research studies on eating disorders

Eating Disorders: Current Knowledge and Treatment Update

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DSM-5 Feeding and Eating Disorder

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• B. Timothy Walsh
• Timothy Walsh
• Eating disorders
• Binge eating disorder
• Anorexia nervosa
• eating disorder not otherwise specified
• avoidant/restrictive food intake disorder
• dialectical behavior therapy
• acceptance and commitment therapy
• integrative cognitive-affective therapy

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In our research lab, we are conducting a number of treatment studies that provide free treatment for anorexia nervosa and bulimia nervosa. Please read further for additional information.

Confirming the Effectiveness of Online Guided Self-Help Family-Based Treatment for Adolescent Anorexia Nervosa

Stanford University is conducting a study on virtual treatments for anorexia nervosa in adolescents.

Who can participate?

• Adolescents living with their families between the ages of 12 and 18 years of age with DSM-5 AN
• Adolescent lives with at least one family member
• Parents are able to read and speak fluent English
• Access to a computer with a reliable internet connection
• Adolescent is medically stable for remote, outpatient treatment
• Virtual family-based treatment (FBT-V) 
• Online guided self-help family-based treatment (GSH-FBT)
• In addition to treatment, participants will complete assessments and questionnaires throughout the course of the study  

If you have any questions, or are interested in signing up for the study, please email Hazal Gurcan at [email protected] . Alternatively, call (650) 723 - 9182.

Family-Based Treatment Training Study

Stanford University is conducting an NIH-sponsored study looking at how to best train therapists in delivering Family-Based Treatment for anorexia nervosa.

• Therapists that have completed a masters or doctoral training in their field (psychology, psychiatry, family therapy, social work) and are licensed in their respective state
• No reports of malpractice or loss of privileges at relevant clinical institutions
• Have computer/web access for online training and assessments
• No previous 2-day in-person workshop training in FBT
• Able to submit baseline data on weight gain from week 1-4 from a previously treated adolescent with AN they have treated in the last 6 months or alternatively one that they treat within the first 3 months of completing their initial screen.

All participants are randomized to one of two trainings:

• Online training which consists of 10 lectures that are self-paced with a maximum of three months to complete with each lecture bundle comprising of short didactic videos that discuss the treatment model and provide mock therapy session video clips (modeling FBT with a typical adolescent AN case), as well as supplementary readings and videotaped role-plays.
• Webinar training which consists of 1-hour weekly webinar lectures over three months. There will be lectures discussing the scientific evidence supporting FBT, how therapists set up treatment for FBT, main interventions used in FBT during each phase, and recorded role-plays illustrating interventions throughout the 3 phases.

Both trainings are followed by post-online expert supervision for a minimum of 1 case and a maximum of 2 cases over the course of 3 months.

Contact information for participant inquiries:  Kyra Citron at (650) 723-9182; [email protected]

Confirming the Efficacy/Mechanism of Family Therapy for Children with Low Weight Avoidant/Restrictive Food Intake Disorder (ARFID)

Children ages 6-12 with a diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) and their families are invited to participate in a Family-Based Treatment (FBT) vs. a manualized Non-Specific Care (NSC) research study through the Stanford Department of Psychiatry and Behavioral Sciences. The study consists of 14 one-hour telehealth sessions in either treatment arm, along with required medical management, over the course of 4 months. Treatment will be provided by doctoral-level, highly skilled therapists.

Recruitment age range:  6-12 years old 

Recruitment gender:  All 

Contact information for participant inquiries:   [email protected]

Key words:  eating disorders, ARFID, Avoidant/Restrictive Food Intake Disorder, Family-Based Treatment 

Emotion Regulation in Adolescents with Binge Eating and Purging

A study for girls 14-18 who struggle with binge/purge behaviors (no formal diagnosis is required to participate). The study involves two appointments - one interview and one fMRI scan. Participants are compensated $100.

Recruitment age range:  14-18 years old

Recruitment gender:  Female

Contact information for participant inquiries:    [email protected]

Key words:  eating disorders, binge eating, emotion regulation

For general information regarding questions, concerns, or complaints about research, research related injury or the rights of research participants, please call (650) 723-5244 or toll-free 1-866-680-2906, or write to the Administrative Panel on Human Subjects in Medical Research, Administrative Panels Office, Stanford University, Stanford, CA 94305-5401.

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Eating Disorders Clinic

Research studies.

Our Center has been at the forefront of research in the field of eating disorders for over 30 years.

Research can encompass many things: structured interviews, questionnaires, computer tasks, observations in specific settings, and imaging modalities all constitute research. These activities are done to try to answer questions about the behaviors, biology, and neurobiology of these illnesses. Participation provides a valuable contribution to the field, and helps inform the future directions.

Current Research Includes:

Optimizing relapse prevention and changing habits (reach+).

Anorexia Nervosa is a serious illness and relapse rates are high. We have shown that behavioral routines get stuck/entrenched. Our newest treatment development research aims to help patients with AN minimize unhelpful routines and develop more healthful, recovery-oriented behavior after they have completed initial treatment on our inpatient unit.  This study aims to evaluate this new outpatient treatment. Interested participants who have achieved weight restoration on the inpatient unit at NYSP will meet with clinicians for outpatient treatment for 6 months to work on changing behaviors, maintaining healthy eating, and maintaining a healthy weight after leaving the hospital.

The Role of Self-Evaluation and Social Stress in Adolescents with Eating Disorders

Self-esteem in adolescents is a critical area to understand right now, as mental health challenges are increasing. Among teen girls, adolescence is a time when eating disorders often begin, and a time when social experiences play a big role. Our research aims to understand the links between eating disorders and how teens think and feel about themselves by looking at what is happening in the brain. We are enrolling teens with anorexia nervosa, bulimia nervosa, or binge eating disorder as well as healthy peers. Participants will be asked to play some games in the lab while we collect EEG monitoring. In addition, we invite participation in our eating lab. We also find out more about life outside the lab using a smartphone app.

The Role of Dopamine in Anorexia Nervosa During Adolescence

Anorexia nervosa is a psychiatric illness with neurobiological underpinnings. Our research aims to understand whether there are disturbances in the neurotransmitter dopamine which may help us understand some of the symptoms of the illness and may help identify new ways of thinking about treatments. In this study, we use a particular type of magnetic resonance imaging (MRI) that can measure the concentration of dopamine in specific brain regions, termed neuromelanin-sensitive MRI. We are enrolling teens with anorexia nervosa and healthy teens. Participation includes an MRI scan, as well as questionnaires and computer tasks.

Longitudinal Assessment of Neural Circuits in Adolescents with Anorexia Nervosa

In this study, we are looking at how the brain changes over time in teens with and without anorexia nervosa. Participants will be asked to answer questionnaires, look at and make decisions about pictures of food in an fMRI scanner, and eat dinner in our eating lab. An MRI uses a magnet to take pictures of the brain (there is no radiation in this study). There are three time-points in this study over the course of two years. We offer prizes throughout the study and compensation at each time-point. 

Discrimination Learning in Anorexia Nervosa

People with anorexia nervosa frequently experience anxiety which may impact their ability to learn new things. This study aims to understand this by evaluating how outcomes of computer tasks motivate learning in adults with and without anorexia nervosa. Participants will be asked to answer questionnaires, complete computer tasks, look at and make decisions about pictures in an fMRI scanner, and eat lunch in our eating lab. An MRI uses a magnet to take pictures of the brain (there is no radiation in this study). The study occurs over the course of three days. 

Gains and Losses in Anorexia Nervosa

Eating patterns are especially difficult to change for those with anorexia nervosa. In this study we are learning about the behavioral and neural underpinnings of decisions about food bylooking at the brain systems associated with gains and losses in learning. We are learning how these systems work when food is involved, for people with and without anorexia nervosa. The study day includes computer games, questionnaires, and an fMRI scan. 

Memory and Decision Making in Anorexia Nervosa

Do patients with anorexia nervosa use the same brain mechanisms to make decisions as those without the illness, and just arrive at different choices? Or are these processes fundamentally different in some way? To answer this question, we ask individuals with anorexia nervosa – as well as healthy peers – to make some decisions while looking at pictures of food in an MRI scanner. Working closely with our cognitive neuroscience colleagues, we use measurement of eye movements as well as brain activation patterns during neuroimaging to understand how these decision-making processes change with illness, and to test whether this relates to actual eating patterns.

Risky Decision-Making in Bulimia Nervosa

People with bulimia nervosa engage in risky behaviors more often than people without this disorder. The aim of this research is to understand the neurobiological underpinnings of risky decision-making in bulimia nervosa by using computer tasks and a type of magnetic resonance imaging (MRI) called neuromelanin-sensitive MRI to measure the concentration of dopamine in the brain. Participation includes completion of an MRI, computer tasks, and some questionnaires. We are enrolling teens and adults with bulimia nervosa, as well as healthy teens and adults. 

Long Term Course of Eating Disorders

The purpose of this study is to gather information about how various eating and weight problems change over time among patients with eating disorders who receive inpatient treatment at the Eating Disorders Research Unit. Participants are contacted once per year for up to ten years to participate in a brief phone interview and will be asked to complete and return several self-report forms. Interviews and self-report forms ask about eating and weight as well as psychological and physical health.

If you are interested in serving as a control subject for a study, please  contact us as well.  You may also contact us via this  link  if you are interested in participating.

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Eating Disorders

What are eating disorders.

There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people’s eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

What are the signs and symptoms of eating disorders?

Anorexia nervosa.

Anorexia nervosa is a condition where people avoid food, severely restrict food, or eat very small quantities of only certain foods. They also may weigh themselves repeatedly. Even when dangerously underweight, they may see themselves as overweight.

There are two subtypes of anorexia nervosa: a "restrictive "  subtype and a "binge-purge " subtype.

• In the restrictive subtype of anorexia nervosa, people severely limit the amount and type of food they consume.
• In the binge-purge  subtype of anorexia nervosa, people also greatly restrict the amount and type of food they consume. In addition, they may have binge-eating and purging episodes—eating large amounts of food in a short time followed by vomiting or using laxatives or diuretics to get rid of what was consumed.

Anorexia nervosa can be fatal. It has an extremely high death (mortality) rate compared with other mental disorders. People with anorexia are at risk of dying from medical complications associated with starvation. Suicide is the second leading cause of death for people diagnosed with anorexia nervosa.

If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline   at 988 or chat at 988lifeline.org   . In life-threatening situations, call 911.

Symptoms include:

• Extremely restricted eating
• Extreme thinness (emaciation)
• A relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight
• Intense fear of gaining weight
• Distorted body image, a self-esteem that is heavily influenced by perceptions of body weight and shape, or a denial of the seriousness of low body weight

Other symptoms may develop over time, including:

• Thinning of the bones (osteopenia or osteoporosis)
• Mild anemia and muscle wasting and weakness
• Brittle hair and nails
• Dry and yellowish skin
• Growth of fine hair all over the body (lanugo)
• Severe constipation
• Low blood pressure
• Slowed breathing and pulse
• Damage to the structure and function of the heart
• Brain damage
• Multiorgan failure
• Drop in internal body temperature, causing a person to feel cold all the time
• Lethargy, sluggishness, or feeling tired all the time
• Infertility

Bulimia nervosa

Bulimia nervosa is a condition where people have recurrent and frequent episodes of eating unusually large amounts of food and feeling a lack of control over these episodes. This binge-eating is followed by behavior that compensates for the overeating such as forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors. People with bulimia nervosa may be slightly underweight, normal weight, or over overweight.

• Chronically inflamed and sore throat
• Swollen salivary glands in the neck and jaw area
• Worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to stomach acid
• Acid reflux disorder and other gastrointestinal problems
• Intestinal distress and irritation from laxative abuse
• Severe dehydration from purging of fluids
• Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium, and other minerals) which can lead to stroke or heart attack

Binge-eating disorder

Binge-eating disorder is a condition where people lose control over their eating and have reoccurring episodes of eating unusually large amounts of food. Unlike bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise, or fasting. As a result, people with binge-eating disorder often are overweight or obese. Binge-eating disorder is the most common eating disorder in the U.S.

• Eating unusually large amounts of food in a specific amount of time, such as a 2-hour period
• Eating even when you're full or not hungry
• Eating fast during binge episodes
• Eating until you're uncomfortably full
• Eating alone or in secret to avoid embarrassment
• Feeling distressed, ashamed, or guilty about your eating
• Frequently dieting, possibly without weight loss

Avoidant restrictive food intake disorder

Avoidant restrictive food intake disorder (ARFID), previously known as selective eating disorder, is a condition where people limit the amount or type of food eaten. Unlike anorexia nervosa, people with ARFID do not have a distorted body image or extreme fear of gaining weight. ARFID is most common in middle childhood and usually has an earlier onset than other eating disorders. Many children go through phases of picky eating, but a child with ARFID does not eat enough calories to grow and develop properly, and an adult with ARFID does not eat enough calories to maintain basic body function.

• Dramatic restriction of types or amount of food eaten
• Lack of appetite or interest in food
• Dramatic weight loss
• Upset stomach, abdominal pain, or other gastrointestinal issues with no other known cause
• Limited range of preferred foods that becomes even more limited (“picky eating” that gets progressively worse)

What are the risk factors for eating disorders?

Eating disorders can affect people of all ages, racial/ethnic backgrounds, body weights, and genders. Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life.

Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. Researchers are using the latest technology and science to better understand eating disorders.

One approach involves the study of human genes. Eating disorders run in families. Researchers are working to identify DNA variations that are linked to the increased risk of developing eating disorders.

Brain imaging studies are also providing a better understanding of eating disorders. For example, researchers have found differences in patterns of brain activity in women with eating disorders in comparison with healthy women. This kind of research can help guide the development of new means of diagnosis and treatment of eating disorders.

How are eating disorders treated?

It is important to seek treatment early for eating disorders. People with eating disorders are at higher risk for suicide and medical complications. People with eating disorders can often have other mental disorders (such as depression or anxiety) or problems with substance use. Complete recovery is possible.

Treatment plans are tailored to individual needs and may include one or more of the following:

• Individual, group, and/or family psychotherapy
• Medical care and monitoring
• Nutritional counseling
• Medications

Psychotherapies

Family-based therapy, a type of psychotherapy where parents of adolescents with anorexia nervosa assume responsibility for feeding their child, appears to be very effective in helping people gain weight and improve eating habits and moods.

To reduce or eliminate binge-eating and purging behaviors, people may undergo cognitive behavioral therapy (CBT), which is another type of psychotherapy that helps a person learn how to identify distorted or unhelpful thinking patterns and recognize and change inaccurate beliefs.

Evidence also suggests that medications such as antidepressants, antipsychotics, or mood stabilizers may also be helpful for treating eating disorders and other co-occurring illnesses such as anxiety or depression. The Food and Drug Administration’s (FDA) website  has the latest information on medication approvals, warnings, and patient information guides.

How can I find a clinical trial for an eating disorder?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

• NIMH’s Clinical Trials webpage : Information about participating in clinical trials
• Clinicaltrials.gov: Current Studies on Eating Disorders  : List of clinical trials funded by the National Institutes of Health (NIH) being conducted across the country

Where can I learn more about eating disorders?

Free brochures and shareable resources.

• Eating Disorders: About More Than Food : A brochure about the common eating disorders anorexia nervosa, bulimia nervosa, and binge-eating disorder, and various approaches to treatment. Also available en español .
• Let’s Talk About Eating Disorders : An infographic with facts that can help shape conversations around eating disorders. Also available in en español .
• Shareable Resources on Eating Disorders : Help support eating disorders awareness and education in your community. Use these digital resources, including graphics and messages, to spread the word about eating disorders.
• Mental Health Minute: Eating Disorders : Take a mental health minute to watch this video on eating disorders.
• Let’s Talk About Eating Disorders with NIMH Grantee Dr. Cynthia Bulik : Learn about the signs, symptoms, treatments, and the latest research on eating disorders.

Research and statistics

• NIMH Eating Disorders Research Program : This program supports research on the etiology, core features, longitudinal course, and assessment of eating disorders.
• Journal Articles   : References and abstracts from MEDLINE/PubMed (National Library of Medicine).
• Statistics: Eating Disorders

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Join a Research Study!

Arfid genes and environment (arfid-gen).

ARFID-GEN is a research study for individuals aged 18 or older or parents of children (aged 7-17) who currently have avoidant/restrictive food intake disorder (ARFID) (previously known as selective eating disorder or extreme picky eating). This is the first (and largest) study ever designed to identify genetic and environmental predictors of ARFID. Click here  to take our survey.

Research Volunteer Registry

To conduct research studies, we need help from volunteers like you – individuals who want to help us better understand eating disorders. You can help by volunteering to join our research registry. Anyone can join our registry. We welcome volunteers with no history of an eating disorder, as well as volunteers with a current or past history of an eating disorder. To learn more, click here .

Eating Disorders Genetics Initiative (EDGI)

EDGI is an international research study designed to understand how your genes can influence your risk for developing an eating disorder. Anyone living in the U.S. who is at least 18 years old and has ever had anorexia nervosa, bulimia nervosa, or binge-eating disorder at any time in their life might be eligible. Click here to take our survey.

Binge Eating Genetics INitiative (BEGIN)

The goal of the BEGIN study is to better understand the genetic factors that may be associated with binge-eating disorder and bulimia nervosa in order to develop better treatments for the millions of people who suffer from these illnesses. Learn more about BEGIN here .

Carolina C.A.R.E.S. (College Assessment for Research and Education in Science)

The purpose of Carolina C.A.R.E.S. is to examine mental health in college students and what factors contribute to how well students do during their college years. Learn more about Carolina C.A.R.E.S. here .

Uniting Couples in the Treatment of Eating Disorders (UNITE)

UNITE is a collaborative treatment study that is examining two different treatments for binge-eating disorder (BED). Learn more about UNITE here .

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Effects of Physical Activity on Disordered Eating Behaviours in Individuals With a Psychotic Disorder

Affiliations.

• 1 Faculty of Arts and Sciences, Department of Psychology, University of Montreal, Montreal, Quebec, Canada.
• 2 Faculty of Medicine, Department of Psychiatry and Addictology, University of Montreal, Montreal, Quebec, Canada.
• 3 Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.
• 4 Department of Physical Activity Sciences, University of Quebec in Montreal, Montreal, Quebec, Canada.
• 5 Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, Quebec, Canada.
• 6 School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada.
• PMID: 39193991
• DOI: 10.1111/eip.13611

Aim: This study aims to determine the effect of physical activity on cognitive restraint, uncontrolled eating and emotional eating in individuals with a psychotic disorder.

Methods: Twenty-seven participants with a psychotic disorder (55% male; mean age: 30 ± 7.5 years; Caucasian: 66.7%; schizophrenia spectrum disorders: 44.4%; bipolar disorder with psychotic features: 29.6%) took part in a 6-month bi-weekly physical activity program (walking, running, yoga, cycling and dancing). The Three-Factor Eating Questionnaire was used to assess participant's eating behaviours, and the frequency of completed physical activity sessions was compiled.

Results: The mixed models analysis approach revealed that the level of cognitive restraint remained unchanged (pre: 39.2 ± 18.7 vs. post: 44.1 ± 18.3; p = 0.24), while the levels of uncontrolled eating (pre: 39.7 ± 19 vs. post: 31.6 ± 19.7; p = 0.02) and emotional eating (pre: 45.5 ± 22.3 vs. post: 32.2 ± 22.2; p < 0.001) decreased at the end of the 6-month physical activity program.

Discussion: This study showed that physical activity has positive effects on disordered eating behaviours in individuals with a psychotic disorder, similarly to previous studies on other populations (e.g., overweight and obese participants, postmenopausal women).

Conclusion: Further studies are warranted to better understand the role of physical activity in moderating eating behaviours.

Keywords: cognitive restraint; eating behaviour; emotional eating; physical activity; psychotic disorder; uncontrolled eating.

© 2024 The Author(s). Early Intervention in Psychiatry published by John Wiley & Sons Australia, Ltd.

PubMed Disclaimer

• Abdel‐Baki, A., V. Brazzini‐Poisson, F. Marois, É. Letendre, and A. D. Karelis. 2013. “Effects of Aerobic Interval Training on Metabolic Complications and Cardiorespiratory Fitness in Young Adults With Psychotic Disorders: A Pilot Study.” Schizophrenia Research 149, no. 1–3: 112–115. https://doi.org/10.1016/j.schres.2013.06.040 .
• Alberti, K. G. M. M., R. H. Eckel, S. M. Grundy, et al. 2009. “Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity.” Circulation 120, no. 16: 1640–1645. https://doi.org/10.1161/CIRCULATIONAHA.109.192644 .
• Annesi, J. J. 2021. “Reciprocal Relationship of Mood and Emotional Eating Changes Through Self‐Regulation of Weight‐Loss Behaviors.” Eating Behaviors 43, no. 101: 559. https://doi.org/10.1016/j.eatbeh.2021.101559 .
• Annesi, J. J., and A. A. Eberly. 2022. “Early Effects of Improved Mood on Propensity for Emotional Eating During the Physical Activity‐Only Phase of a Community‐Based Behavioral Treatment for Obesity in Women With High Mood Disturbance.” Health Behavior Research 5, no. 4: 1–15. https://doi.org/10.4148/2572‐1836.1156 .
• Aymes, E., G. Lisembard, J. Dallongeville, et al. 2022. “Identification of Several Eating Habits That Mediate the Association Between Eating Behaviors and the Risk of Obesity.” Obesity Science & Practice 8, no. 5: 585–594. https://doi.org/10.1002/osp4.593 .

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• Published: 06 September 2024

Preventing eating disorders in the LGBTQ+ community

• Jaclyn A. Siegel 1 &
• Michelle M. Johns   ORCID: orcid.org/0000-0002-9057-2752 1 , 2  

Nature Human Behaviour ( 2024 ) Cite this article

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• Human behaviour

To prevent eating disorders in the LGBTQ+ (lesbian, gay, bisexual, transgender, queer) community, we must enact safeguards for sexual and gender minority individuals to live in their bodies authentically, address stigma against and within the LGBTQ+ community, and fund research to develop a better understanding of the unique drivers of eating disorder behaviours and to tailor prevention efforts.

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Siegel, J.A., Johns, M.M. Preventing eating disorders in the LGBTQ+ community. Nat Hum Behav (2024). https://doi.org/10.1038/s41562-024-01976-8

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Evaluating emotional eating in children from the perspective of parents: psychometric properties of the parent version of the emotional eating scale adapted for children and adolescents.

1. Introduction

• The parent version of the EES-C Short-Form total score will demonstrate adequate internal consistency reliability, as evidenced by a Cronbach alpha statistic of 0.80 or greater [ 24 , 25 ].
• The parent version of the EES-C Short-Form total score will demonstrate moderate test–retest reliability, as evidenced by an intraclass correlation coefficient (ICC) of 0.5 or greater [ 16 , 26 ].
• To support convergent validity, parent version of the EES-C Short-Form total score will be significantly correlated with a theoretically related construct of maladaptive eating behaviors [ 27 , 28 , 29 , 30 ].
• To support discriminant validity, the parent version of the EES-C Short-Form will demonstrate a small, non-significant correlation with a scale measuring gratitude—a theoretically nonrelated construct [ 22 , 27 ].
• There will be moderate agreement between raters (i.e., child self-report and parent-report) on the EES-C Short-Form total score, indicated by an intraclass correlation coefficient (ICC) between 0.5 and 0.75 [ 26 ].
• The parent version of the EES-C Short-Form total score will produce a unidimensional model with good fit, as indicated by goodness-of-fit indices equal to or exceeding cutoff values for adequate model fit (CFI ≥ 0.95, SRMR ≤ 0.09), supporting structural validity [ 24 , 31 ].
• Parents of children who are overweight and obese will report significantly higher levels of emotional eating on the EES-C Short-Form total score than parents of healthy-weight children, evidenced by a medium effect size (i.e., Cohen’s d), approximately 0.5 in magnitude [ 24 , 32 ].

2. Materials and Methods

2.1. measures, 2.1.1. emotional eating scale for children and adolescents short-form, parent and self-report, 2.1.2. the children’s eating behavior questionnaire, 2.1.3. gratitude moments questionnaire, 2.2. statistical analysis, 3.1. participant characteristics, 3.2. internal consistency reliability, 3.3. test–retest reliability, 3.4. convergent validity, 3.5. discriminant validity, 3.6. agreement, 3.7. model fit, 3.8. known groups, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Summers, E.; Limbers, C.A. Evaluating Emotional Eating in Children from the Perspective of Parents: Psychometric Properties of the Parent Version of the Emotional Eating Scale Adapted for Children and Adolescents. Nutrients 2024 , 16 , 3030. https://doi.org/10.3390/nu16173030

Summers E, Limbers CA. Evaluating Emotional Eating in Children from the Perspective of Parents: Psychometric Properties of the Parent Version of the Emotional Eating Scale Adapted for Children and Adolescents. Nutrients . 2024; 16(17):3030. https://doi.org/10.3390/nu16173030

Summers, Emma, and Christine A. Limbers. 2024. "Evaluating Emotional Eating in Children from the Perspective of Parents: Psychometric Properties of the Parent Version of the Emotional Eating Scale Adapted for Children and Adolescents" Nutrients 16, no. 17: 3030. https://doi.org/10.3390/nu16173030

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• 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

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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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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
• , Elizabeth Rieger
• , Sarah-Catherine Rodan
• , Karen Rockett
• , Janice Russell
• , Haley Russell
• , Fiona Salter
• , Susan Sawyer
• , Beth Shelton
• , Urvashnee Singh
• , Sophie Smith
• , Evelyn Smith
• , Karen Spielman
• , Sarah Squire
• , Juliette Thomson
• , Stephen Touyz
• , Ranjani Utpala
• , Lenny Vartanian
• , Sabina Vatter
• , Andrew Wallis
• , Warren Ward
• , Sarah Wells
• , Eleanor Wertheim
• , Simon Wilksch
•  & Michelle Williams

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.

Corresponding author

Correspondence to Jane Miskovic-Wheatley .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

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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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

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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DOI : https://doi.org/10.1186/s40337-023-00801-3

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USA Study: Taylor Swift is a role model in dealing with eating disorders

8.9.2024 - 08:35

US pop singer Taylor Swift repeatedly addresses her eating disorder and the associated doubts about her own body. In doing so, the 34-year-old is apparently helping fans who are struggling with their own body image. This is reported by a US research team in the specialist magazine "Social Science & Medicine".

08.09.2024, 08:35

08.09.2024, 08:36

Inspiration from interviews and song lyrics

In a thematic analysis, the authors evaluated around 200 posts published by Swift fans on the platforms Reddit and Tiktok. According to the study, Swift's role model function plays an important role for her often female fans.

Many of the so-called "Swifties" saw the musician as a pioneer in dealing with eating disorders. Swift's openness inspired them to overcome their own illnesses. Fans repeatedly referred to the documentary "Miss Americana" (2020), in which Swift spoke about the topic.

"Swifties" also used certain songs by the singer in their posts, whose lyrics allow associations with mental health. Songs such as "You're On Your Own, Kid" and "Tied Together With a Smile" were used by fans to deal with their own insecurities, the researchers reported.

Controversy surrounding "anti-hero" video

However, the topic of body image in connection with Taylor Swift was also discussed controversially on the platforms. According to the researchers, the music video for the song "Anti-Hero" from 2022 sparked a debate. In the original version of the clip, Swift stood on a scale displaying the word "fat" in one scene.

While some fans defended the depiction as an expression of Swift's own insecurities, others felt hurt by it. The artist later replaced the video online with another version that no longer contained the word.

"Swifties" objectify their idol

The authors also noted that fans objectified their idol in the posts, i.e. reduced her to her body. For example, current pictures of Swift were juxtaposed with older photos. Users commented on how "healthy" and "happy" Swift looked in comparison to the past. At the same time, however, fans criticized media reports that focused on Swift's appearance or weight.

"This analysis shows the positive impact that celebrities can have, but also highlights the limitations of personal statements when it comes to addressing systemic problems like fatphobic bias," said lead author Lizzy Pope from the University of Vermont.

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Being a Taylor Swift Fan Could Positively Impact Your Body Image, Study Finds

Now, new research from the University of Vermont suggests that Swift’s influence extends far past the realm of entertainment and into the world of disordered eating. According to the study, published in the journal Social Science & Medicine , Swift’s candidness around her own body-image struggles has had a positive influence on fans, helping to reduce the stigma of eating disorders and promote a supportive environment for Swifties.

• Lizzy Pope, PhD, RD , associate professor and director of the undergraduate dietetics program at University of Vermont
• Meghan Gillen, PhD , psychology professor at Penn State Abington

Some celeb-on-fan context

These findings may sound obvious (isn’t candidness around health always a good thing?), but past research has actually found the opposite to be true when it comes to celebrities and their fans.

In a 2016 study published in the Journal of Eating Disorders , researchers found that internet searches for “pro-eating disorder terms” would spike after a high-profile celebrity disclosed their own eating disorder. A 2005 study in the British Journal of Health Psychology also found that younger teenage girls (many of whom are now adult fans of Swift) were more likely to have negative views of their own bodies if they had a parasocial relationship with a celebrity.

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But despite these previous findings, researchers—who analyzed roughly 200 posts on Reddit and TikTok—found Swift to be a uniquely “positive role model,” especially as she’s become more outspoken about her own struggles. In recent years, for example, Swift’s 2022 song “ You're On Your Own, Kid ” includes references to disordered eating and thinking patterns, while her 2023 music video “ Anti-Hero ” features Swift stepping on a scale that reads “fat” (an image that sparked criticism of “ anti-fat bias ” and led Swift’s team to remove it from certain versions of the video).

But Swift’s first—and arguably most notable—disclosure was in her 2020 documentary “ Miss Americana ,” where she revealed that she had long struggled with disordered eating before seeking help. “You don't ever say to yourself, ‘Look, I’ve got an eating disorder,’” Swift says in the documentary. “But you know you're making a list of everything you put in your mouth that day, and you know that's probably not right.”

Swift’s admission—and its ensuing media coverage—is what prompted researchers to dig in and investigate its potential cultural impact. “Taylor Swift is so popular right now, and I had an idea,” study co-author Lizzy Pope, PhD, RD , associate professor and director of the undergraduate dietetics program at the University of Vermont, tells Well+Good. “Did [Swift’s] disclosures in Miss Americana , and in some of her music, actually help people with their own eating disorders and body image issues—or were they harmful?”

Inside the Swift study

To find out, Pope and her co-author Kelsey Rose, MPH, RD , clinical assistant professor at University of Vermont, dissected and analyzed more than 8,000 comments on 200 social media posts since 2019, all related to Taylor Swift and body image. Pope and Rose looked through comments on TikTok (where they searched “Taylor Swift body image” and read comments on the top 100 videos) and on Reddit (where they searched “body image” and “eating disorder” and read through comments within the r/TaylorSwift fan community).

Pope tells Well+Good that she was most surprised by how often commenters mentioned the positive impact Swift had on them, especially in how they take care of and view their bodies. (Of course, it’s also important to recognize the limitations of this study: The comments were limited to those written in English with no identifiable demographics, so it’s possible that people of varying genders, races, ages, and backgrounds may not be as receptive to Swift’s body-image comments).

While Swift is becoming an increasingly popular topic to discuss in academia , the conversation is mainly focused on Swift’s lyrical prowess or her impact on the economy. That’s why some experts are so intrigued by the findings of this study, including Meghan Gillen, PhD , psychology professor at Penn State Abington who specializes in body image and eating behavior.

Gillen tells Well+Good that this study is one of the first of its kind specifically centered on Swift’s positive impact on body image. “Most studies [are focused] on the negative influence of celebrities on people,” Gillen tells Well+Good, “so I was super excited to see this study.”

What about other celebs?

Understandably, the findings of this study don’t necessarily mean that the results would be similar with anyone else. “The context is different for each celebrity,” Gillen says. “Maybe someone who is a bit more controversial might be less positively received.” Kylie Jenner, in fact, made a push a few years ago to speak out about harmful body-image standards , but was met with considerable pushback from critics who felt that her family had a role in perpetuating—and profiting off of—those very standards.

Swift herself has faced some controversy, though, especially around her Anti-Hero music video and its alleged promotion of “anti-fat bias,” according to some critics—who, it’s worth noting, were also criticized for their criticisms. Gillen and Pope say these differing arguments say a lot about the state of body-image discourse: Feelings about bodies are complex, and those struggling with harmful messaging aren’t always immune to spreading it.

“It was interesting to see how [Swift’s] personal disclosures around her issues helped people with their own journeys, but it didn't necessarily translate to a bigger understanding of what anti-fat bias is and how it can show up,” Pope says. “Even if you have an eating disorder, you can still have anti-fat bias; in fact, it’s a hallmark part of the diagnosis.”

Where to go from here

These findings overall prove the immense power that pop culture can have in shaping behavior and beliefs, Pope says. That means those in the public eye have a responsibility to be aware of what messaging they’re putting out into the world—and fans have a responsibility to consider who they’re choosing to idolize.

“Choose your parasocial relationships wisely,” Pope recommends. “They can really help you navigate your mental health and cultural challenges, or they can [potentially] contribute to them.”

If you or someone you know is struggling with an eating disorder, call the National Alliance for Eating Disorders Helpline at 1-866-662-1235 for immediate support, or go to allianceforeatingdisorders.com or anad.org/get-help for more resources.

• Pope, Lizzy, and Kelsey L Rose. “”It’s All Just F*cking Impossible:” The influence of Taylor Swift on fans’ body image, disordered eating, and rejection of diet culture.”  Social science & medicine (1982)  vol. 355 (2024): 117100. doi:10.1016/j.socscimed.2024.117100
• Lewis, Stephen P et al. “Pro-eating disorder search patterns: the possible influence of celebrity eating disorder stories in the media.”  Journal of eating disorders  vol. 4 5. 3 Mar. 2016, doi:10.1186/s40337-016-0094-2
• Maltby, John et al. “Intense-personal celebrity worship and body image: evidence of a link among female adolescents.”  British journal of health psychology  vol. 10,Pt 1 (2005): 17-32. doi:10.1348/135910704X15257

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An update on the prevalence of eating disorders in the general population: a systematic review and meta-analysis

1 Shanghai Yangpu District Central Hospital, Tongji University School of Medicine, Shanghai, China

2 Shanghai Tianyou Hospital, Shanghai, China

Fanxiao Liu

3 Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China

4 Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Hongmei Zhang

5 Shanghai Yangpu District Mental Health Center, Shanghai, China

6 Shandong Mental Health Center, Jinan, China

Associated Data

All data generated or analyzed during this study are included in this published article (and its supplementary information files).

To update the prevalence of eating disorders in the general population before 2021 and to analyze the distribution characteristics at different times and in different regions and sexes, as well as the diagnostic criteria.

Based on the method from a previous report by the authors, studies were identified from the following databases: PubMed/Medline, PsycINFO, ISI Web of Knowledge, Ovid and the 4 most important Chinese databases. Articles in English and Chinese before 2021 were retrieved. The data retrieved at this time were pooled with the data from a previous report for analyses.

Thirty-three studies were identified, which included 18 studies supplemented in this retrieval. The pooled lifetime and 12-month prevalence of eating disorders were 0.91% (95% CI, 0.48–1.71) and 0.43% (95% CI, 0.18–0.78), respectively. The pooled lifetime and 12-month prevalence of the subgroup EDs (any), which covers all types of eating disorders, were 1.69% and 0.72%, respectively. The lifetime prevalence of AN, BN and BED was 0.16% (95% CI, 0.06–0.31), 0.63% (95% CI, 0.33–1.02) and 1.53% (95% CI, 1.00–2.17), respectively. The lifetime prevalence of EDs in Western countries was 1.89%, and was high at 2.58% in females. Prevalence studies using DSM-5 criteria were scarce.

Conclusions

The prevalence of eating disorders might be underestimated thus far. Not all types of EDs were included in a majority of epidemiological surveys, and the prevalence rates of the new types of EDs were significantly higher. Eating disorders were especially common in Western countries and in females. New diagnostic criteria should be used to comprehensively assess all types of eating disorders.

Level of evidence

1, systematic review and meta-analysis.

Introduction

Eating disorders (EDs) are a group of syndromes characterized by eating behaviors and psychological disorders accompanied by weight changes and/or social disorders that have a significant influence on quality of life and social function [ 1 , 2 ]. Moreover, individuals with eating disorders may develop severe somatic complications that can cause a higher risk of suicide [ 3 ] and increased mortality rates, especially anorexia nervosa (AN) [ 4 ], one of the main types, with a fatality rate as high as 5–20% [ 5 ].

The criteria of eating disorders evolved over time. In the Diagnostic and statistical Manual of Mental Disorders, 4th edition (DSM-IV) [ 6 ], eating disorders include anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). EDNOS is a complex diagnosis recognized as all eating disorders that do not meet the diagnostic criteria of AN or BN or cannot be categorized into either of the two. Binge eating disorder (BED) is also classified into EDNOS and is listed in appendix. However, recent studies found that the impact of physical and psychological damage caused by EDNOS is no less than that caused by the classic eating disorder types AN or BN [ 7 ]. In the DSM-5 issued in 2013 [ 8 ], the diagnostic categories of eating disorders were expanded to “feeding and eating disorders”, in which feeding and eating disorders first seen in infants and early childhood were included. Binge eating disorder (BED) was listed individually in the diagnostic criteria. Exclusive of AN, BN and BED, the rest are classified as other specified feeding and eating disorder (OSFED) and unspecified feeding and eating disorder (UFED). OSFED refers to eating disorders that can lead to patients' clinical suffering or damage to social function, such as atypical AN, atypical BN, atypical BED, purging disorder, and night eating syndrome, which do not meet the criteria for AN, BN or BED. Other eating disorders that cause clinical suffering or impaired social function in patients but do not meet the diagnostic conditions listed above are classified as UFED. Apart from the changes in classification, the diagnostic criteria of all types of eating disorders were relaxed in DSM-5. The weight loss requirement has been relaxed, and the requirement of “amenorrhea” has been removed in AN. In the diagnosis of BN, the frequency of binge eating or unduly compensational behavior was lowered from twice a week to once a week. Similarly, the frequency of binge eating in BED diagnostic criteria has also been lowered to once a week (Table ​ (Table1 1 ).

Differences in the diagnostic criteria for eating disorders between DSM-IV and DSM-5

Eating disorders had been claimed to be represented predominantly in Western countries and women in the past, which may be due to cultural beliefs and attitudes in some aspect [ 9 ]. With industrialization and globalization, many regions reported increasing incidence rates of eating disorders [ 10 , 11 ]. What’s more, the reported prevalence of eating disorders in the general population varied widely all along, which ranges from 0.1% [ 12 ] to 3.8% [ 13 ]. To address these issues, a systematic review on the prevalence of eating disorders in the general population was performed in 2013 by the author [ 14 ]. It showed that there were serious limitations in the available epidemiological data, especially from low- and middle-income countries, including China. Only 15 studies were included during the past 30 years since 2013. The pooled lifetime prevalence of eating disorders was 1.01%, but the specific types of eating disorders varied among the studies included. The prevalence of eating disorders was higher in women, and in Western than Asian countries, but South Korea was the only Asian country. The prevalence tended to increase over time but may also be caused by changes in the diagnostic criteria.

With the increasing attention to eating disorders in recent years, more and more related studies have emerged. Epidemiological studies have also increased, with many from the Asia countries and some even reporting high prevalence rates [ 15 , 16 ]. More researches in men have also been reported, and the view that women are dominant seems to have wavered [ 4 , 17 ]. In the meantime, some studies have indicated that the resulting prevalence by using DSM-5 is different from that by using DSM-IV [ 17 – 20 ]. In order to better understand the prevalence and the distribution characteristics of eating disorders, this study updated the systematic review on the prevalence of eating disorders in the general population. Thus, the main objectives of this study are (1) to update the prevalence of eating disorders and various types in the general population before 2021; (2) to analyze the distribution characteristics at different times and in different regions and sexes, as well as the diagnostic criteria between DSM-IV and DSM-5.

Literature retrieval strategies

Previous research methods were followed in this study. The retrieved databases included PubMed/Medline, PsycINFO, ISI Web of Knowledge, Ovid and the Chinese Databases Chinese National Knowledge Infrastructure, Chongqing VIP database for Chinese Technical Periodicals, WANFANG DATA, and China BioMedical Literature Services System (SinoMed). The dates of retrieval were from 1 May 2013 to 31 January 2021. Only English and Chinese articles are included.

Other than the key words ‘eating disorders’, ‘anorexia nervosa’, ‘bulimia nervosa’, ‘prevalence’, and ‘epidemiology’ in both English and Chinese used in our previous study, we added a new key word ‘mental’ in Chinese in this study. Furthermore, articles before May 2013 were additionally retrieved by using the key words 'mental' and ‘prevalence/epidemiology’. All references in the included literature were then retrieved manually.

After all duplicated studies retrieved from the databases were removed automatically by EndnoteX7, preliminary screening based on the title and abstract was carried out by two authors (Jie Qian & Ying Wu) independently. The full texts of the literature above were downloaded and reviewed, followed by screening on the basis of the pre-established inclusion and exclusion criteria. For those studies for which consensus was not reached, even after discussion by both authors, a third member (Wan Yumei) decided whether to include the study or not.

Inclusion and exclusion criteria

Inclusion criteria: (1) the epidemiological survey of the eating disorder evaluated a general population; (2) the diagnostic criteria of the eating disorder conformed to that of DSM or the ICD or the CCMD; (3) tools for screening were admitted; and (4) information such as prevalence and sample size in literatures could be extracted.

Exclusion criteria: (1) nonhuman studies, reviews, case reports and redundant published studies; and (2) studies on special populations, such as women, students, juveniles, hospitals and armies.

Data extraction

For the included literature, data were extracted by Jie Qian and Ying Wu. The extracted items included first author; study year; study region; sampling method; diagnostic criteria; overall sample size; the number of cases; lifetime, 12-month, 3-month and 4-week prevalence rates; and sex.

Evaluation of study quality

Similar to a previous study, the evaluation of the included literature followed the standards of the necessary items listed in Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Every item counted as a score of 1, with the total score ranging from 0 to 22.

Statistical analysis

The Metaprop package in R version 3.6.2 software was applied, and Logit was used to perform rate conversion for consolidation computation. A heterogeneity test was performed. If I 2 (statistics of effect value variation caused by heterogeneity) was less than 50% and the heterogeneity test p  > 0.10, the fixed-effects model was adopted for rate consolidation; otherwise, the random-effects model was adopted. When there was significant heterogeneity among studies, sensitivity analysis was conducted. The funnel chart method was used to evaluate the publication bias of the included studies.

A total of 29,201 unduplicated articles were retrieved at this time, 18,713 of which were in Chinese. After secondary screening, 18 studies were included according to the inclusion and exclusion criteria (Fig.  1 ).

Identification of studies included in the analysis

Characteristics of the included studies

Thirty-three studies were identified, which included 15 studies reported in the systematic review in 2013 [ 14 ]. Among the 18 included studies in this retrieval, 3 studies offered 2 or 3 groups of data: Hay 2017’s study [ 1 ] was performed in 2014 and 2015, respectively; Choi 2015’s study [ 21 ] was divided into KECR-R (performed in 2006–2007) and KECA-2011 (performed in 2011); and Shi 2015’s study [ 12 ] showed three groups of data from Shanxi Province, Gansu Province and Henan Province in China. Hence, there were 22 groups of data in total. The publication times of all studies ranged from 2002 to 2021, and the study times ranged from 2001 to 2017; however, the study time of one article published in 2014 was not specified [ 22 ]. There were 6 Chinese articles (including 3 dissertations [ 12 , 23 , 24 ]) and 13 separate English articles. Three studies were conducted in America [ 13 , 18 , 25 ]; 3 in Australia [ 1 , 26 ]; 1 each in Italy [ 22 ], Switzerland [ 17 ], Korea [ 21 ] and Saudi Arabia [ 15 , 16 ]; and 8 in China [ 12 , 23 , 24 , 27 – 31 ], in which only 1 was national research [ 31 ], while the remaining 7 were regional studies limited to provinces or cities. DSM-IV and DSM-5 were used as newer diagnostic criteria than DSM-III and ICD. DSM-5 alone was applied in 4 studies, DSM-IV alone was applied in 11 studies, and DSM-IV and DSM-5 were both applied in the remaining 3 studies [ 22 ]. The cumulative total sample size of all studies was 242,917, with no subjects under the age of 15 years. There were only three studies involving EDs, of which one encompassed all types of eating disorders [ 13 ]; one included AN, BN and BED [ 17 ]; and the other did not specify the details of the eating disorders [ 12 ]. There were 15 studies referring to AN, 13 to BN and 10 to BED; other than that, there were two involving UFED, a new type in DSM-5, and one involving OSFED (Fig. ​ (Fig.2 2 ).

The proportion of different diagnostic criteria, conduct decade, countries and regions

The 33 studies included 315,877 participants. The studies were conducted from 1984 to 2017, with diagnostic criteria including DSM-III, DSM-IV, DSM-5 and ICD. The studies were conducted in the United States; European countries, including Germany, the Netherlands, Norway, Italy, Switzerland, Belgium, France, and Spain; Asian countries, including South Korea, China and Saudi Arabia; Oceanic countries, including Australia and New Zealand; and Latin countries, including Mexico [ 32 ] and Brazil [ 33 ]. In addition, there was an included study organized by the WHO involving 14 countries [ 34 ]. The specific percentages of study year, region and diagnostic criteria are shown in Table ​ Table2 2 .

Characteristics of the 18 Supplementary included studies

*The article did not provide the specific number of patients, but the prevalence, which was calculated according to

a R random, C cluster, S stratified, M multiphase

b DSM diagnostic and statistical manual, ICD International Classification of Diseases

c ED eating disorders, AN anorexia nervosa, BN bulimia nervosa, BED binge eating disorder

D lifetime lifetime prevalence, 12-m 12-month prevalence, 4-w 4-week prevalence

Evaluation of study quality and the assessment of publication bias

The mean (sd) quality score for the reports of the 19 studies based on the STROBE items was 17.97 (1.71), and the range in this score varied from 15.5 to 22.0. Ten studies scored over 18.0, accounting for 52.6%, indicating high general quality of the literature. The most common problems in the reports of these studies were inadequate descriptions of the numbers of individuals in every phase, the reason for nonparticipation, and the numbers of individuals with missing data.

The assessment of publication bias on the prevalence of eating disorders and the three main types of EDs was conducted using the funnel chart method. The publication bias levels of eating disorders ( t  = − 1.97, p  = 0.077), AN ( t  = − 0.21, p  = 0.839), BN ( t  = 1.12, p  = 0.278) and BED ( t  = 0.1, p  = 0.921) were not statistically significant.

Prevalence rates of eating disorders and the various types

The lifetime, 12-month and 4-week prevalence rates of eating disorders were 0.91% (95% CI, 0.48–1.71), 0.43% (95% CI, 0.18–0.78), and 0.2% (95% CI, 0.09–0.36), respectively. As described above, the specific types of eating disorders in the 11 studies involving eating disorders were not completely the same. Hence, the 11 studies were categorized into 4 groups: ED (any), ED (AN + BN + BED), ED (AN + BN), and ED (unknown), representing the 4 studies including all types of eating disorders [ 13 , 35 – 37 ]; 1 study including AN, BN and BED [ 17 ]; 4 studies [ 38 – 41 ] including only AN and BN; and 2 others without specific content [ 12 , 42 ]. A lifetime prevalence of 3.60% and a 12-month prevalence of 1.1% were reported in the only study from the ED (AN + BN + BED) group. The lifetime prevalence rates of the remaining groups were 1.69% (95% CI, 0.75–3.76) for ED (any), 0.83% (95% CI, 0.35–1.93) for ED (AN + BN), and 0.25% (95% CI, 0.13–0.48) for ED (unknown). The lifetime and 12-month prevalence rates of ED (any) were over twice those of ED (AN + BN), and over 1.5 times those of eating disorders (shown in Table ​ Table3 3 and Fig.  3 ).

Overall and subgroup prevalence of EATING DISORDERS

The lifetime prevalence of eating disorders

The lifetime prevalence rates of AN, BN and BED were 0.16% (95% CI, 0.06–0.31), 0.63% (95% CI, 0.33–1.02) and 1.53% (95% CI, 1.00–2.17), respectively. The lifetime prevalence of BN was nearly 4 times that of AN, and that of BED was nearly 10 times that of AN, with a ratio of approximately 1:4:10. The 12-month prevalence rates were also with great disparity, with a ratio of approximately 1:16:46. BED prevalence was markedly higher than the prevalence of the other two classic types, whereas AN prevalence was the lowest (Tables ​ (Tables4, 4 , ​ ,5 5 and ​ and6 6 ).

Overall and subgroup prevalence of ANOREXIA NERVOSA

Overall and subgroup prevalence of BULIMIA NERVOSA

Overall and subgroup prevalence of BING EATING DISORDER

Three studies involved the 3-month prevalence of AN, BN and BED, all conducted in Australia by Hay et al., with DSM-5 as the diagnostic criteria used. The 3-month prevalence rates of AN were 0.46% during 2008–2009 and 0 in both 2014 and 2015. The 3-month prevalence of BN was 0.99% based on pooled data of 4 groups from the 3 studies. The 3-month prevalence of BED was 1.71% based on pooled data from 3 studies.

The 3-month prevalence of OSFED and UFED was seen only in the report conducted by Hay et al. The 3-month prevalence rates of OSFED were 0 in 2014 and 3.2% in 2015. The 3-month prevalence of UFED was 2.2% based on the pooled data from the 2 studies.

Sensitivity analysis of the main results was conducted, and no study with a significant change in heterogeneity was found.

Subgroup analysis

Diagnostic criteria.

Subgroup analysis using the diagnostic criteria of DSM-5 and DSM-IV was added in this report. No study involving EDs used DSM-5 diagnostic criteria. The pooled lifetime prevalence of AN using DSM-5 was 0.89%, which was 8.9 times that using DSM-IV ( p  < 0.001); the pooled 12-month prevalence was 2 times that using DSM-5 than that using DSM-IV. For BN, the pooled lifetime prevalence using DSM-5 was 1.41%, which was 2.5 times that using DSM-IV. However, for BED, the lifetime and 12-month prevalence rates diagnosed by DSM-5 were slightly lower than those diagnosed by DSM-IV, but the differences were not statistically significant.

Years of study

The lifetime prevalence rates of EDs in the 1990s, 2000s and 2010s were 0.91%, 2.0% and 0.71%, respectively, while the 12-month prevalence rates were 0.36%, 0.68% and 0.26%, respectively. The highest prevalence was in the 2000s for both conditions, with a lower prevalence in the 2010s. The lifetime prevalence rates of AN in the 1980s, 1990s, 2000s and 2010s were 0.01%, 0.06%, 0.13% and 0.42%, respectively, with an upward trend. The lifetime prevalence rates of BN in the 1990s, 2000s and 2010s were 0.53%, 0.41% and 1.08%, respectively, and the 12-month prevalence rates were 0.29%, 0.28% and 0.41%, respectively. The lifetime prevalence rates of BED in the 2000s and the 2010s were 1.58% and 1.48%, respectively, and the 12-month prevalence rates were 0.95% and 0.90%; the prevalence rates in the 2010s were both lower than those in the 2000s for both conditions (shown in Fig.  4 ).

The lifetime prevalence of eating disorders over time

Geographic region

We used the same method for comparing Western and Asian countries as in a previous report. The lifetime and 12-month prevalence rates of EDs in Western countries were 1.89% and 0.68%, respectively, both over 8.5 times those in Asian countries ( p  < 0.01). The lifetime prevalence of AN in Western countries was 21 times that in Asian countries, 7.3-fold for BN and 2-fold for BED. The 12-month prevalence rates were 2-fold and 1.2-fold higher in Western countries than in Asian countries for AN and BN, respectively. The prevalence in Western countries was significantly higher than that in Asia for any type of eating disorder. Furthermore, the pooled lifetime prevalence rates of AN were subdivided by region of South Korea, China, Western Europe and America, with results of 0.01%, 0.02%, 0.47% and 0.52%, respectively (shown in Fig.  5 ).

The lifetime prevalence of AN in different countries or regions

The lifetime prevalence rates of eating disorders in females reached 2.58% (95% CI, 1.06–4.74) and 0.74% (95% CI, 0.24–1.52) in males. Regardless of overall eating disorders or various types, the prevalence in females was evidently several times that in males. The lifetime eating disorder prevalence rates at 12 months and 4 weeks in females were 3.5, 4.2 and 3.1 times those in males, respectively. The ratios of females to males in the lifetime prevalence of AN, BN and BED were 15.5, 3.2 and 2.1, respectively, and 3, 3.2 and 1.8 in the 12-month prevalence. Compared with the classic types AN and BN, the ratio was lower for BED.

Main finding

This study updated the prevalence of eating disorders in the general population before 2021, and analyzed the different conditions included among eating disorders to obtain closer-to-real-level prevalence data. The differences in sex, region, decades and diagnostic criteria were analyzed.

After this update, the pooled lifetime and 12-month prevalence rates of eating disorders were 0.9% and 0.43%, respectively. However, the pooled lifetime and 12-month prevalence rates of ED (any), the subgroup of which covers all types of eating disorders, were 1.69% and 0.72%, respectively, both over 1.5 times those of the eating disorders among all 12 groups of data. Many studies on the prevalence of eating disorders included only the 2 classic types, AN and BN, whereas their prevalence rates were comparatively lower among various types. This reflected the situation in which the prevalence of eating disorders in the general population was underestimated. Another factor that needs to be considered is that the 4 studies of EDs (any) all come from Western high-income countries (Germany, the United States and six other European countries).

The lifetime prevalence rates of AN, BN and BED were 0.16%, 0.63% and 1.53%, respectively, which were all lower than the results in a previous report from 2013. This may be related to the fact that only three studies were from South Korea, the only Asian country included in the previous report, whereas a large number of Asian country studies, especially China, were included in this report.

To date, few studies have used DSM-5 to study the prevalence of eating disorders. Thus, studies that use DSM-5 diagnostic criteria to conduct comprehensive investigations of all types of eating disorders are still lacking. The prevalence of AN using the diagnostic criteria of DSM-5 was much higher than that using DSM-IV, in accord with other study results [ 19 , 20 , 43 ]. This was also in line with the fact that the standards of AN experienced the greatest alteration in DSM-5 diagnostic criteria. For BN, the lifetime prevalence using DSM-5 was higher than that using DSM-IV, in accord with others studied by Lindvall Dahlgren [ 43 ] and Flament [ 19 ], which could be because the frequency of the diagnosis was reduced. However, Mancuso [ 20 ] showed that the prevalence of BN was not different using the two diagnostic criteria and used only self-report questionnaires for diagnosis in adolescents. For BED, although the standards of the frequency of binge eating were relaxed in DSM-5, there was no obvious evidence that the prevalence using DSM-5 was higher than that using DSM-IV. Thus, the conclusions in other studies were in discordance. Lindvall Dahlgren [ 43 ] reported that there had been early evidence indicating a higher prevalence of BED using DSM-5. Flament [ 19 ] found that the prevalence of BED had no change in juveniles. More research using DSM-5 is needed for comparison in the future.

Except for AN, the prevalence of other types of EDs did not significantly increase with time until the 2010s. The prevalence of EDs in the 2000s showed an increase compared with that in the 1990s, which was in accordance with Mitchison's [ 44 ] and Hay's [ 11 ] studies on the prevalence trends of eating disorders. However, the prevalence declined instead of growing in the 2010s. Nevertheless, more studies need to be included, as only 2 studies were included after 2010 [ 12 , 17 ]. The upward trend in AN and the slight downward trend in BN were in line with most other studies [ 4 , 45 , 46 ], but studies of new types of eating disorders are still lacking.

In terms of the distributions of geographic region and sex, the results in this report were consistent with those of a previous study by the authors and others, in which the prevalence rates in Western countries and in females were higher. The lifetime prevalence rates were up to 2.58% in females and 1.89% in Western countries, higher than the prevalence rates of schizophrenia and other mental illnesses. The real prevalence rates in Western countries and in females might be even higher due to underestimation, as mentioned above. Although the prevalence was higher in females, male patients showed a slightly higher proportion of BED than of the classic types AN and BN, consistent with the results of Smink's study [ 4 ].

Strengths and limitations

There have been few reviews about the prevalence rates of eating disorders in the general population. Of the 15 studies included in our former meta-analysis, only 3 studies of one country (South Korea) were from Asia. However, 8 Chinese studies, accounting for 50% of all newly included studies, were included in this report. As the specific contents of eating disorders varied greatly in different studies, subgroup analysis was conducted based on the specific contents, which might provide more authentic data. The number of studies was more than double, and most of the main results were calculated based on more than 10 studies, with publication bias assessed by the funnel chart method, which essentially resolved the limitations of previous reports.

However, the number of studies on the prevalence of eating disorders is still small, concentrated in Europe, America, Australia, New Zealand and a few Asian countries, such as China and South Korea. Studies from other countries were not retrieved, probably due to language limitations, and the distribution of geographic regions cannot be analyzed in a larger scope. The number of studies using DSM-5 was small, with no study covering all types of eating disorders found in DMS-5. Likewise, those of AN, BN and other types were also very small; thus, it is impossible to conduct a comprehensive analysis on the impact of the new diagnostic criteria on the prevalence of eating disorders.

The prevalence of eating disorders may be underestimated thus far. A large number of previous epidemic studies did not include all types of eating disorders, whereas the prevalence in new types was apparently higher. The prevalence of eating disorders was high, especially in Western countries and in females. In addition, we should pay more attention to new types of eating disorders in males. In future epidemic investigations, new diagnostic criteria should be used more often to comprehensively evaluate all types of eating disorders.

Supplementary information

What is already known on this subject.

Only one systematic review on the prevalence of EDs in general population which was done by us in 2013. There have been some epidemiological studies of EDs in recent years with mixed results.

What this study adds?

The prevalence of eating disorders might be underestimated. Not all types of EDs were included in epidemiological surveys. New diagnostic criteria shall be used more to access EDs comprehensively.

Author contributions

JQ, YW, CBL and DHY conceived and designed the study; JQ, YW and YMW conducted data search, data extraction and data election. JQ, YW and FXL performed statistical analyses and wrote the manuscript; YKZ, HJ and HMZ help to revise the manuscript; CBL and DHY help to strengthen the manuscript; all authors have read and approved the final manuscript.

This study was funded by the Shanghai Leading Talents Program (YDH-20170627) and the Project of Shanghai Municipal Health Committee (20194Y0027).

Availability of data and material

Declarations.

Authors declare no conflict of interest related to this article.

This article does not contain any studies with human participants or animals.

As this study is a systematic review, formal consent is not required.

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Jie Qian and Ying Wu contributed equally to this work.