberg; 2014. p. 498–513. https://doi.org/10.1007/978-3-662-44848-9_32

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Walter Kaye and the UCSD Eating Disorders Research team have published over 250 papers on the neurobiology of eating disorders. These publications include behavioral, treatment, and cognitive neuroscience studies that have improved understanding of the clinical presentation, genetics, neurotransmitter systems, and neural substrates involved in appetite dysregulation and disordered eating. These studies are guiding the development of more effective, neurobiologically informed interventions.

• Change in motivational bias during treatment predicts outcome in anorexia nervosa
• Sophie R. Abber MS, Susan M. Murray PhD, Carina S. Brown MS, Christina E. Wierenga PhD
• doi: 10.1002/eat.24156. Epub 2024 February 01.
• Wiley Online Library
• The acceptability, feasibility, and possible benefits of a neurobiologically-informed 5-day multifamily treatment for adults with anorexia nervosa
• Christina E. Wierenga, Laura Hill, Stephanie Knatz Peck, Jason McCray, Laura Greathouse, Danika Peterson, Amber Scott, Ivan Eisler, Walter H. Kaye
• oi: 10.1002/eat.22876. Epub 2018 May 2.
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List of 122 Eating Disorder Research Topics

Are you looking for some eating disorder research topics that you can use as your own? Of course, you are! Otherwise, why would you be reading this blog post? Well, the good news is that we have just what you are looking for right here on this page.

No, you don’t have to download anything. You don’t have to pay anything either. All our 122 eating disorder research topics are free to use as you see fit. We have just finished updating the list, so you can find unique topics that are entirely original. Nobody in your class has probably found them, so you’re safe.

Best Eating Disorder Research Topics on the Internet

Every student should focus on studying or learning for his terms or exams. However, hunting for eating disorder research topics can take hours – if not days. You probably don’t have so much free time on your hands. This is why, if you need to write an eating disorders research paper, you should first visit our blog. You will find that our topics are the best on the Internet. Also, here is what you get if you visit our page periodically:

Our list of topics is updated relatively frequently, so you will probably be able to get an original topic right here in just a couple of minutes. All our topics are relatively easy to write about. You can find plenty of information online about 99% of these topics. You will never have to pay anything to get topics. They are all free. You are also free to reword them to suit your needs. You can get a list of new topics from our expert writers if you can’t find what you are looking for on this page.

So, let’s take a look at our list of the latest and most interesting eating disorder research topics.

Anorexia Research Paper Ideas

Talking about anorexia may not be the easiest thing in the world, but we have some anorexia research paper ideas that are not that complicated right here:

• What causes anorexia in children?
• The 3 most effective anorexia nervosa treatments
• How do affected people perceive their anorexia?
• Physical effects of anorexia nervosa
• Psychological effects of anorexia
• The ethics behind the nasogastric tube treatment
• The link between anorexia and infertility
• The link between osteoporosis
• The link between anorexia and heart damage
• Cultural factors that influence the occurrence of anorexia
• Does anorexia cause depression?
• Anorexia nervosa in evolutionary psychiatry

Eating Disorders Research Paper Topics

Have you been asked by your professor to write a research paper on an eating disorder or related subject? Check out these unique eating disorders research paper topics:

• Best screening tools for eating disorders
• Compare and contrast 2 eating disorders
• Discuss eating disorders to social media
• A short history of eating disorders
• How can one achieve body positivity?
• Most interesting myths about eating disorders
• Differences between bulimia and anorexia
• What causes the relapse of eating disorders?
• The epidemic of anorexia in the United States
• Mass media’s effect on body image in the UK
• Gender role in eating disorders

Children Eating Disorders

We can guarantee that if you write about children eating disorders, you will capture the attention of your professor from the first two sentences. Give these topics a try:

• Self-injury in children with anorexia
• Occurrence of bulimia nervosa in adolescents
• Treating autistic children with anorexia
• What causes eating disorders among children in the US?
• Correcting children’s eating disorders in the United Kingdom
• Preventing relapses in young children
• The developmental psychology behind eating disorders
• Mental development problems in children with anorexia
• Successful parenting to prevent the occurrence of anorexia
• Television and its effects on self-esteem
• The link between fat-shaming and anorexia

Top Questions About Eating Disorders

Wondering what are the top questions about eating disorders today? Our experts have compiled them in an original list of questions below:

• What factors influence complete recovery for eating disorders?
• Can we develop personalized treatments for each patient?
• Should the symptoms be treated first?
• What chances does a person with co-morbidities have to survive an episode of anorexia?
• Which type of treatment offers the best chances of complete recovery?
• What can parents do to help children with anorexia?
• What are the risk factors that lead to bulimia nervosa?
• What causes self-harm in patients with anorexia?
• Why are eating disorders on the rise in developed countries?

Binge Eating Disorder Topics

Yes, binge eating is a very serious eating disorder. So why now write an essay about it? Check out these interesting binge eating disorder topics and pick the one you like:

• The social problems associated with binge eating
• The psychological problems caused by binge eating
• Physical issues caused by the binge eating disorder
• Differences between binge eating and bulimia
• Differences between binge eating and anorexia nervosa
• Prevalence of binge eating in healthy adults in the US
• Underreporting problems in the male population
• Benefits of counseling
• Surgery affects on binge eating
• Best lifestyle interventions in cases of binge eating
• Effective medication against binge eating disorders

Eating Disorder Topics for College

If you are a college student, you need a more complex topic to win a top grade. Take a look at these great eating disorder topics for college and take your pick:

• Household income effects on bulimia incidence
• The accuracy of the Eating Disorder Examination
• Effects of anorexia on the reproductive system
• An in-depth analysis of the refeeding syndrome
• Using hypnotherapy to treat bulimia nervosa
• The effect of selective serotonin reuptake inhibitor on binge eating
• Using olanzapine in anorexia nervosa cases
• Cognitive-behavioral therapy for binge eating
• The mortality rate of anorexia nervosa patients
• The effects of fluoxetine on bulimia nervosa patients
• The role of antidepressants in treating bulimia

Complex Eating Disorder Research Topics

If you want to impress your professor and awe your classmates, you may need to consider picking a topic from our list of complex eating disorder research topics below:

• Discuss physical morbidity caused by eating disorders
• The first documented case of anorexia nervosa
• An in-depth look at eating disorder psychosocial morbidity
• Binge eating in the Roman society
• Effective methods for eating recovery
• Sports effects on the occurrence of bulimia nervosa
• Bulimia nervosa in the 18th century
• Analyze the accuracy of the Anorectic Behavior Observation Scale
• An in-depth look at evolutionary psychiatry
• Topiramate and zonisamide for treating binge eating
• Using anti-obesity medications for bulimia and binge eating

Bulimia Nervosa Essay Topics

Of course, you can write an essay about bulimia nervosa or something related to it. Let’s help you with some bulimia nervosa essay topics:

• 5 lesser-known facts about bulimia
• Famous people who had bulimia
• The psychological consequences of bulimia
• Physical effects of bulimia nervosa
• Gender’s role in the bulimia nervosa disorder
• Effective methods to diagnose bulimia
• Effective treatments against bulimia nervosa
• First symptoms of bulimia
• Incidence of bulimia cases among children in the US
• Can willpower alone treat bulimia nervosa?

Eating Disorder Research Topics in Nursing

If you are a nursing student (or are attending a nursing class), you may find these eating disorder research topics in nursing highly interesting:

• Nursing’s role in eating disorder recovery
• Discuss nursing best practices when dealing with anorexia
• Nursing techniques for patients with bulimia
• Treating the symptoms of anorexia nervosa effectively

Treatments for Eating Disorders

Your professor will surely appreciate you taking the time to research various treatments for eating disorders. You may get some bonus points if you use one of these topics:

• The best treatment for bulimia nervosa
• A universal treatment for all eating disorders
• Medications that are effective against the binge eating disorder
• Talk about the use of hypnosis to treat eating disorders
• Discuss the cure rate for anorexia nervosa

Anorexia Nervosa Research Paper Topics

Did you run out of ideas for your eating disorder research paper? No problem, just check out the following anorexia nervosa research paper topics and pick the one you like:

• First symptoms and manifestations of anorexia nervosa
• Is anorexia nervosa contagious?
• Genetic transmission of the anorexia nervosa disorder
• Risk factors that influence anorexia nervosa in the United States
• Effective medication for the anorexia nervosa disorder

Gender Issues and Eating Disorders

Yes, there are many gender issues that you can talk about when it comes to eating disorders. We have an entire list of gender issues and eating disorders ideas right here for you:

• The gender with the highest rates of eating disorders
• Men and their struggle with anorexia nervosa
• Gender issues that make diagnosis difficult
• Mortality rates of eating disorders by gender
• Stereotypes related to eating disorders

Easy Eating Disorder Research Topics

These easy eating disorder research topics are for students who don’t want to spend days doing the research and writing the essay:

• What causes bulimia?
• Psychiatric help for eating disorder patients
• Effective medications that prevent anorexia episodes
• What causes anorexia nervosa?
• How can the binge eating disorder be treated effectively?
• Psychological problems caused by eating disorders

Controversial Eating Disorder Research Topics

Take a look at some controversial eating disorder research topics and pick one. Probably nobody in your school has even thought about writing a paper on any of these ideas:

• Anorexia Nervosa portrayal in the media in the United States
• Forced therapy in eating disorders in Eastern Europe
• Negative social media effects on the treatment of eating disorders
• False positives when diagnosing people with eating disorders
• Palliative care for people with anorexia and co-morbidities

Eating Disorder Topics for High School

If you are a high school student, you will be thrilled to learn that we have some very simple topics about eating disorders. Check out our list of eating disorder topics for high school students:

• An in-depth analysis of anorexia nervosa
• The history of binge eating in the United States
• Effective treatment options for bulimia nervosa
• The best way to diagnose an eating disorder
• The role of the family in treating eating disorders
• Dangerous medications used to treat eating disorders

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Prevalence and risk factors of disordered eating behavior in youth with hypertension disorders

Affiliations.

• 1 Department of Pediatrics, Section of Nephrology, Brenner Children's, Wake Forest University School of Medicine, One Medical Center Boulevard, Winston Salem, NC, 27157, USA.
• 2 Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
• 3 Department of Pediatrics, Section of Nephrology, Brenner Children's, Wake Forest University School of Medicine, One Medical Center Boulevard, Winston Salem, NC, 27157, USA. [email protected].
• 4 Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston Salem, NC, USA. [email protected].
• 5 Cardiovascular Sciences Center, Wake Forest University School of Medicine, Winston Salem, NC, USA. [email protected].
• 6 Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston Salem, NC, USA. [email protected].
• PMID: 37195544
• PMCID: PMC10189692
• DOI: 10.1007/s00467-023-05921-1

Background: Adolescents with certain health conditions requiring lifestyle management, such as diabetes mellitus, have higher disordered eating behavior (DEB) risk than the general adolescent population, but DEB is underdiagnosed and can lead to adverse health consequences. In youth with other conditions requiring lifestyle counseling such as hypertension (HTN), DEB prevalence and associated risk factors are unknown. We hypothesized that youth with HTN disorders would have higher DEB prevalence than the general adolescent population, and that obesity, chronic kidney disease (CKD), and less specialized lifestyle counseling would be associated with higher DEB risk.

Methods: Prospective cross-sectional study of youth aged 11-18 years with HTN disorders. We excluded patients with diabetes mellitus, kidney failure or transplantation, or gastrostomy tube dependence. We collected data via surveys and electronic health record abstraction. We administered the validated SCOFF DEB screening questionnaire. We compared DEB prevalence using a one-sample z-test of proportions (p 0 = 0.1) and estimated DEB risk by obesity, CKD, and lifestyle counseling source using multivariable generalized linear models.

Results: Of 74 participants, 59% identified as male, 22% as Black or African American, and 36% as Hispanic or Latino; 58% had obesity and 26% had CKD. DEB prevalence was 28% (95% CI 18-39%, p < 0.001). CKD was associated with higher DEB prevalence (adjusted RR 2.17, 95% CL 1.09 to 4.32), but obesity and lifestyle counseling source were not.

Conclusions: DEB prevalence is higher in youth with HTN disorders and comparable to other conditions requiring lifestyle counseling. Youth with HTN disorders may benefit from DEB screening. A higher resolution version of the Graphical abstract is available as Supplementary information.

Keywords: Blood pressure; Chronic kidney disease; Feeding and eating disorders of childhood; Lifestyle counseling; Pediatric obesity.

© 2023. The Author(s), under exclusive licence to International Pediatric Nephrology Association.

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Conflict of interest statement

The authors declare no competing interests.

A higher resolution version of the Graphical…

A higher resolution version of the Graphical abstract is available as Supplementary information

Demographic questionnaire

Example of the directed acyclic…

Example of the directed acyclic graph for the association between obesity and disordered…

Consort flow diagram demonstrating the…

Consort flow diagram demonstrating the number of patients approached during recruitment and the…

Adjusted relative risk of positive…

Adjusted relative risk of positive disordered eating behavior screen by each validated exposure.…

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New Insights Into Eating Disorders

by Denis Storey July 1, 2024 at 11:11 AM UTC

Clinical relevance: Recent articles explore eating disorders, including their impact on fertility and the concept of socially transmitted mental illnesses.

• While EDs affect people of all ages, reproductive stages, and genders, they’re most prevalent in women of reproductive age and can have a profound impact on fertility and obstetric outcomes. 
• New research suggests that ninth-grade students are more likely to develop mental disorders if their classmates have them.
• The DSM-5-TR and ICD-11 classifications overlook many aberrant eating behaviors, which are increasingly documented but await formal recognition.

For all of its benefits – instant news updates, global communication, and a sense of community – social media isn’t without risks, such as cyberbullying, online predators, and often dangerous viral trends.

Social media often presents distorted portraits of body image. A 2023 study found that “Social media usage is a plausible risk factor for the development of eating disorders. Research from Asia suggests that the association is not unique to traditionally Western cultures.”

The Primary Care Companion for CNS Disorders has published news, research, and reader insight that offers new, informed perspectives on eating disorders and the global health issue it presents. This week, we’re presenting summaries of three of the more recent pieces we’ve published – along with links – for further review.

How Do Eating Disorders Influence Fertility In Reproductive-Aged Women?

Eating disorders (EDs) are prevalent among women of reproductive age. And they typically crop up before starting before pregnancy. The three most common EDS include:

• Anorexia nervosa (AN) involves dietary restriction, low weight, fear of weight gain, and lack of concern about malnutrition.
• Bulimia nervosa (BN) includes binge eating and compensatory behaviors like vomiting or laxative misuse.
• Binge eating disorder (BED) involves recurrent binge eating with feelings of guilt.

With all of this in mind, a team of researchers wanted to know how these disorders might affect reproductive health and how they could mitigate whatever risks might exist.

To that end, the researchers reviewed PubMed literature, up to March 27, 2023. In their analysis, the team included search terms related to pregnancy, eating disorders, fertility, and associated outcomes. The authors then singled out and reviewed articles relevant to the impact of EDs on fertility and perinatal outcomes.

The researchers found that the lifetime prevalence for common EDs hovers around 6 percent, with higher rates among women seeking fertility treatment. Their findings include:

• EDs can impact fertility through weight changes affecting hormone levels and menstrual cycles.
• Behaviors like binge eating and dieting can lead to overweight and obesity, further affecting fertility and response to treatment.
• EDs are associated with polycystic ovarian syndrome (PCOS), complicating fertility.

In the perinatal period, EDs alter maternal weight, shaping obstetric outcomes. Both high and low maternal BMI elevate risks such as gestational diabetes, hypertensive disorders, and preterm delivery. Active ED symptoms during pregnancy raise risks for cesarean section and preterm delivery. The research also revealed that EDs are linked to perinatal anxiety and depression, influencing maternal and infant health.

EDs also affect offspring health through maternal weight and nutritional status, altering fetal development and even long-term outcomes. Maternal EDs are linked to adverse neonatal outcomes like low birth weight and preterm birth. This can also change breastfeeding duration.

Screening for EDs in reproductive-aged women is crucial, the authors conclude, especially during fertility treatment and perinatal appointments. Tools like the SCOFF questionnaire and the Prenatal Eating Behaviors Screening (PEBS) Tool help identify ED symptoms.

Treatment primarily involves outpatient behavioral therapies, but severe cases may require hospitalization. Early treatment of EDs can improve fertility outcomes and reduce perinatal risks.

That being said, the researchers insisted that the scientific community must gather more data, including postpartum screening tools and specific treatments for pregnant and postpartum women.

Teenagers Appear to be ‘Spreading’ Mental Illness

A study published in JAMA Psychiatry suggests that ninth-grade students can “infect” their classmates with mental disorders .

The Finnish nationwide cohort study analyzed more than 700,000 individuals born between 1985 and 1997. It found that students exposed to peers with mental disorders in ninth grade were more likely to develop similar conditions themselves. This increased risk lingered even after adjusting for parental, school-level, and area-level factors.

Key findings include:

• A higher “transmission” risk, at least 5 percent, when multiple classmates had mental disorders.
• The risk appeared to be most significant in the first year after exposure, increasing by up to 9 percent for those with one diagnosed classmate and 18 percent for those with multiple classmates.
• Mood, anxiety, and eating disorders were most strongly linked to this elevated risk.

The study suggests that mental disorders might be socially transmitted within adolescent peer networks. Researchers defined “exposure” as having one or more classmates diagnosed with a mental disorder in ninth grade and tracked the participants until they received a mental disorder diagnosis, emigrated, died, or until the end of 2019.

The researchers proposed several mechanisms for this phenomenon, including the normalization of mental disorders through increased awareness and the influence of peer social networks.

For example, prolonged exposure to a peer with depression could lead to the development of depressive symptoms through emotional contagion. The study emphasizes the need for further research to understand how mental disorders spread within peer networks and to develop effective prevention and intervention strategies in school settings. Finally, these findings could help reduce the societal and economic burden of mental disorders.

Readers Address Unrecognized Eating Disorders

In a letter to the editor published in PCC , Ahmed Naguy and Bader Alamiri discuss a variety of aberrant eating behaviors that aren’t formally recognized in the existing major psychiatric classification systems (DSM-5-TR and ICD-11). These behaviors, although still under-researched, are gaining attention and might warrant official acknowledgment at some point.

The authors describe several disorders now categorized under “other nonspecified feeding or eating disorders:”

• Orthorexia nervosa : An obsession with healthy eating, focusing on the quality rather than the quantity of food.
• Anorexia nervosa by proxy : A condition where a mother with anorexia nervosa projects her body image concerns onto her child, potentially leading to malnutrition and stunted growth.
• Pregorexia : Unhealthy behaviors during pregnancy, such as extreme dieting and excessive exercise, aimed at avoiding pregnancy-related weight gain, which can harm both mother and fetus.
• Anorexia athletica : A sport-related eating disorder involving unhealthy eating and weight control behaviors to maintain low body weight for competitive advantage.
• Hypergymnasia : Excessive exercise as a means of weight control, sometimes seen in athletes.
• Drunkorexia/alcoholimia : Restrictive eating patterns to enhance alcohol effects and avoid weight gain.
• Picky/fussy/faddy eating : Limiting food variety, potentially leading to dietary deficiencies, sometimes seen in adults and related to avoidant/restrictive food intake disorder.
• Emetophobia : An irrational fear of vomiting that leads to food restriction and weight loss.
• Gourmand syndrome : A preoccupation with fine food associated with right anterior cerebral hemisphere lesions, resulting in impulse control issues.
• Feederism : A paraphilia involving sexual arousal from feeding partners to encourage weight gain.
• Diabulimia : The intentional omission of insulin by type 1 diabetics to lose weight, significantly reducing life expectancy.
• Bigorexia nervosa : An obsession with one’s body being too small or not muscular enough, more common in males and considered a specifier for body dysmorphic disorder.

Finally, the authors argue that these behaviors highlight the need for broader diagnostic criteria and more research. Understanding these disorders better could lead to more effective treatments and interventions. And it could also address a range of disturbed eating patterns that current classifications fail to encompass.

Original Research

Controlled Study of Metabolic Syndrome Among Offspring of Parents With Bipolar Disorder

In offspring of parents with bipolar disorder, lower socioeconomic status and personal history of mood disorders were associated with greater risk of metabolic syndrome and its components.

Nidhi P. Kulkarni and others

Rounds in the General Hospital

Treatment-Resistant Schizophrenia: Evaluation and Management

If you have ever been uncertain about how to evaluate patients with a chronic psychotic illness or struggled over how best to manage treatment-resistant schizophrenia, then this case vignette and discussion should prove useful.

Carol S. Lim and others

Search Articles

Related articles, table of contents.

• Open access
• Published: 30 May 2023

Eating disorder outcomes: findings from a rapid review of over a decade of research

• Jane Miskovic-Wheatley 1 , 2 ,
• Emma Bryant 1 , 2 ,
• Shu Hwa Ong 1 , 2 ,
• Sabina Vatter 1 , 2 ,
• Anvi Le 3 ,
• National Eating Disorder Research Consortium ,
• Stephen Touyz 1 , 2 &
• Sarah Maguire 1 , 2  

Journal of Eating Disorders volume  11 , Article number:  85 ( 2023 ) Cite this article

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Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality.

This paper forms part of a Rapid Review series scoping the evidence for the field of ED, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/MEDLINE were searched for studies published between 2009 and 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review.

Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates.

Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.

Plain English summary

Eating disorders are complex psychiatric conditions that can seriously impact a person’s physical health. Whilst they are consistently associated with high mortality rates and significant psychosocial difficulties, lack of agreement on definitions of recovery, remission and relapse, as well as variations in methodology used to assess for standardised mortality and disability burden, means clear outcomes can be difficult to report. The current review is part of a larger Rapid Review series conducted to inform the development of Australia’s National Eating Disorders Research and Translation Strategy 2021–2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe to guide policymaking and address urgent health concerns. This Rapid Review synthesises the current evidence-base for outcomes for people with eating disorders and identifies gaps in research and treatment to guide decision making and future clinical research. A critical overview of the scientific literature relating to outcomes in Western healthcare systems that may inform health policy and research in an Australian context is provided in this paper. This includes remission, recovery and relapse rates, diagnostic cross-over, the impact of relapse prevention programs, factors associated with outcomes, and findings related to mortality.

Introduction

Eating disorders (ED), especially Anorexia Nervosa (AN), have amongst the highest mortality and suicide rates in mental health. While there has been significant research into causal and maintaining factors, early identification efforts and evidence-based treatment approaches, global incidence rates have increased from 3.4% calculated between 2000 and 2006 to 7.8% between 2013 and 2018 [ 1 ]. While historically seen as a female illness, poorer outcomes are increasingly seen in other genders, including males [ 2 ].

Over 3.3 million healthy life years are lost worldwide due to ED each year, and many more lost to disability due to medical and psychiatric complications [ 3 ]. Suicide accounts for approximately 20% of non-natural deaths among people with ED [ 4 ]. As this loss of healthy life is preventable, there is a grave responsibility to better understand outcomes for people with ED, including factors which may minimise the detrimental impact they have on individuals, carers, and communities, as well as to optimise recovery.

There has been considerable debate within the clinical, scientific and lived experience (i.e., patient, consumer, carer) communities about the definition and measurement of key outcomes in ED, including ‘remission’ from illness (a period of relief from symptoms), ‘relapse’ (a resumption of symptoms) and ‘recovery’ (cessation of illness) [ 5 , 6 ], which can compromise outcome comparisons. Disparities include outcome variables relating to eating behaviours as well as medical, psychological, social and quality of life factors. There is increasing awareness in the literature of the elevated likelihood of diagnostic crossover [ 7 ]; research examining specific diagnostic profiles potentially misses outcomes where symptom experience transforms rather than alleviates. Methodological approaches in outcomes research are varied, the most significant being length of time to follow up, compromising direct study comparisons.

The aim of this Rapid Review (RR) is to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality. Factors influencing outcomes were summarised including demographic, illness, treatment, co-morbidities, co-occurring health conditions, societal factors, and impact of relapse prevention programs. This RR forms one of a series of reviews scoping the field of ED commissioned to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031 [ 8 ]. The objective is to evaluate the current literature in ED outcomes to identify areas of consensus, knowledge gaps and suggestions for future research.

The Australian Government Commonwealth Department of Health funded the InsideOut Institute for Eating Disorders (IOI) to develop the Australian Eating Disorders Research and Translation Strategy 2021–2031 [ 8 ] under the Psych Services for Hard to Reach Groups initiative (ID 4-8MSSLE). The strategy was developed in partnership with state and national stakeholders including clinicians, service providers, researchers, and experts by lived experience (including consumers and families/carers). Developed through a 2 year national consultation and collaboration process, the strategy provides the roadmap to establishing ED as a national research priority and is the first disorder-specific strategy to be developed in consultation with the National Mental Health Commission. To inform the strategy, IOI commissioned Healthcare Management Advisors (HMA) to conduct a series of RRs to broadly assess all available peer-reviewed literature on the six DSM-V [ 9 ] listed ED. RR’s were conducted in the following domains: (1) population, prevalence, disease burden, Quality of Life in Western developed countries; (2) risk factors; (3) co-occurring conditions and medical complications; (4) screening and diagnosis; (5) prevention and early intervention; (6) psychotherapies and relapse prevention; (7) models of care; (8) pharmacotherapies, alternative and adjunctive therapies; and (9) outcomes (including mortality) (current RR), with every identified paper allocated to only one of the above domains from abstract analysis by two investigators. Each RR was submitted for independent peer review to the Journal of Eating Disorders special edition, “Improving the future by understanding the present: evidence reviews for the field of eating disorders”.

A RR Protocol [ 10 ] was utilised to swiftly synthesise evidence to guide public policy and decision-making [ 11 ]. This approach has been adopted by several leading health organisations, including the World Health Organization [ 12 ] and the Canadian Agency for Drugs and Technologies in Health Rapid Response Service [ 13 ], to build a strong evidence base in a timely and accelerated manner, without compromising quality. RR was chosen as the most suitable design as it is conducted with broader search terms and inclusion criteria allowing to gain a better understanding of a specific field, returning a larger number of search results and providing a snapshot of key findings detailing the current state of a field at study [ 10 ]. A RR is not designed to be as comprehensive as a systematic review—it is purposive rather than exhaustive and provides actionable evidence to guide health policy [ 14 ].

The RR is a narrative synthesis adhering to the PRISMA guidelines [ 15 ]. It is divided by topic area and presented as a series of papers. Three research databases were searched: ScienceDirect, PubMed and Ovid/MEDLINE. To establish a broad understanding of the progress made in the field of eating disorders, and to capture the largest evidence base on the past 13 years (originally 2009–2019, but expanded to include the preceding two years), the eligibility criteria for included studies into the RR were kept broad. Therefore, included studies were published between 2009 and 2022, in English, and conducted within Western healthcare systems or health systems comparable to Australia in terms of structure and resourcing. The initial search and review process was conducted by three reviewers between 5 December 2019 and 16 January 2020. The re-run for the years 2020–2021 was conducted by two reviewers at the end of May 2021 and a final run for 2022 conducted in January 2023 to ensure the most up to date publications were included prior to publication.

The RR had a translational research focus with the objective of identifying evidence relevant to developing optimal care pathways. Searches, therefore, used a Population, Intervention, Comparison, Outcome (PICO) approach to identify literature relating to population impact, prevention and early intervention, treatment, and long-term outcomes. Purposive sampling focused on high-level evidence studies such as: meta-analyses; systematic reviews; moderately sized randomised controlled trials (RCTs) ( n  > 50); moderately sized controlled-cohort studies ( n  > 50), or population studies ( n  > 500). However, the diagnoses Avoidant Restrictive Food Intake Disorder (ARFID), Eating Disorder Not Otherwise Specified (EDNOS), Other Specified Feeding or Eating Disorder (OSFED) and Unspecified Feeding or Eating Disorder (UFED) necessitated a less stringent eligibility criterion due to a paucity of published articles. As these diagnoses are newly captured in the DSM-V [ 9 ] (released in 2013, within the allocated search timeframe), the evidence base is emerging, and fewer studies have been conducted. Thus, smaller studies ( n  ≤ 20) and narrative reviews were also considered and included. Grey literature, such as clinical or practice guidelines, protocol papers (without results) and Masters’ theses or dissertations, was excluded.

Full methodological details including eligibility criteria, search strategy and terms and data analysis are published in a separate protocol paper [ 10 ]. The full RR included a total of over 1320 studies (see Additional file 1 : Fig. S1). Data from included studies relating to outcomes for eating disorders were synthesised and are presented in the current review.

Of the 1320 articles included in the RR, the proportion of articles focused on outcomes in ED was relatively small, just less than 9% ( n  = 116) (see Additional file 2 : Table S1). Studies typically examined outcomes in AN, Bulimia Nervosa (BN) and Binge Eating Disorder (BED), with limited research in other diagnostic groups. Whereas most outcome studies reported recovery, remission and relapse rates, others explored factors impacting outcomes, such as quality of life, co-occurring conditions, and outcomes from relapse prevention programs.

ED, particularly AN, have long been associated with an increased risk of mortality. The current review summarises best available evidence exploring this association. Several factors complicate these findings including a lack of consensus on definitions of remission, recovery and relapse, widely varying treatment protocols and research methodologies, and limited transdiagnostic outcome studies or syntheses such as meta-analyses. Table 1 provides a summary of outcomes reported by studies identified in this review. There is considerable heterogeneity in the reported measures.

Overall outcomes

A good outcome for a person experiencing ED symptomatology is commonly defined as either remission or no longer meeting diagnostic criteria, as well as improved levels of psychosocial functioning and quality of life [ 28 , 29 ]. However, such a comprehensive approach is rarely considered, and there is no consensus on a definition for recovery, remission, or relapse for any of the ED diagnoses [ 30 , 31 ]. To contextualise this variation, definitions and determinants for these terms are presented in Table 2 .

The terms ‘remission’ and ‘recovery’ appear to be used interchangeably in the literature. Whilst ‘remission’ is usually defined by an absence of diagnostic symptomatology, and ‘recovery’ an improvement in overall functioning, the period in which an individual must be symptom-free to be considered ‘remitted’ or ‘recovered’ varies greatly between studies, follow-up (FU) time periods are inconsistent, and very few studies examine return to psychosocial function and quality of life (QoL) after alleviation of symptoms. The current review uses the terms adopted by the original studies. ‘Relapse’ is typically defined by a return of symptoms after a period of symptom relief. The reviewed studies report a variety of symptom determinants including scores on standardised psychological and behavioural interviews or questionnaires, weight criteria [including Body Mass Index (BMI) or %Expected Body Weight (%EBW)], clinical assessment by a multidisciplinary team, self-reported ED behaviours, meeting diagnostic criteria, or a combination of the above.

Remission, recovery, and relapse

In a global overview of all studies reviewed, remission or recovery rates were reported for around half of the cohort, regardless of diagnostic group. For example, a 30 month FU study of a transdiagnostic cohort of patients found 42% obtained full and 72% partial remission, with no difference between diagnostic groups for younger people; however, bulimic symptoms emerged frequently during FU, regardless of initial diagnosis [ 44 ]. A 6 year study following the course of a large clinical sample ( n  = 793) reported overall recovery rates of 52% for AN, 50–52% for BN, 57% for EDNOS-Anorectic type (EDNOS-A), 60–64% for BED and 64–80% for EDNOS-Bulimic type (EDNOS-B) [ 7 ]. Of those who recorded full remission at end of treatment (EOT), relapse was highest for AN (26%), followed by BN (18%), and EDNOS-B (16%). Relapse was less common for individuals with BED (11–12%), and EDNOS-A (4%). Change in diagnosis (e.g., from AN to BN) was also seen within the relapse group [ 7 ].

Longer-term FU studies may more accurately reflect the high rates of relapse and diagnostic crossover associated with ED. A 17 year outcome study of ED in adult patients found only 29% remained fully recovered, with 21% partially recovered and half (50%) remaining ill [ 52 ], noting the protracted nature of illness for adults with longstanding ED. Relapse is observed at high rates (over 30%) among people with AN and BN at 22 year FU [ 61 ]. In a large clinical study using predictive statistical modelling, full remission was more likely for people with BED (47.4%) and AN (43.9%) compared to BN (25.2%) and OSFED (23.2%) [ 41 ]. This result is distinct from other studies citing AN to have the worst clinical outcomes within the diagnostic profiles [ 52 ]. The cut‐off points for the duration of illness associated with decreased likelihood of remission were 6–8 years for OSFED, 12–14 years for AN/BN and 20–21 years for BED [ 41 ]. As with recovery rates, reported rates of relapse are highly variable due to differing definitions and study methodologies used by researchers in FU studies [ 35 , 61 ].

Evidence from a meta-analysis of 16 studies found four factor clusters that significantly contributed to relapse; however, also noted a substantial variability in procedures and measures compromising study comparison [ 62 ]. Factors contributing to heightened risk of relapse included severity of ED symptoms at pre- and post-treatment, presence and persistence of co-occurring conditions, higher age at onset and presentation to assessment, and longer duration of illness. Process treatment variables contributing to higher risk included longer duration of treatment, previous engagement in psychiatric and medical treatment (including specialist ED treatment) and having received inpatient treatment. These variables may indicate more significant illness factors necessitating a higher intensity of treatment.

Importantly, full recovery is possible, with research showing fully recovered people may be indistinguishable from healthy controls (HCs) on all physical, behavioural, and psychological domains (as evaluated by a battery of standardised assessment measures), except for anxiety (those who have fully recovered may have higher general anxiety levels than HCs) [ 29 ].

Diagnostic crossover

Most studies reported outcomes associated with specific ED diagnoses; however, given a significant proportion of individuals will move between ED diagnoses over time, it can be challenging to determine diagnosis-specific outcomes. Results from a 6 year FU study indicated that overall individuals with ED crossed over to other ED diagnoses during the FU observational period, most commonly AN to BN (23–27%), then BN to BED (8–11%), BN to AN (8–9%) and BED to BN (7–8%) [ 7 ]. Even higher crossover trends were observed in the subgroup reporting relapse during the FU period, with 61.5% of individuals originally diagnosed with AN developing BN, 27.2% and 18.1% of individuals originally diagnosed with BN developing AN and BED respectively, and 18.7% of people with a previous diagnosis of BED developing BN [ 7 ].

A review of 79 studies also showed a significant number of individuals with BN (22.5%) crossed over to other diagnostic groups (mostly OSFED) at FU [ 63 ]. A large prospective study of female adolescents and young adults in the United States ( n  = 9031) indicated that 12.9% of patients with BN later developed purging disorder and between 20 and 40% of individuals with subthreshold disorders progressed to full threshold disorders [ 64 ]. Progression from subthreshold to threshold eating disorders was higher for BN and BED (32% and 28%) than for AN (0%), with researchers suggesting higher risk for binge eating [ 66 ]. Progression from subthreshold to full threshold BN and BED was also common in adolescent females over the course of an 8 year observational study [ 33 ]. Some researchers contend that such diagnostic ‘instability’ demonstrates a need for ‘dimensional’ approaches to research and treatment which have greater focus on the severity rather than type of symptoms [ 7 ]. Diagnostic crossover is common and should be considered in the long-term management and monitoring of people with an ED.

Anorexia nervosa (AN)

People with restrictive-type ED have the poorest prognosis compared to the other diagnostic groups, particularly individuals displaying severe AN symptomatology (including lower weights and higher body image concerns) [ 44 ]. There is a paucity of effective pharmacological and/or psychological treatments for AN [ 65 ]. Reported rates of recovery vary and include 18% [ 56 ] to 52% at 6 year FU [ 7 ] to 60.3% at 13 year FU [ 20 ] and 62.8% at 22 year-FU [ 61 ]. Reported relapse rates in AN also vary, for example, 41.0% at 1 year post inpatient/day program treatment [ 35 ] to 30% at 22 year FU [ 61 ]. Average length of illness across the reviewed studies also varies from 6.5 years [ 56 ] to 14 years [ 41 ].

A variety of reported outcomes from treatment studies is likely due to the breadth of treatments under investigation, diverse study protocols and cohorts. For example, in a mixed cohort of female adult patients with AN and Atypical AN (A-AN), 33% were found to have made a full recovery at 3 year FU after treatment with cognitive behavioural therapy (CBT) [ 57 ], while 6.4% had a bad outcome and 6.4% a severe outcome. However, in a 5–10 year FU study of paediatric inpatients (mean age 12.5 years) approximately 41% had a good outcome, while 35% had intermediate and 24% poor outcome [ 66 ]. Multimodal treatment approaches including psychiatric, nutritional, and psychological rehabilitation have been found to be most efficacious for moderate to severe and enduring AN but noting a discrete rate of improvement [ 67 ].

Very few factors were able to predict outcomes in AN. Higher baseline BMI was consistently found to be the strongest predictor of recovery, and better outcomes were associated with shorter duration of illness [ 7 , 55 , 61 , 66 ]. Earlier age of illness onset [ 59 , 68 , 69 ] and older age at presentation to treatment [ 30 ] were related to chronicity of illness and associated with poorer outcome.

There was a consensus across a variety of studies that engagement in binge/purge behaviours (Anorexia Nervosa Binge/Purge subtype; AN-BP) was associated with a poorer prognosis [ 20 , 56 , 70 ]. Similarly, individuals with severe and enduring AN restrictive sub-type (AN-R) are likely to have a better outcome than individuals with AN-BP. AN-BP was associated with a two-fold greater risk of relapse compared to AN-R [ 30 , 35 ]. Some studies, however, were unable to find an association between AN subtype and outcome [ 55 ]. Other factors leading to poorer outcome and higher probability of relapse were combined ED presentations, such as combined AN/BN [ 35 ], higher shape concern [ 57 ], lower desired weight/BMI [ 44 ], more ED psychopathology at EOT, low or decreasing motivation to recover, and comorbid depression [ 35 , 61 ].

Preliminary genetic work has found associations between a single nucleotide polymorphism (SNP) in a ghrelin production gene (TT genotype at 3056 T-C) and recovery from AN-R [ 71 ], and the S-allele of the 5-HTTLPR genotype increasing the risk susceptibility for both depressive comorbidity and diagnostic crossover at FU of AN patients [ 72 ]. These studies, however, need to be interpreted with caution as they were conducted over a decade ago and have not since been replicated. Research in eating disorder genetics is a rapidly emerging area with potential clinical implications for assessment and treatment.

Bulimia nervosa (BN)

Overall, studies pertaining to a diagnostic profile of BN report remission recovery rates of around 40–60%, depending on criteria and FU period, as detailed below. Less than 40% of people achieved full symptom abstinence [ 73 ] and relapse occurred in around 30% of individuals [ 61 ]. A meta-analysis of 79 case series studies reported rates of recovery for BN at 45.0% for full recovery and 27.0% for partial remission, with 23.0% experiencing a chronic course and high rates of treatment dropout [ 63 ]. At 11 year FU, 38.0% reported remission in BN patients, increasing to 42.0% at 21 year [ 45 ]. At 22 year FU, 68.2% with BN were reported to have recovered [ 41 ]. Higher frequency of both objective binge episodes and self-induced vomiting factors influencing poorer outcomes [ 44 ].

Considering impact of treatment, analysis of engagement in self-induced vomiting as a predictor for outcome indicated there were no differences between groups in treatment dropout or response to CBT among a sample of 152 patients with various types of EDs (AN-BP, BN, EDNOS) at EOT [ 74 ]. Meta-analysis of results from 45 RCTs on psychotherapies for BN found 35.4% of treatment completers achieved symptom abstinence [ 73 ] with other studies indicating similar rates of recovery (around 52–59% depending on DSM criteria) [ 7 ].

Studies delivering CBT or other behavioural therapies reported the best outcomes for BN [ 73 ]. Specifically, early treatment progression, elimination of dietary restraint and normalisation of eating behaviour resulted in more positive outcomes [ 22 ]. These findings are supported by results from a study comparing outcomes of CBT and integrative cognitive-affective therapy (ICAT) [ 75 ]. Additional moderating effects were shown at FU (but not EOT), with greater improvements for those with less baseline depression, higher stimulus seeking (the need for excitement and stimulation) and affective lability (the experience of overly intense and unstable emotions) in the ICAT-BN group and lower stimulus seeking in the Enhanced Cognitive Behavioural Therapy (CBT-E) group. Lower affective lability showed improvements in both treatment groups [ 75 ]. Such findings indicate personality factors may deem one treatment approach more suitable to an individual than another.

A review of 4 RCTs of psychotherapy treatments for BN in adolescents (including FBT and CBT) reported overall psychological symptom improvement by EOT predicting better outcomes at 12 months, which underscored the need for not only behavioural but psychological improvement during 6 month treatment [ 31 ]. Other factors leading to poorer outcomes included less engagement in treatment, higher drive for thinness, less global functioning, and older age at presentation [ 45 ]. More research is needed into consistent predictors, mediators and moderators focused on treatment engagement and outcomes [ 22 ].

While many studies combine findings for BN and BED, one study specifically considered different emotions associated with binge eating within the two diagnostic profiles [ 60 ]. At baseline, binge eating was associated with anger/frustration for BN and depression for BED. At FU, objective binge eating (OBE) reduction in frequency (a measure of recovery) was associated with lower impulsivity and shape concern for BN but lower emotional eating and depressive symptoms for BED. These differences may provide approaches for effective intervention targets for differing presentations; however, how these may play out within a transdiagnostic approach requires further enquiry.

Binge eating disorder (BED)

BED is estimated to affect 1.5% of women and 0.3% of men worldwide, with higher prevalence (but more transient) in adolescents. Most adults report longstanding symptoms, 94% lifetime mental health conditions and 23% had attempted suicide, yet only half were in recognised healthcare or treatment [ 76 ].

Compared with AN and BN, long-term outcomes, and treatment success for individuals with BED were more favourable. Meta-analysis of BED abstinence rates suggests available psychotherapy and behavioural interventions are more effective for this population [ 77 ]. Additionally, stimulant medication (i.e., Vyvanse) has been found to be particularly effective to reduce binge eating [see [ 78 ] for full review]. Results from a study of people who received 12 months of CBT for BED indicated high rates of treatment response and favourable outcomes, maintained to 4 year FU. Significant improvements were observed with binge abstinence increasing from 30.0% at post-treatment to 67.0% at FU [ 79 ]. A meta-analysis reviewing psychological or behavioural treatments found Interpersonal Therapy (IPT) to be the treatment producing the greatest abstinence rates [ 73 ]. In a comparative study of IPT and CBT, people receiving CBT experienced increased ED symptoms between treatment and 4 year FU, while those who received IPT improved during the same period. Rates of remission at 4 year FU were also higher for IPT (76.7%) versus CBT (52.0%) [ 80 ].

One study specifically explored clinical differences between ED subtypes with and without lifetime obesity over 10 years. Prevalence of lifetime obesity in ED was 28.8% (ranging from 5% in AN to 87% in BED), with a threefold increase in lifetime obesity observed over the previous decade. Observed with temporal changes, people with ED and obesity had higher levels of childhood and family obesity, older-age onset, longer ED duration, higher levels of ED (particularly BED and BN) and poorer general psychopathology than those who were not in the obese weight range [ 81 ], suggesting greater clinical severity and poorer outcomes for people of higher weight.

Comparison of 6 year treatment outcomes between CBT and Behavioural Weight Loss Treatment (BWLT) found CBT more effective at post-treatment but fading effectiveness over time, with remission rates for both interventions lower than other reported studies (37%) [ 82 ]. A meta-analytic evaluation of 114 published and unpublished psychological and medical treatments found psychological treatments, structured self-help, and a combination of the two were all effective at EOT and 12 month FU but noted a wide variation in study design and quality, and the need for longer term FU. Efficacy and FU data for pharmacological and surgical weight loss treatments were lacking [ 77 ].

Whilst high weight and associated interventions (such as bariatric surgery) can be associated with any ED, they are frequently studied in relation to BED. A significant proportion of individuals seeking bariatric surgery (up to 42%) displayed binge eating symptomatology [ 83 ], yet little is known about the effect of these interventions on ED psychopathology and whether this differs by type of intervention. A systematic review of 23 studies of changes in ED behaviour following three different bariatric procedures found no specific procedure led to long term changes in ED profiles or behaviours [ 84 ]; however, another study investigating the placement of an intragastric balloon in obese patients found post-surgical reductions in grazing behaviours, emotional eating and EDNOS scores [ 85 ]. Bariatric surgery in general is associated with a reduction in ED, binge eating and depressive symptoms [ 86 ].

Outcomes among patients receiving bariatric surgery with and without BED were assessed where weight loss was comparable between the groups at 1 year FU. However, compared with participants receiving a BWLT-based lifestyle modification intervention instead of surgery, bariatric surgery patients lost significantly less weight at a 10.3% difference between groups. There was no significant difference between lifestyle modification and surgery groups in BED remission rates [ 87 ]. These results indicate that BLWT-type interventions are more effective than surgery at promoting weight loss in individuals with BED over a 1 year FU period, and people with BED and higher BMI were able to maintain weight loss in response to psychotherapy (CBT) at up to 5 year FU [ 88 ]. In analysis of health-related quality of life (HRQoL) in people with BED who received various levels of CBT (therapist-led, therapist-assisted and self-help), evaluation indicated that all modalities resulted in improvements to HRQoL. Poorer outcomes were associated with obesity and ED symptom severity at presentation, stressing the importance of early detection and intervention measures [ 89 ]. Research into the role of CBT in strengthening the effect of bariatric surgery for obesity is ongoing but promising [ 90 ].

EDNOS, OSFED and UFED

Similarly to BED, a diagnosis of DSM-IV EDNOS (now OSFED) was associated with a more favourable outcome than AN or BN, including shorter time to remission. One study reported remission rates for both EDNOS and BED at 4 year FU of approximately 80% [ 21 ]. The researchers suggested that an ‘otherwise specified’ diagnostic group might be comprised of individuals transitioning into or out of an ED rather than between diagnostic categories; however, more work is needed in this area to fully understand this diagnostic profile. The reported recovery rate from EDNOS-A has been found to be much lower at 57% than for EDNOS-B at 80% (DSM-V). One factor suggested leading to poorer outcomes for EDNOS-A was a higher association with a co-occurring condition of major depression and/or dysthymia not found in other EDNOS subtypes [ 7 ]. Another study found purging occurred in 6.7% from total (cross-diagnostic) ED referrals, but this subtype did not have different post-treatment remission rates or completion rates compared to non-purging profiles [ 91 ], so results are mixed.

Acknowledging the scarcity of research within these diagnostic groups, remission rates for adolescents including those with a diagnosis of Other Specified Feeding or Eating Disorder (OSFED) and Unspecified Feeding or Eating Disorder (UFED) was reported to be 23% at 12 month FU in the one study reviewed, but no detail was provided on recovery rates by diagnosis [ 26 ]. No available evidence was identified specifically for the DSM-V disorders OSFED or UFED for adults.

Avoidant/Restrictive Food Intake Disorder (ARFID)

Research into outcomes for people with ARFID is lacking, with only three studies meeting criteria for the review [ 23 , 24 , 25 ]. While, like AN, recovery for people with ARFID is usually measured by weight gain targets, one of the three studies [ 63 ] identified by this review instead reported on outcomes in terms of meeting a psychiatric diagnosis, making comparison between the studies difficult.

In a cross-diagnostic inpatient study, individuals presenting with ARFID were younger, had fewer reported ED behaviours and co-occurring conditions, less weight loss and were less likely to be bradycardic than individuals presenting with AN [ 25 ]. Although both groups received similar caloric intakes, ARFID patients relied on more enteral nutrition and required longer hospitalisations but had higher rates of remission and fewer readmissions than AN patients at 12 months. This study highlights the need for further investigation into inpatient treatment optimisation for different diagnostic profiles.

People with ARFID who had achieved remission post-treatment were able to maintain remission until 2.5 year FU, with most continuing to use outpatient treatment services [ 23 ]. In a 1 year FU study assessing ARFID, 62.0% of patients had achieved remission as defined by weight recovery and no longer meeting DSM-V criteria [ 25 ]. In a study following children treated for ARFID to a mean FU of 16 years post-treatment (age at FU 16.5–29.9 years), 26.3% continued to meet diagnostic criteria for ARFID with no diagnostic crossover, suggesting symptom stability [ 24 ]. Rates of recovery for ARFID patients in this study were not significantly different to the comparison group who had childhood onset AN, indicating similar prognoses for these disorders. No predictors of outcome for patients with ARFID were identified by the articles reviewed [ 63 ].

Community outcomes

While most outcome studies derive from health care settings, two studies were identified exploring outcomes of ED within the community. The first reported the 8 year prevalence, incidence, impairment, duration, and trajectory of ED via annual diagnostic interview of 496 adolescent females. Controlling for age, lifetime prevalence was 7.0% for BN/subthreshold BN, 6.6% for BED/subthreshold BED, 3.4% for purging disorder, 3.6% for AN/atypical AN, and 11.5% for feeding and eating disorders not otherwise classified. Peak onset age across the ED diagnostic profiles was 16–20 years with an average episode duration ranging from 3 months for BN to a year for AN; researchers noted that these episodes were shorter than the average duration estimates reported in similar research and may be representative of the transient nature of illness rather than longer term prognosis. ED were associated with greater functional impairment, distress, suicidality, and increased use of mental health treatment [ 27 ].

A second study followed 70 young people (mean age of 14 years at study commencement) meeting DSM-IV criteria for a binge eating or purging ED and found 44% no longer met criteria at ages 17 or 20, while 25% still met criteria at age 20 (the latter individuals were more likely to have externalising behaviour problems and purging behaviour at age 17). Those who experienced a persistent ED were less likely to complete secondary education and report higher depressive and anxiety symptoms at age 20, indicating the ongoing impacts of ED on education and quality of life [ 92 ]. These studies provide information about the course and outcome of early onset ED at the population level with indicators of predictive and maintaining factors.

Factors relating to outcomes

Several factors relating to outcomes have been studied across ED presentations and in specific diagnostic profiles. These include predictors of outcome, moderators or mediators of outcome, and illness reinforcers, considering age of presentation and duration of illness, ED symptomatology, presence of co-occurring medical and psychiatric conditions, and treatment characteristics.

Age of presentation

Age of presentation to treatment has been shown to have a significant impact on outcome in all diagnoses. One study considering ED in general (including AN, BN and EDNOS) showed presentation at mid-life drastically decreased chances of achieving a good outcome in response to treatment (“good” outcome defined as BMI ≥ 18.5, 3 month remission of symptoms and Eating Disorder Examination Questionnaire (EDE-Q) scores within or better than normal range). Six percent of mid-life (≥ 40 years) presentations achieved a good outcome post-treatment compared to 14% of young adults (18–39 years) and 28% of younger people (< 18 years) [ 28 ]. This finding has also been seen in research comparing 22 year outcomes of AN and BN [ 61 ].

People presenting in mid-life often have more complex medical and psychiatric profiles as well as life circumstances. They are also far more likely to have a sustained length of illness by the time of initial presentation: 27.8 years compared with 1.2 years for youths [ 28 ]. Longer duration of illness is associated with greater increase in self-reported clinical impairment [ 93 ]; however, illness duration does not necessarily influence treatment outcome, though wide variation in study protocol and quality limit the interpretability of these findings [ 37 , 94 ]. The disparity in rates of favourable outcome between age groups highlights the importance of prevention, screening, awareness of ED in primary care settings and early intervention programs, as well as targeted programs for those presenting with more complex psychosocial and life challenges.

Clinical features and co-occurring conditions

A systematic review assessed the average duration of untreated illness duration in help-seeking populations at first contact to treatment services at 29.9 months for AN, 53.0 months for BN and 67.4 months for BED [ 69 ]. ED clinical factors significantly influence outcomes, with poorer prognosis in those with time of untreated illness, primary diagnosis of AN [ 95 ], lower BMI at presentation [ 93 ], and presence of binge/purge symptomatology [ 20 , 56 ]. Certain ED behaviours and cognitions at intake predict better outcome such as lower rates of purging behaviour, higher rates of body image flexibility [ 96 ], and lower EDE-Q scores at baseline [ 97 ].

There is strong evidence for the presence of co-occurring medical and psychiatric conditions as a predictor of outcome in ED. At 22 year FU, the presence of co-occurring psychiatric conditions including Major Depressive Disorder (MDD) and Substance Use Disorder (SUD) were negatively correlated with recovery, with those who had recovered from an ED being 2.17 times less likely to have MDD and 5.33 times less likely to have SUD [ 98 ]. Co-occurring mood disorders consistently lead to poorer outcomes [ 47 , 51 , 55 , 99 ] and greater chance of moving between ED diagnoses [ 7 ]. In one study, presence of a mood disorder was the strongest predictor of classification of AN-R (but not AN-BP) [ 61 ]. Comorbid personality disorder was found in several studies to be the most common predictor of poorer outcome in ED [ 20 , 41 , 44 , 67 ].

In an adolescent sample, 39% of individuals with AN met criteria for at least one other psychiatric disorder and poorer prognosis was associated with co-occurring diagnoses of Obsessive Compulsive Disorder (OCD) and autistic traits [ 59 ]. In a large community childhood health longitudinal study, presence of any ED profile was predictive of later anxiety and mood disorders. AN was prospectively associated with long term low weight, while BN and BED with obesity, drug use and deliberate self-harm compared to age-matched children who did not have an ED profile [ 100 ].

Personality traits have also been found to be associated with poorer outcomes such as low persistence and harm avoidance in AN, lower self-directedness (BN) and reward dependence (BED) [ 41 ]. Higher perfectionism at intake predicted a lower likelihood of remission at 12 months in an adolescent sample [ 26 ], a finding consistent with previous research in adult cohorts [ 41 ].

Medical comorbidities such as malnutrition [ 72 ], concurrent type 1 diabetes [ 39 , 42 ], bodily pain [ 55 ] and viral infections [ 72 ] have been identified as risk factors for poorer outcomes and increased rates of relapse. Other co-occurring factors associated with poorer outcomes for people with ED include anxiety [ 47 , 56 , 93 ], dissociative experiences [ 101 ], impulsivity [ 56 ], adjustment disorder [ 95 ], use of psychotropic medications [ 30 ], and autistic traits have been associated with greater use of ED treatment [ 102 ].

Psychosocial, environmental and health factors

A large United States community study found positive correlation between higher rates of smoking behaviour and ED in women [ 99 ]. The same study also reported birth-related outcomes in women with ED including having a later first birth, pregnancy health concerns, experience of miscarriage or abortion [ 99 ], and women with ED may have increased experience of adverse pregnancy and neonatal outcomes, and lower numbers of children [ 3 ]. For women with a history of ED, ED symptoms tend to alleviate during pregnancy; however, they commonly resurface during the postnatal period, and up to a third of women with ED report postnatal depression [ 103 , 104 ].

Demographic factors leading to poorer prognosis include being male [ 72 ], of the LGBTQIA + community [ 105 ], being from a non-white ethnic background, low family education levels [ 99 ], lower socioeconomic status, living in a remote or rural area [ 72 ], poor employment and social adjustment [ 30 ], functional impairment [ 47 ], and having a family member with an ED [ 99 ]. Complicating prognosis are additional factors such as financial stress (individuals with ED face yearly health care costs 48% higher than the general population, while the presence of co-occurring psychiatric conditions is associated with 48% lower yearly earnings [ 3 ]. These financial challenges limit ability to access evidence-based treatments (especially in countries lacking in publicly funded health care) which may prolong illness.

There is strong evidence to suggest QoL is reduced in people with an ED [ 3 , 106 ]. It is important to consider associations between QoL, ED symptomatology and treatment outcome. Evidence-based treatments have demonstrated positive effects on QoL in addition to reduction in ED symptomatology, for example, improvements in QoL and psychological functioning and well-being were seen in response to CBT in a cross-diagnostic sample [ 43 ]. However, a meta-analysis of ED outcome studies found that the QoL of recovered ED patients remained lower than in healthy populations, highlighting the importance of prevention efforts [ 107 ] and restoration of QoL in relapse prevention. These studies highlight the high public health and clinical burden of eating disorders and the need to consider co-occurring medical and psychiatric conditions during comprehensive assessment history-taking, treatment planning and provision.

Treatment factors

Early progression in treatment can provide indication of treatment outcomes. In an RCT comparing Family Based Treatment (FBT) and Adolescent Focused Therapy (AFT) for adolescents with AN, most people who achieved remission at 1 year FU maintained recovery to 4 years FU regardless of treatment arm with remission rates tended to remain stable after 1 year [ 108 ]. The First Episode Rapid Early Intervention for Eating Disorders (FREED) service model for young adults with AN reported significant and rapid clinical improvements in over 53.2% of people compared to 17.9% TAU and also reported more cost-effective treatment [ 109 ]. In a transdiagnostic study comparing inpatient vs outpatient settings, rapid response to treatment (defined here as a clinically meaningful reduction in disorder-specific symptoms within the first ten sessions) was the only outcome predictor accounting for 45.6% of variance in ED symptoms, suggesting future work should evaluate mediators and moderators of rapid response [ 37 ]. A systematic review of outcome predictors and mediators in response to CBT indicated that early behavioural and cognitive change was associated with positive outcomes across ED diagnoses [ 22 ]. Similarly, a recent systematic review and meta-analysis of 20 years of accumulated evidence concluded early response to treatment the most robust predictor of better treatment outcomes, however, only half of people investigated across numerous studies showed early change, and more research was needed to determine outcome predictors [ 110 ]. Ongoing assessment to identify individuals who do not show early response to treatment (defined by healthy weight and absence of ED behaviours at 12 month FU), as well as provision of targeted engagement approaches, may improve outcomes [ 47 ].

Due to the frequent need for medical stabilisation in the early and acute stages of AN, the role of hospitalisation needs to be considered in the evaluation of treatment outcomes. In a large patient cohort study ( n  = 7505) with 5 year FU, a clear trend was observed with the per-patient 5 year cumulated number of inpatient days decreasing by 6% per annum after adjustment for age at diagnosis, parental mental health, and household income. The number of hospital admissions decreased by 2% per year, although there was no change in outpatient visits [ 111 ]. Factors contributing to better outcomes were not identified in this study, but in other research, early change in %EBW and ED psychopathology in adolescent inpatients predicted later change in the same ED variables [ 18 ]. Another study showed longer first admission predicted increased use of the health system in young adults [ 112 ].

In a multicentre RCT there was no difference between higher or lower calorie refeeding on clinical remission or medical hospitalisation to 12 month FU [ 113 ]. A systematic scoping review of 49 studies found adolescent day programs (intensive treatment programmes that do not involve an overnight stay at the treatment facility) can be an effective alternative to inpatient hospitalisation or step up/down in treatment intensity and are generally associated with weight gain and improvements in ED and comorbid psychopathology [ 114 ]. Outcomes in the review were sustained from 3 months to 2 years from EOT; however, due to large variability in the content, structure and theoretical underpinnings of reviewed programs, findings should be interpreted with caution.

Difficulties with emotion regulation are also associated with poor outcome across diagnostic profiles. There is evidence to suggest emotion-focused treatment is beneficial both to emotional functioning and mood as well as ED severity for people with elevated emotion regulation issues at baseline with positive effects lasting up to 5 years FU [ 115 ].

Self-esteem, self-compassion, and motivation

There is little conclusive evidence regarding predictors of poor response to evidence-based treatments [ 22 , 58 ]; however, low self-esteem has been implicated across all ED diagnoses [ 98 , 101 ], particularly AN [ 55 ]. A meta-analysis exploring the role of self-esteem on treatment outcomes indicated that while self-esteem did not predict remission or long-term weight related outcomes, it did mediate progression during inpatient treatment (greater increase in self-esteem during inpatient treatment was associated with higher remission and lower relapse rates at FU) [ 116 ]. Relatedly, high fear of self-compassion was associated with greater severity of ED symptoms in individuals with an active ED, suggesting that a fearful unwillingness to become more self-compassionate, rather than the absence of self-compassion, may lead to more detrimental outcomes [ 117 ].

Greater pre-treatment motivation has also been associated with ED symptom improvement and management of co-occurring anxiety and depression, in a systematic review and meta-analysis of 42 longitudinal studies [ 118 ]. Therapeutic interventions that include enhancement of motivation, self-esteem and self-compassion have been shown across studies to improve treatment outcomes across diagnostic profiles [ 117 ].

Relapse prevention programs

Whilst the role of treatment is crucial in the alleviation of symptoms and restoration of wellbeing, active provision of evidence-based post-treatment recovery care may be an important determining factor in relapse prevention. Research suggests the period in which individuals are at greatest risk of relapse is between four and nine-months following discharge [ 35 ], with between 31 and 41% relapsing at one to two years post-discharge [ 62 ].

To reduce readmission among a group of females receiving inpatient treatment for AN at an Australian specialist child and adolescent ED service, a 10 week transition ‘day’ program was developed and evaluated. The delivered program allowed for a ‘step down’ option and was found to have significant benefit for participants, who achieved an average weight gain of over 1 BMI point and decreased ED symptomatology at six-month FU [ 65 ]. Promising findings were also seen in a 6-session post-(inpatient and/or outpatient) treatment relapse prevention program designed by clinicians, parents, and patients in the Netherlands, which included a take-home workbook and appointments up to 18 months (frequency dependent on patient progress). Evaluated with young people with AN-R and AN-BP, 70% maintained post-discharge recovery to the end of the study period [ 36 ]. Such programs were evaluated in the context of a comprehensive specialist service with no control group comparison to measure the impact of the specific intervention, and there was no FU assessment following conclusion of the intervention to assess maintenance. Although more work is needed, these studies indicate the value of targeted relapse prevention programs.

Online relapse prevention programs

There is emerging evidence to support the safety and efficacy of internet-based relapse prevention programs aimed at preventing readmission to intensive ED treatment following discharge. These programs have the potential to be widely disseminated to individuals who may otherwise disengage from ongoing support due to access issues (e.g., living in an underserviced area, financial burden) or personal reasons such as stigma or shame [ 119 , 120 ].

A 9-session (1/month) CBT-based online relapse prevention program for women with AN discharged from inpatient treatment (baseline BMI x̄  = 17.7) found participants who completed the program had significant gains in BMI at end of program ( x̄  = 19.1) while the treatment as usual (TAU) control group did not ( x̄  = 17.7). Of note, participants who were 1–2 sessions short of completing the program maintained a higher BMI ( x̄  = 18.0) than the TAU group, whereas participants with less than 50% completion had a significantly lower BMI than any group including TAU ( x̄  = 17.0) [ 121 ]. A similar CBT-based online program targeted toward women discharged from inpatient treatment for BN found that the intervention group reported 46.0% fewer vomiting episodes compared to TAU, with some improvement in symptom abstinence (intervention group: 21.4%, TAU control = 18.9%), although this finding was not statistically significant [ 122 ].

In Hungary, an internet-based aftercare support program for individuals who had received inpatient or outpatient treatment for BN or related EDNOS in the 12 months prior to the study included information and support offered via 30 min chat sessions with peers and clinicians. Results showed 40.6% of the intervention group reported improvement compared to TAU waitlist controls (24.4%), although this difference was not statistically significant. The study noted that, although on the waitlist for the internet-based aftercare support program, the TAU group could still access additional treatment if so required. Evaluation findings report the program was feasible and well accepted [ 123 ].

Text messaging-based interventions have also been trialled to maintain engagement post-treatment, whereby participants send regular symptom reports to the clinical team with feedback provided. A 12 week ‘mobile therapy’ study with a group of women exiting CBT treatment for BN resulted in significant improvement in binge/purge frequency, ED and depressive symptoms from baseline to FU, with high rates of protocol adherence (87.0%), although there was no control group comparison [ 124 ]. Further evidence was provided in a 16 week weekly symptom report study of women with BN following inpatient discharge, with a significantly larger proportion of the intervention group achieving remission (51%) compared with TAU (36%) at 8 months FU. There was no significant difference between groups in terms of outpatient service use [ 125 ]. Results from these studies conflict with evidence from a systematic review of 15 studies, which was unable to support the effectiveness of text messaging-based programs for people with ED as either a sole or adjunctive component of the intervention [ 126 ]; however, this review noted the lack of a common evaluation framework making comparison difficult.

Despite advances in awareness and treatment, ED, particularly AN, continue to be associated with increased risk of mortality [ 4 ]. Studies identified that focus on the assessment of ED mortality, as well as data from the Global Burden of Disease Study 2016 are discussed in this section. Importantly, there are several different metrics used to report mortality. These include the Standardised Mortality Ratio (SMR), or the number of observed deaths in a cohort versus the number of expected deaths in a reference population (where a rate greater than one is interpreted as excess mortality); Weighted Mortality Ratio (WMR), or the weighted average of age-specific mortality rates per 100,000 persons; Crude Mortality Rate (CMR) , or the number of deaths in a given period divided by the population exposed to risk of death in that period; and Years of Life Lost (YLL), a summary measure of premature mortality calculated by subtracting the age at death from the standard life expectancy in a reference population.

Standardised, weighted, and crude mortality

AN is consistently described as having the highest mortality rate of the ED, but actual rate difference varies between studies. A summary of Standardised Mortality Ratios across studies is presented in Table 3 . SMRs from a meta-analysis suggest that measured mortality of AN is approximately three times as high as for other ED diagnoses, and in a UK study of ED patients ( n  = 1892) accessing services between 1992 and 2004, the SMR for AN was almost five times higher than other ED [ 127 ]. This is consistent with other research (a meta-analysis summarising 41 studies) reporting people with AN were 5.2 [3.7–7.5] times more likely to die prematurely from any cause [ 128 ]. A longitudinal study ( n  = 246) found SMR of AN to be only twice as high compared to BN, but still 6.5 times the rate expected in the general population [ 49 ].

Some studies did not report higher SMR for AN compared to other ED, however, methodological differences need to be considered. For example, some studies reported comparable SMR for AN to other ED, but subthreshold AN cases were included (previously catagorised as EDNOS) which may have reduced the calculated AN SMR [ 104 , 108 ]. In a British study using English National Hospital Episodes Statistics (2001–2009) comparing AN and BN, little difference in SMRs was reported [ 132 ]. The diagnosis of BN was less likely than other diagnosis to be recorded as the primary diagnosis and may not have been representative.

In a 22 year trial FU of a large sample of inpatients treated for BN, 2.4% had died [ 45 ]; the CMR for BN was 0.32% [ 63 ] and in severely malnourished patients, the crude mortality rate rose to 11.5% with SMR 15.9 [CI 95% (11.6–21.4)], just over 5 years post-treatment [ 137 ]. WMR has been found to be 5.1 for AN, 1.7 for BN, and 3.3 for EDNOS. SMRs were 5.86 for AN, 1.93 for BN, 1.92 for EDNOS [ 4 ] and 1.5–1.8 for BED [ 76 ].

Mortality rates in AN were highest during the first year after admission to treatment, while in BN it is in the first two years [ 134 ], with a higher risk in adolescence [ 140 ]. In AN, peak age of risk of death has been reported to be 15 years of age, BN 22 years and EDNOS 18–22 years [ 141 ]. Substance use disorders (including alcohol and/or cannabis) increased mortality in people with eating disorders across the diagnostic profiles [ 142 ].

In ED, peak age of risk for males may be earlier than females [ 141 ]. SMRs are higher for males (SMR = 7.24; 95% CI 6.58–7.96) relative to females (SMR = 4.59; 95% CI 4.34–4.85) overall, and in all age groups [ 131 ]. This may be due to the lower likelihood of males to self-identify or be identified with ED resulting in treatment delays and higher severity of illness when finally seeking help [ 131 ]. In mortality research conducted with a male-only sample, similarly high SMRs for males with BN and particularly AN as in majority female samples [ 2 ] were reported; however, mortality rates of EDNOS in males were considerably higher than those reported in female-dominant or female-only samples. Moreover, a case-controlled study found there was a sex difference across all diagnostic categories in CMR, with male to female being 15–5% in AN, 8–3% in BN, and 4–3% in EDNOS, but there were no significant sex differences in SMR for any diagnostic group, with males showing a shorter survival time after onset [ 2 ]. Researchers have suggested that increased mortality in males could be due to several factors, including reluctance to seek treatment and current treatment approaches being less effective in males [ 138 ]. Further research in males with ED is required to better understand the impact and response in male patients. Regardless of the mortality metric used, these studies indicate the vital importance of considering elevated mortality risk across the range of ED diagnoses.

Years of life lost/years lived with disability

The Global Burden of Disease Study 2016 reported that YLL due to premature death attributable to AN was 0.4 per 100,000. No YLL were attributed to BN; however, cause-specific mortality (CSM)—where each death is attributed to a single underlying cause—was, per thousand, 0.5 for AN (with a 2.9% increase from 1980 to 2016) and 0.1 for BN (21.8% increase from 1980 to 2016) [ 143 ]. The 2019 extension advocated for the inclusion of BED and OSFED in the Global Burden of Disease Study, previously excluded, as both diagnostic groups accounted for the majority of global ED cases and accounted for an unrepresented 41.9 million people living with ED [ 144 ].

Estimates are that over 3.3 million healthy life years are lost per year worldwide due to eating disorders. Years lived with a disability (YLDs) have increased from 2007 to 2017 for both AN (6.2% increase) and BN (10.3%), a higher rate than other mental disorders (− 0.1%). ED outcomes include reduced self-reported quality of life and estimated health care costs at 48% higher than for the general population [ 3 ].

Risk factors

Little is known about specific risk factors for mortality, although some variables have been reported in the literature. People who receive inpatient treatment for AN have more than five to seven times mortality risk when matched to age and gender and compared to other ED diagnoses [ 3 , 131 , 133 ]. For individuals receiving AN or BN treatment in outpatient settings, the risk is still twice that of controls [ 3 ]. Older age of presentation is a significant risk; adult presentations are associated with much higher mortality rates than adolescent presentations likely due to longer duration of illness at presentation, higher rates of medical and psychiatric complications and less engagement in treatment [ 4 , 28 , 68 , 137 , 139 ]. Higher mortality rates (especially in AN) are associated with lower BMI, longer duration of illness at service presentation [ 4 , 49 , 68 , 137 , 139 ], diuretic use [ 68 ], and occurrence of an in-hospital suicide attempt [ 68 , 137 ]. Certain treatment factors may be associated with higher risk of mortality, including transfer to medical intensive care unit, discharge against medical advice, and shorter hospital stays [ 137 ]. Other factors associated with increased risk of mortality include poor psychosocial functioning, substance use [ 28 , 49 ] and absence of family ED history [ 28 ].

Cause of death

Results from a large prospective 20 year (1985–2005) longitudinal study of individuals admitted to inpatient services in Germany ( n  = 5839) showed people with AN were likely to die from health issues caused by their disorder, most commonly circulatory failure, cachexia, and multiple organ failure [ 133 ]. Other studies have identified somatic risk factors including anaemia, dysnatremia, infection, cardiac complications and haematological comorbidities [ 137 ]. A 2021 study reported rates of medical complications for severe AN, which included anaemia (79%), neutropenia (53.9%), hypertransaminasemia (53.7%), osteoporosis (46.3%), hypokalemia (39.5%), hypophosphatemia (26%), hypoglycaemia (13.8%), infectious complications (24.3%), cardiac dysfunction (7.1%), and proven gelatinous bone marrow transformation (6.5%). Five (1.4%) of the patients in this study died of the following causes: septic shock of pulmonary origin ( n  = 1), septic shock of urinary origin ( n  = 1) and suicide ( n  = 3) [ 145 ].

Suicide is the most common non-natural cause of death in people with AN, BN, BED and EDNOS [ 133 ]. High rates of suicidality were reported in a meta-analysis of 36 studies published between 1966 and 2010 with data showing one in five individuals who died from an ED did so by suicide [ 4 ]. Risk of suicide may be particularly elevated in AN [Hazard Ratio (HR) 5.07; 95% CI 1.37–18.84] and BN (HR 6.07; 95% CI 2.47–14.89) even when specialised treatments are available [ 134 ]: people with AN are 18.1 [11.5–28.7] times more likely to die by suicide than 15–34 year old females in the general population [ 128 ]. This is supported by results from a meta-review exploring risk of all-cause and suicide across major mental disorders. 1.7 million patients and over a quarter of a million deaths were examined, finding all mental health disorders had an increased mortality rate to the general population; however, substance use and AN were the highest, translating into 10–20 year reductions in life expectancy, with borderline personality disorder, AN, depression and bipolar disorder having the highest suicide risk [ 146 ].

This rapid review, which synthesised the available literature on ED remission, relapse and recovery rates including associated moderating and mediating variables such as psychosocial and treatment characteristics, highlighted significant challenges of synthesising outcome literature. This includes a wide variety of ways in which key outcomes ‘remission’, ‘relapse’ and ‘recovery’ are not only defined but also how they are measured and analysed. There is no consensus among clinical or research communities on these definitions for any of the ED diagnoses [ 30 , 31 , 94 ]; thus, comparison between studies is challenging.

As EDs have amongst the highest rates of mortality of the mental health disorders, including one in five deaths caused by suicide, research into preventable causes of death, mitigatable risk, prevention and treatment efficacy is of paramount importance. It is noteworthy that current reported YLL and YLD for ED are likely an underestimate due to lack of robust epidemiological data, methodological limitations of burden of disease studies, absence of the illness group from national surveys and underreporting of mortality [ 147 ].

‘Relapse’ is typically defined by a return of symptoms after a period of reduced symptomatology; however, reviewed studies report a variety of methods to measure this, including multidisciplinary healthcare team assessment, scores on standardised psychological and behavioural interviews or questionnaires, weight criteria (including BMI or %EBW), reported eating disorder behaviours, meeting DSM (IV or V) diagnostic criteria, or a combination of the above. More difficult is determining if there is a difference between ‘remission’ and ‘recovery’, with remission usually determined by an absence of diagnostic symptomatology (again, characterised by a variety of methods), and recovery an improvement in overall functioning. Many studies report remission and recovery interchangeably, and very few incorporate returns to psychosocial functioning and QoL post alleviation of symptoms [ 29 ]. More standardised definitions may progress research [ 148 ] by allowing direct comparison between outcome studies, improving the ability of future investigations to predict and report relapse versus recovery rates and to comprehensively evaluate intervention and relapse prevention approaches.

An additional challenge across studies is a highly variable period between initial assessment or baseline and the time at which ‘outcome’ is assessed—ranging from as little as one week up to 25 years. As rates of relapse increase with illness progression, relatively short FU periods may compromise the understanding of true long-term outcomes. Longer-term FU studies are crucial to understand optimised models of care for sustained recovery and wellbeing.

Along with illness progression over time in individuals, the shift of diagnostic profiles among the individual may differ the definition of relapse or remission and thus impacts on outcome measures. Most research protocols adopt a firm inclusion/exclusion criterion, focusing on specific diagnostic profiles; however, findings from this review suggest considering a transdiagnostic approach in outcomes research which may better reflect the potentially transient nature of ED symptomatology [ 44 ]. This may have implications for diagnoses such as OSFED, potentially a transient category [ 21 ], rather than categorisation in or out of full ED diagnostic syndromes. Identification and consideration of transdiagnostic profiles, combined ED presentations and co-occurring mental health conditions should be considered in the long-term management and monitoring of individuals.

Studies within this review reported on cohorts of individuals with a formal diagnosis and research conducted within treatment settings. However, previous research has suggested that incidence rates within the community are considerable, and yet help-seeking of any type for a problem related to ED symptoms is uncommon, ranging between 22 and 40% [ 106 ] and there can be a significant time delay from first symptom experience [ 69 ]. A recent large community survey of the impact of COVID-19 on people with ED reported up to 70% of people who experienced ED symptoms were not in treatment [ 149 ] suggesting a significant proportion of people with an ED are not captured within this outcome review. Outcomes for this population are largely unknown [ 150 ] but preliminary research suggests they may be less favourable [ 151 , 152 ].

Improved QoL has been shown to be a significant predictor of positive outcome and is an opportunity for broader scope interventions for people with ED [ 107 ], and yet consistent and more wholistic markers of life quality are rarely integrated into research or clinical decision making [ 153 , 154 ]. It is also noted that outcome determinants in the reviewed studies are predominantly biometric (e.g., weight) and ED symptom related, whereas qualitative lived experience evidence suggests a broader range of person-centred metrics should be used to measure outcome. These include supportive relationships (e.g., receiving support, advice and encouragement from others, including family, friends, and/or professional carers), sense of hope, identity, meaning and purpose, feelings of empowerment and self-compassion [ 155 ]. Involvement of those to whom the work pertains (i.e., individuals with lived experience) is essential in future outcomes research to add richness and utility to theoretical frameworks, methodological approaches and conclusions [ 156 ].

Key findings

ED frequently take a chronic course, with less than half of individuals achieving recovery at long-term FU [ 41 , 44 , 52 ]. Between 30 and 41% of people will relapse within two years of receiving treatment [ 35 , 61 ], and between 20 and 61% will experience more than one type of eating disorder [ 7 , 63 , 64 ]. As with much of the extant ED literature, most outcome research has been conducted in AN. Restrictive ED are consistently associated with the poorest prognosis. This review identified recovery rates in the range of 18–60% for AN and an average length of illness of between 6.5 and 14 years [ 41 , 56 ]. Binge/purge symptomatology within AN is associated with worse outcome [ 20 , 56 ]. Recovery rates for BN are slightly more optimistic at 35–59% [ 7 , 45 , 63 , 157 ], and similarly for BED at 37–77% [ 79 , 80 , 82 ]. There is limited data available on outcomes in ARFID, OSFED, and UFED.

Factors associated with a more positive long-term outcome include lower age of presentation [ 28 , 61 ], shorter duration of illness at first presentation [ 69 , 93 , 94 ], higher pre-treatment motivation to recover [ 116 ], and demonstrated early response to treatment [ 18 , 75 , 110 , 112 ]. Factors associated with poorer outcome are lower BMI at presentation [ 93 ], presence of binge/purge symptomatology [ 20 , 30 , 44 , 56 ], and presence of comorbid psychiatric condition/s such as depression, anxiety, or personality disorder [ 44 , 47 , 51 , 55 , 67 , 98 , 99 ]. Males, LGBTQIA + community [ 104 , 105 ], neurodiversity [ 102 ], individuals from non-white/ethnic backgrounds, and those from lower socioeconomic brackets or rural/remote communities are also more likely to experience a poor outcome [ 18 , 72 , 76 , 77 ].

Relapse following ED treatment is common [ 11 , 35 , 36 , 62 , 148 ] and is most likely to occur 4–9 months post discharge [ 35 ]. Up to 41% of individuals will relapse by the second-year post-discharge [ 62 ]. Aftercare relapse prevention programs, including online and face-to-face initiatives such as text-message based interventions, daily feedback to clinicians and intensive day programs have been shown to increase chance of maintaining recovery [ 121 , 123 – 125 ]. The implementation of such programs may be key to improving long-term recovery rates particularly for those individuals who may otherwise disengage from treatment for access reasons (such as living in an underserviced area) or because of the stigma of engaging with mental health care [ 119 , 120 ]. There is emerging evidence in the effectiveness of online intervention for preventing relapse and promoting treatment gains when individuals are motivated to change; however, evidence is not conclusive potentially due to the high variability of the interventions and evaluations of such programs.

ED are associated with unacceptably high mortality rates, and particularly high risk of suicide [ 128 , 133 ]. Of the ED, AN carries the highest mortality risk [ 49 , 127 , 128 ]. Standardised mortality ratios (SMRs) identified by this review ranged between 1.2 and 15.9 for AN; 1.4 and 4.8 for BN; 1.01 and 3.3 for BED; and 1.3 to 4.7 for EDNOS/OSFED [ 2 , 4 , 20 , 121 , 127 , 128 , 132 , 134 , 135 , 137 , 139 ]. Factors associated with increased risk of mortality include having received inpatient treatment [ 3 , 131 , 133 ], longer duration of untreated illness [ 4 , 28 , 68 , 68 , 137 , 139 ] and lower BMI at presentation [ 4 , 49 , 68 , 137 , 139 ]. Males are at higher risk of death than females [ 2 ].

Strengths and limitations

This rapid review has several strengths inherent to the methodological approach of the series, conducted to inform the Australian Eating Disorders Research and Translation Strategy 2021–2031 [ 1 ]. The RR process broadly assessed all available high-level evidence peer-reviewed literature swiftly [ 24 ], included all diagnostic categories covering transdiagnostic continuums, considered the full demographic range available and reported a variety of methodological designs including clinical trials (across a variety of settings), systematic reviews, meta-analyses, and population-level research. It aimed to provide the most comprehensive and current review possible with coordination of complex findings into a more cohesive structure. It was noted where applicable the limitations of conclusions drawn from this review, such as the widely disparate definitions and measurements for key outcome data (i.e., remission, relapse, and recovery rates), crossover from DSM-IV to DSM-V criteria (due to timeframe of search), vastly different periods of follow up impacting findings, and conflicting evidence. As with the series of rapid reviews, the inclusion criteria of evidence may have potentially excluded relevant evidence, and it is noted that evidence is always emerging.

This RR of outcomes in ED identified several gaps in current knowledge and provides direction for future strategic research directives, specifically, defining the key outcomes of remission, recovery, and relapse, with consensus of determinants and inclusion of broader QoL measures and lived experience. Identifying and refining risk factors, mediating and moderating factors that may influence outcomes is ongoing, with longer-term FU research needed to track remission versus relapse, diagnostic crossover and optimisation of treatment engagement and recovery. Regarding mortality literature, this review noted considerable gaps [ 146 ], with variety reporting methods, a paucity of research between population level reporting and small hospital outcome studies, and minimal investigation into life circumstances relating to death, especially as many of these deaths may be preventable. With low rates of remission despite evidence-based care and high risk of mortality, especially for AN, it is strongly recommended that focused, long-term follow-up research is prioritised for people with ED.

Availability of data and materials

Not applicable—all citations provided.

Abbreviations

Atypical anorexia nervosa

Adolescent focused therapy

• Anorexia nervosa

Anorexia nervosa binge/purge subtype

Anorexia nervosa restricting subtype

Avoidant restrictive food intake disorder

• Binge eating disorder

Body mass index

• Bulimia nervosa

Behavioural weight loss therapy

Cognitive behaviour therapy

Enhanced cognitive behavioural therapy

Crude mortality rate

Diagnostic and statistical manual of mental disorders

Expected body weight

• Eating disorders

Eating disorder examination questionnaire

Eating disorder not otherwise specified

Eating disorder not otherwise specified-anorectic type

Eating disorder not otherwise specified-bulimic type

End of treatment

Family-based therapy

Healthcare management advisors

Health related quality of life

Integrative cognitive-affective therapy

InsideOut Institute

Interpersonal therapy

Major depressive disorder

Objective binge eating

Obsessive compulsive disorder

Other specified feeding or eating disorder

Quality of life

Randomised controlled trial

National eating disorder research & translation strategy rapid review

Standardised mortality ratio

Substance use disorder

Treatment as usual

Unspecified feeding or eating disorder

Weighted mortality ratio

Years of life lost

Years lived with a disability

Galmiche M, Déchelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000–2018 period: a systematic literature review. Am J Clin Nutr. 2019;109(5):1402–13.

Article   PubMed   Google Scholar  

Fichter MM, Naab S, Voderholzer U, Quadflieg N. Mortality in males as compared to females treated for an eating disorder: a large prospective controlled study. Eat Weight Disord. 2021;26(5):1627–37.

van Hoeken D, Hoek HW. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Curr Opin Psychiatr. 2020;33(6):521–7.

Article   Google Scholar  

Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Arch Gen Psychiatr. 2011;68(7):724.

Bardone-Cone AM, Hunt RA, Watson HJ. An overview of conceptualizations of eating disorder recovery, recent findings, and future directions. Curr Psychiatr Rep. 2018;20(9):79.

Noordenbos G, Seubring A. Criteria for recovery from eating disorders according to patients and therapists. Eat Disord. 2006;14(1):41–54.

Castellini G, Lo Sauro C, Mannucci E, Ravaldi C, Rotella CM, Faravelli C, et al. Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study. Psychosom Med. 2011;73(3):270–9.

InsideOut Institute for Eating Disorders. Australian Eating Disorders Research and Translation Strategy 2021–2031. 2021.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [Internet]. Fifth Edition. American Psychiatric Association; 2013 [cited 2022 Mar 15]. Available from: https://psychiatryonline.org/doi/book/ https://doi.org/10.1176/appi.books.9780890425596 .

Aouad P, Bryant E, Maloney D, Marks P, Le A, Russell H, et al. Informing the development of Australia’s national eating disorders research and translation strategy: a rapid review methodology. J Eat Disord. 2022;10(1):31.

Article   PubMed   PubMed Central   Google Scholar  

Grilo CM, Pagano ME, Stout RL, Markowitz JC, Ansell EB, Pinto A, et al. Stressful life events predict eating disorder relapse following remission: six-year prospective outcomes. Int J Eat Disord. 2012;45(2):185–92.

Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912–20.

Canadian Agency for Drugs and Technologies in Health. About the Rapid Response Service [Internet]. [Cited 2021 Jun 19]. Available from: https://www.cadth.ca/about-cadth/what-we-do/products-services/rapid-response-service .

Hamel C, Michaud A, Thuku M, Skidmore B, Stevens A, Nussbaumer-Streit B, et al. Defining rapid reviews: a systematic scoping review and thematic analysis of definitions and defining characteristics of rapid reviews. J Clin Epidemiol. 2021;129:74–85.

Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372: n160.

Le Grange D, Hughes EK, Court A, Yeo M, Crosby RD, Sawyer SM. Randomized clinical trial of parent-focused treatment and family-based treatment for adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatr. 2016;55(8):683–92.

Guarda AS, Cooper M, Pletch A, Laddaran L, Redgrave GW, Schreyer CC. Acceptability and tolerability of a meal-based, rapid refeeding, behavioral weight restoration protocol for anorexia nervosa. Int J Eat Disord. 2020;53(12):2032–7.

Brown TA, Murray SB, Anderson LK, Kaye WH. Early predictors of treatment outcome in a partial hospital program for adolescent anorexia nervosa. Int J Eat Disord. 2020;53(9):1550–5.

Fichter MM, Quadflieg N, Lindner S. Internet-based relapse prevention for anorexia nervosa: nine-month follow-up. J Eat Disord. 2013;1(1):23.

Rigaud D, Pennacchio H, Bizeul C, Reveillard V, Vergès B. Outcome in AN adult patients: a 13-year follow-up in 484 patients. Diabetes Metab. 2011;37(4):305–11.

Agras WS, Crow S, Mitchell JE, Halmi KA, Bryson S. A 4-year prospective study of eating disorder NOS compared with full eating disorder syndromes. Int J Eat Disord. 2009;42(6):565–70.

Linardon J, de la Piedad GX, Brennan L. Predictors, moderators, and mediators of treatment outcome following manualised cognitive-behavioural therapy for eating disorders: a systematic review: predictors, moderators, and mediators of outcome for eating disorders. Eur Eat Disorders Rev. 2017;25(1):3–12.

Bryson AE, Scipioni AM, Essayli JH, Mahoney JR, Ornstein RM. Outcomes of low-weight patients with avoidant/restrictive food intake disorder and anorexia nervosa at long-term follow-up after treatment in a partial hospitalization program for eating disorders. Int J Eat Disord. 2018;51(5):470–4.

Lange CRA, Ekedahl Fjertorp H, Holmer R, Wijk E, Wallin U. Long-term follow-up study of low-weight avoidant restrictive food intake disorder compared with childhood-onset anorexia nervosa: psychiatric and occupational outcome in 56 patients. Int J Eat Disord. 2019;52(4):435–8.

Strandjord SE, Sieke EH, Richmond M, Rome ES. Avoidant/restrictive food intake disorder: Illness and hospital course in patients hospitalized for nutritional insufficiency. J Adolesc Health. 2015;57(6):673–8.

Johnston J, Shu CY, Hoiles KJ, Clarke PJF, Watson HJ, Dunlop PD, et al. Perfectionism is associated with higher eating disorder symptoms and lower remission in children and adolescents diagnosed with eating disorders. Eat Behav. 2018;30:55–60.

Stice E, Marti CN, Rohde P. Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women. J Abnorm Psychol. 2013;122(2):445–57.

Ackard DM, Richter S, Egan A, Cronemeyer C. Poor outcome and death among youth, young adults, and midlife adults with eating disorders: an investigation of risk factors by age at assessment: poor outcome and death. Int J Eat Disord. 2014;47(7):825–35.

Bardone-Cone AM, Harney MB, Maldonado CR, Lawson MA, Robinson DP, Smith R, et al. Defining recovery from an eating disorder: conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity. Behav Res Ther. 2010;48(3):194–202.

Le Grange D, Fitzsimmons-Craft EE, Crosby RD, Hay P, Lacey H, Bamford B, et al. Predictors and moderators of outcome for severe and enduring anorexia nervosa. Behav Res Ther. 2014;56:91–8.

Gorrell S, Matheson BE, Lock J, Le Grange D. Remission in adolescents with bulimia nervosa: empirical evaluation of current conceptual models. Eur Eat Disorders Rev. 2020;28(4):445–53.

Keel PK, Dorer DJ, Franko DL, Jackson SC, Herzog DB. Postremission predictors of relapse in women with eating disorders. AJP. 2005;162(12):2263–8.

Stice E, Marti CN, Shaw H, Jaconis M. An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. J Abnorm Psychol. 2009;118(3):587–97.

Agras WS, Walsh BT, Fairburn CG, Wilson GT, Kraemer HC. A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Arch Gen Psychiatr. 2000;57(5):459.

Carter JC, Mercer-Lynn KB, Norwood SJ, Bewell-Weiss CV, Crosby RD, Woodside DB, et al. A prospective study of predictors of relapse in anorexia nervosa: implications for relapse prevention. Psychiatr Res. 2012;200(2–3):518–23.

Berends T, van Meijel B, Nugteren W, Deen M, Danner UN, Hoek HW, et al. Rate, timing and predictors of relapse in patients with anorexia nervosa following a relapse prevention program: a cohort study. BMC Psychiatr. 2016;16(1):316.

Walker DC, Donahue JM, Heiss S, Gorrell S, Anderson LM, Brooks JM, et al. Rapid response is predictive of treatment outcomes in a transdiagnostic intensive outpatient eating disorder sample: a replication of prior research in a real-world setting. Eat Weight Disord. 2021;26(5):1345–56.

Taylor MB, Daiss S, Krietsch K. Associations among self-compassion, mindful eating, eating disorder symptomatology, and body mass index in college students. Transl Issues Psychol Sci. 2015;1(3):229–38.

Custal N, Arcelus J, Agüera Z, Bove FI, Wales J, Granero R, et al. Treatment outcome of patients with comorbid type 1 diabetes and eating disorders. BMC Psychiatr. 2014;14(1):140.

Agüera Z, Riesco N, Jiménez-Murcia S, Islam MA, Granero R, Vicente E, et al. Cognitive behaviour therapy response and dropout rate across purging and nonpurging bulimia nervosa and binge eating disorder: DSM-5 implications. BMC Psychiatr. 2013;13(1):285.

Fernández-Aranda F, Treasure J, Paslakis G, Agüera Z, Giménez M, Granero R, et al. The impact of duration of illness on treatment nonresponse and drop-out: exploring the relevance of enduring eating disorder concept. Eur Eat Disorders Rev. 2021;29(3):499–513.

Colton PA, Olmsted MP, Daneman D, Farquhar JC, Wong H, Muskat S, et al. Eating disorders in girls and women with type 1 diabetes: a longitudinal study of prevalence, onset, remission, and recurrence. Diabetes Care. 2015;38(7):1212–7.

Tomba E, Tecuta L, Schumann R, Ballardini D. Does psychological well-being change following treatment? An exploratory study on outpatients with eating disorders. Compr Psychiatr. 2017;74:61–9.

Helverskov JL, Clausen L, Mors O, Frydenberg M, Thomsen PH, Rokkedal K. Trans-diagnostic outcome of eating disorders: a 30-month follow-up study of 629 patients. Eur Eat Disorders Rev. 2010;18(6):453–63.

Quadflieg N, Fichter MM. Long-term outcome of inpatients with bulimia nervosa—results from the Christina Barz study. Int J Eat Disord. 2019;52(7):834–45.

Carter JC, Stewart DA, Fairburn CG. Eating disorder examination questionnaire: norms for young adolescent girls. Behav Res Ther. 2001;39(5):625–32.

Wade T, Ambwani S, Cardi V, Albano G, Treasure J. Outcomes for adults with anorexia nervosa who do not respond early to outpatient treatment. Int J Eat Disord. 2021;54(7):1278–82.

Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJV. Validity of the eating disorder examination questionnaire (EDE-Q) in screening for eating disorders in community samples. Behav Res Ther. 2004;42(5):551–67.

Franko DL, Keshaviah A, Eddy KT, Krishna M, Davis MC, Keel PK, et al. A longitudinal investigation of mortality in anorexia nervosa and bulimia nervosa. AJP. 2013;170(8):917–25.

Eddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. J Clin Psychiatr. 2017;78(02):184–9.

Lydecker JA, Grilo CM. Psychiatric comorbidity as predictor and moderator of binge-eating disorder treatment outcomes: an analysis of aggregated randomized controlled trials. Psychol Med. 2021;52(16):4085–93.

Eielsen HP, Vrabel K, Hoffart A, Rø Ø, Rosenvinge JH. The 17-year outcome of 62 adult patients with longstanding eating disorders—a prospective study. Int J Eat Disord. 2021;54(5):841–50.

Dare C, Eisler I, Russell G, Treasure J, Dodge L. Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments. Br J Psychiatr. 2001;178(3):216–21.

Kordy H, Krämer B, Palmer RL, Papezova H, Pellet J, Richard M, et al. Remission, recovery, relapse, and recurrence in eating disorders: conceptualization and illustration of a validation strategy. J Clin Psychol. 2002;58(7):833–46.

Wild B, Friederich HC, Zipfel S, Resmark G, Giel K, Teufel M, et al. Predictors of outcomes in outpatients with anorexia nervosa—results from the ANTOP study. Psychiatr Res. 2016;244:45–50.

Zerwas S, Lund BC, Von Holle A, Thornton LM, Berrettini WH, Brandt H, et al. Factors associated with recovery from anorexia nervosa. J Psychiatr Res. 2013;47(7):972–9.

Ricca V, Castellini G, Lo Sauro C, Mannucci E, Ravaldi C, Rotella F, et al. Cognitive-behavioral therapy for threshold and subthreshold anorexia nervosa: a three-year follow-up study. Psychother Psychosom. 2010;79(4):238–48.

Winkler LAD, Bilenberg N, Hørder K, Støving RK. Does specialization of treatment influence mortality in eating disorders?—A comparison of two retrospective cohorts. Psychiatr Res. 2015;230(2):165–71.

Wentz E, Gillberg IC, Anckarsäter H, Gillberg C, Råstam M. Adolescent-onset anorexia nervosa: 18-year outcome. Br J Psychiatr. 2009;194(2):168–74.

Castellini G, Mannucci E, Lo Sauro C, Benni L, Lazzeretti L, Ravaldi C, et al. Different moderators of cognitive-behavioral therapy on subjective and objective binge eating in bulimia nervosa and binge eating disorder: a three-year follow-up study. Psychother Psychosom. 2012;81(1):11–20.

Franko DL, Tabri N, Keshaviah A, Murray HB, Herzog DB, Thomas JJ, et al. Predictors of long-term recovery in anorexia nervosa and bulimia nervosa: data from a 22-year longitudinal study. J Psychiatr Res. 2018;96:183–8.

Berends T, Boonstra N, van Elburg A. Relapse in anorexia nervosa: a systematic review and meta-analysis. Curr Opin Psychiatr. 2018;31(6):445–55.

Steinhausen HC, Weber S. The outcome of bulimia nervosa: findings from one-quarter century of research. AJP. 2009;166(12):1331–41.

Glazer KB, Sonneville KR, Micali N, Swanson SA, Crosby R, Horton NJ, et al. The course of eating disorders involving bingeing and purging among adolescent girls: prevalence, stability, and transitions. J Adolesc Health. 2019;64(2):165–71.

Goldstein M, Peters L, Baillie A, McVeagh P, Minshall G, Fitzjames D. The effectiveness of a day program for the treatment of adolescent anorexia nervosa. Int J Eat Disord. 2011;44(1):29–38.

Herpertz-Dahlmann B, Dempfle A, Egberts KM, Kappel V, Konrad K, Vloet JA, et al. Outcome of childhood anorexia nervosa-the results of a five- to ten-year follow-up study. Int J Eat Disord. 2018;51(4):295–304.

Amianto F, Spalatro A, Ottone L, Abbate Daga G, Fassino S. Naturalistic follow-up of subjects affected with anorexia nervosa 8 years after multimodal treatment: personality and psychopathology changes and predictors of outcome. Eur psychiatr. 2017;45:198–206.

Huas C, Caille A, Godart N, Foulon C, Pham-Scottez A, Divac S, et al. Factors predictive of ten-year mortality in severe anorexia nervosa patients: mortality in severe anorexia nervosa patients. Acta Psychiatr Scand. 2011;123(1):62–70.

Austin A, Flynn M, Richards K, Hodsoll J, Duarte TA, Robinson P, et al. Duration of untreated eating disorder and relationship to outcomes: a systematic review of the literature. Eur Eat Disorders Rev. 2021;29(3):329–45.

Dechartres A, Huas C, Godart N, Pousset M, Pham A, Divac SM, Rouillon F, Falissard B. Outcomes of empirical eating disorder phenotypes in a clinical female sample: results from a latent class analysis. Psychopathology. 2011;44:12–20.

Ando T, Komaki G, Nishimura H, Naruo T, Okabe K, Kawai K, et al. A ghrelin gene variant may predict crossover rate from restricting-type anorexia nervosa to other phenotypes of eating disorders: a retrospective survival analysis. Psychiatr Genet. 2010;20(4):153–9.

Castellini G, Ricca V, Lelli L, Bagnoli S, Lucenteforte E, Faravelli C, et al. Association between serotonin transporter gene polymorphism and eating disorders outcome: a 6-year follow-up study. Am J Med Genet. 2012;159B(5):491–500.

Linardon J. Rates of abstinence following psychological or behavioral treatments for binge-eating disorder: meta-analysis. Int J Eat Disord. 2018;51(8):785–97.

Dalle Grave R, Calugi S, Marchesini G. Self-induced vomiting in eating disorders: associated features and treatment outcome. Behav Res Ther. 2009;47(8):680–4.

Accurso EC, Wonderlich SA, Crosby RD, Smith TL, Klein MH, Mitchell JE, et al. Predictors and moderators of treatment outcome in a randomized clinical trial for adults with symptoms of bulimia nervosa. J Consult Clin Psychol. 2016;84(2):178–84.

Keski-Rahkonen A. Epidemiology of binge eating disorder: prevalence, course, comorbidity, and risk factors. Curr Opin Psychiatr. 2021;34(6):525–31.

Hilbert A, Petroff D, Herpertz S, Pietrowsky R, Tuschen-Caffier B, Vocks S, et al. Meta-analysis on the long-term effectiveness of psychological and medical treatments for binge-eating disorder. Int J Eat Disord. 2020;53(9):1353–76.

Rodan S, Bryant E, Le A, Maloney D, National Eating Disorders Collaboration, Touyz S, et al. Pharmacotherapy, adjunctive and alternative therapies: findings from a rapid review. J Eat Disord. (Under Review).

Fischer S, Meyer AH, Dremmel D, Schlup B, Munsch S. Short-term cognitive-behavioral therapy for binge eating disorder: long-term efficacy and predictors of long-term treatment success. Behav Res Ther. 2014;58:36–42.

Hilbert A, Bishop ME, Stein RI, Tanofsky-Kraff M, Swenson AK, Welch RR, et al. Long-term efficacy of psychological treatments for binge eating disorder. Br J Psychiatr. 2012;200(3):232–7.

Villarejo C, Fernández-Aranda F, Jiménez-Murcia S, Peñas-Lledó E, Granero R, Penelo E, et al. Lifetime obesity in patients with eating disorders: increasing prevalence, clinical and personality correlates. Eur Eat Disorders Rev. 2012;20(3):250–4.

Munsch S, Meyer AH, Biedert E. Efficacy and predictors of long-term treatment success for cognitive-behavioral treatment and behavioral weight-loss-treatment in overweight individuals with binge eating disorder. Behav Res Ther. 2012;50(12):775–85.

Opolski M, Chur-Hansen A, Wittert G. The eating-related behaviours, disorders and expectations of candidates for bariatric surgery: eating in bariatric surgery candidates. Clin Obes. 2015;5(4):165–97.

Opozda M, Chur-Hansen A, Wittert G. Changes in problematic and disordered eating after gastric bypass, adjustable gastric banding and vertical sleeve gastrectomy: a systematic review of pre-post studies: problematic/disordered eating in bariatric surgeries. Obes Rev. 2016;17(8):770–92.

Genco A, Maselli R, Frangella F, Cipriano M, Paone E, Meuti V, et al. Effect of consecutive intragastric balloon (BIB®) plus diet versus single BIB® plus diet on eating disorders not otherwise specified (EDNOS) in obese patients. Obes Surg. 2013;23(12):2075–9.

Ferreira Pinto T, Carvalhedo de Bruin PF, Sales de Bruin VM, Ney Lemos F, Azevedo Lopes FH, Marcos Lopes P. Effects of bariatric surgery on night eating and depressive symptoms: a prospective study. Surg Obes Relat Dis. 2017;13(6):1057–62.

Wadden TA, Faulconbridge LF, Jones-Corneille LR, Sarwer DB, Fabricatore AN, Thomas JG, et al. Binge eating disorder and the outcome of bariatric surgery at one year: a prospective, observational study. Obesity. 2011;19(6):1220–8.

Calugi S, Ruocco A, El Ghoch M, Andrea C, Geccherle E, Sartori F, et al. Residential cognitive-behavioral weight-loss intervention for obesity with and without binge-eating disorder: a prospective case-control study with five-year follow-up: treatment for obesity with binge-eating disorder. Int J Eat Disord. 2016;49(7):723–30.

Mason TB, Crosby RD, Kolotkin RL, Grilo CM, Mitchell JE, Wonderlich SA, et al. Correlates of weight-related quality of life among individuals with binge eating disorder before and after cognitive behavioral therapy. Eat Behav. 2017;27:1–6.

Paul L, van Rongen S, van Hoeken D, Deen M, Klaassen R, Biter LU, et al. Does cognitive behavioral therapy strengthen the effect of bariatric surgery for obesity? Design and methods of a randomized and controlled study. Contemp Clin Trials. 2015;42:252–6.

Tasca GA, Maxwell H, Bone M, Trinneer A, Balfour L, Bissada H. Purging disorder: psychopathology and treatment outcomes. Int J Eat Disord. 2012;45(1):36–42.

Allen KL, Byrne SM, Oddy WH, Crosby RD. Early onset binge eating and purging eating disorders: course and outcome in a population-based study of adolescents. J Abnorm Child Psychol. 2013;41(7):1083–96.

Glasofer DR, Muratore AF, Attia E, Wu P, Wang Y, Minkoff H, et al. Predictors of illness course and health maintenance following inpatient treatment among patients with anorexia nervosa. J Eat Disord. 2020;8(1):69.

Radunz M, Keegan E, Osenk I, Wade TD. Relationship between eating disorder duration and treatment outcome: systematic review and meta-analysis. Int J Eat Disord. 2020;53(11):1761–73.

Li A, Cunich M, Miskovic-Wheatley J, Maloney D, Madden S, Wallis A, et al. Factors related to length of stay, referral on discharge and hospital readmission for children and adolescents with anorexia nervosa. Int J Eat Disord. 2021;54(3):409–21.

Bluett EJ, Lee EB, Simone M, Lockhart G, Twohig MP, Lensegrav-Benson T, et al. The role of body image psychological flexibility on the treatment of eating disorders in a residential facility. Eat Behav. 2016;23:150–5.

Wade TD, Hart LM, Mitchison D, Hay P. Driving better intervention outcomes in eating disorders: a systematic synthesis of research priority setting and the involvement of consumer input. Eur Eat Disorders Rev. 2021;29(3):346–54.

Keshishian AC, Tabri N, Becker KR, Franko DL, Herzog DB, Thomas JJ, et al. Eating disorder recovery is associated with absence of major depressive disorder and substance use disorders at 22-year longitudinal follow-up. Compr Psychiatr. 2019;90:49–51.

O’Brien KM, Whelan DR, Sandler DP, Hall JE, Weinberg CR. Predictors and long-term health outcomes of eating disorders. PLoS ONE. 2017;12(7):e0181104.

Micali N, Solmi F, Horton NJ, Crosby RD, Eddy KT, Calzo JP, et al. Adolescent eating disorders predict psychiatric, high-risk behaviors and weight outcomes in young adulthood. J Am Acad Child Adolesc Psychiatry. 2015;54(8):652-659.e1.

La Mela C, Maglietta M, Lucarelli S, Mori S, Sassaroli S. Pretreatment outcome indicators in an eating disorder outpatient group: the effects of self-esteem, personality disorders and dissociation. Compr Psychiatr. 2013;54(7):933–42.

Li Z, Halls D, Byford S, Tchanturia K. Autistic characteristics in eating disorders: treatment adaptations and impact on clinical outcomes. Euro Eat Disord Rev. 2022;30(5):671–90.

Bye A, Martini MG, Micali N. Eating disorders, pregnancy and the postnatal period: a review of the recent literature. Curr Opin Psychiatr. 2021;34(6):563–8.

Sollid C, Clausen L, Maimburg RD. The first 20 weeks of pregnancy is a high-risk period for eating disorder relapse. Intl J Eat Disord. 2021;54(12):2132–42.

Grammer AC, Vázquez MM, Fitzsimmons-Craft EE, Fowler LA, Rackoff GN, Schvey NA, et al. Characterizing eating disorder diagnosis and related outcomes by sexual orientation and gender identity in a national sample of college students. Eat Behav. 2021;42: 101528.

Hay PJ, Buettner P, Mond J, Paxton SJ, Quirk F, Rodgers B. A community-based study of enduring eating features in young women. Nutrients. 2012;4(5):413–24.

Winkler LA. Funen anorexia nervosa study—a follow-up study on outcome, mortality, quality of life and body composition. Danish Med J. 2017;64(6):B5380.

Google Scholar  

Le Grange D, Lock J, Accurso EC, Agras WS, Darcy A, Forsberg S, et al. Relapse from remission at two- to four-year follow-up in two treatments for adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatr. 2014;53(11):1162–7.

Austin A, Flynn M, Shearer J, Long M, Allen K, Mountford VA, et al. The first episode rapid early intervention for eating disorders-upscaled study: clinical outcomes. Early Interv Psychiatr. 2022;16(1):97–105.

Chang PGRY, Delgadillo J, Waller G. Early response to psychological treatment for eating disorders: a systematic review and meta-analysis. Clin Psychol Rev. 2021;86: 102032.

Støving RK, Larsen PV, Winkler LA, Bilenberg N, Røder ME, Steinhausen H. Time trends in treatment modes of anorexia nervosa in a nationwide cohort with free and equal access to treatment. Int J Eat Disord. 2020;53(12):1952–9.

McClelland J, Simic M, Schmidt U, Koskina A, Stewart C. Defining and predicting service utilisation in young adulthood following childhood treatment of an eating disorder. BJPsych open. 2020;6(3): e37.

Golden NH, Cheng J, Kapphahn CJ, Buckelew SM, Machen VI, Kreiter A, et al. Higher-calorie refeeding in anorexia nervosa: 1-year outcomes from a randomized controlled trial. Pediatrics. 2021;147(4): e2020037135.

Baudinet J, Simic M. Adolescent eating disorder day programme treatment models and outcomes: a systematic scoping review. Front Psychiatr. 2021;12: 652604.

Thompson-Brenner H, Singh S, Gardner T, Brooks GE, Smith M, Lowe M, et al. The Renfrew unified treatment for eating disorders and comorbidity: long-term effects of an evidence-based practice implementation in residential treatment. Front Psychiatr. 2021;12:641601.

Kästner D, Löwe B, Gumz A. The role of self-esteem in the treatment of patients with anorexia nervosa—a systematic review and meta-analysis. Int J Eat Disord. 2019;52(2):101–16.

Kelly AC, Vimalakanthan K, Carter JC. Understanding the roles of self-esteem, self-compassion, and fear of self-compassion in eating disorder pathology: an examination of female students and eating disorder patients. Eat Behav. 2014;15(3):388–91.

Sansfaçon J, Booij L, Gauvin L, Fletcher É, Islam F, Israël M, et al. Pretreatment motivation and therapy outcomes in eating disorders: a systematic review and meta-analysis. Int J Eat Disord. 2020;53(12):1879–900.

Griffiths S, Mond JM, Li Z, Gunatilake S, Murray SB, Sheffield J, et al. Self-stigma of seeking treatment and being male predict an increased likelihood of having an undiagnosed eating disorder: predicting undiagnosed eating disorders. Int J Eat Disord. 2015;48(6):775–8.

Foran A, O’Donnell AT, Muldoon OT. Stigma of eating disorders and recovery-related outcomes: a systematic review. Eur Eat Disord Rev. 2020;28(4):385–97.

Fichter MM, Quadflieg N, Nisslmüller K, Lindner S, Osen B, Huber T, et al. Does internet-based prevention reduce the risk of relapse for anorexia nervosa? Behav Res Ther. 2012;50(3):180–90.

Jacobi C, Beintner I, Fittig E, Trockel M, Braks K, Schade-Brittinger C, et al. Web-based aftercare for women with bulimia nervosa following inpatient treatment: randomized controlled efficacy trial. J Med Internet Res. 2017;19(9): e321.

Gulec H, Moessner M, Túry F, Fiedler P, Mezei A, Bauer S. A randomized controlled trial of an internet-based posttreatment care for patients with eating disorders. Telemed e-Health. 2014;20(10):916–22.

Shapiro J, Bauer S, Andrews E, Pisetsky E, Bulik-Sullivan B, Hamer R, et al. Mobile therapy: use of text-messaging in the treatment of bulimia nervosa. Int J Eat Disord. 2010;43(6):513–9.

Bauer S, Okon E, Meermann R, Kordy H. Technology-enhanced maintenance of treatment gains in eating disorders: efficacy of an intervention delivered via text messaging. J Consult Clin Psychol. 2012;80(4):700–6.

Anastasiadou D, Folkvord F, Lupiañez-Villanueva F. A systematic review of mHealth interventions for the support of eating disorders. Eur Eat Disord Rev. 2018;26(5):394–416.

Button EJ, Chadalavada B, Palmer RL. Mortality and predictors of death in a cohort of patients presenting to an eating disorders service. Int J Eat Disord. 2010;43(5):387–92.

PubMed   Google Scholar  

Keshaviah A, Edkins K, Hastings ER, Krishna M, Franko DL, Herzog DB, et al. Re-examining premature mortality in anorexia nervosa: a meta-analysis redux. Compr Psychiatr. 2014;55(8):1773–84.

Ward ZJ, Rodriguez P, Wright DR, Austin SB, Long MW. Estimation of eating disorders prevalence by age and associations with mortality in a simulated nationally representative US cohort. JAMA Netw Open. 2019;2(10): e1912925.

Nielsen S, Vilmar JW. What can we learn about eating disorder mortality from eating disorder diagnoses at initial assessment? A Danish nationwide register follow-up study using record linkage, encompassing 45 years (1970–2014). Psychiatr Res. 2021;303: 114091.

Iwajomo T, Bondy SJ, de Oliveira C, Colton P, Trottier K, Kurdyak P. Excess mortality associated with eating disorders: population-based cohort study. Br J Psychiatr. 2021;219(3):487–93.

Hoang U, Goldacre M, James A. Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001–2009: mortality following a diagnosis of eating disorder. Int J Eat Disord. 2014;47(5):507–15.

Fichter MM, Quadflieg N. Mortality in eating disorders—results of a large prospective clinical longitudinal study: mortality in eating disorders. Int J Eat Disord. 2016;49(4):391–401.

Suokas JT, Suvisaari JM, Gissler M, Löfman R, Linna MS, Raevuori A, et al. Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995–2010. Psychiatr Res. 2013;210(3):1101–6.

Crow SJ, Peterson CB, Swanson SA, Raymond NC, Specker S, Eckert ED, et al. Increased mortality in bulimia nervosa and other eating disorders. AJP. 2009;166(12):1342–6.

Castellini G, Caini S, Cassioli E, Rossi E, Marchesoni G, Rotella F, et al. Mortality and care of eating disorders. Acta Psychiatr Scand. 2023;147(2):122–33.

Guinhut M, Godart N, Benadjaoud M, Melchior J, Hanachi M. Five-year mortality of severely malnourished patients with chronic anorexia nervosa admitted to a medical unit. Acta Psychiatr Scand. 2021;143(2):130–40.

Quadflieg N, Strobel C, Naab S, Voderholzer U, Fichter MM. Mortality in males treated for an eating disorder—a large prospective study. Int J Eat Disord. 2019;52(12):1365–9.

Rosling AM, Sparén P, Norring C, von Knorring AL. Mortality of eating disorders: a follow-up study of treatment in a specialist unit 1974–2000. Int J Eat Disord. 2011;44(4):304–10.

Crow SJ, Swanson SA, le Grange D, Feig EH, Merikangas KR. Suicidal behavior in adolescents and adults with bulimia nervosa. Compr Psychiatr. 2014;55(7):1534–9.

Zerwas S, Larsen JT, Petersen L, Thornton LM, Mortensen PB, Bulik CM. The incidence of eating disorders in a Danish register study: associations with suicide risk and mortality. J Psychiatr Res. 2015;65:16–22.

Mellentin AI, Mejldal A, Guala MM, Støving RK, Eriksen LS, Stenager E, et al. The impact of alcohol and other substance use disorders on mortality in patients with eating disorders: a nationwide register-based retrospective cohort study. AJP. 2021;179(1):46–57.

Naghavi M, Abajobir AA, Abbafati C, Abbas KM, Abd-Allah F, Abera SF, et al. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1151–210.

Santomauro DF, Melen S, Mitchison D, Vos T, Whiteford H, Ferrari AJ. The hidden burden of eating disorders: an extension of estimates from the Global Burden of Disease Study 2019. Lancet Psychiatr. 2021;8(4):320–8.

Guinhut M, Melchior JC, Godart N, Hanachi M. Extremely severe anorexia nervosa: hospital course of 354 adult patients in a clinical nutrition-eating disorders-unit. Clin Nutr. 2021;40(4):1954–65.

Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatr. 2014;13(2):153–60.

Bryant E, Koemel N, Martenstyn J, Marks P, Hickie I, Maguire S. Mortality and mental health funding—when the dollars don’t add up: a portfolio analysis of eating disorder research funding in Australia 2009–2021. Lancet Regional Health (Western Pacific).

Khalsa SS, Portnoff LC, McCurdy-McKinnon D, Feusner JD. What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. J Eat Disord. 2017;5(1):20.

Miskovic-Wheatley J, Koreshe E, Kim M, Simeone R, Maguire S. The impact of the COVID-19 pandemic and associated public health response on people with eating disorder symptomatology: an Australian study. J Eat Disord. 2022;10(1):9.

Smink FRE, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of eating disorders. Curr Opin Psychiatr. 2013;26(6):543–8.

Vinchenzo C, McCombie C, Lawrence V. The experience of patient dropout from eating disorders treatment: a systematic review and qualitative synthesis. BJPsych open. 2021;7(S1):S299–S299.

Article   PubMed Central   Google Scholar  

Björk T, Björck C, Clinton D, Sohlberg S, Norring C. What happened to the ones who dropped out? Outcome in eating disorder patients who complete or prematurely terminate treatment. Eur Eat Disorders Rev. 2009;17(2):109–19.

Jenkins PE, Hoste RR, Meyer C, Blissett JM. Eating disorders and quality of life: a review of the literature. Clin Psychol Rev. 2011;31(1):113–21.

Calvete E, Las Hayas C, Gómezdel Barrio A. Longitudinal associations between resilience and quality of life in eating disorders. Psychiatr Res. 2018;259:470–5.

Wetzler S, Hackmann C, Peryer G, Clayman K, Friedman D, Saffran K, et al. A framework to conceptualize personal recovery from eating disorders: a systematic review and qualitative meta-synthesis of perspectives from individuals with lived experience. Int J Eat Disord. 2020;53(8):1188–203.

Musić S, Elwyn R, Fountas G, Gnatt I, Jenkins ZM, Malcolm A, et al. Valuing the voice of lived experience of eating disorders in the research process: benefits and considerations. Aust N Z J Psychiatr. 2022;56(3):216–8.

Linardon J, Wade TD. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta-analytic review. Int J Eat Disord. 2018;51(4):287–94.

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Acknowledgements

The InsideOut Institute is a collaboration between the University of Sydney and Sydney Local Health District. We thank all the staff from the Institution for their support of this significant project. The authors would like to thank and acknowledge the hard work of Healthcare Management Advisors (HMA) who were commissioned to undertake the Rapid Review. Additionally, the authors would like to thank all members of the consortium and consultation committees for their advice, input, and considerations during the development process. Further, a special thank you to the carers, consumers and lived experience consultants that provided input to the development of the Rapid Review and wider national Eating Disorders Research & Translation Strategy. Finally, thank you to the Australian Government—Department of Health for their support of the current project. National Eating Disorder Research Consortium Members (alphabetical order of surname): *indicates named authors. Phillip Aouad InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Sarah Barakat InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Robert Boakes School of Psychology, Faculty of Science, University of Sydney, NSW Australia. Leah Brennan School of Psychology and Public Health, La Trobe University, Victoria, Australia. Emma Bryant* InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Susan Byrne School of Psychology, Western Australia, Perth, Australia. Belinda Caldwell Eating Disorders Victoria, Victoria, Australia. Shannon Calvert Perth, Western Australia, Australia. Bronny Carroll InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. David Castle Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia. Ian Caterson School of Life and Environmental Sciences, University of Sydney, Sydney, New South Wales, Australia. Belinda Chelius Eating Disorders Queensland, Brisbane, Queensland, Australia. Lyn Chiem Sydney Local Health District, New South Wales Health, Sydney, Australia. Simon Clarke Westmead Hospital, Sydney, New South Wales, Australia. Janet Conti Translational Health Research Institute, Western Sydney University, Sydney NSW Australia. Lexi Crouch Brisbane, Queensland, Australia. Genevieve Dammery InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Natasha Dzajkovski InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Jasmine Fardouly School of Psychology, University of New South Wales, Sydney, New South Wales, Australia. John Feneley New South Wales Health, New South Wales, Australia. Amber-Marie Firriolo University of Sydney, NSW Australia. Nasim Foroughi Translational Health Research Institute, Western Sydney University, Sydney NSW Australia. Mathew Fuller-Tyszkiewicz School of Psychology, Faculty of Health, Deakin University, Victoria, Australia. Anthea Fursland School of Population Health, Faculty of Health Sciences, Curtain University, Perth, Australia. Veronica Gonzalez-Arce InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Bethanie Gouldthorp Hollywood Clinic, Ramsay Health Care, Perth, Australia. Kelly Griffin InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Scott Griffiths Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia. Ashlea Hambleton InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Amy Hannigan Queensland Eating Disorder Service, Brisbane, Queensland, Australia. Mel Hart Hunter New England Local Health District, New South Wales, Australia. Susan Hart St Vincent’s Hospital Network Local Health District, Sydney, New South Wales, Australia. Phillipa Hay Translational Health Research Institute, Western Sydney University, Sydney NSW Australia. Ian Hickie Brain and Mind Centre, University of Sydney, Sydney, Australia. Francis Kay-Lambkin School of Medicine and Public Health, University of Newcastle, New South Wales, Australia. Ross King School of Psychology, Faculty of Health, Deakin University, Victoria, Australia. Michael Kohn Paediatrics & Child Health, Children's Hospital, Westmead, Sydney, Australia. Eyza Koreshe InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Isabel Krug Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia. Jake Linardon School of Psychology, Faculty of Health, Deakin University, Victoria, Australia. Randall Long College of Medicine and Public Health, Flinders University, South Australia, Australia. Amanda Long Exchange Consultancy, Redlynch, New South Wales, Australia. Sloane Madden Eating Disorders Service, Children’s Hospital at Westmead, Sydney, New South Wales, Australia. Sarah Maguire* InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Danielle Maloney InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Peta Marks InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Sian McLean The Bouverie Centre, School of Psychology and Public Health, La Trobe University, Victoria, Australia. Thy Meddick Clinical Excellence Queensland, Mental Health Alcohol and Other Drugs Branch, Brisbane, Queensland, Australia. Jane Miskovic-Wheatley* InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Deborah Mitchison Translational Health Research Institute, Western Sydney University, Sydney NSW Australia. Richard O’Kearney College of Health & Medicine, Australian National University, Australian Capital Territory, Australia. Shu Hwa Ong* InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Roger Paterson ADHD and BED Integrated Clinic, Melbourne, Victoria, Australia. Susan Paxton La Trobe University, Department of Psychology and Counselling, Victoria, Australia. Melissa Pehlivan InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Genevieve Pepin School of Health & Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia. Andrea Phillipou Swinburne Anorexia Nervosa (SWAN) Research Group, Centre for Mental Health, School of Health Sciences, Swinburne University, Victoria, Australia. Judith Piccone Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia. Rebecca Pinkus School of Psychology, Faculty of Science, University of Sydney, NSW Australia. Bronwyn Raykos Centre for Clinical Interventions, Western Australia Health, Perth, Western Australia, Australia. Paul Rhodes School of Psychology, Faculty of Science, University of Sydney, NSW Australia. Elizabeth Rieger College of Health & Medicine, Australian National University, Australian Capital Territory, Australia. Karen Rockett New South Wales Health, New South Wales, Australia. Sarah-Catherine Rodan InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Janice Russell Central Clinical School Brain & Mind Research Institute, University of Sydney, New South Wales, Sydney. Haley Russell InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Fiona Salter Ramsay Health Care, Perth, Australia. Susan Sawyer Department of Paediatrics, The University of Melbourne, Australia. Beth Shelton National Eating Disorders Collaboration, Victoria, Australia. Urvashnee Singh The Hollywood Clinic Hollywood Private Hospital, Ramsey Health, Perth, Australia. Sophie Smith Sydney, New South Wales, Australia. Evelyn Smith Translational Health Research Institute, Western Sydney University, Sydney NSW Australia. Karen Spielman InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Sarah Squire The Butterfly Foundation, Sydney, Australia. Juliette Thomson The Butterfly Foundation, Sydney, Australia. Stephen Touyz* InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Ranjani Utpala The Butterfly Foundation, Sydney, Australia. Lenny Vartanian School of Psychology, University of New South Wales, Sydney, New South Wales, Australia. Sabina Vatter* InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia. Andrew Wallis Eating Disorder Service, The Sydney Children’s Hospital Network, Westmead Campus, Sydney, Australia. Warren Ward Department of Psychiatry, University of Queensland, Brisbane, Australia. Sarah Wells University of Tasmania, Tasmania, Australia. Eleanor Wertheim School of Psychology and Public Health, La Trobe University, Victoria, Australia. Simon Wilksch College of Education, Psychology and Social Work, Flinders University, South Australia, Australia. Michelle Williams Royal Hobart, Tasmanian Health Service, Tasmania, Australia.

The RR was in-part funded by the Australian Government Department of Health in partnership with other national and jurisdictional stakeholders. As the organisation responsible for overseeing the National Eating Disorder Research & Translation Strategy, InsideOut Institute commissioned Healthcare Management Advisors to undertake the RR as part of a larger, ongoing, project. Role of Funder: The funder was not directly involved in informing the development of the current review.

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Authors and affiliations.

Faculty of Medicine and Health, InsideOut Institute for Eating Disorders, University of Sydney, Level 2, Charles Perkins Centre (D17), Sydney, NSW, 2006, Australia

Jane Miskovic-Wheatley, Emma Bryant, Shu Hwa Ong, Sabina Vatter, Phillip Aouad, Sarah Barakat, Emma Bryant, Bronny Carroll, Genevieve Dammery, Natasha Dzajkovski, Veronica Gonzalez-Arce, Kelly Griffin, Ashlea Hambleton, Eyza Koreshe, Sarah Maguire, Danielle Maloney, Peta Marks, Jane Miskovic-Wheatley, Shu Hwa Ong, Melissa Pehlivan, Sarah-Catherine Rodan, Haley Russell, Karen Spielman, Stephen Touyz, Sabina Vatter, Stephen Touyz & Sarah Maguire

Sydney Local Health District, Sydney, Australia

Healthcare Management Advisors, Melbourne, Australia

School of Psychology, Faculty of Science, University of Sydney, Sydney, NSW, Australia

Robert Boakes, Rebecca Pinkus & Paul Rhodes

School of Psychology and Public Health, La Trobe University, Victoria, Australia

Leah Brennan & Eleanor Wertheim

School of Psychology, Perth, Western Australia, Australia

Susan Byrne

Eating Disorders Victoria, Victoria, Australia

Belinda Caldwell

Perth, Australia

Shannon Calvert

Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia

David Castle

School of Life and Environmental Sciences, University of Sydney, Sydney, NSW, Australia

Ian Caterson

Eating Disorders Queensland, Brisbane, QLD, Australia

Belinda Chelius

Sydney Local Health District, New South Wales Health, Sydney, Australia

Westmead Hospital, Sydney, NSW, Australia

Simon Clarke

Translational Health Research Institute, Western Sydney University, Sydney, NSW, Australia

Janet Conti, Nasim Foroughi, Phillipa Hay, Deborah Mitchison & Evelyn Smith

Brisbane, Australia

Lexi Crouch

School of Psychology, University of New South Wales, Sydney, NSW, Australia

Jasmine Fardouly & Lenny Vartanian

University of Sydney, Sydney, NSW, Australia

Carmen Felicia & Amber-Marie Firriolo

New South Wales Health, Sydney, NSW, Australia

John Feneley & Karen Rockett

School of Psychology, Faculty of Health, Deakin University, Victoria, Australia

Mathew Fuller-Tyszkiewicz & Ross King

School of Population Health, Faculty of Health Sciences, Curtain University, Perth, Australia

Anthea Fursland

Hollywood Clinic, Ramsay Health Care, Perth, Australia

Bethanie Gouldthorp & Jake Linardon

Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia

Scott Griffiths & Isabel Krug

Queensland Eating Disorder Service, Brisbane, QLD, Australia

Amy Hannigan

Hunter New England Local Health District, New Lambton, NSW, Australia

St Vincent’s Hospital Network Local Health District, Sydney, NSW, Australia

Brain and Mind Centre, University of Sydney, Sydney, Australia

School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia

Francis Kay-Lambkin

Westmead Hospital, Sydney, Australia

Michael Kohn

College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia

Randall Long

Exchange Consultancy, Redlynch, NSW, Australia

Amanda Long

Eating Disorders Service, Children’s Hospital at Westmead, Sydney, NSW, Australia

Sloane Madden

The Bouverie Centre, School of Psychology and Public Health, La Trobe University, Victoria, Australia

Sian McLean

Clinical Excellence Queensland, Mental Health Alcohol and Other Drugs Branch, Brisbane, QLD, Australia

Thy Meddick

College of Health and Medicine, Australian National University, Canberra, ACT, Australia

Richard O’Kearney & Elizabeth Rieger

ADHD and BED Integrated Clinic, Melbourne, VIC, Australia

Roger Paterson

Department of Psychology and Counselling, La Trobe University, Victoria, Australia

Susan Paxton

School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC, Australia

Genevieve Pepin

Swinburne Anorexia Nervosa (SWAN) Research Group, Centre for Mental Health, School of Health Sciences, Swinburne University, Victoria, Australia

Andrea Phillipou

Children’s Health Queensland Hospital and Health Service, Brisbane, QLD, Australia

Judith Piccone

Centre for Clinical Interventions, Western Australia Health, Perth, WA, Australia

Bronwyn Raykos

Central Clinical School Brain & Mind Research Institute, University of Sydney, Sydney, NSW, Australia

Janice Russell

Ramsay Health Care, Perth, Australia

Fiona Salter

Department of Paediatrics, The University of Melbourne, Parkville, Australia

Susan Sawyer

National Eating Disorders Collaboration, Victoria, Australia

Beth Shelton

The Hollywood Clinic Hollywood Private Hospital, Ramsey Health, Perth, Australia

Urvashnee Singh

Sydney, Australia

Sophie Smith

The Butterfly Foundation, Sydney, Australia

Sarah Squire, Juliette Thomson & Ranjani Utpala

Eating Disorder Service, The Sydney Children’s Hospital Network, Westmead Campus, Sydney, Australia

Andrew Wallis

Department of Psychiatry, University of Queensland, Brisbane, Australia

Warren Ward

University of Tasmania, Hobart, TAS, Australia

Sarah Wells

College of Education, Psychology and Social Work, Flinders University, Adelaide, SA, Australia

Simon Wilksch

Royal Hobart, Tasmanian Health Service, Hobart, TAS, Australia

Michelle Williams

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National Eating Disorder Research Consortium

• Phillip Aouad
• , Sarah Barakat
• , Robert Boakes
• , Leah Brennan
• , Emma Bryant
• , Susan Byrne
• , Belinda Caldwell
• , Shannon Calvert
• , Bronny Carroll
• , David Castle
• , Ian Caterson
• , Belinda Chelius
• , Lyn Chiem
• , Simon Clarke
• , Janet Conti
• , Lexi Crouch
• , Genevieve Dammery
• , Natasha Dzajkovski
• , Jasmine Fardouly
• , Carmen Felicia
• , John Feneley
• , Amber-Marie Firriolo
• , Nasim Foroughi
• , Mathew Fuller-Tyszkiewicz
• , Anthea Fursland
• , Veronica Gonzalez-Arce
• , Bethanie Gouldthorp
• , Kelly Griffin
• , Scott Griffiths
• , Ashlea Hambleton
• , Amy Hannigan
• , Susan Hart
• , Phillipa Hay
• , Ian Hickie
• , Francis Kay-Lambkin
• , Ross King
• , Michael Kohn
• , Eyza Koreshe
• , Isabel Krug
• , Jake Linardon
• , Randall Long
• , Amanda Long
• , Sloane Madden
• , Sarah Maguire
• , Danielle Maloney
• , Peta Marks
• , Sian McLean
• , Thy Meddick
• , Jane Miskovic-Wheatley
• , Deborah Mitchison
• , Richard O’Kearney
• , Shu Hwa Ong
• , Roger Paterson
• , Susan Paxton
• , Melissa Pehlivan
• , Genevieve Pepin
• , Andrea Phillipou
• , Judith Piccone
• , Rebecca Pinkus
• , Bronwyn Raykos
• , Paul Rhodes
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Contributions

AL carried out and wrote the initial review from the first search; JMW conducted subsequent reviews, analysed results, wrote the first manuscript and the final edit; EB, SHO and SV contributed to specific sections, detailed tables and figures, responded to review comments and contributed to ongoing drafts to manuscript completion; the National Eating Disorder Research Consortium reviewed and provided expert feedback; ST and SM provided project direction, methodological design, comprehensively reviewed the manuscript and provided overall supervision and leadership. All authors read and approved the final manuscript.

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Correspondence to Jane Miskovic-Wheatley .

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ST receives royalties from Hogrefe and Huber, McGraw Hill and Taylor and Francis for published books/book chapters. He has received honoraria from the Takeda Group of Companies for consultative work, public speaking engagements and commissioned reports. He has chaired their Clinical Advisory Committee for Binge Eating Disorder. He is the Editor in Chief of the Journal of Eating Disorders. He is a committee member of the National Eating Disorders Collaboration as well as the Technical Advisory Group for Eating Disorders. AL undertook work on this RR while employed by HMA. JMW and SM are guest editors of the special issue “Improving the future by understanding the present: evidence reviews for the field of eating disorders.”

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Additional file 1: fig. s1..

PRISMA flow diagram.

Additional file 2: Table S1.

Studies included in the Rapid Review.

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Miskovic-Wheatley, J., Bryant, E., Ong, S.H. et al. Eating disorder outcomes: findings from a rapid review of over a decade of research. J Eat Disord 11 , 85 (2023). https://doi.org/10.1186/s40337-023-00801-3

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Experiences of eating disorders from the perspectives of patients, family members and health care professionals: a meta-review of qualitative evidence syntheses

Sanna aila gustafsson.

1 School of Law, Psychology and Social Work, Örebro University, University Health Care Research Center, 701 82 Örebro, Sweden

Karin Stenström

2 Swedish Agency for Health Technology Assessment and Assessment of Social Services, P.O. Box 6183, 102 33 Stockholm, Sweden

3 Sweden’s Innovation Agency Vinnova, Mäster Samuelsgatan 56, 101 58 Stockholm, Sweden

Hanna Olofsson

Agneta pettersson, karin wilbe ramsay, associated data.

All relevant data and information are provided in figures, tables and additional files. Additional in-depth information on methods etc. can be provided upon request from the authors.

Eating disorders are serious conditions that cause major suffering for patients and their families. Better knowledge about perceptions of eating disorders and their treatment, and which factors that facilitate or hinder recovery, is desired in order to develop the clinical work. We aimed to explore and synthesise experiences of eating disorders from the perspectives of those suffering from an eating disorder, their family members and health care professionals through an overarching meta-review of systematic reviews in the field.

A systematic literature search was conducted in the databases PubMed, PsycInfo, Scopus, and CINAHL. Inclusion criteria were systematic reviews of qualitative research on experiences, perceptions, needs, or desires related to eating disorders from the perspective of patients, family members or health care professionals. Systematic reviews that fulfilled the inclusion criteria were assessed for relevance and methodological limitations by at least two researchers independently. The key findings were analysed and synthesised into themes.

We identified 17 systematic reviews that met our inclusion criteria. Of these, 13 reviews reported on the patients’ perspective, five on the family members’ perspective, and three on the health care professionals’ perspective. The study population in the reviews was predominantly girls and young women with anorexia nervosa, whilst systematic reviews focusing on other eating disorders were scarce. The findings regarding each of the three perspectives resulted in themes that could be synthesised into three overarching themes: 1) being in control or being controlled, 2) balancing physical recovery and psychological needs, and 3) trusting relationships.

Conclusions

There were several similarities between the views of patients, family members and health care professionals, especially regarding the significance of building trustful therapeutic alliances that also included family members. However, the informants sometimes differed in their views, particularly on the use of the biomedical model, which was seen as helpful by health care professionals, while patients and family members felt that it failed to address their psychological distress. Acknowledging these differences is important for the understanding of anorexia nervosa and other eating disorders, and may help clinicians to broaden treatment approaches to meet the expectations of patients and family members.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40337-021-00507-4.

Plain English summary

The current paper brings together existing knowledge on experiences of eating disorders. We were interested in the views of patients, family members and health care professionals. A literature search identified 17 systematic reviews which addressed these questions. The identified research focused mainly on girls and young women with anorexia nervosa, while research on other eating disorders was limited. Overall, this review suggests that it is important to acknowledge that patients, family members and health care professionals may have different experiences and views regarding treatment of eating disorders, and that it is important to consider all these views in the development of the care of eating disorders.

Introduction

Eating disorders (EDs) are serious psychiatric conditions that often have both psychological and physical consequences and significant societal costs [ 1 , 2 ]. An ED can lead to social problems and reduced quality of life for both the victim and his or her family [ 3 ]. The debut is often during adolescence, although in recent years there has been an increase in new-onset EDs in adults [ 4 , 5 ]. The lifetime prevalence of EDs in Western countries has been estimated to 1.89% [ 6 ]. Girls and women are more often affected than men. Previously, it has been estimated that about 90 percent of those affected are women, but new studies estimate that the proportion of men could be around 20 percent [ 7 ].

ED often require multi-disciplinary treatment [ 8 ]. Most patients are treated in outpatient care, but in more serious cases there may be both day care and inpatient medical or psychiatric care. There are also several inpatient units that specialise in treatments for patients with an ED [ 9 ].

The recommended psychological treatment for adult patients is cognitive behavioural therapy (CBT), which has is strongest empirical support for patients with bulimia nervosa (BN) and binge eating disorder (BED), but is also increasingly recommended for patients with anorexia nervosa (AN) [ 8 – 10 ]. Family-based treatment is the treatment method that is primarily recommended for adolescents. The method is mainly adapted for patients with AN or other restrictive conditions but is also considered to have a good effect for adolescents with BN [ 8 , 9 ].

It is estimated that about half of all people with AN are fully recovered after treatment. At ten-year follow-up, about 73 percent are in remission. The short-term effect of treatment is slightly better for other types of EDs, but there is a significant risk of relapse. In ten years' time, there are marginally more people recovering from BN compared with AN [ 11 ].

Health care professionals often describe that patients with an ED are a challenging group of patients and that it can be difficult to establish a good treatment alliance [ 12 ]. Patients, on the other hand, often describe strong feelings of ambivalence and resistance, which of course complicates treatment, and leads to conflicts with family and friends [ 13 , 14 ].

An improved common understanding of EDs from the perspective of those affected, their family members and caregivers can contribute to better care and treatment for those struggling with EDs and help reduce the strain on their relationships.

Against this background, the aim of the present study was to investigate experiences of living with an ED and factors that facilitate or hinder recovery from the perspectives of patients, their family members and health care professionals.

The current meta-review is based on an assessment conducted at The Swedish Agency for Health Technology Assessment and Assessment of Social Services [ 15 ]. The literature overview was undertaken in accordance with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement [ 16 ] following an a priori protocol that was registered locally at the agency.

Search strategy

A systematic literature search covering literature published from January 1, 1990 to September 26, 2018, was conducted in the electronic databases PubMed (NLM), PsycInfo (EBSCO), Scopus (Elsevier), and CINAHL (EBSCO). A complementary, multi-database, search was also conducted. The databases Academic Search Elite, ERIC, Psychology and Behavioral Sciences Collection, and SocINDEX, were searched simultaneously through the EBSCO platform. The detailed search strategy is provided in Additional File 1 .

Eligibility criteria

Inclusion and exclusion criteria were specified in advance. We only included systematic reviews of qualitative research that were published in peer reviewed journals in English, Swedish, Norwegian, or Danish within the time period 1990 to 2018. To be included, a systematic review should cover experiences, perceptions, needs or desires related to EDs from at least one of the following perspectives: persons with eating disorders, family members or health care professionals. All types of EDs according to the DSM-5 classification were considered relevant except for pica, rumination disorder and avoidant/restrictive food intake disorder. There were no restrictions regarding the age of the informants. The targeted reviews were required to cover original studies of qualitative research or of mixed methodology. Systematic reviews using both broad and narrow search strategies were accepted. Grey literature, such as theses, book chapters, and conference abstracts, were excluded.

Study selection

The titles and abstracts retrieved from the literature search were examined independently by two of the authors using the web-based screening tool Rayyan[ 17 ]. If at least one author found an abstract potentially relevant, the article was ordered in full text and assessed for eligibility by at least two authors independently. Systematic reviews that fulfilled the eligibility criteria were forwarded to quality assessment.

Assessment of methodological quality, data extraction and analysis

Systematic reviews that fulfilled the eligibility criteria were assessed for quality by at least two authors independently, using a tool developed at the Swedish Agency for Health Technology Assessment and Assessment of Social Services (Additional File 2 ). The tool was developed specifically to assess methodological limitations of qualitative evidence synthesis and consists of 13 questions that were adapted from the ENTREQ recommendations [ 16 ]. The summarised risk of methodological limitations in the systematic reviews was judged as being of minor, moderate or high concern. Any disagreement between assessors was resolved by discussion. Systematic reviews with high concerns of methodological limitations were excluded from the subsequent process.

Relevant data were extracted from eligible systematic reviews with minor to moderate methodological concerns and summarised in tables.

The findings of selected systematic reviews (reviews with a narrow focus were not included in the synthesis) were analysed using the method of thematic analysis described by Braun and Clarke [ 18 ]. For each group of informants (patients, family members and health care professionals), findings were coded through an inductive analysis. Next, the coded findings were structured by subject within each group of informants and synthesised into themes. The themes were reviewed, similarities and disparities between the three groups of informants were analysed and the themes were assembled into main themes. Data extraction and synthesis was carried out by the first author (SAG) who has clinical experience treating EDs as well as expertise in qualitative research. Data extraction and synthesis of themes were carefully read and partly checked against the original data by three other authors who have experience of qualitative (AP) or quantitative research (KS, KWR) and expertise in conducting systematic reviews. The differing backgrounds of the authors presumably reduced the risk of introducing bias in the analysis and presentation of data. Throughout the synthesis, the authors discussed the findings with each other and reflected over how their background and position may have affected the analysis and whether there were other ways to interpret the results.

The literature search identified 3,082 citations, after removal of duplicates (Fig.  1 ). From the screening of title and abstracts, 79 reviews were retrieved and assessed for eligibility in full text, and 25 of these fulfilled our inclusion criteria. Eight reviews were considered to have high concerns of methodological limitations and were excluded from the subsequent process. The remaining 17 reviews were included and described (Table ​ (Table1). 1 ). Of these, four reviews had a scope that differed substantially from the other reviews (two reviews focused on pregnant women with AN [ 19 , 20 ], one review focused on gender issues [ 21 ] and one focused on treatment seeking [ 22 ], therefore, they were only included in the descriptive summary but not in the thematic analysis. Thus, the thematic analysis included data from 13 systematic reviews.

PRISMA flow chart

Included systematic reviews

Descriptive summary of the systematic reviews

The 17 systematic reviews with minor or moderate concerns of methodological limitations were published between 2009 and 2018 and were based on a total of 255 unique qualitative primary studies. An assessment of study overlap revealed that few of the primary studies were included in more than one review (see Additional File 3 ). The majority of the included reviews were based on studies using qualitative methods only, but three reviews also included studies that used mixed methods [ 22 – 24 ]. Most of the original studies had used interviews as the primary source of data, but some studies were based on focus group discussions, survey responses, or observations of behaviour.

Most reviews carried out synthesis using meta-ethnography [ 19 , 25 – 33 ]. Other synthesis methods were thematic analysis [ 22 , 23 ], qualitative meta-analysis [ 34 ], and various forms of integrative synthesis methods [ 20 , 21 , 24 , 35 ]. Few of the included reviews stated that they had followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement[ 22 , 34 ] or the Enhancing Transparency in Reporting the synthesis of Qualitative research (ENTREQ) system[ 31 , 32 ]. In most reviews, however, the Critical Appraisal Skills Programme (CASP) had been used to assess the quality of the primary studies [ 19 – 21 , 25 – 29 , 31 – 34 ].

A total of 13 systematic reviews described the patients’ perspectives [ 19 – 23 , 25 , 27 , 28 , 30 – 34 ], five concerned the family members’ perspectives [ 24 , 26 , 29 , 31 , 32 ], and three focused on the health care professionals’ perspectives [ 31 , 32 , 35 ]. Most reviews included both men and women with EDs, and only three reviews focused exclusively on women [ 19 , 20 , 33 ]. Most reviews did not specify age under the inclusion criteria, but no review included studies on young children. Five reviews focused on adolescents with EDs but they also included young adults [ 23 , 24 , 30 – 32 ]. Nine reviews focused exclusively on AN [ 23 , 25 , 27 , 28 , 30 – 33 , 35 ], while the remaining reviews included all EDs, or did not specify diagnosis in the inclusion criteria. One of the reviews that covered health care professionals’ perspectives included interviews exclusively with nurses [ 35 ] whereas the other two comprised nurses, therapists, and treatments teams [ 31 , 32 ]. The informants in the reviews that included family members were predominantly parents, but siblings and partners were also included in some of the reviews [ 24 , 26 , 29 , 31 , 32 ].

Thematic analysis of the systematic reviews

In each of the three perspectives we identified three themes that described experiences of the disease, the care provided and the recovery process. When the three perspectives were analysed together, we identified three overarching themes that were shared among all three perspectives (see Table ​ Table2). 2 ). The themes are described in the table below and organized by perspective. Illustrative quotes for each theme are provided in Table ​ Table3 3 .

Overview of subthemes and overarching themes from the 13 systematic reviews that were included in the thematic analysis

Themes and quotations from the systematic reviews

The perspective of individuals with ED

Nine systematic reviews describing the patients’ perspectives were included in the thematic analysis [ 23 , 25 , 27 , 28 , 30 – 34 ]. This perspective comprised three themes; a lonely struggle for control (covered by three studies [ 28 , 31 , 33 ]), a wish to be seen as a whole person (covered by four studies [ 23 , 27 , 30 , 32 ]), and finding the keys to recovery (covered by five studies [ 23 , 25 , 27 , 33 , 34 ]).

A lonely struggle for control

Life with an ED was described as a lonely and isolated existence, with health problems and difficulties in relationships [ 28 , 31 , 33 ]. Low self-esteem, a negative body image and perfectionist demands on themselves were seen as underlying factors that led to a difficult adolescence, and uncertainty about who they were.

For those with AN, the disorder was seen as an integral part of their personality and the person they were, which also made them afraid to get well since they feared that it could mean losing their identity [ 28 , 31 , 33 ].

Living with AN was described as a struggle to be in control while simultaneously feeling controlled by the disease. The positive experience of control contributed to feeling special and having power (for example over their treatment) and the ED was described as a "coping strategy" that helped them deal with difficult emotions and events. For the majority of patients, the other side of the coin was a difficult experience of losing, or giving up control, for example when entering treatment, or feeling trapped in their illness and symptoms. The subjects described how their whole life revolved around a compulsive focus on calorie counting and compensatory behaviours and how this resulted in a lonely and isolated existence [ 28 , 31 , 33 ].

A wish to be seen as a whole person

When seeking treatment, patients had often felt ill-treated and misunderstood, especially in general care [ 23 , 27 , 30 , 32 ], and therefore, they stressed the necessity of access to specialised ED care. The patients often felt that the health care focused too much on physical recovery and on normalization of eating and weight. This was perceived as unempathetic and gave patients the impression that the therapists did not understand the patient's real problems. Although patients could see that normalization of weight and eating was an important and necessary part of treatment, they felt that focusing too heavily on physical recovery led to feel that they were being reduced to their disease [ 23 , 27 , 30 , 32 ].

Instead, they emphasised that there must be room for conversation about thoughts and feelings and that the care they received should take their wider life situation into account. It was also felt necessary that the therapistwas able to adapt and change his/her approach during the course of the treatment. Initially, the patients might need a therapist that was proactive and took control. At a later stage when the patient was able to take responsibility, treatment should empower and encourage the patient to take control of his/her own life.

Family-based treatment was common for young patients. These patients often felt considerable guilt towards parents and siblings, and they described that a positive aspect of family treatment was that it could help the whole family to feel better, bring them together, and improve their communication. However, patients also described feeling unable to talk about everything that was important to them in family treatment. This risked the treatment becoming superficial and focused on concrete behavioural changes instead of dealing with the underlying causes of the condition. The young patients therefore felt that it was important that family treatment was combined with individual therapy. Individual therapy was seen as an important forum for motivating, engaging and giving patients hope. Patients perceived that it was important to address issues such as relationships both within and outside the family, and to be seen as a unique individual, rather than simply as a person with AN [ 23 , 27 , 30 , 32 ].

Finding the keys to recovery

In the studies that focused on AN, patients consistently described recovery as something “greater” than the mere absence of an ED diagnosis. An experience of being healthy did not arise automatically once weight and eating were normalized. Patients described recovery as a process of getting to know themselves and daring to admit that the false sense of control that the ED had given them had actually come to control them. Recovery meant being able to stick to healthy behaviors even when it felt difficult [ 23 , 25 , 27 , 33 ].

Four factors were described as central to recovery; to regain control and power over one's own life, changing the anorexic identity and finding and accepting oneself behind the disease; getting in touch with one's true feelings and acknowledging the consequences of the disease for oneself, thereby challenging the anorexic thoughts.

In the systematic review that described recovery more generally for people with an ED, it was found that patients perceived the term "healthy" as including feeling well emotionally, socially and psychologically. It included having strategies for dealing with difficulties that arise in life and feeling a sense of belonging or feeling that life is meaningful.

Recovery was described as a process that took place in stages and sometimes with setbacks. Recovery was facilitated by supportive relationships, such as with family and friends. Trusting relationships with family and friends could have a double impact, both by motivating the ill person to seek treatment [ 25 ] and by providing support during the recovery process. Trusting relationships with health care professionals were also considered important both for the motivations to seek and stay in treatment [ 25 ] and for the recovery process itself [ 34 ].

The health care perspective

Three systematic reviews included the experiences of health care staff [ 31 , 32 , 35 ], and all three focused mainly on AN. Two of them [ 31 , 32 ] examined similarities and differences in perceptions of AN and its treatment among staff, patients and relatives. The third overview [ 35 ] explored the knowledge, attitudes and perceived challenges of health care professionals.

The health care perspective also revealed three themes: a tug of war over control, the necessity of physical recovery, and being let into someone’s world.

A tug of war over control

The health care staff saw control as a central aspect of AN and they felt that besides the need to control their own body, patients also felt a need to control their family through the ED [ 32 ]. The staff perceived that the need for control became a force outside the patient's active choice and that the ED ended up controlling the patient instead. The staff therefore felt that they had to "take over" control from the young person through clear structure and rules regarding treatment [ 32 , 35 ]. This was considered to create security for the young person, and to give them the opportunity to allow themselves to let go of control. However, in one study, nurses also stressed the importance of knowledge and understanding of the disease, and described how a lack of knowledge could lead to staff using control strategies in a repressive and punishing way that could create resentment [ 35 ].

The necessity of physical recovery

The health care staff used a biomedical model to understand AN [ 31 , 32 ]. AN was seen as a disease to be treated. This meant that staff emphasised weight rehabilitation and changes in other observable ED symptoms as important parts of treatment. The staff expressed that they were lacking knowledge about ED symptoms and diagnosis, and that they had insufficient skills for dealing with patients' problems [ 35 ]. This led them to feel frustrated and insecure in meeting the patients. Increased knowledge was seen as essentialfor improving staff attitudes towards people with EDs.

The medical view of the ED was perceived as helpful by staff because it was considered to reduce the patient's and their relatives' feelings of guilt. Health care professionals found it helpful to see the disease as a phenomenon separate from the individual. The staff used this "externalisation" to distinguish between disease and patient as a treatment strategy [ 31 , 32 ]. It was considered to reduce the patient's feelings of guilt and increase the patient's motivation.

Even under this theme, a review by Salzman et al. [ 35 ] also emphasised the other side of the coin, meaning.e., that although weight rehabilitation was important, a single-minded focus on physical issues could hamper the relationship with the patient.

Being let in to someone’s world

A good alliance between patient and therapist was considered essential [ 31 , 32 , 35 ]. Honesty, understanding, respect and a non-judgmental and empathetic attitude were important for building an alliance. The staff expressed that patients with EDs were a difficult and demanding patient group with whom it was challenging to form an alliance and who often expressed suspicion and distrust of their caregivers. Staff became frustrated with patients' ambivalence or reluctance to engage in treatment and sometimes perceived patients as manipulative.

One of the systematic reviews examined the health care professionals' experiences of meeting relatives, in this case parents of people with an ED [ 32 ]. The staff emphasised the importance of building a positive alliance with the parents and engaging them in the treatment. This was considered a necessary condition for effective treatment of young patients with AN.

The perspective of family members

Five systematic reviews covered the perspective of family members [ 24 , 26 , 29 , 31 , 32 ]. All of them focused mainly or exclusively on AN. Like the other two perspectives, the perspective of family members also revealed three themes; the balancing act between control and trust, a call for a more holistic approach to treatment, and a wish for a working alliance with the whole family.

The balancing act between control and trust

The family members felt that the whole family was negatively affected by the afflicted person’s illness [ 24 , 26 , 29 , 31 , 32 ]. The family members described the ED as an active choice which the sufferer, at least at some point during the course of the disease, could have refrained from [ 29 ]. The family members felt that controlling eating and weight had, for the ill person, become a way of coping in a life where other things felt uncontrollable, but that the ED had instead taken control of their loved one and changed her personality and behaviour [ 26 , 29 , 31 ]. Family patterns and old roles changed [ 24 , 26 , 29 , 31 , 32 ] and the family members described communication as characterised by conflict, mistrust and uncertainty. It could be perceived that the person with the ED had regressed, which led parents to become more controlling. The opposite sometimes happened with siblings, who would take on a more mature role, becoming a "mediator" in the family and taking greater responsibility.

Family members described a difficult balancing act between adapting to the ill person by, for example changing the family's eating habits and activities, andbeing more demanding. The family members tried to find a balance between controlling and making demands on the ill person, and at the same time reinforcing and encouraging positive steps and showing trust in her/him. To some extent, they felt that it was important to adapt the family's social activities and meals by, for instance, not having certain foods in the house. However, this sometimes resulted in them "walking on eggshells" and accepting behaviours that were counterproductive in the long term. Siblings were often critical of the parents' strategies and thought that they adapted too much.

A common strategy to cope with this balancing act was to distinguish the disease from the individual and to see certain behaviours as “the disease that speaking”. This helped the family members to maintain a supportive attitude, even when they felt that the person with the ED was misbehaving [ 24 , 26 , 29 , 31 , 32 ].

A call for a more holistic approach to treatment

It was stressful to see the person with an ED suffering, and the family members felt anxiety, frustration and guilt. Their everyday lives were affected, both socially and professionally. Many informants reported that the family became more isolated and that they stopped associating with others. Several of the systematic reviews reported that family membersno longer had time for hobbies and that working life was affected [ 24 , 29 ]. Against this background, family members stressed the importance of easier and faster access to specialised care with experienced and committed staff who could give the whole family including siblings information and support, and put them in touch with support networks outside the family to connect with others who were in the same situation. [ 24 , 26 , 29 , 31 , 32 ].

Parents often felt that the health care model was too biomedical and focused too much on physical symptoms such as starvation. They perceived that the unique person behind each patient was not seen [ 24 , 29 , 32 ]. Although the biomedical explanatory model could help to relieve parents' feelings of guilt, it also conveyed a negative image of the patient's chances of recovery [ 29 ]. The family members emphasised that it was important that the therapist saw the patient as an individual and that the therapy did not focus too narrowly on correcting the ED symptoms, but also incorporated other things that were important to the patient [ 24 , 29 , 32 ].

A wish for a working alliance with the whole family

The parents often blamed themselves for their child’s ED [ 24 , 26 , 29 , 31 , 32 ] and they thought a lot about it’s possible origins in the family and the child’s upbringing. The siblings felt severely affected by the situation, something that was also described by their parents [ 24 , 26 , 29 , 32 ]. Siblings became anxious and often took great responsibility for both the afflicted sibling and their parents. At the same time, they often felt angry with their unwell sibling, and sometimes jealous that they were receiving more time and attention from their parents. The healthy siblings sometimes felt a conflict of loyalty and also were compelled to mediate between the afflicted sibling and the parents [ 29 ].

Family members often experienced a lack of support from the health service, especially at the beginning of the illness [ 24 , 26 , 29 , 31 , 32 ]. It was difficult to get a correct diagnosis and adequate help, and family members had to fight to get the right care for the affected person. Family members often felt excluded from care and experienced that health care staff did not support them or listen to them. This exclusion was often attributed to rules or principles that had to do with confidentiality or legislation. Family members also felt that they received conflicting advice and suggestions from the health service or that they were not taken seriously [ 29 ].

The three overarching themes

Our synthesis identified three themes in common among the views of patients, family members and health care professionals (Table ​ (Table2). 2 ). The first theme pertained to the patients’ need for control, which was seen by the family members and the health care professionals as a false control, where the affected person was in fact controlled and limited by the ED. The second theme was the balancing of physical recovery and psychological needs, where the biomedical model was viewed differently from each of the three perspectives. Health care professionals felt that, if used with the right knowledge and competence, the model gave them the support they needed to define target symptoms and goals for recovery, while patients and family members felt that the model placed too much focus on the somatic aspects of the disorder and failed to address psychological distress. The third theme was the importance of forming trusting relationships for accomplishing a well-functioning therapeutic alliance that recognises the whole individual and not just the disease, and that also involves family members.

This meta-review brings together a substantial amount of qualitative research, including data from 255 unique studies, on the experiences of EDs from the perspectives of patients, family members and health care professionals. Three themes emerged from the synthesis; the patients’ need for control, balancing physical recovery and psychological needs, and the importance of trusting relationships in the treatment of the disorders. Although all three main themes were identified in the views of all three groups of informants, there were some differences in their expression that may be important to acknowledge.

Implications for health care systems

The ED causes a great deal of suffering for both the affected person and the family members, and both parties emphasise the importance of getting the right treatment. From our synthesis, however, there appears to be a divergence between ED patients and their family members on the one hand, and the health care staff on the other, regarding how the ED should be understood and treated. Health care professionals often represent a biomedical explanatory model, while ED patients and their family members feel that this model is not sufficient. These different approaches are not necessarily conflicting, but can potentially complicate the alliance building and pull the treatment in different directions, where the professionals place more emphasis on symptom reduction and weight rehabilitation, while the patients and their family members want a more holistic approach to treatment and recovery. This conflict, and suggestions for how to avoid it, was also emphasised in one of the studies involving health care staff [ 35 ]. The main suggestion from patients, family members and health care staff on how to achieve this holistic approach, while still attending to the physical needs of the patient, was to increase the knowledge. The importance of having access to staff who are knowledgeable in terms of both understanding the disease and attending to the patient’s physical needs, and understanding their psychological struggles, and are able to meet the patient in a respectful way, cannot be overemphasised.

In today's health care, and among policy makers, there is an increasing focus on using manual-based treatments and on measuring the outcomes of treatment. Great emphasis is placed on questions about which treatment method has the best scientific support, and how to make sure that therapists actually deliver the method according to the manual [ 36 ]. These are of course important questions that need to be addressed. However, it is important to acknowledge that these aspects seem to be entirely absent from patients’ and families’ descriptions of what is lacking or what is important in treatment. On the contrary, persons with an ED's desire treatment that is more flexible and individualised, with greater focus on their unique, individual situation. None of the systematic reviews in this study mentioned that patients or family had called for any specific method of treatment, instead they called for a more holistic and individually-adapted care. Since a significant proportion of ED patients discontinue treatment prematurely [ 37 ], and a common reason for this is lack of motivation [ 38 ], it is important that health care providers increase their knowledgeabout how patients and family members perceive the care provided, and what would motivate patients to stay in treatment.

Treatment manuals are a set of principles designed to be applicable to each individual patient. When delivered flexibly and skilfully there is no reason why individualised care should be in conflict with the use of treatment manuals [ 39 ]. However, many clinicians regard treatment manuals as constraining their practice and limiting the individualisation of interventions [ 39 ]. Against this background, and the findings of this study in terms of patients and relatives calling for a more holistic and individualised treatment, it seems that ED treatment faces a great challenge in integrating theory, research, clinical knowledge and the important perspectives of patients and their families in order to improve and adapt ED treatment. For this to be successful, it has been suggested that we need to expand the scope of treatment research and stimulate diversity within ED treatment and research [ 40 ].

Limitations and strengths

One limitation of this meta-review, which is a common problem in qualitative research syntheses, is the considerable variability in research aims, data collection approaches and methods of synthesis that were present in reviews as well as in the primary studies. Another problem that is difficult to avoid in qualitative syntheses is the possibility that the authors’ underlying assumptions may have introduced bias through selection of the experiences and views that are presented in the studies. The risk of overestimating the findings through data redundancy should also be considered, but is probably not a major problem in this meta-review since most of the included reviews had a unique focus and the study overlap was limited (Additional File 3 ).

In our quality assessment, we found that most systematic reviews that fulfilled our inclusion criteria were of high or moderate methodological quality. However, relatively few of the included reviews stated that they had followed the PRISMA or ENTREQ statement, and the compliance with these guidelines can indeed be enhanced – for example, by reporting how many reviewers were involved in the screening of studies and whether they worked independently (PRISMA checklist item 8)[ 41 ]. Other shortcomings in the included reviews were inadequate reporting of when in the progression of the disorder the data was collected, and inadequate information on the study authors’ competence in the field. In most reviews, however, a tool for critical appraisal of the original studies had been used, such as the CASP tool.

The major strengths of this meta-review are its broad scope – including three different perspectives of key informants – and the rigorous methodology of the literature screening, which involves systematic assessment of methodological limitations in the included reviews. The tool that we used for assessment of qualitative systematic reviews was developed in parallel to this meta-review and incorporates elements from the PRISMA guidelines [ 41 ] and the ENTREQ recommendations [ 16 ]. We believe that this tool can also be useful for other authors of qualitative meta-reviews. Another strength of the current study is the adequacy of the data. Most of the findings in our meta-review were based on at least three different systematic reviews and seven to 32 primary studies.

The study population and research needs

The included reviews focused mainly on anorexia nervosa (AN) or on EDs in general, without specifying a particular diagnosis. None of the identified reviews exclusively evaluated individuals with bulimia nervosa (BN) or binge eating disorder (BED), which was somewhat surprising. The possibility to generalise our findings to other EDs than AN is thus limited. To our knowledge, no systematic review that specifically focuses on experiences of BN or BED have been published after our literature search was performed. Considering the high prevalence of BN and BED that have been reported [ 6 ], there is a need to highlight experiences of these disorders in future qualitative systematic reviews.

Most of the included systematic reviews concerned both women and men with EDs, but men were underrepresented relative to their expected incidence, which possibly reflects the proportions of women and men that are studied in the primary qualitative studies of EDs. This is confirmed by a recent systematic review on men’s experiences of ED treatment[ 42 ], which identified only nine primary studies (not included in this review since it was published after our literature search). Since the prevalence of EDs is known to be higher among women, there might be a tendency to overlook the problem in men and boys. However, the prevalence of EDs among men has increased substantially over the last two decades and it is estimated that men and boys constitute 20% of all individuals with EDs [ 7 ]. Thus, there is an increasing need to acknowledge their experiences, which may not necessarily be interchangeable with those of girls and women.

Since our literature search was performed, a few additional systematic reviews have been published on EDs from the patients’, family members’ and/or health care professionals’ views. These mainly confirm our findings [ 43 – 45 ]. However, there are some interesting new results that build on preexisting knowledge and are worth mentioning. For example one systematic review focused exclusively on the experiences of males with an ED, and besides confirming the findings of this study regarding the call for an individual and person centered approach in treatment, it also added interesting results about recognition, help-seeking and treatment from a male perspective [ 42 ].

A systematic review by Johns et al. gave new insights about the perceptions of health care professionals, patients and their family members in terms of meeting professional staff with knowledge about EDs [ 12 ]. Another systematic review by Graham et al. described the dilemma faced by health care professionals using the key concept of “coping with caring without curing”, elegantly illustrating the dissonance between careers’ aspiration to help and the reality of their working situation [ 46 ].

To our knowledge, this is the first meta-review of qualitative systematic reviews focusing on experiences of EDs. The compilation acknowledges some important similarities and differences between the views of the three different informants, where health care professionals felt that the biomedical model was helpful, while patients and family members felt that it was insufficient and failed to address their psychological distress. Viewing these perspectives as complementary rather than conflicting may contribute to a better understanding of the complexity of treating EDs. Acknowledging experiences from various perspectives may eventually lead to adaptations in health care that can hopefully improve treatment compliance and recovery rates for individuals with EDs.

Our meta-review also indicates that there is a need for methodologically well conducted qualitative systematic reviews on EDs in which the population is clearly described regarding age, sex, and diagnosis. In particular, there is a need for systematic reviews on experiences regarding BN and BED.

Acknowledgements

Not applicable.

Abbreviations

Authors' contributions

SAG: Study design, screening of full-text articles, data extraction, major contribution in thematic analysis and interpretation of data, major contribution in writing the manuscript. KS: Study design, screening of abstracts and full-text articles, data extraction control, assessment of methodological limitations, analysis and interpretation of data. HO: Design and execution of literature search. AP: Assessment of methodological limitations, analysis and interpretation of data. KWR: Study design, screening of abstracts and full-text articles, data extraction control, analysis and interpretation of data, major contribution in writing the manuscript. All authors have read and approved the final manuscript.

The project was funded by The Swedish Agency for Health Technology Assessment and Assessment of Social Services.

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The authors have no competing interests.

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