research project on eating disorders

• Open access
• Published: 10 March 2023

Prevention and early intervention in eating disorders: findings from a rapid review

• Eyza Koreshe 1 ,
• Susan Paxton 2 ,
• Jane Miskovic-Wheatley 1 ,
• Emma Bryant 1 ,
• Anvi Le 3 ,
• Danielle Maloney 1 ,
• National Eating Disorder Research Consortium ,
• Stephen Touyz 1 &
• Sarah Maguire 1  

Journal of Eating Disorders volume  11 , Article number:  38 ( 2023 ) Cite this article

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Eating disorders (EDs) are complex psychological disorders, with low rates of detection and early intervention. They can lead to significant mental and physical health complications, especially if intervention is delayed. Given high rates of morbidity and mortality, low treatment uptake, and significant rates of relapse, it is important to examine prevention, early intervention, and early recognition initiatives. The aim of this review is to identify and evaluate literature on preventative and early intervention programs in EDs.

This paper is one of a series of Rapid Reviews, designed to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031, funded, and released by the Australian Government. To provide a current and rigorous review, peer-reviewed articles between 2009 and 2021 published in English were searched across three databases: ScienceDirect, PubMed and Ovid/Medline. Priority was given to high-level evidence including meta-analyses, systematic reviews, Randomised Control Trials, and large population studies. Findings from selected studies pertaining to prevention and early intervention in EDs were evaluated and are presented in this review.

In total, 130 studies were identified in the current review, 72% relating to prevention and 28% to early intervention. Most programs were theory-driven and targeted one or more ED risk factors such as thin-ideal internalisation and/or body dissatisfaction. There is reasonable evidence to support prevention programs reducing risk factors, particularly as part of school or university-based programs, with established feasibility and relatively high acceptance among students. There is increasing evidence around the use of technology (to increase dissemination potential) and for use of mindfulness approaches (targeting emotional resilience). Few longitudinal studies assessing incident cases following participation in a prevention program exist.

Conclusions

Although several prevention and early intervention programs have been shown to significantly reduce risk factors, promote symptom recognition, and encourage help-seeking behaviour, most of these studies have been conducted in older adolescent and university aged students, past the age of peak ED onset. One of the most targeted risk factors, body dissatisfaction, is found in girls as young as 6 years old, indicating a need for further research implementing prevention initiatives at younger ages. Follow-up research is limited; thus, the long-term efficacy and effectiveness of studied programs is unknown. Greater attention should be paid to the implementation of prevention and early intervention programs in identified high-risk cohorts or diverse groups, where a more targeted approach may be necessary.

Plain English Summary

A large proportion of individuals with eating disorders (ED) or ED symptomatology within the community do not seek treatment or professional help. Low rates of detection and early intervention, low treatment uptake, stigma, shame and lack of motivation to seek help can lead to significant physical and psychological impairment. Research has shown preventative and early intervention programs can significantly reduce ED risk factors, increase self-awareness and motivation to seek help and treatment. Greater allocation of time and resources is important to explore the long-term effectiveness and reach of these interventions within this population, to reduce the prevalence of EDs, particularly within individuals at a greater risk. To reduce the duration of untreated illness and increase treatment uptake, extensive efforts are needed to bridge the gap between early symptom recognition and timely access to evidence-based specialist services.

Introduction

Eating disorders (EDs) are complex, multifaceted psychological illnesses with high rates of morbidity and mortality, low rates of early detection and intervention, and high rates of relapse [ 1 , 2 , 3 , 4 ]. Low levels of help-seeking behaviour, low treatment uptake, and high rates of treatment dropout can lead to prolonged illness, poor prognosis, and high health care costs [ 1 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ]. Considering the significant physical and psychological impacts of EDs it is imperative that research interest is directed towards effective and implementable ED prevention and early intervention strategies.

According to the American Institute of Medicine, prevention programs can be classified into three categories: universal (i.e., applied to the whole population irrespective of risk, with a primary aim of managing risk factors and reinforcing protective factors), selective (i.e., targets a subgroup who have a higher risk than average), and indicated (i.e., targets individuals who already exhibit symptoms without meeting a diagnostic criteria) [ 12 ]. A recent systematic review concluded that most ED prevention research has been directed towards selective and indicated prevention programs, targeting individuals at higher risk of developing an ED (e.g., adolescent females) and therefore focused on universal prevention [ 13 ]. It is important to note, however, that these classifications are not mutually exclusive, with some ED prevention programs using a combination of features from universal, selective, and indicated prevention programs.

Widely reported prevention programs, including cognitive dissonance-based interventions, media literacy-based programs, and multi-risk factor programs such as school-based interventions, frequently aim to target one or more of the modifiable ED risk factors such as body dissatisfaction, dietary restraint, thin-ideal internalisation, perceived pressure to appear thin, or negative affect [ 13 , 14 ]. Other empowerment-based and mindfulness-based prevention programs are not as specific in targeting ED risk factors—rather they focus on emotional regulation and empowering individuals to make positive behavioural change concerning food, eating and body image [ 13 , 15 ]. However, few resources have been allocated to long-term implementation and evaluation of these prevention programs, limiting the ability to demonstrate their effectiveness in preventing future ED onset [ 16 ].

Low rates of early intervention and help-seeking behaviour have been widely reported in the literature [ 17 , 18 ] with only 17–31% of individuals in the community meeting ED diagnostic criteria seeking ED-specific treatment [ 18 , 19 ]. Early recognition and intervention, especially within the first three years of illness, are integral to recovery, with poorer outcomes being associated with delayed intervention [ 18 ]. This is especially important for children and adolescents with an early onset of illness who have been found to experience the longest mean duration of untreated illness [ 20 ]. The Duration of Untreated ED (DUED) is the time between onset of an eating disorder and first receiving specialist evidence-based care, and is a crucial factor for early intervention [ 21 , 22 ]. Early intervention aims to target prodromal or at-risk individuals to prevent or delay onset of illness and increase chances of recovery [ 23 ]. However, the time from illness onset to first intervention and duration of illness are often conflated in the literature especially for EDs, highlighting the need for more early intervention studies [ 24 ]. According to a recent (2020) systematic review, the average DUED ranges from around 2.5 years for Anorexia Nervosa (AN) to about 6 years for Binge Eating Disorder (BED) [ 21 ]. Although there is no established critical window for early intervention for EDs, the most effective time period for delivering an intervention has been found to be within the first three years of illness onset for a greater likelihood of recovery, after which outcomes may deteriorate [ 23 , 25 ]. Early, timely access to intervention and enhanced help-seeking behaviour can shorten DUED, hence helping prevent prolonged illness and unnecessary suffering [ 8 , 25 ].

This rapid review aims to identify and evaluate the literature on prevention and early intervention programs in EDs, with a focus on preventing ED onset or reducing existing ED pathology by specifically targeting prodromal ED and the first three years of illness. The aim of the rapid review process is to assess recent, relevant, and high-quality research within the focus area, to inform policy and practice.

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 [ 26 ] under the Psychological 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 two-year national consultation and collaboration process, the strategy provides the roadmap to establishing EDs 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 rapid reviews (RRs) to broadly assess all available peer-reviewed literature on the six DSM-5 listed EDs.

A RR Protocol [ 27 ] was utilised to swiftly synthesise evidence in order to guide public policy and decision-making [ 28 ]. This approach has been adopted by several leading health organisations including the World Health Organisation [ 29 ] and the Canadian Agency for Drugs and Technologies in Health Rapid Response Service [ 30 ], to build a strong evidence base in a timely and accelerated manner, without compromising quality. 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 [ 31 ].

This RR is a narrative synthesis and sought to adhere to the PRISMA guidelines [ 32 ]. 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 EDs, and to capture the largest evidence base on the past 13 years (originally 2009–2019, but expanded to include 2020–2021), the eligibility criteria for included studies into the rapid review were kept broad. Therefore, included studies were published between 2009 and 2021, 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 were 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.

The RR presented here 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 studies (RCTs) (n > 50); moderately sized controlled-cohort studies (n > 50); and population studies (n > 500). However, the diagnoses Avoidant/Restrictive Food Intake Disorder (ARFID) and Unspecified Feeding or Eating Disorder (UFED) necessitated less stringent eligibility criteria due to a paucity of published articles. As these diagnoses are newly captured in the DSM-5 (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 (r) due to the broad scope of the RR, which included a total of 1320 studies [ 33 ] (see Additional File 1 ). Data from included studies relating to prevention and early intervention were synthesised and are presented in the current review.

The RR identified 1327 studies in total, of which 131 studies were categorised in the ‘ Prevention and Early Intervention ’ category which were based upon the agreed inclusion/exclusion criteria, as described in the Rapid Review Methodology [ 33 ]. Of these, 73% ( n  = 96, Additional File 1 ) related to prevention and 27% ( n  = 35, Additional File 2 ) to early intervention (within the first three years of symptomatology) in EDs.

A complete list of included studies for this topic including population, intervention types, and outcome measures can be found in Additional File 2 . Results are subdivided into two categories: (i) Prevention, and (ii) Early Intervention.

A total of 96 studies examining prevention programs in EDs, were identified. The three major types of prevention programs (universal, selective, and indicated) used a broad range of approaches focused on reducing ED risk factors and symptoms for preventing future ED onset. Based on the commonly cited prevention approaches and for the purposes of this review, these studies are categorised as (i) cognitive dissonance-based prevention, (ii) universal multi-risk factor programs, (iii) media literacy-based prevention, (iv) mindfulness-based prevention, and (v) other prevention programs.

A 2017 systematic review and meta-analysis of 112 studies found Cognitive Dissonance (CD) and Media Literacy (ML) for EDs to be promising preventive approaches spanning universal, selective and indicated interventions [ 34 ]. Despite the small to moderate effect sizes observed, some studies reported a significant reduction in risk for up to three years following the intervention [ 34 ]. Among the programs, selective prevention programs aimed at high-risk groups (including females and adolescents over the age of 15) showed the strongest evidence for reducing ED symptomatology [ 34 ]. However, for interventions targeting thin-ideal internalisation and body dissatisfaction, research suggests that targeting ages of 12–13 years could help to prevent the downstream effects of ED [ 35 ], including both personal and health system burden.

A recent meta-analytic review identified 15 trials that examined whether prevention programs do infact prevent ED onset. There was a significant effect of the prevention programs reviewed, with dissonance-based and lifestyle modification interventions proving most effective, however sensitivity to detecting moderators correlating with larger prevention effects was limited due to sample size, and almost half of these studies had a mean participant age of > 18 at program delivery, past the peak age of ED onset [ 36 ].

A systematic review examining cost-effectiveness of ED prevention programs concluded that although the number of published studies on the economic evaluation of ED prevention programs had doubled between 2011 and 2017, they were unable to determine value-for-money of interventions due to heterogeneity of studies [ 37 ], highlighting the need for further research in this area. The cost-effectiveness of specific programs is described below.

Cognitive dissonance-based programs

Cognitive Dissonance (CD) based programs aim to generate dissonance that reduces an individual’s pursuit of an unattainable and unrealistic thin-ideal, as individuals align their attitudes with their behaviours [ 10 , 38 ]. Six CD programs were identified within this RR, one example being the Body Project CD prevention program, which was developed for a wide range of target groups and which has been extensively delivered online or face-to-face within primary care [ 39 , 40 , 41 , 42 , 43 ]. It comprises four 1-h group sessions involving thought-challenging exercises, open discussion around personal body image concerns, challenging of thin-ideal statements, home exercises and role plays [ 10 ].

CD-based programs have the strongest evidence-base of the prevention approaches, resulting in almost 60% reduction in future ED onset in at-risk young females with body dissatisfaction and thin ideal internalisation compared to controls, significantly reducing ED symptoms and risk factors such as dieting, thin idealisation, body dissatisfaction, and negative affect [ 10 , 34 , 44 ]. Dissonance-based interventions have been found to be particularly effective for selective prevention, while Cognitive-Behavioural Therapy (CBT) is more effective for indicated prevention [ 45 ]. Successful programs aimed at reducing ED risk factors are often grounded in a cognitive-behavioural theory that contain content on healthy eating and nutrition, media literacy and sociocultural aspects associated with beauty ideals, and body acceptance and body satisfaction [ 16 ]; however, both online dissonance-based and online cognitive-behavioural interventions have been found to be effective in lowering ED risk factors in a high-risk population [ 46 ] and both approaches and theories should be considered for ED prevention.CD-based preventative approaches have also been shown to be cost-effective. A 2012 cost-effectiveness analysis of the program found that the intervention cost approximately US$70 (A$104) per person to deliver, well below the ‘willingness to pay’ threshold for EDs [ 39 ]. Cost-effectiveness modelling of a national school-based CD prevention program in Australia found delivering the program would result in a mean of 16 DALYs (Disability-Adjusted Life Years) averted and would be 80% cost-effective if run for at least five years [ 47 ].

A novel dissonance-based intervention with university-aged couples involving interactive role plays, open discussion and interpersonal skills-building significantly reduced numerous key risk factors for EDs including environmental pressures to be thin, internalisation of the thin and athletic ideals, state body dissatisfaction, and actual-ideal body discrepancy [ 48 ]. Other smaller trials adapting this content to provide interactive interventions have also demonstrated CD’s effectiveness at reducing ED symptomatology [ 49 ]. When delivered by trained facilitators to high school-aged females (i.e., ages 14–18 years), compared with the provision of education brochures, the ‘ Body Project’ CD intervention was found to reduce body dissatisfaction in participants at up to three-years follow-up (FU) and decrease ED behaviours among girls considered ‘high-risk’ at one-year FU [ 41 , 42 ]. The CD intervention was also found to be effective at reducing social and appearance related anxiety and perfectionism among high school-aged females (i.e., ages 14–18 years) [ 50 ]. However, delivery of the ‘ Body Project’ to younger female students (i.e., middle school, ages 11–13 years) was unable to produce the same reductions in body dissatisfaction and ED risk factors [ 51 ]. Further analysis and comparison of data from three ‘ Body Project’ trials confirmed the intervention had greater measured effectiveness when delivered to older students (14 years and over) and to those with elevated thin-ideal internalisation at baseline [ 52 ]. Evidence suggests that while peak ED onset does not generally occur until late adolescence or early adulthood, girls as young as 6 years old can exhibit body dissatisfaction [ 53 , 54 ] and peak onset of the most severe eating disorder AN is earlier than other EDs [ 55 , 56 ], suggesting a mismatch between these facts and at least one study reporting prevention efforts to be most effective when delivered to females at age 14 [ 57 ].

A retrospective study of the ‘ Body Project’ CD prevention program compared participants (under 18 years of age) who developed an ED versus those who did not at three-year FU. Non-responders (or those who developed an ED despite participating in the prevention program) were found to have higher levels of thin-ideal internalisation, body dissatisfaction, ED symptoms, and negative affect at baseline compared to those who did not go on to develop an ED [ 58 ]. The intervention reduced ED symptoms and risk factors but was unable to prevent onset in this group. A more intensive version of the intervention delivered early to the non-responders with higher baseline symptomatology may have prevented risk exacerbation [ 58 ].

In a trial delivered to university students in the US, ‘Project Health’ , a CD-based intervention was compared to an existing ‘Healthy Weight’ lifestyle change program, and a control group where participants watched an obesity education video [ 59 ]. Results from the study indicated that while the CD ‘Project Health’ intervention was more effective at reducing obesity onset in participants compared with the ‘Healthy Weight’ intervention, incidence of ED in both intervention groups was the same at two-year FU. However, ED incidence was non-significantly lower in both intervention groups (both at 3%) compared to the control group (9%), indicating potential effectiveness as an ED and obesity prevention program [ 59 ].

Analysis of the capacity of CD programs to prevent ED onset by type indicates that risk factors targeted by these interventions are more effective for Bulimia Nervosa (BN), Binge Eating Disorder (BED) and Purging subtypes, than for Anorexia Nervosa (AN) [ 60 ]. For individuals at risk of developing AN whose low body weight is due to genetic factors rather than intentional pursuit of the thin ideal, impaired interpersonal functioning and depressive/anxiety symptoms have been identified as relevant targets for future prevention programs [ 60 ].

While the majority of CD-based programs target adolescent girls and young women, several trials have also adapted CD interventions for males which focus on varied expressions of body dissatisfaction including muscle dysmorphia [ 61 ]. This is important given emerging evidence that EDs are also becoming a concern among males, particularly within older age ranges [ 62 ]. In this regard, gender biases in the interpretation of ED symptoms in males have been reported, suggesting an probably underdiagnosis of Other Specified Feeding or Eating Disorder (OSFED) and UFED in a group of Australian university students [ 63 ]. In a younger school-based sample, no significant differences in psychosocial impairment as a result of engagement in ED behaviours were observed between genders [ 64 ]. Males in this cohort were found to experience equivalent psychological distress and negative impacts on their Quality of Life (QoL) as females, stemming from core ED symptomatologies [ 64 ]. Peer-led prevention programs may provide additional benefits to both genders due to the relationship between peer comments, body dissatisfaction, and ED pathology observed in a large community sample [ 65 ].

Peer-led cognitive dissonance-based programs

Peer-led CD interventions have demonstrated efficacy at reducing ED risk factors and have an additional benefit of higher engagement among students [ 66 , 67 ]. In a comparison of clinician-led versus peer-led CD interventions, a significant reduction in risk factors and ED symptomatology was observed in both intervention groups compared to controls [ 68 ]. At one-year FU, the clinician-led intervention group had sustained reductions compared with the peer-led group; however, the peer-led intervention maintained significantly better outcomes than controls [ 69 ]. Peer-led studies with high-risk groups (e.g., athletes) and students have demonstrated efficacy of CD and healthy weight interventions. Significant reductions in shape/weight concern, bulimic symptoms, and negative affect were observed in study of athletes, while a separate study of students achieved; reductions in thin-ideal internalisation, body dissatisfaction, dietary restriction, and bulimic symptoms. Gains were maintained to 12 and 14 month FU, respectively [ 67 , 70 ].

A study comparing the effectiveness of a mixed gender adaptation of the’ Body Project’ CD peer-led intervention among university students found that participation in the program had a greater benefit for males than females [ 71 ]. Compared with females where only small reductions in ED symptomatology were observed at post-intervention, improvements among male participants were much larger and maintained to six-month FU [ 71 ]. In a peer-led CD intervention for gay males, significant reduction in body dissatisfaction, drive for muscularity, dietary restraint, and bulimic symptoms was observed compared with controls. However, the study only included a four-week FU period, therefore, longer-term outcomes of the interventions are unknown [ 72 ]. When the ‘Body Project’ programme was evaluated among high school females in a pilot RCT, the improvements in body dissatisfaction, thin ideal internalization, dietary restraint, and loneliness in the intervention arm suggest that the programme was effective compared to the control arm [ 73 ].

A further peer-led CD intervention, ‘REBeL’, used a module based, self-selection model of prevention delivered in high schools. This differs in format from other programs identified which utilised either a targeted or universal approach [ 74 , 75 ]. In this program, peer-educators self-selected to provide the intervention. Preliminary results showed decreases in ED risk factors and increases in empowerment indicating potential benefit for this model [ 74 , 75 ].

Online cognitive dissonance-based programs

Results from studies delivering the ‘Body Project’ intervention to university-aged students (i.e., over 18 years) [ 40 , 46 , 76 , 77 , 78 ], including several trials of the intervention delivered online ( ‘eBody Project’ ), indicate that regardless of whether students enjoy the program, CD can be highly effective at reducing ED symptomatology, including body dissatisfaction and thin-ideal internalisation. This indicates its potential benefit as a prevention program delivered to a wide range of schools and universities [ 79 ]. Observed effects of the ‘eBody Project’ intervention also include prevention of weight gain in participants and reduction in ED symptoms [ 40 ]. Due to the similar targets and shared characteristics of ED and obesity prevention programs, there is growing literature relating to combining these interventions [ 80 ] as they have been found to be effective and cost-effective in preventing disordered weight control behaviours and obesity [ 81 , 82 ].

In contrast, a study conducted in an Australian university cohort examining the effectiveness of a short online CD prevention program compared to an imagery rescripting intervention found participants who received imagery rescripting intervention to have higher body image acceptance than the CD group [ 83 ], supporting the use of online-adapted imagery-based strategies to reduce disordered eating and the risk of developing an ED; however, further exploration of imagery rescripting techniques in preventing disordered eating is required [ 83 ].

Universal multi-risk factor programs

Universal prevention programs appear to be less effective than selective or indicated approaches in reducing risk factors for EDs [ 13 ] and comorbidities including depression [ 84 ]. However, universal prevention programs such as multi-risk factor school-based programs have high acceptability and can be beneficial for children and adolescents independent of their risk status [ 85 , 86 ]. A systematic review of universal prevention programs delivered between 2006 and 2017 found that these interventions were able to reduce important risk factors including body dissatisfaction (i.e., thin-ideal internalisation and media internalisation) but had less impact on later ED development [ 13 ].

The current review identified 10 school-based prevention programs. One of these projects, ‘Planet Health’ , utilised the principles of social cognitive theory to promote behaviour change in high-school children and found participation in the program to be associated with reductions in disordered weight control behaviours [ 87 ]. Another intervention ( ‘PriMa’) involved presenting preadolescent girls with images and information about AN [ 88 ]. Following the intervention, participants reported significantly increased knowledge of AN compared to the control group at three-month FU. However, improvements in self-esteem in the intervention group were only observed post-intervention and not at FU, with no significant differences in eating behaviours between the intervention and control groups [ 88 ]. A subsequent FU study of ‘PriMa’ eight years after receiving the intervention found that self-esteem was significantly higher in the intervention group compared with the control group, however no significant differences between groups in terms of ED behaviours were found [ 89 ].

A similar program, ‘Torera’ (built on ‘PriMa’), aims to reduce binge eating behaviours related to BN and BED with messaging about self-esteem, physical activity, managing negative emotions and avoiding the cycle of binge eating and dieting [ 90 ]. Interestingly, while the intervention was able to produce a significant increase in self-esteem and decrease in disordered eating behaviours across genders post-intervention, median effect of self-esteem on eating behaviours was only observed in females, which was found to be attributable to a lower baseline body-related self-esteem in females compared with males [ 90 ]. There is a need for further research into prevention programs targeting young males, with a large survey of school students in Switzerland indicating that half of male students reported eating concerns or unhealthy eating behaviours [ 91 ].

The ‘MaiStep’ program was designed for both young males and females, and compared an ED prevention program delivered by psychologists and trained teachers to a universal prevention program for stress prevention delivered by untrained teachers (active control) [ 88 ]. Content of the MaiStep program focused on mindfulness, body image, negative emotions, and interpersonal conflict, and included group discussion. Participants who did not display ED symptoms experienced a reduction in body image related thoughts and increase in interoceptive awareness at 12-month FU. However, the intervention was unable to produce any statistically significant improvements among individuals with existing ED symptomatology [ 92 ].

Several other teacher-delivered universal programs were found to be beneficial for participating students. A study in the UK delivering a body image-based program to adolescent girls, significantly reduced thin-ideal internalisation; however, no differences were observed in relation to eating pathology when compared to the control group [ 93 ]. On the other hand, the ‘POPS-Program’ delivered in the Netherlands, instead of focusing on providing education on ED risk factors or symptoms, focused on self-esteem, body image, and nutrition and resulted in significant reductions on almost all measures of ED symptomatology, maintained at one-year FU [ 94 ]. Further investigation of a multi-risk factor body image dissatisfaction prevention program in Australian classrooms found that ‘Happy Being Me’ was effective at increasing self-esteem and reducing thin ideal internalisation, body dissatisfaction, and dietary restraint when delivered as a selective prevention to girls aged 11–14 [ 95 ] and as a universal prevention delivered to co-educational groups [ 96 ].

Building on a growing evidence base relating to the utility of combining ED and obesity prevention programs for delivery in schools, three studies were identified by this RR, examining the potential effectiveness of these interventions. Two of these studies reported on comparison of three interventions in Australian students [ 97 , 98 ]. The media-literacy program ‘ Media Smart’ was compared to ‘ Life Smart’ and ‘ HELPP’ , all delivered with the same frequency and duration of lessons (all programs described further in the section below) [ 97 ]. Both Media Smart and HELPP had a focus on reducing ED symptoms, while Life Smart had broader ED and obesity risk factor targets. Of the three interventions, Media Smart was the only program where both ED and obesity risk factors were reduced among participants [ 97 ]. Further analysis of study outcomes found that, among participants with higher shape/weight concern at baseline, participation in Life Smart and HELPP increased eating concern and led to higher rates of meal skipping compared to controls [ 98 ].

An online prevention program delivered at two high schools in the US— ‘Staying Fit’ —offered two separate pathways for universal and indicated delivery based on students’ Body Mass Index (BMI) and appeared to be the only school-based program aimed at reducing unhealthy behaviours associated with BED [ 99 ]. Staying Fit demonstrates the feasibility of delivering a prevention program with two streams based on assessed risk [ 99 ].

Media literacy-based prevention

Six articles identified by the RR investigated the effectiveness of media-literacy interventions, with a large proportion of these relating to the ‘Media Smart’ program delivered to adolescents and young adults in Australia and New Zealand [ 100 ]. Similar to CD interventions, media-literacy interventions target thin idealisation but adopt a divergent approach, focusing on critical analysis of media content to educate and empower individuals to identify, analyse, and challenge unhealthy and stereotypical messages portrayed in the media [ 101 ]. A systematic review found media literacy to be the most effective universal prevention approach, showing significant modest effects on risk factors, and demonstrated positive effects for both males and females, resulting in a reduction of weight/shape concern and media internalisation compared to controls at up to 30-month FU [ 34 , 45 ].

‘ Media Smart’ , was evaluated with the aim of reducing risk among Australian school children and was found to produce favourable results including reduction in shape/weight concern and a significant reduction in weight-related peer teasing, a known risk factor in the development of EDs [ 102 , 103 ]. An online adaptation, ‘Media Smart-Targeted’ , when delivered to young adult women with elevated baseline ED risk or already reporting disordered eating behaviours (i.e., a more indicated prevention approach), reduced ED development by 66% within 12 months of intervention compared to controls [ 100 ]. A larger RCT comparing ‘ Media Smart-Targeted’ to ‘Student Bodies’ (an online prevention program targeting young adult women seeking to improve their body image) found ‘ Media Smart-Targeted’ to be significantly more effective at reducing ED symptomatology than the comparison intervention [ 104 ]. Further, participation in the ‘ Media Smart-Targeted’ program was found to reduce depression at up to 12-month FU [ 105 ].

Programs have also demonstrated effectiveness for younger cohorts. A universal prevention program using a media literacy approach delivered to school children (i.e., ages 12–15 years) in Spain found the intervention resulted in significant improvements to beauty ideal internalisation, disordered eating attitudes and weight-related teasing [ 106 ] and self-esteem [ 107 ] compared with controls over a 12- and 13-month FU period, respectively. Further assessment of participants at 30-month post intervention found that children in the media literacy programme had greater body satisfaction than those in the control group [ 108 , 109 ]. In a study comparing prevention programs using a media literacy approach (two prevention programmes with and without nutritional education), resulted in reductions in perceived pressure to be thin and improvements in nutritional knowledge, which were consistent across both intervention conditions; however, larger reductions were observed among girls at higher ED risk [ 110 ]. More pronounced improvements were also observed among participants with greater engagement in interactive activities involved in the prevention program [ 111 ]. A pilot study examining a social media literacy intervention among adolescent females found that those receiving the intervention showed improvements in body image (body esteem-weight), disordered eating (dietary restraint) and media literacy (realism scepticism) compared to the control group [ 112 ].

Assessment of the impact of the gender mix of groups on the effectiveness of media-literacy programs indicated that girls who participated in the mixed-gender version of the intervention derived more significant benefit than the girls-only group on almost all measures of media literacy and body image used by the study, potentially due to the positive interactions between genders from typically higher levels of confidence and self-esteem displayed by males [ 113 ]. Further research is required to confirm this finding and to identify further aspects of media literacy-based programs for universal prevention optimisation, although extant research in this area shows promise.

Mindfulness-based prevention programs

Mindfulness is the practice of focusing one's attention in a non-judgmental way on the present moment, while acknowledging and accepting one's thoughts, feelings, and bodily sensations [ 114 ]. Examples of mindfulness training include breathing exercises, meditation, progressive relaxation, autogenic training, hypnosis, imagery, and tai chi [ 115 ]. Three studies examining the effectiveness of mindfulness-based prevention compared with other established approaches were identified by the RR. Mixed results were reported by these studies on the benefits of mindfulness to reduce ED and other mental health symptomatology.

A systematic review and meta-analysis of mindfulness-based prevention programmes offers a critique on CD interventions commenting that, while they have demonstrated efficacy among females in late adolescence and early adulthood, there is less evidence of their effectiveness in other demographic groups [ 115 ]. Mindfulness interventions were effective in reducing body image concern and negative affect (emotional distress or negative emotions) and increasing body appreciation in female participants compared to waitlist or assessment only control groups. Additionally, compared to CD preventions, there is evidence for greater effectiveness of mindfulness prevention in increasing self-esteem and reducing negative affect among participants. Findings from this review suggest integration of mindfulness techniques with CD could increase effectiveness of prevention efforts [ 115 ], especially for higher risk groups like young women.

Several mindfulness-based prevention programs have been trialled in Australia. Two studies compared mindfulness to CD prevention, one in young adult females and one in female high-school students [ 116 , 117 ] with conflicting results. In the study involving high-school girls (i.e., ages 14–18), significant reductions in ED symptomatology and risk factors were observed across both intervention types compared with control groups [ 116 ]. However, in the pilot study involving young adult females (ages 17–31), the mindfulness intervention was significantly superior at reducing ED symptomatology and associated psychological impairment post-intervention compared to the CD intervention where no significant differences in outcomes were noted between the intervention and control groups [ 117 ]. In contrast, a mindfulness-based prevention program delivered in an Australian high school found no benefits for participants receiving the intervention compared with controls [ 118 ]. Additionally, some individuals who received the intervention reported higher anxiety than those who did not, possibly due to increased awareness of emotional states associated with undertaking mindfulness activities [ 118 ].

There is limited evaluation of mindfulness-prevention programs within other settings. In the only study investigating an intervention delivered to women in the workplace, it was found that a 10-week group prevention program based on mindfulness and intuitive eating was able to significantly reduce body dissatisfaction in the intervention group compared with a waitlist control [ 119 ]. Although incorporation of yoga and wellness in ED prevention and treatment is being increasingly explored, in a study of a yoga-based wellness and ED prevention program, no significant differences in ED symptomatology were found between the intervention and control groups. However, significant reductions were observed in risk factors including drive for thinness and body dissatisfaction among the intervention group [ 120 ]. Similarly, an earlier study of this yoga-based prevention program delivered to a group of ethnically diverse girls found no differences in response to the program based on ethnicity or other socio-demographic factors [ 121 ]. Overall, evidence for the effectiveness of mindfulness-based prevention programs, even as an adjunct to other interventions, is limited.

Other prevention programs

Prevention programs with novel approaches or conducted in populations not typically targeted by ED programs, or in settings not previously discussed, are summarised below. These studies investigated the effectiveness of programs delivered outside of a school setting; and interventions delivered to younger children and physical education teachers, providing evidence for the potential application of a wide range of approaches to target known ED risk factors. Three studies were categorised to this diverse subgroup within the rapid review.

To test the potential efficacy of a selective prevention program delivered outside of a classroom to both primary- and high-school-aged girls (between ages 10 and 16 years) in Australia, a 10-week intervention, ‘ Girls on the Go!’, aimed at improving body image was delivered at a local community centre in Melbourne [ 122 ]. Participation in the program resulted in significant improvements to self-esteem, indicating the program could be feasibly and effectively delivered outside of a school environment [ 122 ].

One of the few programs for early primary school children is the ‘ ABC4YC ’ program. In Australia, it was developed in response to a lack of access to universal prevention programs for primary school aged children (i.e., ages 5–8 years) and was found to significantly improve self-esteem in participants. Program content included education on body diversity, non-appearance related qualities, and non-appearance related functions of the body [ 123 ].

Increased risk for ED and excessive exercise has also been observed among physical education teachers in Australia [ 124 ]. Delivery of an intervention which combined evidence-based approaches, media-literacy, and CD among this cohort was able to demonstrate the greatest effectiveness at reducing ED symptoms and risk factors [ 124 ]. Selective intervention programs have also been shown effective with professional ballet dancers (15 + years later) who reported fewer bulimia-related thoughts and behaviours during and following the intervention [ 125 ].

Diabetes is considered a risk factor for the development of ED in adolescents. To address this risk, a pilot program was developed in Australia with the objective of preventing ED onset among girls with type 1 diabetes [ 126 ]. The brief interactive intervention which comprised characteristics of previously successful ED risk factor reduction programmes targeting perfectionism, media literacy, and self-esteem in young adolescents, was found to increase self-esteem and self-efficacy related to diabetes management among participants, demonstrating potential benefit as a program for wider delivery to adolescents with diabetes [ 126 ].

Mode of delivery

Assessment of evidence from online prevention programs indicated that, while they were generally less effective than face-to-face interventions, they provided an essential service as part of a stepped care model for ED [ 127 ]. On the other hand, evidence from a meta-analysis of 20 studies found that internet-based prevention programs were effective at reducing ED symptoms and risk factors with small to moderate effect, however, as the evidence base was so small, no firm conclusions can be drawn from such treatment studies [ 128 , 129 ]. There was more evidence to support internet-based prevention than intervention, particularly for the ‘Student Bodies’ program, which produced a small reduction in ED psychopathology and levels of weight concern and drive for thinness [ 128 , 129 , 130 ].

A further internet-based, cognitive behavioural, indicated prevention program was identified for individuals with AN [ 131 ]. This intervention included elements of motivational interviewing and content on psychoeducation, media literacy, coping with negative emotions, healthy eating, and exercise with a specific focus on restrictive eating. This intervention was a pilot study with a small sample size and no control group and showed a reduction in dietary restraint and increased BMI in participants, although increased drive for thinness occurred during this weight increase. Further research is required to confirm findings for this intervention [ 131 ].

• Early intervention

Evidence from three reviews identified by the RR suggest that early intervention initiatives provided within the first three years of onset of ED symptomatology may reduce delays in help-seeking by: (1) targeting parents and helping them recognise early signs of ED during peak time of onset in adolescence [ 132 ]; (2) increasing motivation for change among patients with ED [ 133 ]; and (3) addressing stigma and shame associated with ED pathology [ 134 ].

Evidence from a systematic review and meta-analysis indicated that some approaches to stigma reduction in ED may be more effective than others, with education about the biological underpinnings of EDs having a small to moderate impact on attitudinal stigma toward EDs [ 135 ]. However, the majority of the studies reviewed were conducted in student populations and thus may not be generalisable or produce sustained attitudinal and behavioural change in wider community populations [ 135 ]. This review highlights the need for more research to identify more effective approaches to reduce stigma in ED.

Early recognition and treatment

An assessment of 140 AN patients found that the mean duration of untreated illness in this group was 25 months with a range of 0 months to 16.2 years, with individuals with early onset (under 14 years old) experiencing the longest mean duration [ 20 ]. As most participants in the study had been diagnosed and referred to specialist treatment by their general practitioner (GP) or paediatrician, this study highlights the importance of educating clinicians on EDs and including parents and teachers in prevention and early intervention initiatives. Encouragement of help-seeking behaviour is particularly important considering the study also found that individuals with earlier onset AN are more likely to be responsive to external motivators [ 20 ].

A public health intervention ‘Psychnet’ delivered in Germany with the objective of facilitating early recognition and treatment in individuals with AN consisted of several different components delivered over a year. These included a public health literacy campaign; an internet-based treatment guide for individuals with ED, their families, and healthcare professionals; a CD prevention program delivered in schools to adolescents; establishment of multidisciplinary networks of practitioners meeting quarterly to discuss the intervention and present ED cases; and implementation of a specialist AN outpatient service [ 129 ]. This intervention was unable to demonstrate any reductions in duration of untreated illness among individuals with AN in the sample population or reductions in the time between disorder onset and first contact with services [ 136 ]. However, given the small sample of participants involved in the ‘post-intervention’ group ( n  = 18), findings are difficult to interpret and should be considered in the context of the broader body of literature.

For instance, results from a pilot study of a novel transdiagnostic First Episode and Rapid Early Intervention (FREED) service for EDs, delivered to young adults with an ED duration of ≤ 3 years, had far more promising results in increasing engagement with services [ 130 ]. This intervention took a holistic, person-centred approach to provide evidence-based psychotherapy tailored to the individual. Participants in the intervention group had a mean wait time of 42 days between referral and initial assessment compared to 62 days in the control group [ 137 ]. Psychological interventions provided to participants with an emerging ED produced significant reductions in ED symptomatology and increases in BMI for individuals with AN, while their carers demonstrated improved general psychopathology, expressed emotion, and less accommodation of ED symptoms [ 137 ].

Single-session interventions (SSIs) have been examined as an alternative to costly, time-consuming multi-session treatment protocols. A 2017 meta-analysis reported on 50 RCTs involving over 10,000 youths, finding that SSIs can be effective at reducing psychiatric dysfunction, particularly anxiety, however overall effects were smaller than those observed for multisession treatment protocols [ 138 ]. In response to long waiting list times at specialist ED clinics in Western Australia, a single-session psychoeducation intervention was delivered to patients referred to a major ED clinic who were placed on a waitlist for services; this was incorporated into their assessment appointment [ 139 ]. Delivery of this single session intervention was found to achieve a reduction in objective binge eating episodes, self-induced vomiting, and overeating in participants, and resulted in a decrease in waitlist time and dropout rates [ 139 ].

Disordered eating interventions

Two studies were identified investigating use of an Interpersonal Psychotherapy (IPT) to reduce loss of control overeating (LOC-eating) as a risk factor for BED in children. In both the pilot [ 140 ] and a parallel-group RCT [ 141 ], researchers sought to prevent the development of BED in participants who displayed LOC-eating using two interventions: a family-based interpersonal therapy (FB-IPT) and a health education intervention. In the pilot, reductions in likelihood of LOC-eating, depression, and anxiety were shown in the group of children receiving IPT versus the health education intervention [ 140 ], and a reduction in number of objective binge-eating episodes was also observed in the IPT intervention group [ 134 ]. Measurement of the reduction in BMI of study participants found that both IPT and health education were effective with no difference between groups [ 141 ].

In older age groups, studies suggest that body dissatisfaction and disordered eating continue to persist in midlife as body dissatisfaction is closely associated with perceptions of aging and the accompanying changes in appearance [ 142 ]. An early intervention program targeting women in mid-life (i.e., ages 30–60 years) found a significant reduction in body image concern and disordered eating among participants in the intervention group compared to the controls. This was the only early intervention identified by the RR targeting older adults and findings from this study indicate that further research in this population is warranted [ 142 ].

In the only study identified by the RR relating to interventions targeted towards culturally and linguistically diverse (CALD) groups, Mazzeo et al. [ 143 ] assessed the efficacy of a Dialectical-Based Therapy (DBT) against a weight management program for adolescent girls engaging in binge and LOC eating. Significant improvements were observed in both groups in terms of ED symptoms including weight/shape concern and dietary constraint, as well as negative affect [ 143 ]. There is a significant paucity of research of prevention and early intervention in CALD and other diverse groups.

Online interventions

A considerable number of early intervention studies identified by the RR were delivered online. Although some of the internet-based early intervention programs discussed were unable to show significant benefit, combined screening and early intervention programs such as ‘ Healthy Body Program’ and ‘ ProYouth’ , present a valuable opportunity for early intervention in large proportions of the population who may not wish to engage in face-to-face services [ 144 ]. Low engagement with face-to-face treatment is a common challenge encountered within specialist ED services. ‘MotivATE’ a web-based intervention designed to increase treatment adherence was delivered at an ED service in the UK, to participants prior to their first appointment. Although uptake of the pre-assessment MotivATE program was low, individuals who registered for and completed the intervention were almost ten times more likely to attend their assessment appointment than those who did not register [ 145 ]. It was suggested that low overall uptake may have been a consequence of researchers choosing not to actively recruit for the intervention or simply being attributed to general low motivation among individuals with EDs to change, but preliminary findings are promising.

Evidence from other online interventions aiming to reduce ED symptoms and increase motivation to change among participants through online engagement reported more promising results. An early study comparing online and face-to-face CBT delivered to Australian women with body concerns and disordered eating, ‘ Set Your Body Free’ , found significant improvements in both groups in body dissatisfaction compared with the delayed treatment control. Post-treatment improvements were greater in the face-to-face than online intervention, however, no significant differences between groups in symptom improvement were evident at six-month FU [ 146 ], so long-term benefits are still unclear.

A multi-session online program, ‘ESS-KIMO’ , with therapist feedback for females with symptoms of AN or BN, aimed to help these participants recognise the negative impact of their ED symptoms and increase motivation to change. Following the intervention, women receiving the intervention had lower measured dietary restraint and increased self-esteem and were also more likely to perceive their behaviours as a problem compared with participants in the control group [ 147 , 148 ]. Like most studies, longer term FU to evaluate ongoing outcomes were not conducted.

In a trial in the Netherlands designed to support individuals in the community with bulimic symptoms (without any formal BN diagnosis), online CBT with therapist support was compared with CBT-based bibliotherapy without therapist support, and a waitlist control condition [ 149 ]. A significant reduction in binge/purge frequency as well as ED symptomatology was observed in the online CBT group compared with both bibliotherapy and waitlist control groups. While superiority of the online CBT intervention was reported, lack of therapist support provided to the bibliotherapy comparator suggests this may be the critical point of difference in efficacy between the two interventions rather than the medium through which the intervention was delivered [ 149 ].

‘Parents Act Now’ , a multi-national internet-based early intervention, was conducted across two sites in the US and Germany [ 150 ]. The intervention was aimed at parents of female adolescents screened as ‘at-risk’ for AN. The intervention was FBT-based and resulted in favourable outcomes for completers with 35% achieving a reduction in AN risk [ 150 ]. However, some parents who were interested in accessing FBT were unable to in their local area, indicating a need for early intervention programs to consider linkages with health system services rather than acting as standalone programs. ‘ E@T’, another internet based FBT intervention, delivered to girls at risk of AN, resulted in significantly increased weight within the intervention group compared to waitlist controls. However, no significant differences were observed relating to other ED risk factors or symptoms measured including excessive exercise, subjective binge eating, or fasting [ 151 ]. In many instances, early prevention programs may suit a suite of interventions to provide options for individual cases but may have limited effect if presented in isolation.

A meta-analysis of data was conducted on eight RCTs delivering the ‘StudentBodies’ internet-based indicated prevention program designed for women displaying ‘subclinical’ ED symptoms [ 152 ]. The analysis found the StudentBodies program to significantly reduce negative body image and drive for thinness compared with controls at FU (10 weeks to 12 months) with moderate effect sizes [ 152 ]. Long-term FU of students participating in ‘ StudentBodies’ at three years post intervention found that 11.2% had developed full or subthreshold BN or BED [ 153 ]. Further research assessing the effectiveness of the moderated discussion group feature of the ‘ StudentBodies’ intervention found significantly less weight concern among the group who participated in the guided discussion than those who did not [ 154 ]. An expanded form of the ‘ StudentBodies’ intervention, ‘IaM’ for ‘high-risk’ women with comorbid depression, was unable to produce a protective effect over the control group for ED despite significantly reducing weight/shape concern among participants [ 104 ]. Assessment of the relationship between weight/shape concern and depression in participants over 24 months found the symptoms to be reciprocal with weight/shape concern predicting onset of depression and anxiety, which then increased weight/shape concern [ 155 ].

Publicly-targeted interventions

Research has shown that providing information on mental health first aid may increase the confidence of members of the public to assist individuals who are developing a mental illness or experiencing a mental health crisis [ 7 ]. Researchers have developed ED specific first-aid guidelines in consultation with clinicians, consumers, and carers [ 156 ]. Piloting of a program delivering this ED-specific mental health first aid training to participants resulted in significant increases in problem recognition and knowledge maintained at six-month FU [ 157 ]. Approximately 27% of participants also reported providing first-aid to a person with a suspected ED during this FU period, with seven of these individuals progressing to seeking professional help [ 157 ]. Additional research reported 85% of participants who underwent ED-specific first-aid training were able to assist others in the three-month FU period [ 151 ]. Participants also showed increased knowledge regarding BN and BED, including symptom recognition [ 158 , 159 ]. Importantly, 91.9% of participants responded that they were more likely to approach someone exhibiting ED behaviours because of attending the three-hour workshop [ 158 ]. This work suggests a single session of ED-first-aid training could increase help-seeking among individuals with a suspected ED as a result of the increased capacity of their friends and family members to approach them about their eating behaviours, an important early intervention strategy [ 157 , 158 ].

Early intervention programmes are often under-evaluated in other ethnic and minority groups, across various age ranges and males, which are important sociodemographic factors that can affect the probability of seeking treatment [ 159 , 160 ]. Similarly, risk factors, such as eating and feeding difficulties in childhood, should also be considered as they can predict ED symptomatology in adolescence and early adulthood [ 161 ] and may require more targeted intervention. Another study also found that those adolescents who did not recognise having disordered eating were less likely to seek mental health treatment [ 162 ], which highlights the importance of focusing on health promotion for better outcomes.

This rapid review aimed to provide a broad synthesis of the literature relating to prevention and early intervention initiatives for EDs. There is considerable evidence relating to prevention programs for EDs, particularly around cognitive dissonance-based strategies, universal multi-risk factor prevention programs (such as school-based prevention programs), media-literacy based prevention, mindfulness-based prevention programs and other novel prevention programs conducted in uncommon settings and/or targeting populations not typically targeted by ED programs. The RR also identified several early intervention programs with a considerable number of interventions delivered online, primarily targeting AN and BN. Evidence from these studies suggest that early intervention efforts, particularly when delivered within the first three years of ED onset, may increase motivation and help-seeking behaviour among individuals, reducing DUED.

In the last two decades, eating disorder prevention interventions have advanced considerably, with successful programs, such as cognitive dissonance, cognitive-behavioural therapy and media literacy, demonstrating significant beneficial impacts on ED risk factors and symptom reduction [ 16 , 34 ]. Most prevention and early intervention programs identified in this RR focused on reducing one or more ED risk factors, such as thin-ideal internalisation, body dissatisfaction, negative affect, dietary restraint, shape/weight concerns and preventing future ED onset. However, it is important to note that many of the studies captured by the review report on the reduction of risk or putative vulnerabilities to ED, and due to the short duration of most studies (ranging from 3 months to 3 years), there is insufficient evidence to demonstrate whether preventing and reducing ED risk factors and symptoms does indeed have an impact on future ED onset.

Several promising universal, selective, and indicative prevention approaches were identified in this review. Notably, there is strong evidence for the effectiveness of cognitive dissonance prevention approaches targeting thin-ideal internalisation and body image concern, which are considered potential predictors for AN, BN, and BED onset [ 10 , 34 , 60 ]. CD programs, designed to reduce subscription to the thin-ideal, were considered to be most effective as universal, selective, and indicated preventions, resulting in significant reduction in ED risk factors, symptoms, and future ED onset [ 10 , 45 ]. CD programs were found to be highly efficacious among university aged couples, adolescents, and young adult females [ 38 , 48 , 163 ]. Additionally, there is a need to explore the effectiveness of these interventions in broader populations, age groups, and cultural settings. It would be advantageous to study FU periods longer than 3 years (the longest FU identified by the review), to understand the long-term effectiveness of these programs [ 10 ].

The target population for most prevention studies was female high school and university-aged students. Younger females and males were rarely targeted, and there is some evidence that programs we do have may not be as effective in these age groups, begging the question as to whether we are developing and testing prevention programs early enough to really prevent the onset of eating disorders which peak in early and later adolescence. Older female adults were also rarely targeted, with only one study exploring the association between aging and increased body image concern and disordered eating in females in midlife [ 142 ]. The point prevalence of ED in women in midlife has been estimated at around 4% [ 164 , 165 ]. Interventions targeting middle-aged females have been shown to be efficacious, leading to clinically significant differences in body image concerns and disordered eating, and emphasising the need for further research in this cohort [ 142 ]. Further, EDs in men have become increasingly prevalent in recent decades, with males now representing around 33% of all ED cases [ 72 , 91 ]. Research suggests that males with ED experience similar levels of detrimental impact on quality of life (QoL) as females with ED, and may yield greater benefits (including symptom reduction) from effective prevention initiatives [ 64 , 71 ], but may require programs specifically designed for them. Gay men are at particular risk of ED, with demonstrated higher levels of risk compared to heterosexual males [ 72 ]. Thus, ED prevention efforts should aim to be inclusive and take a gender and sexuality-sensitive approach. Research is needed to examine the feasibility, acceptability, and efficacy of dissonance-based interventions in such populations.

Evidence has shown the benefits of implementing effective prevention programs that jointly target major public health concerns with shared risk factors, such as obesity, diabetes, and EDs. Individuals with obesity and type 1 diabetes mellitus (T1DM) are at a higher risk of developing EDs, with an increased risk of morbidity and mortality. It is therefore crucial to focus on prevention, early detection, and intervention for this population for lasting health and recovery. Combining ED and obesity prevention programs could be efficacious in reducing ED risk factors, symptoms, and disordered weight control behaviours in people of higher weight [ 40 , 59 , 81 , 82 , 97 , 166 ]. Similarly, for adolescents with T1DM, effective prevention programs can make positive impacts on their self-esteem and self-efficacy related to diabetes management and protective factors for disordered eating [ 126 ].

A significant proportion of reviewed interventions took place in schools, universities, within the community, or in outpatient treatment settings. Multi-risk factor universal prevention programs such as school-based interventions were highlighted in this rapid review due to their high acceptability and benefits for both children and adolescents. Although universal prevention interventions are, by design, unable to produce large effect sizes, they can provide long-term benefits when delivered in an interactive, multi-session format by a professional [ 13 , 34 ]. School-based prevention programs provide an opportunity for wider reach and have been found to significantly increase self-esteem, reduce ED risk factors and symptomatology [ 90 , 93 , 94 , 95 , 96 , 123 ]. However, scalability of such programmes is limited, and acceptability, feasibility, and efficacy are varied [ 93 ]. Among the interventions, media literacy, when universally delivered, has been found to be an effective intervention for improving ED symptoms, encouraging behaviour change, and reducing risk factors in the long-term leading to sustainable changes in adolescent health [ 97 , 98 , 99 , 100 ]. While media literacy prevention interventions have been proven effective in improving ED symptoms, further exploration is needed in the context of the new media environment to re-evaluate and refine these interventions to maximise their effects [ 167 ].

Several other school-based programs have been evaluated with children and adolescents, which were outside the scope of this review due to eligibility criteria (i.e., from 2009), but are noteworthy of mention. The ‘New Moves’ obesity prevention program was evaluated in a RCT with adolescent females, where active arm participants experienced positive changes in their physical activity, eating patterns and self-image, and their behaviour towards physical activity changed during the intervention, compared to the control arm [ 168 ], indicating high feasibility and acceptability among adolescents. Another quasi-experimental multi-component program among elementary school students, ‘Very Important Kids’, demonstrated that students receiving the intervention were less likely to be teased about appearance and weight, compared to the control group, highlighting the importance of implementing prevention programs at a young age [ 169 ]. In a student-led health promotion program called ‘Healthy Buddies’, older students (4–7th grades) taught younger students (Kindergarten-3rd grade) about nutrition, physical activity, and healthy body image [ 170 ]. Following the program, all students receiving the intervention showed a higher knowledge of healthy lifestyle, older students’ BMI and weight increased less, and younger students’ height increased more in the active arm, compared with control students [ 170 ]. These programs showcase the feasibility and efficacy of implementing school-based programs to elementary and middle school students and involving students in peer-taught buddy programs to promote healthy living across a range of school-aged individuals. A significant number of prevention and early intervention studies included in this RR were delivered online. While face-to-face interactions are typically more effective, online programs can provide an accessible, cost-effective service as part of a stepped care model for ED, and may increase treatment engagement among individuals with low motivation to seek help [ 13 , 127 , 171 ]. They may also have a wider reach/increase dissemination, even if less effective than face-to-face delivery.

Limited evidence exists exploring prevention and early intervention programs in other underrepresented populations including CALD populations. This is significant given prevalence rates of EDs vary by ethnicity and race [ 172 ]. Further, while most prevention programs target risk factors common to most EDs, there tends to be greater focus on AN and BN, and to a lesser degree BED. Thus, findings may not be applicable across a broader spectrum of ED diagnoses such as ARFID, Purging Disorder (PD), UFED, and OSFED.

While this RR identified several early intervention programs for ED, there is still a paucity of research, with many studies classifying early intervention as within the first three years of full syndrome illness. To develop successful early intervention strategies, further exploration is necessary to better understand the DUED, pathways to care and to identify the perceived barriers to seeking and engaging in evidence-based treatment during the early stages of an ED, including patient-related factors such as lack of recognition of illness severity, low self-awareness, or motivation to seek help and service-level delays while waiting for treatment.

While the effectiveness of delivering interventions designed to encourage early symptom recognition and engagement within at-risk populations has been explored, further research in this area is warranted. Prioritising research into early identification and early intervention may prevent downstream impacts of EDs in this population including decreased motivation for change as the illness progresses. Combining screening and early intervention programs presents a valuable opportunity for early intervention in large proportions of the population who may not wish to engage in face-to-face services [ 144 , 173 ].

Researchers have indicated a need to replicate and scale-up successful prevention programs as well as identify any potential barriers to wider dissemination to increase their reach [ 174 ]. Strategies to increase mental health literacy such as ED-specific mental health training could aid early intervention efforts and encourage help-seeking behaviours and increase engagement with services [ 11 , 175 ]. First-aid training has been found to increase the knowledge and confidence of individuals in problem recognition and the ability to approach individuals exhibiting ED symptoms and behaviours, encouraging them to seek help [ 156 , 157 ]. While early intervention can improve prognosis in EDs, long waiting periods for eating disorder services are common and can lead to detrimental impacts on the patient’s health. Evidence suggests that providing early access to intermediary supports or psychoeducation could potentially reduce waitlist time and treatment dropouts.

Capacity to increase the reach of ED prevention programs and enhance treatment uptake are critical for making a significant public health impact and for reducing the burden caused by EDs [ 176 ]. While there is a significant knowledge base for effective ED prevention and experience in delivering trials, there remains a lack of translation to clinical and practical settings, highlighting issues around significant time investment required to initiate, and lack of prioritisation in government funding [ 177 ]. The need for greater allocation of time and funds to support the implementation of such interventions is crucial to evaluate the long-term efficacy of these interventions.

This RR provides a comprehensive overview of the current landscape of prevention and early intervention initiatives developed and tested over the 13 reviewed years. However, due to the broader scope of the RR, which aimed to inform the national research and translation strategy, this review had several limitations. Broadly defined search terms were used to provide a high-level review of the literature, thus a thorough search using specific or detailed terms was beyond scope. Methodological constraints led to the exclusion of grey literature and unpublished or non-peer reviewed research. Similarly, the RR was limited to English language studies conducted in Western countries, or countries with healthcare systems translatable to an Australian context. This means certain cultural and systemic factors of prevention and early intervention in EDs may have been missed. Nevertheless, this RR has identified important gaps in prevention and early intervention research in EDs and highlighted areas which require further research and validation. Broadly, this review found that most prevention interventions were theory-driven, interactive, targeted one or more ED risk factors, and had broader dissemination potential with online models, and included a wide variation of content suggesting that a range of programs could have a positive impact on ED pathology across a variety of populations.

Prevention and early intervention programs have been shown to significantly reduce some risk factors, promote early symptom recognition, and encourage help-seeking behaviour for people with EDs, however, existing studies have mostly been conducted in cohorts past the age of peak onset and relatively short FU periods mean there is a lack of information on the long-term impacts of the interventions. Effective development and dissemination of successful prevention and intervention strategies necessitates further research, conducted in younger age groups, into early stages of illness, pathways of care and potential barriers to accessing evidence-based treatment and care, especially within identified high-risk groups.

Availability of data and materials

Not applicable—all citations provided.

Abbreviations

Anorexia nervosa

Avoidant/restrictive food intake disorder

Binge eating disorder

Body mass index

Bulimia nervosa

Culturally and linguistically diverse

Cognitive behavioural therapy

Cognitive dissonance

Disability-adjusted life year

Dialectical-based therapy

Diagnostic and statistical manual of mental disorders, 5th edition

Duration of untreated eating disorder

Eating disorder

Family based therapy

Family-based interpersonal therapy

General practitioner

Healthcare management advisors

InsideOut Institute for Eating Disorders

Loss of control

Other specified feeding or eating disorder

Purging disorder

Quality of life

Randomised controlled trial

Rapid review

Treatment as usual

Unspecified feeding or eating disorder

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Acknowledgements

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. 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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Eyza Koreshe, Jane Miskovic-Wheatley, Emma Bryant, Danielle Maloney, Stephen Touyz & Sarah Maguire

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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
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• , Danielle Maloney
• , Peta Marks
• , Sian McLean
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• , 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
• , 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

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DM, ST, and SM oversaw the Rapid Review process; AL carried out and wrote the initial review; EK and SP wrote the first manuscript; all authors edited and approved the final manuscript.

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Correspondence to Emma Bryant .

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ST receives royalties from Hogrefe and Huber, McGraw Hill and Taylor and Francis for published books/book chapters. He has received honoraria from the Takeda Group of Companies for consultative work, public speaking engagements and commissioned reports. He has chaired their Clinical Advisory Committee for Binge Eating Disorder. He is the Editor in Chief of the Journal of Eating Disorders. ST 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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Koreshe, E., Paxton, S., Miskovic-Wheatley, J. et al. Prevention and early intervention in eating disorders: findings from a rapid review. J Eat Disord 11 , 38 (2023). https://doi.org/10.1186/s40337-023-00758-3

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Eating disorders in adolescence: attachment issues from a developmental perspective

Manuela gander, kathrin sevecke, anna buchheim.

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Edited by: Gian M. Manzoni, eCampus University, Italy

Reviewed by: Julian B. Nesci, Austin Health, Australia; Alessandra Simonelli, University of Padova, Italy; Rossella Procaccia, eCampus University, Italy

*Correspondence: Manuela Gander, Institute of Psychology, University of Innsbruck, Innrain 52, Innsbruck, 6020, Austria, [email protected]

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Received 2015 Mar 25; Accepted 2015 Jul 21; Collection date 2015.

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In the present article we review findings from an emerging body of research on attachment issues in adolescents with eating disorders from a developmental perspective. Articles for inclusion in this review were identified from PsychINFO (1966–2013), Sciencedirect (1970–2013), Psychindex (1980–2013), and Pubmed (1980–2013). First, we will outline the crucial developmental changes in the attachment system and discuss how they might be related to the early onset of the disease. Then we will report on the major results from attachment studies using self-report and narrative instruments in that age group. Studies with a developmental approach on attachment will be analyzed in more detail. The high incidence of the unresolved attachment pattern in eating disorder samples is striking, especially for patients with anorexia nervosa. Interestingly, this predominance of the unresolved category was also found in their mothers. To date, these transgenerational aspects are still poorly understood and therefore represent an exciting research frontier. Future studies that include larger adolescent samples and provide a more detailed description including symptom severity and comorbidity would contribute to a better understanding of this complex and painful condition.

Keywords: attachment, eating disorders, adolescence, measurement of attachment, unresolved attachment

Attachment Patterns in Eating Disorders

While eating disorders (ED) can affect individuals from different age groups, the average age of onset takes place during adolescence. During the second half of the 20th century, the prevalence rates of ED have dramatically increased and have remained relatively stable over the last 20 years ( Voderholzer et al., 2012 ). Results from different studies looking at the prevalence of ED indicate that between 1 and 4% of adolescents meet the DSM-IV-TR criteria for anorexia nervosa (AN) or bulimia nervosa (BN) and at least 5% meet the criteria for eating disorders not otherwise specified (EDNOS; Hoek, 2006 ; Allen et al., 2013 ). Adolescents seem to be the most at-risk group to develop an eating disorder and this is due to a number of different environmental, social, psychological and biological factors. Attachment theory, originating from work Bowlby’s (1969) , offers a comprehensive framework for understanding the individual and family characteristics contributing to the development of ED in this age group. Furthermore, it provides an insight into a range of different psychological functions like emotion regulation and interpersonal functioning which are relevant for ED.

Attachment has an important influence on how young people can deal with the challenging transformations during adolescence ( Allen, 2008 ). Throughout the developmental history of an individual, secure attachment relationships provide emotional support, comfort and availability especially during stressful situations and moments of important change. When children grow older, they start to internalize daily interactions and experiences with their parents. In other words, they develop so called “internal working models of attachment” that derive from variations in how caregivers respond to their child’s attachment behavior ( Bowlby, 1969 ). In securely attached infants, attachment events have led them to anticipate their caregivers’ availability, understanding and responsiveness. Consequently, they will experience themselves as competent and valuable. In contrast, when caregivers show a rejecting or inconsistent response to the signals of their children, they tend to experience themselves as incompetent and unlovable ( George and West, 2012 ). According to attachment theory, a secure quality of attachment relationship is crucial in solving developmental tasks in adolescence like adjusting to physical changes, creating an own identity or defining goals for the future and thus represents an important buffer for psychological risks.

During adolescence the redefinition of the parent–child relationship in accordance with the developmental process of individuation represents one of the most challenging tasks ( Allen, 2008 ; Dubois-Comtois et al., 2013 ). Teenagers achieve independence from their primary attachment figures on different emotional and behavioral levels. For example, they start to create alternative methods to deal with stress which range from relying on peers to using internal cognitive strategies. Furthermore, they make decisions independently, take actions on their own and have their personal attitudes and beliefs regarding spirituality, politics and moral values ( Allen and Miga, 2010 ). This struggle for autonomy can be very distracting as it seems to be directly in competition with their attachment system. On the one hand they need to master new environments on their own and thus decrease their need for dependence on their parents. On the other hand they seek their parents’ comfort and solace especially under conditions of severe stress. This often paradoxical situation can lead to tremendous stress. A successful negotiation between these contradictory issues can only be achieved when both parents and their children can openly communicate their current emotional states and related thoughts ( Cassidy, 2001 ; Allen, 2008 ).

Another important attachment issue of adolescence is the capacity to re-evaluate the nature of the attachment relationship with parents. When young people start to become more autonomous, they develop accurate and thoughtful responses to attachment experiences. Even if this process might be uncomfortable for parents, it is fundamental to form secure relationships with others in the future and reconsider and alter the own states of mind regarding attachment ( Allen, 2008 ). Theorists propose that difficulties of adolescents and their parents in facilitating developmental strivings toward independence are a significant precursor for the development of an ED ( Bornstein and Greenberg, 1991 ; Rhodes and Kroger, 1992 ).

The aim of this article is to review studies looking at attachment issues and their relation to adolescent ED from a developmental perspective. Additionally we will outline clinical implications of attachment-related issues in this age group which affect practice areas like psychological assessment, case formulation, therapy compliance and specialized intervention plans. A growing number of papers on attachment and ED have been published in the last decade, including some reviews ( O’Shaughnessy and Dallos, 2009 ; Zachrisson and Skårderud, 2010 ; Tasca et al., 2011 ; Tasca and Balfour, 2014 ). However, research examining attachment issues in adolescents with ED have only recently begun. To date, there is no review analyzing results in adolescents with ED in particular. In the present article, we want to expand previously published reviews by reporting on findings in the field of adolescent ED with a special focus on research adopting a developmental approach. In the upcoming sections, we will offer a comprehensive overview on the latest findings from self-report and narrative-based research in adolescents with ED. For the first time, we analyze results from studies with a developmental approach on attachment in more detail. These findings will then be discussed in the context of different methods used by researchers before moving to the significance of the unresolved attachment pattern in ED. Based on these data, we identify some interesting avenues for future research and outline the clinical implications for the assessment and treatment of adolescents with ED.

The existing literature examining attachment in adolescents with ED is small but a search of current research databases ( PsychINFO , Sciencedirect , Psychindex , and Pubmed ) reveals that the number of papers looking at this age group specifically has increased in the last years. Articles for inclusion in this review were identified from PsychINFO (1966–2013), Sciencedirect (1970–2013), Psychindex (1980–2013) and Pubmed (1980–2013). The search terms “ adolescence ,” “ eating disorders ,” “ anorexia nervosa ,” and “ bulimia nervosa ” were used as major descriptors. We only included articles which (1) stated the use of the search terms in the title, key words or abstracts, (2) are published in the English or German language in a peer-reviewed journal or book chapter and either (3) used a clinical sample including adolescents (≤ 18 years) or young adults or (4) a non-clinical adolescent sample with significant eating problems that are defined as sub-clinical degrees of disturbed eating behaviors and attitudes as well as body and weight dissatisfaction. As we need to keep the scope of this review contained and manageable, we only included studies using self-report questionnaires of attachment style (e.g., The Attachment Style Questionnaire; Experiences in Close Relationships Questionnaire) and narrative attachment measurements (AAI, AAP). We excluded studies that (1) only use self-report questionnaires assessing parental styles (e.g., The Parental Bonding Instrument) as they measure a concept that is different from attachment styles and patterns (for a recently published review on parental bonding in patients with ED, see Tetley et al., 2014 ) (2) focus on the period of childhood and preadolescence (< 12 years) (3) only include adult or older patients (> 24 years). Furthermore, we focus on AN, BN and EDNOS as the primary conditions in adolescents and therefore, we excluded studies solely concentrating on obesity, binge eating disorder (BED) or feeding disorders in childhood. Using the search terms mentioned above we found 81 published studies and 5 reviews on ED and attachment. From these 81 studies, 12 studies employ narrative techniques and 69 use self-report questionnaires to measure attachment. Furthermore, we identified 21 studies including an adolescent sample that will be reviewed in more detail. First, we will present age-specific findings from self-report adolescent studies and incorporate these results into the large body of research in adults. Then we will focus on the developmental approach and report on the major results concerning the unresolved attachment representation. Finally, we will outline implications for therapeutic intervention in adolescents and describe some interesting avenues for future attachment research in that age group.

Adolescent Attachment and ED Using Self-report Questionnaires

In recent years, an increasing number of researchers examining attachment in adolescents with ED have come to rely on self-report questionnaires of attachment. Self-report questionnaires either assess categories of attachment style or they measure the degree to which dimensions of attachment styles are present ( Ravitz et al., 2010 ). The outcome of self-report items is a product of thoughts about attachment that have entered the consciousness of a person and therefore reflect how the individual wishes to represent him- or herself toward others. Several self-report measurements like for example the Adult Attachment Questionnaire and the Experiences in Close Relationships converge on two dimensions of insecurity. Attachment anxiety refers to individuals with a negative sense of the self. They tend to expect separation, abandonment or insufficient love and they are preoccupied with the availability and responsiveness of others. Furthermore, they tend to maximize negative experiences, they are hypervigilant to potential threat and they demonstrate a hyperactivation of attachment behavior. In contrast, attachment avoidance refers to individuals with a negative sense of others. They are characterized by self-reliance, an avoidance of intimate relationships and they devaluate the importance of close relationships. In addition, they minimize feelings of distress and deactivate attachment behavior. To date, attachment studies using self-report questionnaires in adolescents have addressed fundamental questions about possible links between attachment styles, ED subtypes, symptom severity and treatment outcome.

The overall patterns of results across different studies provide strong evidence that there is a relationship between attachment classifications and ED. Collectively, findings from studies using self-report attachment questionnaires assessing secure, avoidant, anxious and for some measures fearful attachment styles (i.e., high insecurity on both attachment avoidance and anxiety) suggest that adolescents and young adults with ED have an insecure attachment style ( Orzolek-Kronner, 2002 ; Steins et al., 2002 ; Bäck, 2011 ). Some authors found a higher prevalence of the avoidant attachment style ( Ramacciotti et al., 2001 ; Latzer et al., 2002 ) and others found more anxious attachment styles in adolescent patients with ED ( Salzman, 1996 ; Tereno et al., 2008 ). Some authors speculated that an anxious attachment style characterized by a tendency for affective dysregulation might be associated with binge eating and purging behavior whereas avoidant attachment style characterized by a tendency to down regulate emotions might be linked to dietary restriction. However, the study results are not consistent concerning these associations suggesting that the diagnostic subgroup is not necessarily related to attachment insecurity dimensions ( Troisi et al., 2005 ; Strauss et al., 2006 ; Tereno et al., 2008 ; Illing et al., 2010 ; Dakanalis et al., 2014 ).

Thus, recent work in this field started to rather investigate links between adolescent attachment styles and symptom severity. This approach holds a good deal of promise for advancing our understanding of the psychopathological profile of patients with ED. Studies in young adults with AN and BN have already demonstrated that higher attachment anxiety was significantly related to greater ED symptom severity and poorer treatment outcome in patients with AN and BN ( Cash and Annis, 2004 ; Illing et al., 2010 ). A recently published study by Keating et al. (2015) has expanded this research by examining the influence of pre-treatment attachment insecurity on post-treatment depressive symptoms in adolescent and adult patients with ED. In their study, patients with a pre-treatment anxious attachment style demonstrated less reduction in depression than those with an avoidant attachment style. These results indicate that the increased need for approval and the hyperactivation of emotions in anxiously attached patients may impair their ability to develop useful coping strategies leading to a comparison with unrealistic standards. This is consistent with results from a growing number of studies demonstrating that hyperactivating strategies are mediators for attachment anxiety and depressive symptomatology in adolescents and adults ( Tasca et al., 2009 ; Malik et al., 2014 ). Even though these findings suggest that attachment anxiety influences symptom severity, only very little is known about the role of an insecure attachment style on the ED symptom change during and after treatment. Thus an interesting avenue for future research is to examine attachment-related predictors for short- and long-term outcomes in adolescents with AN. Furthermore, the aforementioned studies assessed attachment style only at pre-treatment and as studies from adults demonstrate that attachment can change after treatment it would be interesting to measure it at post-treatment as well ( Buchheim et al., 2008 , 2012a ; Smith and George, 2012 ; George and Buchheim, 2014 ; Salcuni et al., 2014 ).

In addition to these possible links between attachment styles, symptom severity and treatment outcome, researchers have become increasingly interested in how far attachment style represents a potential risk factor for developing an ED in adolescence. According to attachment theory, attachment styles have lasting implications for social information processing, emotion regulation and self-evaluative processes making individuals vulnerable to ED. Milan and Acker (2014) found that attachment insecurity is related to increased responsivity to individual (e.g., weight gain) and interpersonal (e.g., maternal negative affect) ED risk factors during adolescence. However, only few studies to date have addressed specific underlying cognitive and emotional processes explaining why attachment insecurity places adolescents at a greater risk for developing an ED. Demidenko et al. (2010) found that insecure attachment in adolescents is related to a poorer self-concept and lower identity differentiation—two dimensions commonly known as risk factors for developing an ED. Mindfulness seems to be another mechanism underlying this relationship ( Pepping et al., 2015 ). That is, individuals with an insecure attachment style are less capable to be aware of and accept the present moment without judging it leading to an impaired recognition of hunger and satiety as well less acceptance of the body and the self. Additionally, maladaptive perfectionism and problematic affect regulation seem to mediate the relationship between attachment insecurity and ED in adults ( Tasca et al., 2009 ; Dakanalis et al., 2014 ). To draw further conclusions on causal relationships, future studies should examine these associations longitudinally and find out in how far findings vary according to the stage of recovery. As all of the previously mentioned studies only include female participants, it remains unknown whether the same patterns of results would be observed in males.

In the last decades, a growing body of researchers has examined the role of the family for adolescents with ED. Some studies investigated in how far the relationship between parents and their children are related to the development of an ED in adolescents ( Troisi et al., 2005 ; Bäck, 2011 ). In one of the first studies examining attachment phenomena in adolescents with ED, Kenny and Hart (1992) found that parental fostering of autonomy and affectively positive and emotionally supporting parental relationships lead to less weight preoccupation, feelings of ineffectiveness and bulimic behaviors in young people. These results are consistent with subsequent literature findings concerning characteristics of parental relationships in ED patients ( Latzer et al., 2002 ; Bäck, 2011 ). Concerning the issue of parental relationships, Orzolek-Kronner (2002) hypothesized that ED behaviors like starvation, binge eating and purging might lead to close physical encounters between mothers and their daughters and thus increase physical and psychological proximity. In her study, adolescents with ED reported more proximity seeking behaviors than the clinical and non-clinical control groups. One unexpected finding emerging from this study was that adolescents with ED viewed their mothers as greater facilitators of independence compared to the control groups. This finding seem to be contradictory to earlier results demonstrating that undermining an adolescent’s autonomy striving might lead to more body dissatisfaction and greater risk for the development of ED symptoms ( Kenny and Hart, 1992 ; Latzer et al., 2002 ). Furthermore, there seems to be evidence of maternal and paternal overprotection and a higher amount of fragile, dependent mothers who strive toward a symbiosis with their ED daughters ( Tereno et al., 2008 ; Amianto et al., 2013 ). Thus the description of their mothers as supporting their autonomy might reflect the adolescents’ attempts to preserve the idealization of their primary caregiver. The idealization of parents is considered as a common feature of an avoidant attachment style and might explain why some authors have found a higher prevalence of this style in adolescent patients with ED ( Latzer et al., 2002 ).

In sum, the results found in these studies highlight the importance of attachment-related aspects for the etiology, psychopathological profile, treatment outcome and parental relationships in adolescents with ED (for details on the sample and measurements see Table 1 ).

Studies using self-report questionnaires in a sampleincluding adolescents with ED .

ECR, experiences in close relationships questionnaire; BSQ, behavioral systems questionnaire; AN, anorexia nervosa; BN, bulimia nervosa; ASQ, attachment style questionnaire; EDNOS, eating disorders not otherwise specified; RQ, relationships questionnaire; BED, binge eating disorder; AAS-R, adult attachment scale- revised; AAS, adult attachment scale; IPPA, inventory of parent and peer attachment; PAQ, parental attachment questionnaire.

While these investigations look at thoughts about attachment that have entered the consciousness of a person and therefore reflect how adolescents perceive themselves in relationships, they are not concerned with unconscious defensive processes and strategies which are essential for the developmental approach ( Ravitz et al., 2010 ; George and West, 2012 ). Using narrative techniques to assess developmental attachment patterns allows us to look beyond conscious thoughts of relationships and evaluate mental representations of attachment by analyzing patterns of responses when people talk about attachment situations. Employing these techniques might provide a deeper understanding of unconscious aspects of attachment-related defenses and behaviors and allow assessing attachment disorganization and trauma ( George and West, 2012 ; George and Buchheim, 2014 ).

Adolescent Attachment and Eating Disorders Using Narrative Techniques

The majority of the studies on attachment in adolescents and young adults with ED are using self-report measures and only very few make use of narrative techniques. The adult attachment interview (AAI; George et al., 1996 ) and the adult attachment projective picture system (AAP; George and West, 2001 , 2012) are two narrative interviews, which emphasize mental representations. These techniques allow analyzing unconscious defensive processes—a dimension which is lost in self-report measures. In the AAI individuals are asked to describe childhood and current experiences with their caregivers and recall specific attachment-related events. Secure individuals (F) are able to reflect and integrate positive and negative experiences with their caregivers and their evaluation of attachment experiences is coherent. In contrast to them, insecure-dismissing individuals (Ds) tend to idealize or devaluate their attachment experiences by deactivation of attachment distress. The insecure-preoccupied (E) group is enmeshed with their caregivers and they show anger and low autonomy in their narrative evaluation. Finally, the unresolved category (U) refers to individuals who show a breakdown of defensive and coping strategies when talking about traumatic experiences like loss and abuse. Their evaluation is incoherent and often includes fearful affect ( Buchheim and George, 2011 , 2012 ). The AAP is a narrative-based attachment measure that provides attachment classification based on the analysis of “story” responses to a set of theoretically-derived attachment-related drawings of scenes depicting solitude, illness, separation, death, and potential maltreatment. The AAP narratives of secure individuals (F) demonstrate the ability and willingness to think about attachment distress. In their stories characters reach out to attachment figures for comfort, they show a lot of constructive actions and they often describe mutual enjoyment in their relationships to others. The insecure-dismissing (Ds) group is characterized by a predominance of deactivating defensive processes that emphasize distance in relationships. Their narratives often focus on achievement and exploration. Attachment relationships usually provide functional care or they are described as authoritarian. The AAP stories of insecure-preoccupied (E) individuals include a lot of material that confuses and obscure attachment relationships. They typically concentrate on emotions related to problems, their responses have several undecided themes or story endings and they often focus on the past rather than on the present. This confusion in the story line is also reflected in the blurring of the hypothetical story with personal experiences. The unresolved attachment (U) refers to a group of individuals who are not able to contain and reorganize stories including features that evidence danger, helplessness, failed protection or isolation. Unresolved individuals become momentarily flooded by their attachment fears that cannot be reorganized in the narratives ( George and West, 2012 ).

To our knowledge, there are only eight studies using the AAI or the AAP in a sample including adolescents and young adults with ED ( Cole-Detke and Kobak, 1996 ; Salzman, 1996 ; Ramacciotti et al., 2001 ; Ward et al., 2001 ; Dallos and Denford, 2008 ; Dias et al., 2011 ; Lis et al., 2011 ; Sevecke, 2013 ) and interestingly, there are only three studies looking explicitly at adolescents ( Dallos and Denford, 2008 ; Lis et al., 2011 ; Sevecke, 2013 ). In the following paragraphs we are going to outline the main results of these studies by focusing on attachment strategies and underlying neurophysiological correlates in adolescents with ED before moving to the significance of the unresolved attachment status for this age group (for details on the sample and measurements see Table 2 ). In the final part of this section we discuss implications of these findings for future research.

Studies using narrative techniques in a sampleincluding adolescents with ED .

AN, anorexia nervosa; AAP, adult attachment projective picture system; BN, bulimia nervosa; EDNOS, eating disorders not otherwise specified; AAI, adult attachment interview.

In narrative-based attachment research, a number of studies have addressed the issue of attachment patterns in adolescents with ED using the AAI. Salzman (1996) investigated links among attachment patterns, affective instability and ED in young college women. Her most striking observation was that the insecure-dismissing attachment group showed the highest prevalence of ED. The dismissing daughters described the nature of the attachment to their mothers as “hot and cold,” “addictive love,” and a “push and pull relationship.” During the AAI, they focused on their mothers’ emotional inconsistency and they held their mothers responsible for their own distress. Furthermore, they mentioned unpredictable and hurtful attacks of their mothers on their self-image and social acceptability. At the same time they talked about moments of true understanding, i.e., when mothers are caring and offering the promise of a special connection. This paradox of longing for their mother on the one hand, and rejecting her on the other hand might be the trap that leads to affective dysregulation and an eating disorder. The starving might serve as a kind of nurturance that they cannot get from their mothers. It must be noted that although these results are based on a very small sample ( n = 7), they are consistent with the Ward et al. (2001) and Ringer and Crittenden (2007) findings of a push- and pull strategy for both denying any need for help and also seeking care. This interesting association between attachment patterns in adolescents and ED led to further investigations on attachment strategies in ED patients that define how individuals process distress-related memories in the AAI.

For example, Cole-Detke and Kobak (1996) examined attachment strategies in a sample of 44 college freshmen with clinically significant ED symptoms.. While a secure strategy means that a person can adaptively tolerate distressing childhood memories, defensive strategies develop when attachment figures are unavailable, insensitive or unresponsive. Researchers distinguish two subtypes of defensive strategies. The deactivating strategy develops when an individual perceives an attachment figure as rejecting or ignoring and therefore has to divert attention away from attachment distress. The hyperactivating strategy develops when attachment figures are perceived as inconsistently responsive and therefore individuals excessively focus on attachment-related information during the AAI which then results in passive or angry preoccupation ( Dias et al., 2011 ). When depression was statistically controlled, the authors found that young women with deactivating strategies were prone in reporting elevated levels of ED symptoms. It is assumed that these women have to shift their attention away from attachment toward more attainable goals like one’s appearance in order to win the approval of their emotionally unavailable and highly critical fathers. There are a couple of noteworthy limitations to this study. First of all, the study included a subclinical sample which limits the generalizability of the results. Second, the predominance of deactivating strategies among women with ED is mostly explained by the poor relationships to fathers but not to the mothers. Third, we have to keep in mind that a significant amount of women with ED symptoms also met depressive criteria ( n = 19). As there is a high comorbidity rate of depression in patients with ED, which would be associated with hyperactivating strategies during the AAI, future studies should address if there are differences between ED with and without psychiatric comorbidity in adolescence ( Salbach-Andrae et al., 2008 ; Hughes et al., 2013 ).

Underlying autonomic parameters of these attachment strategies in adolescents were investigated by Dias et al. (2011) . In their study they examined the physiological response of 47 women including adolescents with ED during the AAI. Interestingly they found that hyperactivating strategies were rather associated with the purging/binge eating group (BN, AN-binge eating/purging, BED and EDNOS with “chaotic” eating behavior) than with the restrictive group (AN-restrictive, EDNOS with high control/restrictive features). Concerning attachment patterns, 70% of the participants were classified as insecurely attached with a higher proportion of preoccupied individuals. On a physiological level these individuals displayed a higher electrodermal reactivity and cardiac reactivity when compared to the securely attached group. These results go in line with a number of other studies investigating the neurophysiological correlates of attachment during the AAI ( Beijersbergen et al., 2008 ; Holland and Roisman, 2010 ; Gander and Buchheim, 2015 ). The underlying autonomic parameters might suggest that patients with ED and an insecure attachment pattern feel more challenged when talking about early experiences. Furthermore, their emotion regulation strategies might be less productive when confronted with their own attachment experiences with caregivers. Interestingly, the heart rate variability was significantly correlated with attachment insecurity when they were asked to name five adjectives about the relationship with their fathers. Although these results extend previous work on autonomic correlates of adult attachment by including a clinical sample of patients with ED, the results must be interpreted with caution. The authors did not control for psychiatric medication which potentially could influence the physiological parameters and they did not use a control group to compare the results. Furthermore, both of the above mentioned studies did not include the unresolved category into their research. When looking at disorganized infants in the Strange Situation, we observe that they suffer from tremendous stress as indicated by high cortisol levels, increased heart rate and skin conductance ( Bernard and Dozier, 2010 ). Therefore an interesting avenue for future psychobiological attachment research is to identify and connect the moment of breakdown in unresolved individuals with recordings of physiological reactivity.

Currently, there are only a handful of published studies including the unresolved attachment category in a clinical sample of ED. In the following paragraphs we are going to discuss the main results of these studies and present one of the only studies focusing explicitly on adolescents.

The Role of the Unresolved Attachment Status (U) for ED

Narrative-based attachment studies indicate a high prevalence rate of the unresolved attachment category and provide an interesting insight into the nature of these traumatizing events. Furthermore, first studies demonstrate how attachment issues can be integrated into a multimethod assessment and be used for interventions in ED. Before launching into characteristics of the unresolved attachment classifications and its implications for the treatment in adolescents with ED, it is necessary to explore the role of trauma for this ED in general. It is well known that sexual and physical traumatization represent non-specific risk factors for the later development of an ED ( Jaite et al., 2012 ; Lejonclou et al., 2014 ). Practitioners who treat patients with ED often encounter histories of various traumatic and abusive experiences. With regard to the whole spectrum of traumatic experiences, patients with ED frequently report interpersonal trauma and adverse childhood circumstances like emotional abuse, mental health problems in parents or parental divorce during their upbringing ( Lejonclou et al., 2014 ). The results of different studies suggest that sexual trauma is associated more often with BN, AN-binge-eating/purging type and BED than with AN-restrictive type ( Brewerton, 2007 ; Jaite et al., 2012 ). However, only very little is known about the relationship between early traumatizing events and ED.

When it comes to attachment research, there are only very few studies looking at unresolved attachment representation in ED. In summary, studies including the unresolved attachment status indicate a predominance of this category in ED ( Ward et al., 2001 ; Ringer and Crittenden, 2007 ; Sevecke, 2013 ; Delvecchio et al., 2014 ; Von Wietersheim et al., 2014 ). One of the first studies examining the prevalence of an unresolved attachment status (U) was done by Fonagy et al. (1996) . They investigated the relationship between attachment patterns and psychiatric patients and found a high prevalence of U with respect to loss and abuse in the ED group. Although the sample size ( n = 14) is very small, it is an interesting result that 13 of the patients were classified as U when using the four-way attachment distribution of the AAI. Additionally, they found a high idealization of parents and low reflective functioning (i.e., the capacity to understand and reflect on mental states of the self and others) in these patients. When talking about attachment experiences, they never reflected on mixed emotions, conflict or uncertainty about feelings of others. Furthermore, their responses appeared somewhat clichéd, banal or superficial. This high prevalence rate of the U category could also be found in other studies using the AAI ( Ward et al., 2001 ; Zachrisson and Kulbotten, 2006 ; Ringer and Crittenden, 2007 ; Barone and Guiducci, 2009 ) and the AAP in anorexic and bulimic adolescent and adult samples ( Delvecchio et al., 2014 ; Von Wietersheim et al., 2014 ). In the study of Delvecchio et al. (2014) half of the adult anorexic patients were classified as U and 37% were classified as Ds. Interestingly, Sevecke (2013) assessed attachment representations with the AAP in inpatient adolescent girls with AN ( n = 34) and found that even 65% had an unresolved attachment status. These findings might suggest that adolescents with ED have an even higher prevalence of the U than adults.

A growing body of research has made notable strides in understanding specific characteristics of the unresolved attachment status by analyzing the narratives of ED patients. Delvecchio et al. (2014) found that the majority of anorexic women with an insecure or unresolved attachment classification reported a lot of traumatic material including eerie, evil or surreal elements in their response to the AAP picture stimuli. Ringer and Crittenden (2007) analyzed the content of AAI narratives in a larger sample of women with ED ( n = 67) and found a lack of resolution of trauma and loss related to the mothers and also hidden family conflict between the parents. One third of the daughters with ED were classified as unresolved concerning the following aspects: (1) fighting between the parents, (2) vicarious experience of a parent’s trauma or (3) an imagined relation between an event and ED. This is consistent with the results of the Dallos and Denford (2008) study. When examining the main areas of unresolved and traumatic processes in four families with anorexic daughters, they observed that one of their female anorexic adolescents showed a terrible fear that her parents might do something awful to each other. Yet interestingly, also the mother of this girl reported unresolved traumatic memories of her own depressed mother and her angry, unpredictable and abandoning father. Similarly, most of these unresolved traumas in the Ringer and Crittenden (2007) study were not based on a direct threat to the woman herself. Unfortunately, the parents’ AAI were not available for this study. However, in the discussion the authors comment on interviews of parents outside this sample that they have read. Surprisingly, the parents appear responsible and really caring for their daughters. However, during the AAI their mothers reported losses and severe dangers in their past (e.g., war, repeated sexual abuse, loss of a parent). The most outstanding feature of their discourse was their strong desire that their daughters are not affected by this. In other words, they wanted to protect their daughters from these unspeakable threats and disappointments of their own lives.

Ward et al. (2001) examined the attachment representations in mothers and their daughters with ED. Although this study had a small sample size (daughters n = 20, mothers n = 10), the high rate of the U category (67% of the mothers and 50% of the daughters) with respect to loss, particularly among the mothers, is quite striking. Now the question is in how far this affects the mother’s behavior. It can be hypothesized that although they seek a special closeness to their daughters and protect them from their own traumatic histories, they retreat or become unavailable in crucial moments when their daughters need them the most. Hardly anything is known about the nature of these traumatizing experiences in mothers. One possible traumatizing event in mothers was found by Shoebridge and Gowers (2000) . They observed a high frequency of obstetric losses (e.g., multiple miscarriages, stillbirth, early neonatal death) prior to the birth of their daughters who later on developed AN. Furthermore, there are no published studies looking at attachment using the AAI in fathers of these daughters with ED. Therefore an interesting avenue for future research would be to investigate a larger number of mother-daughter pairs/father-daughter pairs looking for transgenerational similarities. In addition, Barone and Guiducci (2009) found the unresolved attachment status only in patients ( n = 30) with BN and BED but not in AN. However, this unequal distribution also requires a replication using a larger sample to draw further conclusions.

Another interesting aspect is the integration of an attachment tool in a multimethod assessment in patients suffering from an ED. Lis et al. (2011) discussed the clinical implications using an attachment tool for a better etiological understanding and treatment plan. They presented a single case study of a 17-year old anorexic girl, who was classified as unresolved on the AAP. The in-depth analysis of the AAP indicates that she could not integrate and reorganize the pain and isolation she felt in relation to her illness and also the inability of her parents to provide comfort. Based on this preliminary finding, it would be an interesting avenue to analyze disorganized specific characteristics for ED patients and see in how far they differentiate from other psychiatric disorders. First studies looking at these aspects were already done for other psychiatric disorders like borderline personality disorder (PD), anxiety disorder, depression, PTSD and schizophrenia ( Buchheim et al., 2008 ; Buchheim and George, 2011 ; Juen et al., 2013 ). Such investigations would make important contributions to our understanding the complex etiology of ED in adolescence.

The aim of this article was to review the literature which examines the associations between attachment patterns and ED with a focus on adolescence. This approach is still a relatively untapped area of research. Most of the studies focusing on adolescents are using self-report measures, which directly assess an individual’s conscious appraisals of feelings and behaviors in close relationships but they cannot evaluate defensive processes when participants talk about their attachment experiences. In contrast, studies employing the AAI are underrepresented in the literature and they often only include small sample sizes as the interview procedure and the coding of this narrative instrument are very time-consuming. Another issue concerning the AAI is that it is valid for assessing loss through death and physical abuse which are important aspects of the unresolved attachment status. However, according to the AAI instruction guidelines interviewers rightfully should not ask for traumatic material that interviewees do not want to talk about. That is, if an interviewee fails to discuss traumatic experiences these are edited out of the AAI transcript ( George and West, 2011 ). The AAP is another narrative instrument that circumvents some of these potential practical drawbacks of the AAI as picture scenes serve as stimuli for the individual narratives and thus frightening memories might come up in the stories without being articulated as the interviewee’s own experiences ( George and Buchheim, 2014 ). In addition the AAP requires less time for administration and coding but at the same time shows an impressive agreement to the AAI. It also demonstrated acceptable validity for assessing attachment representation in adolescents and thus is amenable for use in a wide range of clinical settings including younger patients ( Buchheim et al., 2014 ).

Even though attachment is defined differently by the two approaches, the overall pattern of results from adolescent and adult samples suggest that most of ED patients are insecurely attached. One of the most striking results that emerge from narrative-based studies is the high prevalence of the unresolved attachment status in patients with ED and their mothers ( Ward et al., 2001 ; Ringer and Crittenden, 2007 ; Barone and Guiducci, 2009 ). This is particularly important for adolescents, as there seems to be considerable evidence for a higher prevalence of the unresolved attachment status in adolescent samples ( Sevecke, 2013 ) compared to adults ( Ringer and Crittenden, 2007 ; Lunn et al., 2012 ; Delvecchio et al., 2014 ). Research has already demonstrated that a mother’s unresolved trauma may lead to an impaired ability to sensitively respond to her child and thus may contribute to the transgenerational transmission of trauma ( Iyengar et al., 2014 ). However, the nature of these traumatizing experiences related to attachment is still an untapped area of research. Hence, a key priority for future research is to examine the nature of the trauma not only in adolescents with ED but also in their mothers. These investigations might broaden our understanding of the role of unresolved attachment status for an early onset of ED. Given that traumatized mothers also tend to superimpose their own needs on those of their daughters, one might expect that daughters remain dependent on their mothers to supply a sense of self as they have never learned to differentiate their own needs. However, studies unexpectedly found that adolescents with ED tend to idealize their parents and view their mothers as great facilitators of independence ( Orzolek-Kronner, 2002 ). In contrast, attachment studies in adults found more subjectively reported problematic mother-daughter relationships. They are characterized by a loving but at the same time neglecting, rejecting and role-reversing stance leading to an exaggerated display of angry feelings, an angry demand of the caregiver’s compliance and confusion regarding the parental behavior in their adult daughters ( Ringer and Crittenden, 2007 ; Barone and Guiducci, 2009 ). Replicating these findings using a longitudinal design would clearly be a promising area for future studies. Additionally, it appears that the role of fathers has largely been neglected in most of the studies using narrative techniques. A small number of studies have examined the attachment to fathers by using self-report measures (e.g., Parental Attachment Questionnaire, Parental Bonding Instrument, Inventory of Parent and Peer Attachment) in an adolescent sample with ED. The main findings show that patients feel more alienated from their fathers and they describe them as less caring and more controlling ( Orzolek-Kronner, 2002 ; Fujimori et al., 2011 ; Pace et al., 2012 ; Horesh et al., 2015 ). Therefore, it requires future studies including the fathers of patients to draw further conclusions on the dyadic nature of attachment in ED.

The question why attachment insecurity or disorganization places adolescents at a greater risk for developing an ED has received increasing attention in recent years. A growing number of studies found that insecure attachment style is related to a poorer self-concept, lower identity differentiation, lower acceptance of the own body and self and an impaired recognition of hunger and satiety. Regarding these risk factors in adolescence, studies from adults with ED demonstrate that additionally maladaptive perfectionism and personality characteristics like neuroticism and extraversion that manifest during early adulthood significantly mediate the relationship between insecure attachment style and ED in adults ( Eggert et al., 2007 ; Dakanalis et al., 2014 ). Future research on adolescent ED would profit by relating age-specific risk factors to different attachment patterns. An interesting question for subsequent studies is whether adolescents with an unresolved attachment status show a different amount and quality of risk factors that places them at a greater risk for an early onset than those who are insecurely attached. Furthermore, the higher prevalence of insecure attachment in adults raises fascinating questions about the role of romantic relationships for this age group. In how far attachment-related difficulties in intimate relationships represent potential risk factors or facilitate the maintenance of ED in adulthood has largely been unexplored in the research literature and thus represents an exciting research frontier for future studies ( Evans and Wertheim, 2005 ).

Another interesting question is in how far attachment classification can be linked to diagnostic subgroups of ED. One of the major problems is that past studies on attachment have tended to focus exclusively on AN and BN but studies on BED and obesity in adolescence are still rare. Moreover, the research to date demonstrates very controversial results due to the different methods employed in the studies. As the self-report questionnaires and the narrative instruments define attachment classifications in a different way, future studies should be careful when comparing their results as this might lead to confusion of terminology ( Ward et al., 2001 ; Ravitz et al., 2010 ; George and West, 2012 ). As suggested by O’Shaughnessy and Dallos (2009) it would be more helpful to examine if there is an association between attachment patterns and the symptom severity in ED. Yet, if future research is to identify these possible correlations we must also consider the high prevalence rate of comorbid disorders in ED like depression, anxiety and PD. In a very recent review on PD in adolescents with ED, Magallón-Neri et al. (2014) found that between 64 and 76% of adolescents with BN had a comorbid borderline PD or histrionic PD. In patients with AN the most common PD was the anankastic PD. Studies have demonstrated that the unresolved attachment classification predominates in borderline PD patients and thus the presence of a comorbid borderline PD might also have a significant influence on the attachment status of a patient with an ED ( Buchheim et al., 2008 ). Similar results were found in a preliminary study by Sevecke (2013) who investigated associations between attachment representations and PD in 34 adolescent patients with AN. Interestingly 65% of the girls were classified as unresolved on the AAP and even 82% fulfilled the criteria for a PD. The unresolved group showed a significantly higher PD comorbidity rate when compared to the other attachment groups. Furthermore, insecurely attached patients reported more borderline traits, self-harming behaviors, identity problems and greater emotional dysregulation.

In addition to that, studies have shown a significant association between trauma and a greater comorbidity in adolescents with ED ( Jaite et al., 2012 ). Based on these results, an interesting avenue for future research is to investigate the attachment-related mechanisms by which traumatic experiences, especially childhood maltreatment and interpersonal traumas, might lead to an ED in adolescence. Tasca et al. (2013) examined for the first time in how far attachment insecurity mediates the relationship between childhood trauma and eating pathology in a clinical sample of adults. Their findings indicate that attachment anxiety and avoidance measured with the Experiences in Close Relationships Questionnaire can partly explain this association between trauma and ED. To draw further conclusions, replication of this study using a narrative instrument to assess the unresolved attachment status and also analyze different affect regulation strategies associated with the different attachment patterns is needed ( Burns et al., 2012 ; Danner et al., 2014 ).

The clinical implications of the preceding issues on attachment in ED affect several practice areas, including the psychological assessment, case formulation and treatment of patients. Assessing a patient’s attachment pattern can not only provide new insights into the symptoms but also helps the clinician to predict the treatment outcome ( Buchheim et al., 2012b ; Salcuni et al., 2014 ). To put it differently, assessing different domains of attachment functioning (e.g., interpersonal style, affect regulation, unresolved mental states related to loss or trauma) allows the practitioner not only to address attachment-related goals for treatment, but also provides a template by which differential treatment approaches can be applied for each individual with an ED (for a detailed review, see Tasca, 2014 ). These new directions might result in better symptom outcomes, a higher treatment completion and an improved long-term interpersonal functioning.

The emerging body of attachment research in patients with ED provides us a promising insight into the interplay between environmental, social and individual factors and how they contribute to the development of this complex and painful condition. Although research in adolescents with ED is still at an early stage, first studies illuminate very interesting details about transgenerational aspects, unresolved trauma and loss, neurophysiological correlates of attachment and its implications for treatment and outcome.

The findings of this theoretical review illuminate relevant details about attachment related issues in adolescents with ED and their implications for assessment, case formulation and treatment. In our systematic analysis we found 13 studies using self-report measures of attachment and eight studies employing narrative instruments like the AAI and the AAP in an adolescent and young adult sample. Even though these two approaches measure different facets of attachment, the overall pattern of results from adolescent samples suggest that most of ED patients have insecure attachment. Results regarding links between diagnostic subgroups and the two different insecure attachment styles are not consistent. Some authors found a higher prevalence of the avoidant and others found more anxious individuals among adolescents with ED. The most striking result that emerges from the latest state of narrative-based research is the high prevalence of the unresolved attachment status in adolescent patients and their mothers. Only a small number of studies included fathers and they show that patients feel more alienated from them and they describe them as less caring and more controlling. Furthermore, recent studies demonstrate that adolescents with an unresolved attachment representation have a greater rate of comorbid disorders like PD and depression and higher ED symptom severity. Future studies that investigate traumatizing events, symptom severity and comorbidity in a larger sample of adolescents with ED using a narrative attachment measure might provide a better understanding and treatment of this complex and painful condition.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Abbreviations

adult attachment interview

adult attachment projective picture system

anorexia nervosa

binge eating disorder

bulimia nervosa

eating disorders

eating disorders not otherwise specified

personality disorder

unresolved attachment status.

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The landscape of eating disorders research: A 40-year bibliometric analysis

Affiliations.

• 1 School of Humanities and Social Science, The Chinese University of Hong Kong, Shenzhen, China.
• 2 School of Journalism, Fudan University, Shanghai, China.
• 3 Eating Disorder Assessment and Treatment Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
• 4 Department of Psychology, University of South Alabama, Mobile, Alabama, USA.
• 5 Department of Information Resource Management, School of Management, Tianjin Normal University, Tianjin, China.
• 6 School of Information Management, Wuhan University, Wuhan, China.
• PMID: 35040236
• DOI: 10.1002/erv.2884

Objective: Employing bibliometric methods, the present study aimed to map out the general landscape of existing research on eating disorders (EDs) over the past decades.

Method: Using the Web of Science database, we retrieved 41,917 research articles related to EDs published from 1981 to 2020. After removing those without an abstract, a total of 37,446 articles were retained. The study outlined the distribution of scholarship by time, languages, regions, and countries, and identified major research lines by applying latent topic modelling.

Results: Results revealed a general increasing trend in the number of publications on EDs research, and researchers from Western countries dominated the production of related scholarship. The distribution of published scholarship varied significantly by languages, regions, and countries. Seven main research topics emerged from past research (i.e., animal studies of food intake, risk factors and at-risk groups for eating disorders, body image in eating disorders, studies of cognition and brain in eating disorders, symptomatology and comorbidity of eating disorders, body weight and nutrition status in eating disorders, and treatment of eating disorders), with different topics showing unique research trends across the years.

Conclusions: This bibliometric analysis presents the most complete up-to-date overview on published research on EDs. While there is an increasing trend for EDs research, the available research evidence is generally from Western countries; thus, it is suggested that cooperation on EDs research should be strengthened between Western countries and other countries in the future.

Keywords: bibliometric analysis; citation analysis; eating disorders; latent topic modelling; research topics.

© 2022 Eating Disorders Association and John Wiley & Sons Ltd.

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• Bibliometrics*
• Feeding and Eating Disorders* / epidemiology
• Publications

• UNC Chapel Hill

The UNC Center of Excellence for Eating Disorders is on the leading edge of eating disorders research.

Led by Dr. Cynthia Bulik, our work encompasses inquiries into genetic and environmental causes of eating disorders, prevention of eating disorders, and the development of effective treatments for anorexia nervosa, bulimia nervosa, and binge eating disorder.

With active collaborations in over 21 countries around the world, our work is truly global. Our projects extend from cell to society and employ contemporary methods to decode the causes of eating disorders. As an interdisciplinary research team, we bring varied perspectives together to advance science.

At UNC, all patients are given the opportunity to participate in research.

Committed to bridging the research-practice gap, we aim to fully integrate our clinical and research teams—with our research continually improving our clinical service, and our clinical work informing our research.

Participation in any research project is completely voluntary. The choice to participate or not to participate is entirely yours. That decision in no way influences your clinical care. Your first priority is recovery from your eating disorder.

Questions? Contact our Associate Research Director, Dr. Jessica Baker .

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• Review Article
• Published: 06 May 2022

Genetics and neurobiology of eating disorders

• Cynthia M. Bulik   ORCID: orcid.org/0000-0001-7772-3264 1 , 2 , 3 ,
• Jonathan R. I. Coleman   ORCID: orcid.org/0000-0002-6759-0944 4 , 5 ,
• J. Andrew Hardaway 6 ,
• Lauren Breithaupt 7 , 8 ,
• Hunna J. Watson 1 , 9 , 10 ,
• Camron D. Bryant   ORCID: orcid.org/0000-0003-4505-5809 11 &
• Gerome Breen   ORCID: orcid.org/0000-0003-2053-1792 4 , 5  

Nature Neuroscience volume  25 ,  pages 543–554 ( 2022 ) Cite this article

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• Feeding behaviour
• Psychiatric disorders

Eating disorders (anorexia nervosa, bulimia nervosa and binge-eating disorder) are a heterogeneous class of complex illnesses marked by weight and appetite dysregulation coupled with distinctive behavioral and psychological features. Our understanding of their genetics and neurobiology is evolving thanks to global cooperation on genome-wide association studies, neuroimaging, and animal models. Until now, however, these approaches have advanced the field in parallel, with inadequate cross-talk. This review covers overlapping advances in these key domains and encourages greater integration of hypotheses and findings to create a more unified science of eating disorders. We highlight ongoing and future work designed to identify implicated biological pathways that will inform staging models based on biology as well as targeted prevention and tailored intervention, and will galvanize interest in the development of pharmacologic agents that target the core biology of the illnesses, for which we currently have few effective pharmacotherapeutics.

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Acknowledgements

C.M.B. is supported by the National Institute of Mental Health (R01MH120170, R01MH124871, R01MH119084, R01MH118278 and R01MH124871), a Brain and Behavior Research Foundation Distinguished Investigator grant, the Swedish Research Council (Vetenskapsrådet, award no. 538-2013-8864), and the Lundbeck Foundation (grant no. R276-2018-4581). J.R.I.C. and G.B. acknowledge that the paper represents independent research part funded by the National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. J.A.H. is supported by K01DK115902. C.D.B. is supported by U01DA050243 and U01DA055299. L.B. is supported by T32MH112485, a Harvard Medical School Livingston Fellowship and the International OCD Foundation. G.B. is also supported by the UK Medical Research Council (MR/V012878/1, MR/V03605X/1 and MR/R024804/1) and Charlotte’s Helix.

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Bulik, C.M., Coleman, J.R.I., Hardaway, J.A. et al. Genetics and neurobiology of eating disorders. Nat Neurosci 25 , 543–554 (2022). https://doi.org/10.1038/s41593-022-01071-z

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Founded in 2010

Novel integrative approach of clinical- neuroscience collaborations

Funding from HEFCE, MRC, Sir Jules Thorne Charitable Trust, Charles Wolfson Charitable Trust, Swiss Anorexia Foundation, Placito Bequest

We work to understand the cognitive, biological, emotional and somatic processes underpinning the severe eating disorder Anorexia Nervosa in particular, and Eating Disorders in general. Our trans-disciplinary research, involving clinicians and neuroscientists, aims to translate research findings into novel treatment strategies.

Our work focuses on Anorexia Nervosa , a severe eating disorder, which has the highest mortality rate of any psychiatric disorder. It  remains one of the most challenging to treat and recover from, with a lack of evidence-based treatments. We aim to develop more effective treatments we need a better understanding of processes underpinning the illness.

We are proud of the innovative way our research brings together cognitive science, neuroscience and experimental psychology. This integration helps generate a deeper understanding of how cognitive, emotional and bodily processes interact to maintain the illness. With an international reputation in the field of Eating Disorders, we  have made important advances in understanding the neurobiology of Anorexia Nervosa using functional magnetic resonance imaging, fMRI and MEG. These findings not only help us to better understand the disorder but enable us to push forward with research that is directly relevant to the development of new treatments.

Collaboration

In collaboration with world-class neuroscientists our work investigates brain processes underpinning thinking, feeling and experiencing reward, and how these differ for people with Anorexia Nervosa. Recent research has focused on the role of ruminative thought processes,  abnormal reward processing and compulsivity. We hope to translate research findings into developing new forms of treatment and relapse prevention.

Multimodal Imaging

In  collaboration with Professor Tipu Aziz, the Nuffield Department of Surgery, the Wellcome Centre for Ethics and Humanities and  the Oxford Centre for Human Brain Activity allowed us to initiate complimentary multimodal imaging studies of neural processing and reward in individuals with current and past Anorexia Nervosa, now published.

Deep Brain Stimulation

We also developed the first registered UK study of Deep Brain Stimulation (DBS) targeted at neural reward centres, for individuals with severe enduring Anorexia Nervosa, with full HRA approval. These studies explored the neural processing and behavioural correlates of aberrant reward and habit formation in Anorexia Nervosa, and importantly to set the worlds first  ethical  gold standard to guide experimental brain research in  Anorexia nervosa. The findings will contribute to  an understanding of the neural processes underpinning Anorexia Nervosa and in tandem develop novel treatment strategies. With the aid of additional grants and generous charitable donations we continue with DBS study, which is now in the follow-up phase. We have now published the protocol and an important ethics gold standard to guide such studies worldwide.

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OxBREaD benefits from affiliations with HBA  well established groups within the Department of Psychiatry:

Wellcome Centre for Integrative Neuroimaging, OHBA

Wellcome Centre for ethics and humanities :  Professor Ilina Singh

CREDO1 : Professor Chris Fairburn’s research group is world leading in the development of treatments for Eating Disorders.

PERL : Professors Catherine Harmer's group has an international reputation for excellence in the field of neuroscience and neuroimaging.

Rebecca Park

Associate Professor and Honorary Consultant Psychiatrist

Selected publications

Journal article

Tsompanaki E. et al, (2024), Contemp Clin Trials

Pike AC. et al, (2023), Transl Psychiatry, 13

Martens MA. et al, (2022), J Psychopharmacol

SCAIFE J. et al, (2022), Frontiers in Behavioral Neuroscience

Braeutigam S. et al, (2022), Front Behav Neurosci, 16

Interested in helping eating disorder research?

Do join our research interested list if you have any personal experience of an eating disorder, currently or in the past; or if you would be keen to participate in future research studies on eating disorders . Please contact us if you want to know more about our work, and we will then send you information. 

Email: [email protected]  

Do check out our new papers in the 'selected publications' section of this page!

In memoriam

We are deeply grateful for the recent donations from the family and friends of the late Emma Bruce. We never met Emma but she had suffered from Anorexia for many years, and not long before she died, she was given hope after hearing about the work of OxBREaD.

Current collaborations

• Professor Phil Cowen (Neurosciences, Oxford University)
• Professor Catherine Harmer (Neurosciences, Oxford University)
• Professor Kia Nobre (OHBA, Oxford University)
• Professor Tipu Aziz  (Department of Neurosurgery, Oxford University),
• Dr Jacinta Tan, Psychiatrist and ethicist, (University of Swansea)
• Dr Sanne de Witt (University of Amsterdam),
• Dr Claire Gillan (Trinity College Dublin) 

We are not currently recruiting. 

Related research themes

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Binge Eating Disorder: The Next Generation of Research

Marian tanofsky-kraff , phd, cynthia m bulik , phd, marsha d marcus , phd, ruth h striegel , phd, denise e wilfley , phd, stephen a wonderlich , phd, james i hudson , md, scd.

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Correspondence: Marian Tanofsky-Kraff, PhD, Associate Professor, Department of Medical and Clinical Psychology, USUHS, 4301 Jones Bridge Road, Bethesda, MD 20814; Phone: 301-295-1482; Fax: 301-295-3034; [email protected]

Issue date 2013 Apr.

Introduction

In 2009, when it appeared likely that binge eating disorder (BED) would be recommended for inclusion as an official diagnosis in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a number of researchers believed that it was important to initiate planning for the next generation of research. At the time, it had been established that BED is associated with significant impairment. The robust relationship between BED and obesity prompted researchers in many fields such as eating disorders, addictions, pediatrics, cardiology, and health disparities, to investigate disinhibited eating. Although a large body of research was generated, the researchers in these varied fields were working largely independently.

To enhance communication and collaboration across fields, we received a grant from the National Institute of Mental Health to conduct a workshop in April, 2012 entitled, “Binge Eating Disorder: The Next Generation of Research”. Investigators, representatives from the National Institutes of Health (NIH), clinicians, and lay advocates in the fields of eating disorders, obesity, and addictions were in attendance. Participants are listed in Table 1 and presentation slides are in Appendix 1 . The goal of the workshop was to promote lively and forward-thinking discussions to outline future steps for BED research. This document represents a summary of the proceedings from the workshop.

Workshop Agenda and Participants

Note. Served on Workshop Planning Committee

Why BED will be in DSM-5

State of current knowledge.

In 1994, BED was introduced into the DSM-IV as a provisional set of criteria describing a syndrome characterized by recurrent episodes of binge eating in the absence of the inappropriate compensatory behaviors that define bulimia nervosa. Its inclusion paved the way for a plethora of studies exploring the epidemiology, etiology, clinical presentation, course and treatment of BED. One of the goals of the DSM-5 Eating Disorders Task Force was to determine, based on these data, whether BED should remain in the DSM and, if so, whether the criteria should be preserved or modified. In doing so, the Task Force considered three guiding principles. First, the DSM should be of maximum clinical utility. Therefore, changes should improve clinicians’ ability to help clients encountered in their daily practice. Second, changes should be based on scientific evidence. Third, care should be taken to preserve continuity from DSM-IV to DSM-5 without conflicting with the former two principles.

Presently, the largest obstacle to optimal clinical utility of the DSM-IV is that a majority of individuals who seek treatment for an eating disorder do not meet diagnostic criteria for anorexia nervosa or bulimia nervosa. Rather, their clinical symptoms best fit a diagnosis of eating disorder not otherwise specified (EDNOS). As a result, EDNOS includes a heterogeneous group of symptom constellations and represents the largest eating disorder category. This limits the clinical utility of the diagnosis of EDNOS in that the prognosis implied by, or the treatments effective for, one form of EDNOS (e.g., subthreshold anorexia nervosa) may differ quite markedly from another (e.g., BED). Moreover, although EDNOS is supposed to represent a full-syndrome psychiatric disorder, some presentations included under EDNOS are subthreshold variants of anorexia nervosa or bulimia nervosa and thus may contribute to the sense that EDNOS conditions are “lesser” problems. Indeed, some insurance companies will not pay for services associated with treating EDNOS.

Several factors led to BED being separated out from EDNOS and becoming a candidate for an independent diagnosis. First, individuals with a diagnosis of BED comprise a large percentage of those receiving an EDNOS diagnosis in clinical settings. Second, BED criteria can be reliably applied to clinical cases. Third, individuals with BED differ on meaningful clinical indicators from individuals without BED and from individuals with conditions that share some clinical features such as bulimia nervosa or obesity. Fourth, effective treatments are available for BED. On the basis of these four observations, including BED as an official diagnosis in DSM-5 is in concert with the first two guiding principles for DSM-5. Its inclusion in DSM-5 as a distinct diagnostic entity would reduce the large EDNOS category without creating a substantial number of new psychiatric cases. With regard to the third principle (i.e., continuity between DSM-IV and 5), the Task Force suggested that only the frequency criterion (D) be modified such that binge eating occurs, on average, at least once a week for 3 months. This minor modification represents a change from BED in DSM-IV, but makes the binge eating frequency criterion BED consistent with the binge eating frequency criterion of bulimia nervosa.

Future Directions of the Task Force

Along with the recommendation to “upgrade” BED to an official diagnosis in the DSM-5, the Eating Disorders Task Force suggested areas for future research. Because the following sections will describe future directions in more detail, only three are briefly mentioned herewith. The next generation of research should consider developmental aspects of BED. For example, defining and measuring binge eating poses a challenge in children since the overeating criterion of a binge episode may be limited by parental restrictions and evaluating a large amount of food may be beyond children’s cognitive capacities. In line with this example, another proposed area for research involves elucidating whether loss of control is a more critical component than overeating in adult binge eating episodes and whether both elements are necessary. Lastly, further exploration is required to determine whether the BED duration criterion of 3 months is unduly restrictive.

Key References

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Lifespan: Risk Factors

BED typically manifests in adolescence or adulthood. However, retrospective data from adult samples and prospective studies in young children suggest that risk for BED may be present well before the manifestation of the disorder or even symptoms of the disorder. For example adult studies show that the heritability of BED is approximately 50%. Moreover, retrospective studies of adults have found self-reported childhood risk factors for BED. Specifically, child obesity, maltreatment including teasing and bullying, as well as perceived stress are risk factors for the disorder.

Although development of the full syndrome of BED is uncommon in childhood, episodes of loss of control eating (an inability to stop eating or control the amount or type of food consumed) are not infrequently reported by pre-adolescent youth. Paralleling adult BED, children who report loss of control eating have excess adiposity and endorse greater eating disordered attitudes and depressive symptoms than children without such episodes. Loss of control eating prior to adolescence appears to confer risk for development of excess weight and fat gain, metabolic syndrome components and most notably, partial or full-syndrome BED. Risk factors for loss of control eating in childhood may include genetic factors (for example, pediatric loss of control eating is associated with at least one candidate gene, FTO rs9939609 obesity risk alleles, after accounting for the contribution of body weight), and psychosocial factors (such as parental under-involvement and critical comments).

Future Directions

An important area for investigation should be identifying early risk factors for BED and loss of control eating in animal and human models. Proposed prospective designs should involve elucidating the biological, psychological, and social factors influencing the entire family, including examining relevant variables related to mothers and fathers prior to conception and during pregnancy (e.g., parental weight history, paternal age, maternal nutrition during pregnancy). Importantly, the interaction among and between physical and environment variables should be considered. Research focused on developing early interventions is an important next step for BED. Once risk profiles for BED are identified, potential areas for early intervention can be pursued such as perinatal identification; training programs for parents of young children; and family-based interventions during middle childhood and early adolescence.

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There are two main levels of assessment that should be considered. The first is at the level of the syndrome and involves, for example, diagnostic criteria in the DSM. The second is at the level of the components of the syndrome, and involves assessment of features such as consumption of a large amount of food, sense of loss of control over eating, behavioral indicators of loss of control, and distress about the eating behavior.

Current methods of assessment can be divided into those using self-report (which includes interviews, diaries, and ecological momentary assessment), and direct observation, such as laboratory meals. The reliability of assessments has been examined at the syndromal level for diagnosis, and also at the component level for amount of food consumed and loss of control. Generally, there is acceptable reliability within a method, but the cross-method reliability (e.g., diary vs. laboratory meals for food consumption during binges) is less clear.

Each method of assessment has advantages and disadvantages. Interviews allow structured questions and the ability to probe, but are time consuming and rely on skill of the interviewer and the reporting ability of the interviewee. Self-report is time efficient, but relies on the interviewee’s understanding of questions and accuracy. Ecological momentary assessment obtains data in real time, but relies on the participant’s cooperation and ability to report accurately. Laboratory meals obtain objective data regarding eating, but the non-naturalistic setting influences behavior and psychological state.

In summary, the diagnosis of BED can be reliably established by interview and self-report, with interview being the consensus method of choice. Different methods of assessment have different advantages and disadvantages, and agreement across methods is variable.

A priority for future research is cross-method validation; for example, comparing the results of different methods used to assess the same construct. Also, there should be more study of the relationship between components; for example, the relationship of loss of control to amount consumed. Furthermore, the contributions of the various components of the syndrome to the overall validity of the syndrome should be investigated; for example, examining the relative contribution to diagnostic validity of loss of control over eating vs. amount of food consumed. Finally, objective measures should be developed to help assess components of the syndrome; for example, using biomarkers of stress in the assessment of distress.

• 1. Engel SG, Kahler KA, Lystad CM, Crosby RD, Simonich HK, Wonderlich SA, Peterson CB, Mitchell JE. Eating behavior in obese BED, obese non-BED, and non-obese control participants: a naturalistic study. Behav Res Ther. 2009;47:897–900. doi: 10.1016/j.brat.2009.06.018. [ DOI ] [ PubMed ] [ Google Scholar ]
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Comorbidity and Consequences

Individuals with BED experience significant impairment in psychosocial functioning. Compared with obese adults without BED, obese adults with the disorder report lower quality of life in the domains of physical health conditions and mobility, emotional well-being, work, sexual life, public distress, and self-esteem. Individuals with BED also experience impaired functioning in both their social life and at home. Moreover, BED is associated with higher levels of disability and health problems. With regard to comorbid diagnoses, similar percentages of adults with BED experience Axis I psychiatric disorders, such as major depressive disorder, anxiety disorders, and substance use disorders as individuals with anorexia nervosa and bulimia nervosa. BED is also commonly comorbid with impulse control disorders such as ADHD. The most common comorbid Axis II (personality) disorders in individuals with BED are avoidant, borderline, and obsessive-compulsive personality disorders. Despite consistent findings from cross-sectional studies that BED is associated with the co-occurrence of a wide range of disorders, the potential impact of the presence of any of these comorbid disorders on the course or outcome of BED is unclear.

Given the dearth of naturalistic prospective studies on the outcome of BED, an essential next research step involves examining the psychiatric consequences, quality of life, and psychosocial functioning of the individuals with the disorder. Furthermore, since BED often presents with various comorbid disorders, the etiologic, pathophysiologic, and treatment implications of psychopathology-related heterogeneity in BED should be investigated.

• 1. Rieger E, Wilfley DE, Stein RI, Marino V, Crow SJ. A comparison of quality of life in obese individuals with and without binge eating disorder. Int J Eat Disord. 2005;37:234–40. doi: 10.1002/eat.20101. [ DOI ] [ PubMed ] [ Google Scholar ]
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Research Domain Criteria (RDoC)

At present, psychiatric nosology is based on clinical observation and symptom reports, as exemplified by the Diagnostic and Statistical Manual of the American Psychiatric Association and the International Classification of Diseases. However, new data from neuroscience research on genetic factors, brain circuit abnormalities, and behavioral factors do not map well onto current diagnoses. Thus, the Research Domain Criteria (RDoC) project was initiated to implement the NIMH strategic goal to “develop for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.” There are a number of guiding principles of RDoC. First, RDoC is conceived as a dimensional system, spanning from normal to abnormal. RDoC is agnostic with regard to current diagnostic categories. Thus, the approach involves identifying relevant neurobiological dimensions and linking them to salient clinical phenomena rather than starting with current DSM diagnostic categories. In addition, RDoC proposes the use of multiple units of analysis to assess the validity of the dimensional constructs. Specifically, genes, molecules, cells, circuits, physiology, behavior, and self-reports may be utilized to elucidate the psychopathological phenomena. Thus, RDoC provides a novel heuristic to guide the examination of salient domains and constructs that underlie different eating disorder diagnoses as well as other forms of psychopathology. This approach has promise to promote understanding of the heterogeneity within diagnostic categories (e.g., BED) and similarities in phenotypic expression across disorders.

Although RDoC is a work in progress, this framework may prove useful in elucidating the heterogeneity in symptom presentations within BED and the other eating disorders. RDoC also may hold promise for understanding phenotypic similarities and distinctions among eating disorders and other diagnoses in which binge eating is common (e.g., bipolar disorder and attention deficit hyperactivity disorder).

• 1. http://www.nimh.nih.gov/research-funding/rdoc/nimh-research-domain-criteria-rdoc.shtml
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Relationship of Addictions to Obesity

Similar brain mechanisms may underlie drug addiction and obesity. Brain signals that control drug consumption via the reward circuit and dopaminergic neurotransmission also control food consumption. Individuals with cocaine and alcohol abuse show blunted dopamine increase to stimulants, and individuals with high BMI also show decreased response to food reward compared with individuals with low BMI. Dopamine D2 receptors are decreased in addiction and also in obese individuals. These results and similar studies, including pre-clinical studies, suggest common processes in drug addiction and obesity.

A systems model of addiction and of obesity has been proposed. In the healthy individual, the salience of the rewarding substance (drug or food) is normal, and there is normal self-regulation, which leads to appropriate inhibitory control over the drive to consume. In contrast, in an individual whose system is dysregulated, the salience is enhanced (augmented by amplified memory or conditioning) and the self-regulation is weaker, leading to less control over the drive to consume.

The main potential implication of this body of work for BED is that individuals with BED display not only appetite and weight dysregulation but also other forms of dysregulated behavior, including addictions. Therefore, BED, especially when coupled with overweight or obesity, may represent a form of disordered eating and weight dysregulation driven and maintained by similar pathophysiological abnormalities associated with addictions. Further studies should examine the extent to which BED shares neurobiological abnormalities with addictions and whether these abnormalities are more likely to be present in individuals who are obese and have BED than in obese individuals who do not binge eat (see also future directions for addictive processes below).

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Addictive Processes

Neuropsychological systems associated with addictions-related processes include the impulsive system and the executive system. The impulsive system is embodied in the limbic and para-limbic brain regions, functions in biological reinforcement, and is most often hyperactive in disease states. The executive system is embodied in the prefrontal cortex, functions in valuation of the future, planning, and remembering of events, and is most often hypoactive in disease states.

Addiction-related processes are relevant to BED in that they may be involved in food reinforcement and loss of control of eating. In terms of food reinforcement, imaging studies have shown that dopamine release is associated with BED (using positron emission tomography), and enhanced reward sensitivity associated with greater activation of the orbitofrontal cortex in BED. Turning to loss of control, studies of executive function, decision-making, or related measures in BED have found impairment in BED compared with non-obese individuals without BED (in all studies), and also compared with individuals with obesity who do not have BED (in most studies).

Future directions for research include examination of the full range of impulsive and executive function categories in BED; comparison of BED with addictive disorders, other eating disorders, and obesity; and investigation of the extent to which BED relates to an underlying addictive process based on neural circuit abnormalities or other endophenotypic abnormalities.

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Obesity: The relationship of Obesity to Ultra-Processed Energy-Dense Foods

The current food environment is replete with highly energy-dense, ultra-processed foods served in enormous portion sizes. These food types may promote obesity and associated health comorbidities. Since humans acutely regulate food intake by volume, more so than by calorie content, chronic consumption of highly energy dense foods may increase risk for excess body weight by overeating.

Ultra-processed foods are also low in nutrient and fiber content. Animal data suggest that low intake of micronutrient and phytochemicals may increase energy intake and are associated with increased adiposity. Fiber has been shown to have a modest positive impact on body weight and a major beneficial effect for reducing cardiovascular disease and diabetes. Moreover, a high fiber diet may potentially protect against cancer and reduce mortality.

In addition, ultra-processed foods are often comprised of solid fats, including saturated and trans- fats. Unlike liquid fats that protect against cardiovascular disease, solid fats promote these diseases. Solid fats may also have an impact on body weight. Indeed, trans -fats increase abdominal obesity and insulin resistance in monkeys, while humans fed polyunsaturated experience improved adiposity and adiponectin levels.

Furthermore, the high-intensity flavoring of ultra-processed foods may promote obesity. Sweet, salty and fatty flavors of these foods are enhanced through chemical manipulation. High-intensity flavoring may override endogenous satiety mechanisms and cause naturally sweet foods, such as fruit, to taste bland and unsweet foods, such as vegetables, to taste unpalatable.

Also, ultra-processed foods impact the rate of nutrient digestion and absorption. In contrast to unprocessed foods that are digested slowly and elicit high levels of satiety, highly processed foods are typically digested quickly, likely causing overconsumption. This phenomenon can be described by the glycemic index, a measure of how blood glucose level changes in the postprandial after consumption of carbohydrate-containing foods. A high glycemic index diet is predictive of increased body weight in adults and children.

Taken together, numerous aspects of ultra-processed products may override the biological and behavioral regulators of food intake, causing food consumption to become dysregulated from biological requirements. In susceptible individuals, these stimuli may lead to obesity or disordered eating.

Given data showing that binge and loss of control eating episodes are often comprised of highly palatable, energy-dense foods, an important next research step involves studying the effects of ultra-processed food on BED or loss of control eating. Furthermore, more generally, investigations are needed to elucidate the causal links between BED and obesity.

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Obesity-Related Consequences

There is a strong association of BED with obesity in cross-sectional studies. However, there are few longitudinal studies, so that the nature of the causal relationships between BED and obesity is uncertain. Specifically, it is unclear whether BED causes excessive weight gain and obesity. However, among children and adolescents, loss of control of eating predicts subsequent excessive weight gain. In addition, there is some evidence that childhood loss of control eating and adult BED are associated with subsequent development of components of the metabolic syndrome independent of potential mediating effects of obesity.

A major priority for future research is to conduct longitudinal studies to determine if the development of BED or loss of control eating at different ages is predictive of subsequent excessive weight gain and obesity, as well as obesity-related and other health outcomes. To facilitate this goal and to link data on BED and loss of control eating to disease registries, it will be useful to include brief assessments of loss of control eating and other proxy measures of BED in large cohort studies, assessments used by health maintenance organizations, and surveys used in military screening.

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Animal/Basic

Animal models of binge eating have been developed in rodents. In these models, rodents are exposed to cyclic caloric restriction and re-feeding to simulate dieting, and are exposed to stress (e.g., foot shock or letting rat see and smell, but not taste, food). The binge eating that appears in animal models has clinical human parallels in that large food intakes are greater than those produced by hunger; persist despite punishment; can be triggered by stress or a single “morsel” of palatable food; and are associated with biomarkers of stress, depression, and anxiety.

The primary physiologic targets investigated in animal models have included stress mechanisms (e.g., corticosterone, brain stress-hormone receptors); reward and craving mechanisms (e.g., dopamine, opioids, glutamate, gamma amino butyric acid); and hunger and satiety mechanisms (serotonin and the melanocortin system).

Different drug types work best on different animal models of BED, depending on the factors used to develop these models. These results suggest that different etiologic factors may affect the brain differently to express binge eating.

A priority for future research is to refine drug testing to develop more targeted and efficacious treatments. Animal models should be used to help identify genetic markers, the biology of BED-relevant gene-environment interactions, and the biology discriminating risk for BED associated with obesity versus BED not associated with obesity.

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Psychological Treatment

Psychological treatment for BED targets reducing binge eating, weight, and shape concerns, and preventing excess weight gain and/or inducing modest weight loss. The psychotherapies most evaluated in clinical trials include cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), behavioral weight loss (BWL) and CBT self-help approaches (CBTgsh). CBT is based on the restraint model, which proposes that decreasing dietary restraint will improve attitudes toward eating, weight, and shape, which in turn, will decrease binge eating. IPT proposes that by improving interpersonal functioning and self-esteem, negative affect is decreased and, in turn, binge eating is reduced. CBT and IPT produce marked and long-lasting impact on binge eating and associated psychopathology and lead to modest, long-term weight loss in those who cease binge eating. CBT demonstrates significant specificity of treatment effects compared to medication, supportive psychotherapy, and BWL. As compared to medication, CBT may be especially relevant for those BED patients with overvaluation of shape and weight on the outcomes of depression and associated eating disorder psychopathology. IPT evidences high retention and treatment acceptability, and is superior to CBTgsh for more severely ill patients; for example, those presenting with high frequency of binge eating and compensatory behavior, high weight/shape concern, negative affect, and distress and in patients with low self-esteem. BWL does not specifically target binge eating, but may be more easily disseminated than CBT and IPT, and increases restraint and induces modest weight loss in the short term. However, it is not as effective as CBT or IPT with respect to remission of binge eating in the long term. Given its cost-effectiveness, CBTgsh may be an optimal first-line treatment option, especially when specialist care (e.g., CBT or IPT) is not available.

Given that effective treatments exist for most individuals with BED, future research is needed to bolster public health impact by improving access to empirically supported treatments, by investigating how best to disseminate such treatments into the community. Specifically, future research should examine best implementation methods for training therapists and best methods for increasing scalability of these interventions. Another area requiring study involves addressing the diverse needs of patients, particularly those who do not respond to established treatments. Research is also needed that focuses on early intervention. Finally, data on the cost effectiveness of early intervention and treatment are needed.

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Pharmacologic Treatment

The underlying rationale for pharmacologic treatment is that biological factors influence BED, and medications have been useful in the treatment in the treatment of conditions commonly comorbid with BED, such as mood disorders, anxiety disorders, and substance use disorders. Although as yet no specific targets identified for BED (or for its comorbid conditions), potential targets include neurotransmitters (such as monoamines) and medications targeting certain brain pathways, such as the reward circuit via dopamine modulation.

Examining the results of clinical trials of pharmacologic treatment in BED, three medications or classes of medications have been studied in two or more placebo-controlled trials and therefore provide some basis for preliminary conclusions about efficacy. There have been six studies of selective serotonin reuptake inhibitors (SSRIs), two studies of sibutramine, and two studies of topiramate. All three of these groups produce clinically meaningful reductions in frequency of binge eating relative to placebo in short-term trials, and sibutramine and topiramate (but not SSRIs) also produce clinically meaningful reductions in body weight. However, sibutramine has been withdrawn from the market and topiramate is frequently associated with problematic cognitive effects, thus limiting its clinical utility.

A number of medications have been studied in either a single-placebo controlled trial or in an open-label case series. It is difficult to assess efficacy from these reports. However, none of these medications has thus far shown extraordinary promise in terms of its combination of efficacy and safety so that future development will likely seek to find other medications for BED, rather than develop further these particular agents.

The medications used thus far in clinical studies have a large variety of potential mechanisms of action in BED, including effects on neurotransmitters (serotonin, norepinephrine, dopamine, glutamate, gamma-aminobutyric acid), effects that are antiepileptic (e.g., topiramate, zonisamide and lamotrigine), and effects related potentially to the reward pathway (e.g., dopamine).

Larger, more definitive trials command a high research priority to determine the efficacy and safety of drug treatment for BED. Another priority for future research is to identify better targets for drug intervention, including genetic factors, neural circuit abnormalities, and mechanisms controlling food intake. Also, since no drug for treatment of BED is approved for marketing in the US or other countries, a pathway for approval should be developed that includes consensus about what constitute adequate demonstration of efficacy and how to integrate the effects of treatment not only on binge eating, but also on body weight, into the overall assessment of efficacy.

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Surgical Treatment

Currently, the three main procedures used for bariatric surgery are Roux-en-Y gastric bypass, gastric banding, and sleeve gastrectomy. All induce loss of body weight, but the gastric band is less effective than the other two procedures. The mechanisms involved include restriction (all three), malabsorption (gastric bypass), and hormonal changes such as effects on glucagon-like peptide 1 (GLP-1) and peptide YY 3-36 (gastric bypass and sleeve gastrectomy). In terms of the relationship of bariatric surgery to BED, the presence of BED predicts less weight loss or more weight regain in some studies, but this is not a consistent finding. However, the presence of loss of control eating post-surgery consistently predicts less loss or greater weight regain.

A priority for future research is to develop pre- and post-surgical interventions to prevent the emergence or reemergence of loss of control eating. Also of importance is elucidating the mechanism whereby bariatric surgery suppresses binge eating and by which loss of control eating emerges post-surgery. In particular, it is likely that these mechanisms involve hormonal changes (in addition to other effects), and understanding these hormonal changes, in turn, could help shed light on mechanisms related to loss of control eating. In this regard, studies using the gastric sleeve may be useful, in that this procedure has no pouch, but does induce hormonal changes.

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Relevance to Military Health and Readiness

Members of the military are likely at high-risk for BED. Although this hypothesis has not been tested, the strict requirements for weight and fitness to which military personnel must adhere result in a heightened external pressure for weight loss. It is proposed that this pressure often leads to excessive dietary restraint and, in response individuals are led to engage in binge eating. In addition, deployments as well as frequent relocations may contribute to binge eating in response to stress. To date, only five studies of binge eating have been conducted in military populations and most used of self-report questionnaires. Notably, none specifically captured DSM-IV criteria for BED; rather research assessed for EDNOS. Across studies, the prevalence estimates for binge eating have ranged from 10% – 35%, with higher estimates (upwards of 60%) for those not meeting their service weight standards. However, there are no data on whether BED is accurately identified and diagnosed in military settings, and there is no research on treatment efficacy in military populations. There are also no studies on the numbers of military members not deployable due to BED, and no information on the frequency of fitness and weight “failures” among individuals with the disorder. Although military members who receive effective treatment for BED may be able to remain in service, personnel failing weight standards may be separated from (no longer allowed to serve in) the military. Given the strong association between BED and excess body weight, members who suffer from the disorder likely struggle to meet the required weight and fitness regulations mandated by their service. Therefore, members may be separated from the military due to their weight, rather than receiving appropriate treatment for BED and remaining in service.

Given the dearth of data on BED and the military, the future research directions proposed were relatively straightforward. Less straightforward, and beyond the scope of the workshop, was a discussion of the barriers and challenges to conduct research in military populations. Nevertheless, there was unanimous agreement that the primary next research step includes determining the prevalence of BED in military populations and subpopulations to elucidate not only the scope of the problem, but to understand if military members are at greater risk for the disorder than civilian populations. Part of this effort should involve examining whether one branch or service of the military is at greater risk for BED than another. In addition, it should be determined how many of those individuals not meeting weight or fitness standards are struggling with BED. Another important research direction should involve determining whether treatment response to BED is similar to that observed in civilian studies. Lastly, studies should be conducted to assess the impact of BED on both military readiness and the financial burden on the Department of Defense.

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Personal and Societal Cost

There is clear personal cost to BED. Individuals with the disorder suffer from psychological distress including isolation, stigmatization, and difficulties with interpersonal and family relationships. Despite some effective treatments for BED, it is often difficult for individuals with the disorder to access care. Lack of knowledge, limited numbers of trained professionals, and insufficient insurance coverage are among the reasons that individuals with BED do not receive appropriate intervention. BED also incurs a cost to society. In addition to poor social functioning with friends, family and co-workers, those with BED have a higher prevalence of multiple health problems that often result in missed work, which in turn impacts on individual businesses and the broader economy. Furthermore, healthcare expenses incurred due to the associated physical problems also result in societal costs.

Raising awareness of BED and its associated costs is required. Individuals and organizations need to be informed about how BED impacts society. This effort involves educating the general public, mental health and allied health professionals, educators, payers, and policy-makers. Another important next step includes increasing advocacy, education, fund-raising, and outreach responsibility to national, regional, and local eating disorder, obesity and provider organizations.

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With the inclusion of BED in the DSM-5, we face a new frontier of exciting and important research opportunities. To date, investigators in the fields of eating disorders, obesity and addictions have worked primarily independently. In a workshop including representatives from many fields and from the NIH, overviews of the state of the field and future directions for research were discussed. While the current report represents the proceedings from the meeting, it is not comprehensive in terms of all potential directions for study, but rather provides a foundation for the next generation of BED research.

Acknowledgments

Research support : National Institute of Mental Health R13 MH094127-01 to Marian Tanofsky-Kraff and James I. Hudson.

Appendix 1. Binge Eating Disorder: The Next Generation of Research Slide Presentations

Conflict of Interests

Drs. Tanofsky-Kraff and Bulik report no conflicts of interest. Dr. Marcus served on the DSM-5 Eating Disorders Work Group and is on the Scientific Advisory Board of United Health Care. Dr. Striegel has received consultant fees from Wellness and Prevention, Inc. (a Johnson & Johnson company) and served on the DSM-5 Eating Disorders Work Group. Dr. Wilfley has received research support from Shire Development and consulting fees from GlaxoSmithKline Consumer Healthcare; Minnesota Obesity Center; United Health Group, Childhood Obesity Initiative; and Wellspring Healthy Living Academy. Dr. Wonderlich served on the DSM-5 Eating Disorders Work Group. Dr. Hudson has received research support from Eli Lilly, Otsuka, and Shire, and consulting fees from Genentech, HealthCore, Pfizer, Roche, and Shire.

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Take Part in Eating Disorder Research

Further research is essential to helping us end the pain and suffering of eating disorders. If you have experienced an eating disorder yourself, supported someone with an eating disorder, or worked in eating disorders professionally there will be opportunities for you to take part in research. By doing so you can help researchers continue to learn more about these complex mental illnesses. If you are interested in participating in research, you can check this page regularly or follow us on social media to find out when new studies are added.

Please note: These studies are led by external researchers and not by Beat . Some people can find participating in research to be a triggering experience. If you are at all concerned about this, please make sure to read each study's information sheet carefully and to get in contact with the researcher to ask them any questions you might have about participation. You might also like to to discuss any concerns with others close to you and/or a healthcare professional if you are currently receiving treatment, before deciding whether to take part. Your health and well being should be the top priority.

Research Studies

7 October 2024

Beat is very pleased to report a significant new investment in UK eating disorder research. A group of research funders, led by

10 June 2024

A study seeking clinicians working in eating disorder services to take part in an online focus group.

29 May 2024

Exploring sixth-form pupil and caregiver perspectives on disordered eating support, prevention, and education within NI schools

14 June 2021

The Eating Disorders Genetics Initiative (EDGI) is the UK's largest ever genetic research project into eating disorders.

How do young people talk about eating disorders online?

25 April 2024

A study exploring eating disorder recoveries in young people

9 April 2024

Take part in a focus group or interview to help inform the design of a virtual reality body representation intervention.

LENS aims to understand young people’s experiences of eating disorders and how support can be better in the future.

19 February 2024

RaISE is a study investigating the effectiveness and acceptability of a novel treatment for young people with anorexia nervosa

25 July 2023

This piece of research is to gain an understanding of experiences of parents that are caring for a child diagnosed with ARFID.

27 July 2021

The Eating Disorders Genetics Initiative (EDGI) UK is the UK’s largest ever genetic research project into eating disorders. The aim is to collect the psychological, medical, and genetic information of 10,000 people with experience of any eating disorder. This will help us to better understand the role our genes and environment play on the development and treatment of these illnesses. EDGI is part of an international collaboration, with many countries coming together as part of the same initiative.

Eating Disorder Statistics

We believe approximately 1.25 million people in the UK have an eating disorder.

Transforming the understanding and treatment of mental illnesses.

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Eating Disorders Research Program

This program supports research on the etiology, core features, longitudinal course, and assessment of eating disorders. It also supports studies focusing on the elucidation of risk factors for the onset or recurrence of psychopathology. Intervention development studies grounded in findings from psychopathology are supported as the next step in the translation of basic research to effective treatments.

Areas of Emphasis

• Identifying phenotypes and endophenotypes as new targets for assessment and therapeutics that are emerging from integrative genetics, pathophysiology, and psychopathology research
• Conducting translational research on cognition, emotion, and affect dysregulation to find new strategies for treating eating disorders
• Identifying ways in which genetic and environmental factors interact to raise or lower risk for eating disorders
• Developing new preventive and treatment interventions targeted to specific cognitive, emotional, or interpersonal components of the psychopathology of eating disorders
• Using modern psychometric and statistical theories to advance fundamental conceptualizations of nosology and consequent approaches toward more focused assessment and treatment of the many dimensions and subtypes that constitute eating disorders

Mark Chavez, Ph.D. Program Chief 6001 Executive Boulevard, Room 7126, MSC 9632 301-443-8942, [email protected]

The Douglas Research Centre

Affiliated with McGill University and the Montreal West Island IUHSSC

Research projects – Eating disorders

On-going studies, i. neurobiological mechanisms of eating disorders, 1. epigenetic processes.

Title: A prospective study of DNA methylation in women and girls with Anorexia Nervosa: Relationship to stage of illness and nutritional status Principal investigators :  Howard Steiger (nominated PI), PhD; Linda Booij, PhD (co-PI). Co-investigators : Luis Agellon; Lise Gauvin; Mimi Israël; Ridha Joober; Aurélie Labbe; Annie St-Hilaire; Moshe Szyf; Lea Thaler; Linda Wykes. Funding : Canadian Institutes of Health Research (CIHR)

We are studying DNA methylation processes in adults and adolescents with anorexia nervosa, individuals who have recovered from Anorexia nervosa and people who never had an eating disorder. We have collected DNA samples and clinical and behavioral measures from more than 300 individuals. Our results to date show DNA methylation alterations in people with anorexia nervosa in genes regulating metabolism, immune function and psychiatric status (Booij et al., 2015; Steiger et al., 2019, 2023). Further, we showed that DNA methylation alterations observed in the active phase of anorexia nervosa are reversible (Steiger et al., 2019, 2023).

2. Brain processes

Title: The neurodevelopmental trajectory of youth with anorexia nervosa: A Canada-wide longitudinal multi-modal imaging study Principal Investigators : Linda Booij (nominated PI); Paul Arnold; Gina Dimitropoulos (co-PIs). Co-investigators : Holly Agostino; Nicholas Chadi; Jennifer Coelho; Jennifer Couturier; Guillaume Dumas; Deborah Katzman; Sarosh Khalid-Khan; Andrée-Anne LeDoux; Daniel LeGrange; Frank MacMaster; Mark Norris; Nicole Obeid; Howard Steiger; Danielle Taddeo. Funding : Canadian Institutes of Health Research (CIHR)  

We developed a brain initiative on anorexia nervosa ( A norexia N ervosa IM aging A dults and TE ens; ANIMATE). To date, the search for brain correlates underpinning the clinical features of eating disorders has been unsuccessful. Brain-imaging studies in eating disorders with large sample sizes are a priority for the field to move forward. In collaboration with eight other eating-disorder programs across Canada, the study aims to investigate brain developmental mechanisms and reversibility of nervous system changes in people with anorexia nervosa. The study is led by Dr. Linda Booij at the Eating Disorders Continuum, and is in close collaboration with eating disorder programs at CHU Sainte-Justine, Montreal Children’s Hospital, CHEO (Ottawa), Hotel Dieu Hospital (Kingston), Hospital for Sick Children (Toronto), McMaster Children’s Hospital (Hamilton), Alberta Children’s Hospital (Calgary) and BC Children’s Hospital (Vancouver).

 II. Biopsychosocial predictors and trajectories of treatment response

Individuals treated in our eating-disorder program regularly complete questionnaires during their course of treatment. Whereas data could be used to monitor people’s individual treatment progress, we also aim to use the data for research purposes. Specifically, anonymized questionnaire data are added to a large clinical research database, and we used this database to answer various research questions. This includes for example, projects on the role of motivation for treatment in predicting treatment outcome (Thaler et al., 2016; Steiger et al., 2017; Sansfacon et al. 2018), clinical or treatment features as predictors of treatment course (e.g., Paquin-Hodge et al., 2019; Thaler et al., 2021); and studies on the psychometric properties of eating-disorder questionnaires (Dufour et al. 2023; St-Hilaire et al., 2017, Sansfacon et al., 2019).

III. Development and application of virtual interventions

Our research aims to assess the effectiveness of digital technologies in treatment delivery and in patient outcomes. Some projects on that branch include:

• The impact of treatment modality (virtual vs. in person) on symptoms and satisfaction among people receiving specialized treatment for eating disorders (e.g. Steiger et al., 2022).
• Development of a transdiagnostic digital application (ASTrA) for eating disorders and perceptions on implantation in clinical practice (Booij et al., 2023).
• Effectiveness of a virtual intervention on symptoms among individuals recently referred to specialized ED treatment (ongoing).

IV. Effectiveness of knowledge transfer initiatives

The Eating Disorders Continuum runs a highly successful knowledge transfer program, with the goal to increase primary health-care professionals’ capacity to assess and treat adolescents and adults with eating disorders. Since 2015, we have trained more than 1600 mental health professionals at various CIUSSS and CISSS sites all across Quebec. In our research, we showed the effectiveness of our program in terms of building capacity at local sites and treatment responses in people treated in the community (Thaler et al., 2018, 2022). We continue to train more health professionals in the community. With the results of our research integrated into this knowledge transfer initiative, we continue to adapt and refine our knowledge transfer program.

Contact information

If you would like to participate in any of our research studies at the Eating Disorders Continuum, please contact the research team at [email protected] or by phone at 514-761-6131, ext. 2899.

For inquiries about research, including academic training, research positions, media requests or any other relevant information, please contact Dr. Linda Booij , Head of Research and Academic Development. Tel: 514-761-6131, ext. 3522. Email: [email protected]

Recent and relevant publications from staff members of the Eating Disorders Continuum from the past 5 years

In bold: staff members working at the Eating Disorders Continuum *student or research assistant supervised by a staff member at the EDC.

*Kirkpatrick, R.H., *Breton, E., Biorac, A., Munoz, D., & Booij, L. (2024). Non-suicidal self-injury among individuals with an eating disorder: A systematic review and prevalence meta-analysis. International Journal of Eating Disorders , 57(2):223-248. doi: 10.1002/eat.24088

*Dufour R ., *Breton E., Morin, A.J.S., Côté S., Vitaro F., Boivin M., Dubois L., Tremblay R.E., & Booij L. (2023). Childhood hyperactivity, eating behaviours, and executive functions: Their association with the development of eating-disorder symptoms in adolescence. Journal of Eating Disorders , 11(1):183.  doi: 10.1186/s40337-023-00902-z

Austin, A., De Silva, U., Ilesanmi, C., Likitabhorn, T., Miller, I., Fialho,… ,….., Steiger, H ., Tan, E., Trujillo-Chi Vacuán, E., Meg Tseng, M., van Furth, E.F., Wildes, J.E., Peat, C. & Richmond, T. K. (2023). International consensus on patient-centred outcomes in eating disorders.  The Lancet Psychiatry . Sep 25:S2215-0366(23)00265-1

Steiger, H. (2023). “You mean it’s more than just an eating disorder?”: Commentary on Wade et al.(2023).  International Journal of Eating Disorders , 10, 966–973. doi: 10.1002/eat.24060.

Booij, L. , Israel., M. , Ferrari, M., St-Hilaire, A. , Paquin-Hodge, C. , Allard, M., *Blaquière, A., Dornik, J. , Freiwald, S. , Long, S., Monarque, M., Pelletier, W.D., Thaler, L. , Yaffe, M. , & Steiger, H. (2023). Development of a transdiagnostic digital interactive application for eating disorders: Psychometric properties, satisfaction, and perceptions on implementation in clinical practice. Journal of Eating Disorders , 11(1):146. doi: 10.1186/s40337-023-00871-3.

Soullane, S., Israël, M. , Steiger, H. , Chadi, N., Low, N., Dewar, R., … & Auger, N. (2023). Association of hospitalization for suicide attempts in adolescent girls with subsequent hospitalization for eating disorders.  International journal of eating disorders . Aug 30.  doi: 10.1002/eat.24052

Steiger, H. , Booij, L. , St-Hilaire, A. , & Thaler, L. (2023). Eating Disorders. In Blaney, P; Krueger, R. Oxford. Textbook of Psychopathology . 4th. Oxford University Press, United States.

Steiger, H. , Booij, L. , Thaler, L. , St-Hilaire, A. , Israël, M. , *Casey, K.F., *Oliverio, S., *Crescenzi, O., *Lee, V., Turecki, G., Joober, R., Szyf, M., *Bréton, E. (2023). DNA methylation in people with anorexia nervosa: Epigenome-wide patterns in actively ill, long-term remitted, and healthy-eater women. World Journal of Biological Psychiatry , 24(3), 254–259. doi:10.1080/15622975.2022.2089731.

Coelho, J. 1 , Booij, L. 1 , Katzman, D., Dimitropoulos, G., & Obeid, N. (2023). The economic impact of eating disorders in children and youth in Canada: a call to action to improve youth eating-disorder research and care. Journal of Eating Disorders , 11(1):74.  doi: 10.1186/s40337-023-00794-z. 1 Shared first author

Alberga, A.S., *Sacco, S., & Booij, L. (2023). Unintended consequences: The overlooked outcomes in pediatric obesity management. JAMA Pediatrics , 177:997-998. doi: 10.1001/jamapediatrics.2023.2190.

Novack, K., *Dufour, R., Picard, L., Taddeo, D., Nadeau, P-O, Katzman, D., Booij, L. , & Chadi, N. (2023). Canadian pediatric eating disorder programs and virtual care during the COVID-19 pandemic: A mixed-methods approach to understanding clinicians’ perspectives. Annals of General Psychiatry , 22(1):16. doi: 10.1186/s12991-023-00443-4

* Breton, E., Cote S., Dubois L., Vitaro, F., Boivin, M., Tremblay, R.E., & Booij, L. (2023). Childhood overeating and disordered eating from early adolescence to young adulthood: a longitudinal study on the mediating role of BMI, victimization and desire for thinness. Journal of Youth and Adolescence , 52(8):1582-1594. doi: 10.1007/s10964-023-01796-5.

*Breton, E., Juster, R-P, & Booij. L. (2023). Gender and sex in eating disorders: A narrative review of the current state of knowledge, research gaps, and recommendations. Brain & Behavior, 13(4):e2871. doi: 10.1002/brb3.2871.

Loose, T., Geoffrey, M-C., Orri, M., Chadi, N., *Scardera, S., Booij, L. , *Breton, E., Tremblay, R.E., Boivin, M., Côté, S. (2023) Pathways of association between disordered eating in adolescence and mental health outcomes in young adulthood during the COVID-19 pandemic. Canadian journal of public health, 114(1), 22–32. doi:10.17269/s41997-022-00715-8.

Steiger, H. (2023). A Canadian case of ‘lifespan’ programming for people with eating disorders. Australasian Psychiatry, 31(1), 106–107. doi:10.1177/1039856221105465

Auger, N, Steiger, H, Luu, TM, Chadi, N, Low, N, Bilodeau-Bertrand, M, Healy-Profitós, J, Ayoub, A, Brousseau, É, Israël, M .(2023). Shifting age of child eating disorder hospitalizations during the Covid-19 pandemic. Journal of Child Psychology and Psychiatry , 64(8):1176-1184. doi: 10.1111/jcpp.13800.

Auger, N., Low, N., Chadi, N., Israël, M., Steiger, H., Lewin, A., Ayoub, A., Healy-Profitós, J., Luu, T. M. (2023). Suicide attempts in children 10-14 years of age during the first year of the COVID-19 pandemic. Journal of Adolescent Health , 72, 899-905. doi: 10.1016/j.jadohealth.2023.01.019.

Himmerich, H., Lewis, Y.D., Mutwalli, C.C.H., Andreas Karwautz, … Steiger, H ., … World Federation of Societies of Biological Psychiatry (WFSBP) guidelines update 2023 on the pharmacological treatment of eating disorders (2023). World Journal of Biological Psychiatry , 24, 1-64. doi: 10.1080/15622975.2023.2179663

Thaler, L. , Paquin-Hodge, C. , Leloup, A.G., Wallace, A., *Oliverio, S., Freiwald, S. , Israël, M. , & Steiger, H. (2022). Barriers and facilitators to the implementation of an eating disorders knowledge exchange program for non-specialist professionals. The Journal of Behavioral Health Services & Research , 50(3), 365-380.  doi: 10.1007/s11414-022-09822-3.

*Oliverio, S., Steiger, H. , St-Hilaire, A. , Paquin-Hodge, C., Leloup, A. G., Israël, M. , & Thaler, L. (2022). Barriers and facilitators to providing autonomy supportive counselling to individuals seeking treatment for an eating disorder.  Eating and Weight Disorders, 27(7), 2919–2929. doi:10.1007/s40519-022-01395-6

Thaler, L. , Booij, L. , *Burnham, N., *Kenny, S., *Oliverio, S., Israël, M. , &

Steiger, H. (2022). Predictors of non‐completion of a day treatment program for adults with eating disorders. European eating disorders review, 30(2), 146–155. doi:10.1002/erv.2879.

Steiger, H. , Booij, L. , *Crescenzi, O., *Oliverio, S., *Singer, I., Thaler, L. , St-Hilaire, A. , & Israël, M. (2022). In-person versus virtual therapy in outpatient eating-disorder treatment: A COVID-19 inspired study. International Journal of Eating Disorders, 55(1), 145–150. doi:10.1002/eat.23655.

*Dufour, R., Novack, K. Chadi, N., & Booij, L. (2022) The use of technology in the treatment of youth with eating disorders: A scoping review. Journal of Eating Disorders , 10(1):182. doi:10.1186/s40337-022-00697-5.

*Breton, E., *Fotso-Soh, J., & Booij, L. (2022). Immunoinflammatory processes: overlapping mechanisms between obesity and eating disorders? Neuroscience and Biobehavioral Reviews, 138:104688. doi: 10.1016/j.neubiorev.2022.104688.

*Breton, E., *Dufour, R., Coté, S.M., Dubois, L., Vitaro, F., Boivin, M., Tremblay, R.E., & Booij, L. (2022). Developmental trajectories of eating disorder symptoms: A longitudinal study from early adolescence to young adulthood. Journal of Eating Disorders ,10(1):84. doi: 10.1186/s40337-022-00603-z.

Auger, N., Potter, B.J., Ukah, U.V., Low, N., Israël, M. , Steiger, H. , Healy-Profitós, J., Paradis, G. (2021). Anorexia nervosa and the long-term risk of mortality in women. (Letter to the Editor). World Psychiatry, 20(3), 448. doi:10.1002/wps.20904

*Sansfaçon, J. 1 , Booij, L. 1 , Gauvin, L., *Fletcher, E., Islam, F., Israël, M. , & Steiger, H. (2020). Pre-treatment motivation and therapy outcomes in eating disorders: A systematic review and meta-analysis. International Journal of Eating Disorders, 53(12), 1879–1900. doi:10.1002/eat.23376. 1 Shared first author

Booij, L. & Steiger, H. (2020). Applying epigenetic science to the understanding of eating disorders:   A promising paradigm for research and practice. Current opinion Psychiatry , 33(6), 515–520. doi:10.1097/YCO.0000000000000632

Wonderlich, S.A, Bulik, C.M., Schmidt, U., Steiger, H. , & Hoek, H.W.   (2020). Severe and enduring Anorexia Nervosa: Update and observations about the current clinical reality. International Journal of Eating Disorders, 53(8), 1303–1312. doi:10.1002/eat.23283

Steiger, H. & Booij, L. (2020). Eating disorders, heredity and environmental activation: Getting epigenetic concepts into practice: Journal of Clinical Medicine, 9(5), E1332. doi:10.3390/jcm9051332

*Burdo, J., Booij, L. , *Kahan, E., Thaler, L. , Israël, M. , Agellon, L.B., Nitschmann, E., Wykes, L., & Steiger, H. (2020). Plasma levels of one-carbon metabolism nutrients in women with Anorexia Nervosa . International Journal of Eating Disorders , 53(9), 1534–1538. doi:10.1002/eat.23292

Linnaranta, O., Bourguignon, C., *Crescenzi, O., Sibthorpe, D., Buyukkurt, A., Steiger, H. , & Storch, K-F. (2020). Late and unstable sleep phasing is associated with irregular eating patterns in eating disorders. Annals of behavioral medicine , 54(9), 680–690. doi:10.1093/abm/kaaa012

Thaler, L. , *Brassard, S., Booij, L. , *Kahan, E., McGregor, K., Labbe, A., Israël, M. , & Steiger, H. (2020). Methylation of the OXTR gene in women with Anorexia Nervosa: Relationship to social behavior. European Eating Disorders Review , 28(1), 79–86. doi:10.1002/erv.2703

Paquin-Hodge, C. , Gauvin, L., St-Hilaire, A. , Israël, M. , Azzi, M., *Kahan, E., Thaler, L ., Dansereau, E., & Steiger, H. (2019). A naturalistic comparison of two inpatient treatment protocols for adults with Anorexia Nervosa: Does reducing duration of treatment and external controls compromise outcome? International Journal of Eating Disorders , 52(9):1015–1023. doi:10.1002/eat.23150

Steiger, H. , Booij, L. , *Kahan, E., McGregor, K., Thaler, L. , *Fletcher, E., Labbe, A., Joober, R., Israël, M. , Szyf, M., Agellon, L.B., Gauvin, L., St-Hilaire, A. , & *Rossi, E. (2019). A longitudinal, epigenome-wide study of DNA methylation in anorexia nervosa: results in actively ill, partially weight restored, long-term remitted, and non-eating-disordered women. Journal of psychiatry & neuroscience , 44(3), 205–213. doi:10.1503/jpn.170242

Thaler, L. , Freiwald, S. , Paquin-Hodge C. , *Fletcher, E., *Cottier, D., *Kahan, E., *Rossi, E., Piat, M., Lal, S., Israël, M. & Steiger, H. (2018). A tertiary-care/primary-care partnership aimed at improving care for people with eating disorders. Community Mental Health Journal, 54(8), 1154–1161. doi:10.1007/s10597-018-0290-4.

*Sansfaçon, J., Gauvin, L., *Fletcher, E., *Cottier, D., *Rossi, E., *Kahan, E., Israël, M. & Steiger, H. (2018). Prognostic value of autonomous and controlled motivation in outpatient eating-disorder treatment. International Journal of Eating Disorders , 51(10):1194–1200. doi:10.1002/eat.22901.

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October 24, 2024

This article has been reviewed according to Science X's editorial process and policies . Editors have highlighted the following attributes while ensuring the content's credibility:

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Risk for psychiatric disorders up for offspring of moms with eating disorder

by Elana Gotkine

Offspring of mothers with an eating disorder or prepregnancy body mass index (BMI) outside the normal weight range have an increased risk for psychiatric disorders, according to a study published online Oct. 22 in JAMA Network Open .

Ida A.K. Nilsson, Ph.D., from the Karolinska Institutet in Stockholm, and colleagues conducted a population-based cohort study using Finnish national registers to examine the association of maternal eating disorders and prepregancy BMI with offspring psychiatric diagnoses.

The study included 392,098 mothers, of whom 1.60 percent had a history of an eating disorder and 5.89 and 53.13 percent had prepregnancy underweight and overweight or obesity, respectively. The researchers found that 16.43 percent of the 649,956 offspring had received a neurodevelopmental or psychiatric diagnosis. Even after adjusting for potential covariates, maternal eating disorders, prepregnancy underweight, and overweight or obesity were associated with most of the studied mental diagnoses in offspring.

The largest effect sizes were seen for maternal eating disorders not otherwise specified with offspring sleep disorders (hazard ratio, 3.34) and social functioning and tic disorders (hazard ratio, 2.79), and for maternal severe prepregnancy obesity with offspring intellectual disabilities (hazard ratio, 2.04). The risks for offspring having other feeding disturbances of childhood and infancy (e.g., hazard ratio, 4.53 for maternal eating disorders) and attention-deficit/ hyperactivity disorder and conduct disorder (e.g., hazard ratio, 2.27 for maternal anorexia nervosa) were further increased in association with adverse birth outcomes.

"Furthering the knowledge about these associations and underlying biological mechanisms can provide information of value for the development of relevant management and treatment," the authors write.

Copyright © 2024 HealthDay . All rights reserved.

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