A systematic review with meta-analyses of the relationship between recurrent binge eating and sleep parameters

BACKGROUND

Sleep problems are known to compound the negative effects of other health issues, such as eating disorders and the associated behavior of binge eating. Previous studies suggested associations between binge eating and sleep problems, but the strength of the relationship is unknown.

METHODS

We conducted a systematic review with meta-analyses examining the relationship between binge eating and sleep parameters. We searched for studies in Scopus, PubMed, and PsycInfo. The quality of evidence, including risk of bias, was assessed with adaptations of the Newcastle-Ottawa Scale and the Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies, depending on study design. Data was synthesized as the difference in sleep between people who did or did not have binge eating.

RESULTS

Thirty-one reports of studies met our eligibility criteria. Results are presented in 12 meta-analyses. In the 7 reports of studies (with 4448 participants) that assessed poor overall sleep quality, we found poorer overall sleep quality in people with binge eating compared to people without binge eating, with a standardized mean difference of 0.77 (95% confidence interval [CI] 0.61-0.92; P < 0.001), which is a large effect size. In addition, we found evidence that people with binge eating had significantly greater hypersomnia/daytime sleepiness (7 reports of studies with 4370 participants), insomnia (5 reports of studies with 12,733 participants), and difficulty falling asleep (3 reports of studies with 4089 participants) compared to people without binge eating, with moderate effect sizes (standardized mean differences of 0.57-0.66).

CONCLUSIONS

People with binge eating exhibit poorer overall sleep quality compared to people without binge eating, and may also exhibit greater hypersomnia/daytime sleepiness, insomnia, and difficulty falling asleep. It is recommended that healthcare professionals routinely screen for poor overall sleep quality when treating people with binge eating-and address sleep difficulties when present.

Associations among relationship status, gender, and sexual attraction in Australian adolescents' eating pathology

OBJECTIVE

Engaging in romantic relationships in adolescence may inadvertently increase participation in appearance culture and the risk for eating pathology. Little research has considered this effect, particularly as it relates to adolescents' gender identity and sexual attraction. Therefore, this study examined the associations among relationship status, gender, and sexual attraction in adolescents' eating pathology.

METHODS

Data from the first wave of the EveryBODY study, a large sample of Australian adolescents aged 11-19 years (n = 3262, M_age  = 15.00, 53.80% girls), were used. Participants reported their relationship status and eating pathology (fasting, purging, binge eating, driven exercise, steroid use, and shape/weight concerns) using an online survey.

RESULTS

Logistic regressions adjusting for age and BMI percentile revealed that romantic relationships were associated with higher adjusted odds (AORs) for reporting clinical frequency/severity threshold of fasting, purging, steroid use, and shape and weight concerns (AORs: 1.34-3.68). Relative to boys, girls had higher adjusted odds of reporting clinical frequency/severity threshold of all eating disorder features (AORs: 1.47-7.40), except for steroid use for muscle gain. Adolescents who reported same-sex attraction, were unsure of their sexual attraction, or did not endorse any sexual attraction had greater adjusted odds of reporting clinical frequency/severity threshold of fasting, purging, and shape and weight concerns (AORs: 1.35-1.83) than those with only other-sex sexual attraction. Interactions among relationship status, gender, and sexual attraction were nonsignificant.

CONCLUSIONS

Romantic experience emerged as a novel correlate for adolescents' eating pathology. Future research should uncover the contextual factors within relationships that may contribute to this association.

PUBLIC SIGNIFICANCE

The initiation of romantic relationships is normative during adolescence. However, adolescents' romantic desirability is often determined by their physical appearance, increasing the risk for eating pathology. Among a large sample of Australian adolescents, romantic involvement was associated with greater likelihood of clinical threshold eating pathology for adolescent boys and girls, regardless of sexual attraction. It is urgent to identify the factors within romantic relationships that are associated with eating pathology.

Disentangling eating disorder diagnostic schemes. Commentary on Walsh et al., "A systematic review comparing atypical anorexia nervosa and anorexia nervosa"

This commentary discusses the systematic review by Walsh et al. that has found that people with atypical anorexia nervosa have similar symptoms and severity as have people with anorexia nervosa. In this paper, the discussion is broadened to other eating disorders diagnoses and the problem of overlap and crossover between syndromes that impacts adversely on the need for diagnoses to be distinct both at assessment but also over time. It is argued that the derivation of eating disorder diagnostic criteria has also been vulnerable to erroneous assumptions and biased observations. Whether atypical anorexia nervosa becomes a standalone diagnosis or is joined with an expanded anorexia nervosa, future delineations should be based on empirical research including neuroscience.

Difficulties with emotion regulation and weight/shape concerns as predictors of eating disorder behaviors among adolescents

BACKGROUND

Difficulties with emotion regulation are a proposed key transdiagnostic factor of mental health difficulties, including eating disorders. However, it remains unclear whether difficulties with emotion regulation prospectively predict engagement in eating disorder behaviors. The current study examined whether difficulties with emotion regulation were associated with eating disorder behaviors after 1 year, in addition to weight and shape concerns.

METHOD

A community sample of high school students (n = 3,074; 53.2% girls) completed self-report measures of eating behaviors, weight/shape concerns, and difficulties with emotion regulation at two timepoints, 1 year apart.

RESULTS

Findings indicated that greater difficulties with emotion regulation were uniquely associated with engaging in binge eating, fasting, and purging after 1 year. However, only greater weight and shape concerns, not difficulties with emotion regulation, were uniquely associated with engaging in driven exercise. Limited associations were detected for the frequency of eating disorder behaviors. Additionally, exploratory analyses were conducted to examine potential onset and persistence of eating disorder behaviors. Few gender differences were observed across analyses, with the exception of driven exercise, which was linked to difficulties with emotion regulation only among adolescent boys, but not girls.

CONCLUSIONS

Findings suggest that difficulties with emotion regulation are a distinct factor in the occurrence of some eating disorder behaviors among adolescents. Exploratory findings further suggest that difficulties with emotion regulation appear to be particularly involved in the persistence of these behaviors in adolescents. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prevention of high body mass index and eating disorders: a systematic review and meta-analysis

BACKGROUND

Eating disorders (EDs) and high body mass index (BMI) are two important public health issues with significant health and cost impacts. The aim of this systematic review and meta-analysis was to establish whether interventions are effective in preventing both issues.

METHODS

Electronic databases were searched up to 10 May 2021. Studies were included if they were randomised or quasi-randomised controlled trials that evaluated a preventive intervention (regardless of its aim to prevent ED, high BMI or both) and reported both EDs and BMI-related outcomes. Both narrative synthesis and meta-analysis were used to synthesise the results. Publication bias was also investigated.

RESULTS

Fifty-four studies were included for analysis. The primary aim of the studies was ED prevention (n = 23), high BMI prevention (n = 21) and both ED and high BMI prevention (n = 10). Meta-analysis results indicated that preventive interventions had a significant effect on several ED outcomes including dieting, shape and weight concerns, body dissatisfaction, negative affect, eating disorder symptoms and internalization, with effect sizes ranging from - 0.16 (95% CI - 0.27, - 0.06) to - 0.61 (95% CI - 0.29, - 0.04). Despite several studies that demonstrated positive impacts on BMI, there was no significant effect on BMI-related measures in the meta-analysis. The risk of publication bias was low for the majority of the pooled effect results.

CONCLUSION

Preventive interventions were effective for either high BMI or EDs. However, there is limited evidence to show that current preventive interventions were effective in reducing both outcomes. Further research is necessary to explore the risk factors that are shared by these weight-related disorders as well as effective prevention interventions.

LEVEL OF EVIDENCE

Level I: systematic review.

A consensus document on definition and diagnostic criteria for orthorexia nervosa

PURPOSE

Since the term orthorexia nervosa (ON) was coined from the Greek (ὀρθός, right and ὄρεξις, appetite) in 1997 to describe an obsession with "correct" eating, it has been used worldwide without a consistent definition. Although multiple authors have proposed diagnostic criteria, and many theoretical papers have been published, no consensus definition of ON exists, empirical primary evidence is limited, and ON is not a standardized diagnosis. These gaps prevent research to identify risk and protective factors, pathophysiology, functional consequences, and evidence-based therapeutic treatments. The aims of the current study are to categorize the common observations and presentations of ON pathology among experts in the eating disorder field, propose tentative diagnostic criteria, and consider which DSM chapter and category would be most appropriate for ON should it be included.

METHODS

47 eating disorder researchers and multidisciplinary treatment specialists from 14 different countries across four continents completed a three-phase modified Delphi process, with 75% agreement determined as the threshold for a statement to be included in the final consensus document. In phase I, participants were asked via online survey to agree or disagree with 67 statements about ON in four categories: A-Definition, Clinical Aspects, Duration; B-Consequences; C-Onset; D-Exclusion Criteria, and comment on their rationale. Responses were used to modify the statements which were then provided to the same participants for phase II, a second round of feedback, again in online survey form. Responses to phase II were used to modify and improve the statements for phase III, in which statements that met the predetermined 75% of agreement threshold were provided for review and commentary by all participants.

RESULTS

27 statements met or exceeded the consensus threshold and were compiled into proposed diagnostic criteria for ON.

CONCLUSIONS

This is the first time a standardized definition of ON has been developed from a worldwide, multidisciplinary cohort of experts. It represents a summary of observations, clinical expertise, and research findings from a wide base of knowledge. It may be used as a base for diagnosis, treatment protocols, and further research to answer the open questions that remain, particularly the functional consequences of ON and how it might be prevented or identified and intervened upon in its early stages. Although the participants encompass many countries and disciplines, further research will be needed to determine if these diagnostic criteria are applicable to the experience of ON in geographic areas not represented in the current expert panel.

LEVEL OF EVIDENCE

Level V: opinions of expert committees.

Longitudinal relationship between experience of sexual harassment and 2-year body image and weight outcomes in adolescence: mediation through self-objectification and psychological distress

BACKGROUND

The current study investigated the experience of sexual harassment as a risk factor for weight gain and weight/shape concerns in a community sample of adolescents, with potential mediating factors self-objectification and psychological distress.

METHOD

1034 Australian adolescents (aged 11 to 19 years) from the EveryBODY longitudinal study of disordered eating pathology participated. Data were collected through online surveys annually for 3 years. Participants completed self-report measures of demographics, sexual harassment, psychological distress, self-objectification, weight/shape concerns and BMI percentile.

RESULTS

A parallel mediation model adjusting for baseline scores found no direct effect between baseline experiences of sexual harassment and change in BMI percentile or weight/shape concern after 2 years. Experiences of sexual harassment significantly increased self-objectification scores after 1 year in female adolescents. Subsequently, higher self-objectification significantly increased the risk of greater weight/shape concern after 1 year in female adolescents. However, no significant mediating relationship was found in the relationship between sexual harassment and weight/shape concern or BMI percentile for either gender. Psychological distress was found to be a clear risk factor for weight/shape concern in both genders after 1 year.

CONCLUSIONS

Intervention programmes in schools should focus on developing policies to reduce sexual harassment, self-objectification and distress in adolescents.

LEVEL OF EVIDENCE

Level IV, longitudinal multiple time series without intervention.

Adolescent Depression from a Developmental Perspective: The Importance of Recognizing Developmental Distress in Depressed Adolescents

OBJECTIVE

To make the case that developmental distress needs to be assessed when evaluating adolescent depression.

METHODS

Reviews of relevant papers relating to adolescent depression.

RESULTS

Adolescent depression is a common and costly health condition, confounded by a lack of consensus among health professionals regarding evidence-based approaches regarding treatments. Little attention has been paid to the contribution of developmental distress.

CONCLUSION

The current adult-like model of adolescent depression fails to advance the understanding of adolescent depression. A systematic evidence-based approach to identifying developmental self-perception distress in depressed adolescents could provide important advances in treatment to improve short-term and longer-term mental health outcomes. This paper proposes the creation of a psychometric tool to systematically measure developmental self-perception distress in adolescents with depression.

Treatment of eating disorders: A systematic meta-review of meta-analyses and network meta-analyses

MONTELEONE, A.M., F. Pellegrino, G. Croatto, M. Carfagno, A. Hilbert, J. Treasure, T. Wade, C. Bulik, S. Zipfel, P. Hay, U. Schmidt, G. Castellini, A. Favaro, F. Fernandez-Aranda, J. Il Shin, U. Voderholzer, V. Ricca, D. Moretti, D. Busatta, G. Abbate-Daga, F. Ciullini, G. Cascino, F. Monaco, C.U. Correll and M. Solmi. Treatment of Eating Disorders: a systematic meta-review of meta-analyses and network meta-analyses. NEUROSCI BIOBEHAV REV 21(1) XXX-XXX, 2022.- Treatment efficacy for eating disorders (EDs) is modest and guidelines differ. We summarized findings/quality of (network) meta-analyses (N)MA of randomized controlled trials (RCTs) in EDs. Systematic meta-review ((N)MA of RCTs, ED, active/inactive control), using (anorexia or bulimia or eating disorder) AND (meta-analy*) in PubMed/PsycINFO/Cochrane database up to December 15th, 2020. Standardized mean difference, odds/risk ratio vs control were summarized at end of treatment and follow-up. Interventions involving family (family-based therapy, FBT) outperformed active control in adults/adolescents with anorexia nervosa (AN), and in adolescents with bulimia nervosa (BN). In adults with BN, individual cognitive behavioural therapy (CBT)-ED had the broadest efficacy versus active control; also, antidepressants outperformed active. In mixed age groups with binge-eating disorder (BED), psychotherapy, and lisdexamfetamine outperformed active control. Antidepressants, stimulants outperformed placebo, despite lower acceptability, as did CBT-ED versus waitlist/no treatment. Family-based therapy is effective in AN and BN (adolescents). CBT-ED has the largest efficacy in BN (adults), followed by antidepressants, as well as psychotherapy in BED (mixed). Medications have short-term efficacy in BED (adults).

Assessing cognitive flexibility in anorexia nervosa using eye tracking: A registered report

OBJECTIVE

Cognitive flexibility research in anorexia nervosa (AN) has primarily focused on group differences between clinical and control participants, but research in the general population utilizing the mixed pro- anti-saccade flexibility task has demonstrated individual differences in trait anxiety are a determinant of switching performance, and switching impairments are more pronounced for keypress than saccadic (eye-movement) responses. The aim of the current research is to explore trait anxiety and differences in saccadic and keypress responding as potential determinants of performance on flexibility tasks in AN.

METHOD

We will compare performance on the mixed pro- anti-saccade paradigm between female adult participants with a current diagnosis of AN and matched control participants, observing both saccadic and keypress responses while controlling for trait anxiety (State - Trait Anxiety Inventory) and spatial working memory (Corsi Block Tapping Test). Associations with eating disorder-related symptoms (Eating Disorder Examination Questionnaire), flexibility in everyday life (Eating Disorder Flexibility Index), and the Clinical Perfectionism Questionnaire will also be assessed.

RESULTS

Data which controls for individual differences in trait anxiety and assesses flexibility at both the task- and response-set level may be used to more accurately understand differences in performance on cognitive flexibility tasks by participants with AN.

DISCUSSION

Clarifying the effects of trait anxiety on flexibility, and differences between task- and response-set switching may advance our understanding of how cognitive flexibility relates to flexibility in everyday life and improve translation to therapeutic approaches.

PUBLIC SIGNIFICANCE STATEMENT

This research will compare performance on a flexibility task between participants with anorexia nervosa (AN) and controls while observing their eye-movements to examine whether trait anxiety and type of response (eye-movement and keypress) are associated with performance. This data may improve our understanding of why participants with AN perform more poorly on cognitive flexibility tasks, and how poor cognitive flexibility relates to eating disorder-related issues with flexibility in everyday life.

Prevalence of muscle dysmorphia in adolescents: findings from the EveryBODY study

BACKGROUND

We sought to provide the first point prevalence estimates of muscle dysmorphia (MD), a form of body dysmorphic disorder characterized by a preoccupation with perceived insufficient muscularity, in adolescents.

METHODS

Data were taken from a survey of 3618 Australian adolescents (11.172-19.76 years; 49.3% girls). Measures captured demographic characteristics, symptoms of MD and eating disorders, psychological distress and functional impairment. Diagnostic criteria for MD developed by Pope et al. (1997, Psychosomatics, 38(6), 548-557) were applied, entailing preoccupation with insufficient muscularity causing significant levels of distress or disability that cannot be better accounted for by an eating disorder.

RESULTS

The point prevalence of MD was 2.2% [95% confidence interval (CI) 1.6-3.0%] among boys and 1.4% (95% CI 0.9-2.0%) among girls. Prevalence was not associated with gender (V = 0.031) or socioeconomic status (SES) (partial η²< 0.001), but was marginally associated with older age (partial η² = 0.001). Boys with MD were more likely than girls with MD to report severe preoccupation with muscularity (V = 0.259) and a weight-lifting regime that interfered with their life (V = 0.286), whereas girls with MD were more likely to report discomfort with body exposure (V = 0.380).

CONCLUSIONS

While future epidemiological research using diagnostic interviews is needed to verify these estimates, the findings suggest that MD is relatively common from early to late adolescence. Gender differences in MD prevalence may be minimal; however, the symptom profile appears to diverge between boys and girls. These findings provide a platform for future, analytical research designed to inform clinical and public health interventions.

Measuring exercise in eating disorder patients: a Delphi study to aggregate clinical and research knowledge

BACKGROUND

Exercise is a prominent feature of most eating disorders, and has been shown to have a number of detrimental effects on treatment outcome. There is some disagreement in the literature regarding the construct of compulsive exercise, and assessment and treatment varies significantly. This study therefore aimed to aggregate expert clinicians' and researchers' views on how to define and measure compulsive exercise in eating disorder patients. The expert panel was also asked about questionnaire design, and possible problems when measuring compulsive exercise.

METHOD

This study used the Delphi method to establish consensus amongst an expert panel. Three successive rounds of questionnaires were distributed to the panel over a period of six months. The first round consisted of four open-ended questions regarding the definition and measurement of compulsive exercise in eating disorder patients. For Round 2, 70 statements were derived from the answers, and panelists were asked to rate each item on a Likert-based scale. An 85% consensus level was chosen. In Round 3, 44 statements were re-rated by the panel.

RESULTS

Seventeen of 24 participants completed all three rounds of the study. Consensus was achieved for 63% of the items, while 18.5% reached near consensus, and 18.5% did not reach consensus after Round 3. The panel agreed on a number of important aspects of compulsive exercise. Several suggestions regarding the format of a questionnaire assessing this behavior were also endorsed. The panel further identified common difficulties when assessing compulsive exercise in eating disorder patients, notably a lack of consensus still apparent in the literature.

CONCLUSION

The current findings constitute a further step towards a unified definition of compulsive exercise, and contribute important suggestions to the measurement of this behavior.

Paper 2: a systematic review of narrative therapy treatment outcomes for eating disorders-bridging the divide between practice-based evidence and evidence-based practice

BACKGROUND

Narrative therapy has been proposed to have practice-based evidence however little is known about its research evidence-base in the treatment of eating disorders. The aim of this study was to conduct a systematic review of the outcome literature of narrative therapy for eating disorders.

METHOD

Treatment outcome data were extracted from 33 eligible included studies following systematic search of five data bases. The study is reported according to Preferred Reporting items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of the identified 33 studies, 3 reported positive outcomes using psychometric instruments, albeit some were outdated. Otherwise, reported outcomes were based on therapy transcript material and therapist reports. The most commonly reported treatment outcome was in relation to shifts in identity narratives and improved personal agency with a trend towards under-reporting shifts in ED symptoms. Some improvements were reported in interpersonal and occupational engagement, reduced ED symptoms, and improved quality of life, however, there was an absence of standardized measures to support these reports.

CONCLUSIONS

This systematic review found limited support for narrative therapy in the treatment of eating disorders through practice-based evidence in clinician reports and transcripts of therapy sessions. Less is known about systematic treatment outcomes of narrative therapy. There is a need to fill this gap to understand the effectiveness of narrative therapy in the treatment of EDs through systematic (1) Deliveries of this intervention; and (2) Reporting of outcomes. In doing so, the research arm of narrative therapy evidence base will become more comprehensively known.

Paper 1: a systematic synthesis of narrative therapy treatment components for the treatment of eating disorders

BACKGROUND

There are presently a number of eating disorder treatment interventions that have a research-evidence base to support their effectiveness. However, rates of attrition and treatment outcomes demonstrate that there is no one-size fits all for the treatment of eating disorders. Narrative therapy is a promising, but under-researched, intervention for the treatment of eating disorders (EDs). The aim of this study was to conduct a narrative synthesis of the literature to explore the content and use of narrative therapy in the treatment of EDs.

METHOD

Data were extracted from 33 eligible included studies following systematic search of five data bases. Data included aims and objectives, sample characteristics, treatment details and components of narrative therapy, which informed the narrative synthesis. The study is reported according to the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Narrative therapy interventions for EDs consisted of several components including the narrative worldview; unpacking the problem story; finding, thickening the meaning and performance of stories hidden by the problem story; and safety considerations. A notable proportion of the extracted articles discussed components of unpacking problem stories, and finding and re-authoring openings (or unique outcomes) that were hidden by problematic stories. Relatively fewer papers discussed the processes by identity shifts were performed or lived out, including in the eating practices of those with a lived ED experience. Furthermore, few papers addressed how therapists established client safety within the narrative framework when working with EDs.

CONCLUSION

This narrative synthesis found that narrative practitioners utilise a variety of narrative therapy techniques in working with individuals with a lived ED experience. The current literature has emphasis on specific narrative therapy techniques used in ED treatments, with some aspects of the narrative worldview and safety considerations left undiscussed. Additional research is needed to explore how identity shifts in narrative therapy are performed and lead to measurable behavioural changes, and to consider how safety considerations can be established within the narrative worldview. There are a number of psychological therapies for eating disorders that have research evidence-base. These treatments, however, do not work for everyone as indicated by drop-out rates and eating disorders running a severe and enduring course for some people. Narrative therapy is a therapeutic intervention that has been reported as a promising intervention for people with an eating disorder. The focus of narrative therapy is to engage the person in finding identities hidden by problem-saturated identities and in the performance of these hidden identities. In this review, we have explored the use of narrative therapy for eating disorders to identify what aspects of this therapy are currently being used and which components are less referenced in the literature. Findings from this study support the need for further research into narrative therapy components in the treatment of eating disorders, particularly how hidden identities are performed and safety considerations are integrated into this therapeutic intervention.

Beyond screening in primary practice settings: Time to stop fiddling while Rome is burning

OBJECTIVE

This forum presents the current state of research in the screening and identification of people with eating disorders in community and primary care, taking a longer-term perspective that highlights the slow rate of progression in development of instruments, and impact on polices and practice.

METHOD

An historical overview is presented, followed by a critique of contemporary instruments and practice, and barriers to case detection and appropriate referral pathways.

RESULTS

There are now many instruments but all lack high levels of positive predictive power. However, some do have high sensitivity. Barriers contributing to poor detection and the treatment gap include need for improved education and support for primary care professionals and lack of confidence of individuals with eating disorders to initiate a discussion with health professionals. The best screening instrument would not overcome either of these barriers.

DISCUSSION

We purport there is an urgent need to improve current screening instruments (not to develop more), particularly those with high sensitivity. These should be being employed alongside programs to both improve primary care professionals' skills in assessment and management of people with eating disorders, and to empower consumers to navigate care pathways.

PUBLIC SIGNIFICANCE STATEMENT

We argue that further screening instruments for eating disorders are not needed. Rather, it is more urgent to have a greater research focus on how to encourage primary care workers to ask about eating and body image and how to best translate that to more individuals with eating disorders being offered treatment. This work needs to be linked with tools that empower consumers to navigate care pathways.

Body image as a multidimensional concept: A systematic review of body image facets in eating disorders and muscle dysmorphia

Body image disturbance is core to the psychopathology of eating disorders (EDs), and related disorders such as muscle dysmorphia (MD). Global measures of body image fail to quantify specific aspects of body image disturbance that characterizes EDs, and may be differentially associated to outcomes. The aim of this systematic review was to provide an overview of specific body image facets and synthesize findings from controlled studies that compared clinical ED/MD and control-comparison groups in body image disturbance. One-hundred sixty-seven studies met inclusion criteria, and reported on comparisons among 30,584 individuals in 28 body image facets, which were more broadly grouped into evaluative, perceptual, cognitive-affective and motivational categories for the purpose of the present review. Effect sizes were calculated as Cohen's d for every comparison between ED and control groups. Body dissatisfaction (evaluative category) was the most prevalent facet assessed across studies (62 %), and differences between clinical and control groups were the largest in this category, especially for bulimia nervosa (d = 1.37). Scarcity of studies with male and MD clinical samples, and use of single-item and non-validated measures, should encourage development of instruments for body image facets pertinent to EDs and MD that can be validly applied across gender.

Management of eating disorders for people with higher weight: clinical practice guideline

INTRODUCTION

The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.

AIM

The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.

METHODS

The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.

RECOMMENDATIONS

Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.

CONCLUSIONS

This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.

Validation of the Brazilian version of the Short Inventory of Grazing (SIG)

OBJECTIVE

Grazing is a disturbed eating pattern that has been associated with eating disorders and obesity. One of the new measures to investigate this eating behavior is the Short Inventory of Grazing (SIG), a two-item questionnaire that assesses grazing in general and grazing associated with the feeling of loss of control over eating (LOC grazing). However, the psychometric properties of the SIG have not been assessed in the Brazilian population. The present study aimed to cross-culturally adapt and validate a Brazilian version of the SIG.

METHODS

The SIG was adapted to the Brazilian context following international guidelines. Then, 90 undergraduate students completed an online survey including questions from the SIG, the Binge Eating Scale (BES), the Patient Health Questionnaire-9 (PHQ9), the Generalized Anxiety Disorder-7 (GAD7), and a question related to self-reported health status. The internal consistency, test-retest reliability, and convergent validity of the questionnaire were assessed.

RESULTS

The prevalence rates of at least one weekly episode of grazing in general and LOC grazing were 71.1 and 54.5%, respectively. The internal consistence of the SIG was acceptable (0.81). In addition, SIG scores on both items were positively and significantly associated with BES, GAD7, and PHQ9 scores, and with poorer self-rated health. However, SIG test and retest scores differed significantly.

CONCLUSION

Overall, the Brazilian version of the SIG demonstrated adequate psychometric properties. The instrument had adequate internal consistency, with both items exhibiting good convergent validity with related measures.

Distinguishing delusional beliefs from overvalued ideas in Anorexia Nervosa: An exploratory pilot study

BACKGROUND

Characterised by the belief that more weight needs to be lost-despite emaciation, failing organs, medical instability and prospect of death-Anorexia Nervosa (AN) is a condition in which irrational, and highly-skewed, beliefs can be of delusional intensity. However, the nexus between delusion and rational awareness and how this is related to body image acceptance and perception has yet to be examined in AN. The current study aims to investigate the relationship between body dissatisfaction and beliefs of delusional intensity in an adult AN inpatient sample.

METHODS

Twenty-one adults (n_(women) = 20; n_(men) = 1), with a mean age of 27 years old (SD = 10), presenting for inpatient treatment for AN (ranging in severity from mild to severe; M_{(Body Mass Index)} = 17 kg/m²; M_{(Length of Stay)} = 22 days) participated in the study. Participants' dominant beliefs (related to AN) and level of insight (delusional; overvalued idea; or fair insight) were measured using either the Brown Assessment of Beliefs Scale (BABS) or the Nepean Beliefs Scale (NBS). The degree of body dissatisfaction was determined by examining the discrepancy between "perceived" and "ideal" body perception. To determine subjective and objective beliefs both the Contour Drawing Rating Scale (subjective) and computerised Body Image Assessment Software (objective) were used.

RESULTS

Almost one quarter (23.7%; n = 5) of participants appeared to have beliefs of delusional intensity related to their body shape (M = 27.4; SD = 23.03). Although a positive linear trend was indicated, there were no significant differences in body dissatisfaction scores between level-of-insight. Individuals whose belief was categorised as delusional were more likely to hold a negative affective body image state based on their ratings on the body image state survey when compared to the group who had good/fair insight (95% CI [0.53, 18.19]; p = 0.03).

CONCLUSIONS

The current exploratory pilot study concurs with others in the published literature that demonstrate that approximately 25 percent of participants with AN may have delusional ideas. The implications for treatment in similar samples warrant attention. Future research should also seek to understand the clinical significance of this delusional categorisation, the benefits of its utility in this population, and its relation to the severity of AN or stage of illness.

An exploratory examination of executive functioning as an outcome, moderator, and predictor in outpatient treatment for adults with anorexia nervosa

OBJECTIVE

People with anorexia nervosa often exhibit inefficiencies in executive functioning (central coherence and set shifting) that may negatively impact on treatment outcomes. It is unclear from previous research whether these inefficiencies can change over treatment. We aimed to (1) investigate whether executive functioning can improve over treatment, (2) determine whether baseline executive functioning moderates treatment outcome, and (3) examine whether baseline executive functioning predicts early change (i.e., increase in body mass index over the first 13 weeks of treatment) or remission.

METHOD

We conducted linear mixed model and logistic regression analyses on data from the Strong Without Anorexia Nervosa trial (Byrne et al. in Psychol Med 47:2823-2833, 2017). This study was a randomised controlled trial of three outpatient treatments for people with anorexia nervosa: Enhanced Cognitive Behavioural Therapy, Maudsley Model Anorexia Nervosa Treatment for Adults, and Specialist Supportive Clinical Management.

RESULTS

While set shifting clearly improved from baseline to end of treatment, the results for central coherence were less clear cut. People with low baseline central coherence had more rapid reductions in eating disorder psychopathology and clinical impairment than those with high baseline central coherence. Baseline executive functioning did not predict early change or remission.

DISCUSSION

The detail-focused thinking style commonly observed among people with anorexia nervosa may aid treatment outcomes. Future research that is more adequately powered should replicate this study and examine whether the same pattern of results is observed among people with non-underweight eating disorders.

The psychometric properties of the grazing questionnaire in an obesity sample with and without binge eating disorder

BACKGROUND

Despite being the first validated measure of grazing, the Grazing Questionnaire (GQ) has not been investigated among individuals with obesity. Therefore, the current study aimed to examine the psychometric properties of the GQ in an obesity sample.

METHODS

Participants (N = 259) were recruited from community and clinical settings in Australia. The sample comprised adults with normal weight (n = 77) and obesity (n = 182). A portion of individuals with obesity (n = 102) had binge eating disorder (BED). Data from the obesity group was examined to establish the factor structure, validity, and reliability of the GQ. A one-way ANOVA with planned contrasts was conducted to compare scores on the GQ across groups.

RESULTS

Confirmatory factor analysis revealed that the 2-factor model of the GQ was the best model fit for individuals with obesity. The GQ demonstrated high internal consistency, test-retest reliability over 3 months, and convergent and divergent validity. As hypothesised, the obesity group had significantly higher scores on the GQ than the normal weight group, while the obesity with BED group had significantly higher scores than the obesity without BED group.

CONCLUSION

This was the first study to investigate the psychometric properties of the GQ in an obesity sample. Overall, findings indicated that the GQ is a psychometrically sound measure of grazing among individuals with obesity. These findings provide further support for two distinct subtypes of grazing and highlight the importance of increased assessment and management of grazing behaviours for individuals with obesity and eating disorders. Maintaining a healthy weight is one of the greatest challenges for individuals with obesity. Certain eating patterns such as grazing may contribute to difficulties in weight management. Grazing is the repetitive and unplanned eating of small amounts of food that is not related to feeling hungry. Researchers and clinicians often use self-report questionnaires to measure grazing. However, the first validated questionnaire of grazing has not been investigated among individuals with obesity. Therefore, the goal of this study was to examine and validate the Grazing Questionnaire in individuals with obesity. Overall, our results showed that the Grazing Questionnaire is a valid and reliable self-report measure of grazing in individuals with obesity. Similar to previous research, we found that there are two subtypes of grazing. The first subtype involves continuous, unplanned eating. The second subtype is associated with a sense of loss of control over eating. We also found that people with obesity and binge eating disorder graze more than people with obesity that do not have binge eating disorder, while both groups graze more than individuals with normal weight. We recommend that clinicians routinely assess and treat unhelpful grazing patterns when working with individuals with obesity and eating disorders.

Associations between therapy experiences and perceived helpfulness of treatment for people with eating disorders

BACKGROUND

Although eating disorders cause significant impairment to an individual's function, many people disengage from treatment. There is a paucity of literature that focuses on both positive and negative aspects of eating disorder treatment experiences as perceived by the experiencing person. This study aimed to identify the associations between features of therapy with perceived treatment helpfulness across individuals' most and least helpful treatment experiences.

METHODS

An online cross-sectional survey was developed and disseminated, with the data of participants (n = 235) being utilised for statistical analyses, including multiple linear regressions.

RESULTS

As predicted, factors in the therapeutic relationship such as the therapist's ability to instil a sense of hope, provide freedom of choice, understand the person, and address participant concerns had significant explanatory value in perceived treatment helpfulness. Contrary to our hypothesis, change being retrospectively identified as important or possible by the participant did not have a high degree of relation. These outcomes highlighted the significance of the therapeutic relationship in governing positive treatment experiences and responses. The results also suggested motivation to change when commencing treatment may not be strongly related to perceived treatment helpfulness and support further exploration.

Interactions between emotion regulation and everyday flexibility in anorexia nervosa: Preliminary evidence of associations with clinical outcomes

The current study explored interactions between emotion regulation (ER) and cognitive-behavioral flexibility in everyday life in individuals with anorexia nervosa (AN). Participants were 97 female adults with current (57%) or past (43%) full or partial AN syndrome diagnosis. Participants completed the Difficulties with Emotion Regulation Scale, Emotion Regulation Questionnaire, Eating Disorder Flexibility Index, Eating Disorder Examination Questionnaire and Depression Anxiety Stress Scale short form. Lower flexibility was a strong independent predictor of more severe ED-related cognitions and higher frequency of compensatory behaviors beyond individual differences in emotion regulation and mood. ER measures did not predict clinical characteristics. However, two interactions between flexibility and ER measures were observed which suggested there was a stronger association between greater flexibility and higher BMI for individuals with either higher levels of cognitive reappraisal use, or higher levels of global ER difficulties. Interactions between flexibility and emotion regulation provide evidence that co-occurring difficulties may impact clinical outcomes in AN.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

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

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

Designing an online intervention for adults with addictive eating: a qualitative integrated knowledge translation approach

INTRODUCTION

Codesign is a meaningful end-user engagement in research design. The integrated knowledge translation (IKT) framework involves adopting a collaborative research approach to produce and apply knowledge to address real-world needs, resulting in useful and useable recommendations that will more likely be applied in policy and practice. In the field of food addiction (FA), there are limited treatment options that have been reported to show improvements in FA symptoms.

OBJECTIVES

The primary aim of this paper is to describe the step-by-step codesign and refinement of a complex intervention delivered via telehealth for adults with FA using an IKT approach. The secondary aim is to describe our intervention in detail according to the TIDieR checklist.

DESIGN

This study applies the IKT process and describes the codesign and refinement of an intervention through a series of online meetings, workshops and interviews.

PARTICIPANTS

This study included researchers, clinicians, consumers and health professionals.

PRIMARY OUTCOME MEASURE

The primary outcome was a refined intervention for use in adults with symptoms of FA for a research trial.

RESULTS

A total of six female health professionals and five consumers (n=4 female) with lived overeating experience participated in two interviews lasting 60 min each. This process resulted in the identification of eight barriers and three facilitators to providing and receiving treatment for FA, eight components needed or missing from current treatments, telehealth as a feasible delivery platform, and refinement of key elements to ensure the intervention met the needs of both health professionals and possible patients.

CONCLUSION

Using an IKT approach allowed for a range of viewpoints and enabled multiple professions and disciplines to engage in a semiformalised way to bring expertise to formulate a possible intervention for FA. Mapping the intervention plan to the TIDieR checklist for complex interventions, allowed for detailed description of the intervention and the identification of a number of areas that needed to be refined before development of the finalised intervention protocol.

Everyday flexibility and functional milestones in anorexia nervosa: survey results from a mixed community sample

PURPOSE

This study examined the relationship between self-reported cognitive-behavioral flexibility scores on the Eating Disorder Flexibility Index (EDFLIX) and objective social and occupational functional milestones in participants with a lifetime diagnosis of anorexia nervosa (AN). The Work and Social Adjustment Scale (WSAS) was included to compare objective and subjective measures.

METHODS

114 female adult participants with a current (53.5%) or past (46.5%) full or partial AN syndrome diagnosis completed an online survey which included functional milestone questions, the EDFLIX, WSAS, EDE-Q, and DASS-21.

RESULTS

Everyday flexibility scores were significantly associated with WSAS scores, but not functional milestones for the same domain. Lower flexibility was related to higher WSAS work impairment but was not associated with poor occupational outcomes. Lower flexibility was related to higher WSAS social impairment but was not associated with less frequent social contact with friends. Milestones across work, social and relationship areas were not significantly correlated, suggesting individuals have areas of strength and weakness across functional domains. In contrast, WSAS ratings indicated broad functional impairment.

CONCLUSION

Results from the milestones suggest self-reported cognitive-behavioral flexibility is not a strong determinant of everyday function. Results from the subjective WSAS function measure and the more objective functional milestones were not consistent. To obtain a more balanced assessment of everyday functioning in AN, both subjective and objective measures should be considered.

LEVEL OF EVIDENCE

Level III Case-control analytic study.

Intuitive Eating Scale-2: psychometric properties and clinical norms among individuals seeking treatment for an eating disorder in private practice

PURPOSE

Intuitive Eating (IE) is an approach to eating designed to facilitate a positive relationship with food. Its use in clinical settings and in the community is rapidly growing in popularity. The Intuitive Eating Scale 2 (IES-2) is a widely used measure that indexes intuitive eating motivations and behaviour, however evidence of its validity in populations with clinical eating disorders remains scarce. The objective of the proposed study was thus to evaluate the factor structure of the IES-2 in a large sample of individuals seeking treatment for eating disorders in private practice.

METHODS

Data collected from 569 women and men aged 12-68 years seeking treatment for an eating disorder in one of eight specialist private outpatient eating disorder clinics were examined using confirmatory factor analysis (CFA). Relationships between IES-2 scores and measures of psychopathology were also examined.

RESULTS

Results were relatively consistent with the purported four-factor structure of the IES-2. The measure displayed strong construct validity and good internal consistency. Scores on the IES-2 were inversely associated with scores of depression, anxiety, and disordered eating, providing evidence for divergent validity of the measure. Clinical norms are provided for anorexia nervosa (AN) spectrum disorders and bulimia nervosa (BN) spectrum disorders, as well as for the clinical sample as a whole.

CONCLUSION

Findings suggest that the IES-2 may be an appropriate measure for evaluating behaviours relating to IE in community outpatient eating disorder settings, and provide further evidence for the association between IE and positive health outcomes.

LEVEL OF EVIDENCE

III, evidence obtained from well-designed cohort or case-control analytic studies.

Research Review: Neuropsychological functioning in young anorexia nervosa: A meta-analysis

BACKGROUND

Cognitive inflexibility and compulsive behaviours are commonly observed in patients with anorexia nervosa (AN) and are often considered to be caused by impairments in executive functioning and visuospatial processing. Despite an increasing number of young individuals presenting with AN, there is a lack of meta-analytic evidence on the neuropsychological functioning in this population. Our primary aim was to review and synthesize the differences in neuropsychological test performance between young people with AN and healthy controls, and to explore potential moderators.

METHODS

A database search following PRISMA guidelines of MEDLINE, PsycINFO, ISI Web of Science and Epistemonikos was conducted. Hedges' g served as an effect size indicating the standardized mean differences. We utilized mixed-effects meta-regression and machine learning meta-analyses to identify relevant moderators.

RESULTS

Sixteen studies met the inclusion criteria with a total of 1333 participants (665 with AN) and 59 effect sizes. Random-effects meta-analyses demonstrated a small and insignificant difference between young individuals with AN and controls ( g¯  = -0.144, 95% CI [-0.328, 0.041]) in overall neuropsychological functioning. However, the difference was significant for the cognitive domains of memory, working memory and visuospatial abilities. Moderator and machine-learning analyses revealed a stronger negative effect in older participants and moderator effects of country and assessment quality.

CONCLUSIONS

Our findings highlight the significant impact of age on neuropsychological test performance in patients with AN. There is a need for a more widespread inclusion of potentially confounding variables in primary studies as well as instruments specifically targeted at younger populations.

Physical and mental health outcomes of an integrated cognitive behavioural and weight management therapy for people with an eating disorder characterized by binge eating and a high body mass index: a randomized controlled trial

BACKGROUND

Bulimia nervosa (BN) and binge eating disorder (BED) are eating disorders (EDs) characterized by recurrent binge eating. They are associated with medical complications, impaired adaptive function and often a high BMI, for which a multidisciplinary treatment approach may be needed. This study explored the efficacy of a novel intervention integrating Cognitive Behavioural Therapy- Enhanced (CBT-E) and weight management for people with recurrent binge eating episodes and high BMI with respect to physical, psychopathological and quality of life outcomes.

METHODS

Ninety-eight adults diagnosed with BN, BED, or Other Specified/Unspecified Feeding or Eating Disorder (OSFED/UFED) and BMI ≥ 27 to <40 kg/m² were randomized to a multidisciplinary approach, the Healthy APproach to weIght management and Food in Eating Disorders (HAPIFED) or to CBT-E. Metabolic parameters, health-related quality of life, general psychological and ED symptoms and ED diagnostic status outcomes are reported. Data were analyzed with mixed effects models adopting multiple imputed datasets where data were missing.

RESULTS

Both HAPIFED and CBT-E showed statistical significance for the time effect, with reduction in stress (p < 0.001), improvement in mental health-related quality of life (p = 0.032), reduction in binge eating severity (p < 0.001), and also in global ED symptoms scores (p < 0.001), with the significant changes found at end of treatment and sustained at 12-month follow-up. However, no statistical significance was found for differences between the interventions in any of the outcomes measured. Despite a high BMI, most participants (> 75%) had blood test results for glucose, insulin, triglycerides and cholesterol within the normal range, and 52% were within the normal range for the physical component of quality of life at baseline with no change during the trial period.

CONCLUSION

Integrating weight and ED management resulted in comparable outcomes to ED therapy alone. Although adding weight management to an ED intervention had no adverse effects on psychological outcomes, it also had no beneficial effect on metabolic outcomes. Therefore, more intense weight management strategies may be required where indicated to improve metabolic outcomes. Safety will need to be concurrently investigated.

TRIAL REGISTRATION

US National Institutes of Health clinical trial registration number NCT02464345 , date of registration 08/06/2015. Changes to the present paper from the published protocol paper (Trials 18:578, 2015) and as reported in the Trial registration (clinicaltrials.gov) are reported in Supplementary File 1.

Neural Response to Low Energy and High Energy Foods in Bulimia Nervosa and Binge Eating Disorder: A Functional MRI Study

Objective

Bulimia nervosa (BN) and binge eating disorder (BED) are eating disorders (EDs) characterized by recurrent binge eating (BE) episodes. Overlap exists between ED diagnostic groups, with BE episodes presenting one clinical feature that occurs transdiagnostically. Neuroimaging of the responses of those with BN and BED to disorder-specific stimuli, such as food, is not extensively investigated. Furthermore, to our knowledge, there have been no previous published studies examining the neural response of individuals currently experiencing binge eating, to low energy foods. Our objective was to examine the neural responses to both low energy and high energy food images in three emotive categories (disgust; fear; and happy) in BN and BED participants.

Methods

Nineteen females with BN (n = 14) or BED (n = 5), comprising the binge eating group (BEG; N = 19), and 19 age-matched healthy control (HC)’s completed thorough clinical assessment prior to functional MRI (fMRI). Neural response to low energy and high energy foods and non-food images was compared between groups using whole-brain exploratory analyses, from which six regions of interest (ROI) were then selected: frontal, occipital, temporal, and parietal lobes; insula and cingulate.

Results

In response to low energy food images, the BEG demonstrated differential neural responses to all three low energy foods categories (disgust; fear; and happy) compared to HCs. Correlational analyses found a significant association between frequency of binge episodes and diminished temporal lobe and greater occipital lobe response. In response to high energy food images, compared to HC’s, the BEG demonstrated significantly decreased neural activity in response to all high energy food images. The HC’s had significantly greater neural activity in the limbic system, occipital lobe, temporal lobe, frontal lobe, and limbic system in response to high energy food images.

Conclusion

Results in the low energy food condition indicate that binge frequency may be related to increased aberrant neural responding. Furthermore, differences were found between groups in all ROI’s except the insula. The neural response seen in the BEG to disgust food images may indicate disengagement with this particular stimuli. In the high energy food condition, results demonstrate that neural activity in BN and BED patients may decrease in response to high energy foods, suggesting disengagement with foods that may be more consistent with those consumed during a binge eating episode.

Perspectives on barriers to treatment engagement of people with eating disorder symptoms who have not undergone treatment: a qualitative study

BACKGROUND

Many people with an eating disorder (ED) never engage with an evidence-based ED treatment. Of the few studies that have qualitatively explored barriers to receiving treatment, some do so in relation to mental health conditions in general, and others focus on participants who have already undergone treatment. This study aims to address this gap in the literature by exploring the barriers to ED treatment engagement from the perspectives of individuals in the community with an ED (either self-identified or professionally diagnosed) and had not received ED treatment/s.

METHOD

Fifty-six of 772 participants in an online Eating Disorders Treatment Experience survey had self-identified as having symptoms consistent with an ED, or had received a diagnosis of an ED and indicated that they had never undergone treatment for an ED. They were asked to share the reasons for which they did not receive treatment with an open-ended question. Qualitative analysis of survey responses was completed using the Framework Method to generate overarching themes that encapsulated the diverse participant accounts.

RESULTS

The thematic analysis generated two main themes, each with two subthemes. The first theme was the negotiation of the need for treatment within oneself (intrapersonal factors; theme 1). The second theme explored interpersonal contexts that shaped the participant's decision not to seek treatment (interpersonal/external factors; theme 2). Two cross-cutting subthemes of fear and health literacy were also generated that demonstrated a high degree of overlap with the aforementioned main themes.

CONCLUSIONS

The process by which individuals decide whether or not to engage with ED treatment services is complex and involves intra- and interpersonal negotiations intertwined with health literacy and fear. A factor not prominent in previous research was negative self-perceptions and the belief of being undeserving of treatment. These factors have implications for ongoing community and clinical interventions to further address barriers to ED treatment engagement.

Binge eating disorder

Binge eating disorder (BED) is characterized by regular binge eating episodes during which individuals ingest comparably large amounts of food and experience loss of control over their eating behaviour. The worldwide prevalence of BED for the years 2018-2020 is estimated to be 0.6-1.8% in adult women and 0.3-0.7% in adult men. BED is commonly associated with obesity and with somatic and mental health comorbidities. People with BED experience considerable burden and impairments in quality of life, and, at the same time, BED often goes undetected and untreated. The aetiology of BED is complex, including genetic and environmental factors as well as neuroendocrinological and neurobiological contributions. Neurobiological findings highlight impairments in reward processing, inhibitory control and emotion regulation in people with BED, and these neurobiological domains are targets for emerging treatment approaches. Psychotherapy is the first-line treatment for BED. Recognition and research on BED has increased since its inclusion into DSM-5; however, continuing efforts are needed to understand underlying mechanisms of BED and to improve prevention and treatment outcomes for this disorder. These efforts should also include screening, identification and implementation of evidence-based interventions in routine clinical practice settings such as primary care and mental health outpatient clinics.

Conceptualising specialist supportive clinical management (SSCM): current evidence and future directions

BACKGROUND

Current evidence-based treatments for adult anorexia nervosa (AN) have limitations, with high attrition, very poor outcomes for 20% of people, and no clearly superior manualised therapy for adults with AN. Specialist Supportive Clinical Management (SSCM) was designed as a control treatment but has evolved as a valid first line treatment. The present paper aims to provide an overview of the evidence base for SSCM and a pedagogical reconceptualization with expansion by theoretical integration (TI). BODY: A secondary meta-analysis endorses SSCM as a promising treatment. This paper positions SSCM as a manualised therapy for adult AN with six unique features, namely (1) a philosophy which is person-centred, non-prescriptive, and informed by the person's strengths and values, (2) a focus on the person through inclusion of supportive psychotherapy and problem (clinical management), within target symptoms as defined in relation to AN, (3) a flexible and responsive therapy that could be delivered by a variety of clinicians with experience treating AN (4) a commitment to reversing starvation though a directional approach and a defined yet flexible stance on dietetic intervention (5) a commitment to the therapeutic relationship within all three phases of treatment, and (6) a therapy 'uncluttered' by specific mandates. In addition, this paper positions SSCM as a treatment that may be strengthened by other modalities and may also be adapted to the treatment of other eating disorders (ED), not just AN. The level of therapist sophistication to deliver upon the supportive psychotherapy component is explored and future directions are offered.

CONCLUSION

SSCM is a unique and valid first line treatment for AN and would benefit from further expansion in line with emerging understandings of AN to strengthen it as a treatment. Speculation on aspects of potency would benefit from further testing. The proposed re-conceptualisation of SSCM in the context of its evidence may strengthen it as a treatment overall, position it as adaptable for treatment of other eating disorders and make it more accessible to clinicians.

Informing the development of Australia's National Eating Disorders Research and Translation Strategy: a rapid review methodology

BACKGROUND

Eating disorders (EDs) are highly complex mental illnesses associated with significant medical complications. There are currently knowledge gaps in research relating to the epidemiology, aetiology, treatment, burden, and outcomes of eating disorders. To clearly identify and begin addressing the major deficits in the scientific, medical, and clinical understanding of these mental illnesses, the Australian Government Department of Health in 2019 funded the InsideOut Institute (IOI) to develop the Australian Eating Disorder Research and Translation Strategy, the primary aim of which was to identify priorities and targets for building research capacity and outputs. A series of rapid reviews (RR) were conducted to map the current state of knowledge, identify evidence gaps, and inform development of the national research strategy. Published peer-reviewed literature on DSM-5 listed EDs, across eight knowledge domains was reviewed: (1) population, prevalence, disease burden, Quality of Life in Western developed countries; (2) risk factors; (3) co-occurring conditions and medical complications; (4) screening and diagnosis; (5) prevention and early intervention; (6) psychotherapies and relapse prevention; (7) models of care; (8) pharmacotherapies, alternative and adjunctive therapies; and (9) outcomes (including mortality). While RRs are systematic in nature, they are distinct from systematic reviews in their aim to gather evidence in a timely manner to support decision-making on urgent or high-priority health concerns at the national level.

RESULTS

Three medical science databases were searched as the primary source of literature for the RRs: Science Direct, PubMed and OVID (Medline). The search was completed on 31st May 2021 (spanning January 2009-May 2021). At writing, a total of 1,320 articles met eligibility criteria and were included in the final review.

CONCLUSIONS

For each RR, the evidence has been organised to review the knowledge area and identify gaps for further research and investment. The series of RRs (published separately within the current series) are designed to support the development of research and translation practice in the field of EDs. They highlight areas for investment and investigation, and provide researchers, service planners and providers, and research funders rapid access to quality current evidence, which has been synthesised and organised to assist decision-making.

The potential role of stimulants in treating eating disorders

BACKGROUND

Many individuals with eating disorders remain symptomatic after a course of psychotherapy and pharmacotherapy; therefore, the development of innovative treatments is essential.

METHOD

To learn more about the current evidence for treating eating disorders with stimulants, we searched for original articles and reviews published up to April 29, 2021 in PubMed and MEDLINE using the following search terms: eating disorders, anorexia, bulimia, binge eating, stimulants, amphetamine, lisdexamfetamine, methylphenidate, and phentermine.

RESULTS

We propose that stimulant medications represent a novel avenue for future research based on the following: (a) the relationship between eating disorders and attention deficit/hyperactivity disorder (ADHD); (b) a neurobiological rationale; and (c) the current (but limited) evidence for stimulants as treatments for some eating disorders. Despite the possible benefits of such medications, there are also risks to consider such as medication misuse, adverse cardiovascular events, and reduction of appetite and pathological weight loss. With those risks in mind, we propose several directions for future research including: (a) randomized controlled trials to study stimulant treatment in those with bulimia nervosa (with guidance on strategies to mitigate risk); (b) examining stimulant treatment in conjunction with psychotherapy; (c) investigating the impact of stimulants on "loss of control" eating in youth with ADHD; and (d) exploring relevant neurobiological mechanisms. We also propose specific directions for exploring mediators and moderators in future clinical trials.

DISCUSSION

Although this line of investigation may be viewed as controversial by some in the field, we believe that the topic warrants careful consideration for future research.

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders

OBJECTIVE

Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group - anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder.

METHOD

Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13-60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis).

RESULTS

Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group.

CONCLUSION

Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.

People's lived experience with an eating disorder during the COVID-19 pandemic: A joint virtual issue of research published in leading eating disorder journals

The COVID-19 pandemic has profoundly disrupted people's daily life and contributed to adverse health and mental health outcomes. People with pre-existing mental health conditions are particularly likely to experience symptom exacerbation. Complementing the adverse impacts of the pandemic are eating disorder specific risk factors for worsening of eating disorder symptoms and/or impeding treatment progress and recovery. For this joint Virtual Issue, we selected 15 articles that have been published in two leading journals in the field of eating disorders (International Journal of Eating Disorders and Journal of Eating Disorders) to highlight studies that offer information about individuals' lived experience with an eating disorder during the COVID-19 pandemic. In these studies, most participants reported worsening of eating disorder symptoms which they attributed to challenges arising from changes in daily routines including eating and exercise related habits, increased stress, and diminished social contacts. These research findings reported a mixed picture about patients' perceptions of the ease of the transition to virtual delivery of treatment and the quality of care they received during the pandemic. Qualitative studies suggested strategies for supporting people with eating disorders during pandemic conditions, with some of these holding promise for improving care for individuals who experience an eating disorder.

Impact of the COVID-19 Pandemic on the Professional Identity of Massage Therapists: The Reporting of a Quantitative Strand of a Mixed-Methods Study

Introduction: In late 2019, a pathogen outbreak occurred that rapidly spread, resulting in the coronavirus disease 2019 (COVID-19) global pandemic. Governments responded to the pandemic with a range of strategies, including forced quarantines and nationwide lockdowns. Research on professional identity during the pandemic has predominately focused on health care providers declared as "essential" rather than "nonessential." In this study, the authors examine the impacts on the professional identity of massage therapists (MTs) who were predominately deemed as nonessential health care providers during the COVID-19 pandemic. Materials and methods: An online, questionnaire-based study sought to answer "In what ways has the professional identity of MTs in Canada and Australia been impacted by the COVID-19 global pandemic?" MTs in Canada and Australia were recruited using convenience sampling through e-mail and social media. A questionnaire was developed and pilot tested before implementation. Results: Six hundred and forty-nine MTs participated (329 from Canada and 316 from Australia). Known constructs of professional identity that were affected during the pandemic included not feeling respected as a health care practitioner, feeling less professional than other health care providers, and experiencing burnout. New constructs that may have developed out of the pandemic and the measures established to manage them included being classified as nonessential and feeling a sense of camaraderie and belonging. Conclusions: This study is the first of its kind to report the impact of the COVID-19 pandemic on the professional identity of MTs. The emerging constructs reported will be used to create interview questions for the subsequent qualitative strand of this explanatory mixed-methods study. In the qualitative study, respondents will be invited to share their experiences with their own voice to further the understanding of the impact of the COVID-19 pandemic on MTs' professional identity.

Emotion Dysregulation and Eating Disorder Symptoms: Examining Distinct Associations and Interactions in Adolescents

Emotion dysregulation has been posited as a key transdiagnostic factor of mental health difficulties, including eating disorders. However, how this transdiagnostic factor interacts with the disorder-specific factor of weight and shape concerns remains unclear. The current study examined whether emotion dysregulation is associated with eating disorder behaviors over and above the association between weight and shape concerns and whether these two factors interacted. The current study used data from two samples, a community sample of high school students (n = 2699), and a clinical sample of adolescents receiving outpatient treatment for an eating disorder (n = 149). Participants completed self-report measures on their eating behaviors, weight/shape concerns, and emotion dysregulation. Findings showed that emotion dysregulation had a unique association with engaging in binge eating and purging (community sample only). Weight and shape concerns were found to have a unique association with engaging in binge eating, fasting, purging, and driven exercise (community sample only). Additionally, weight and shape concerns moderated the association between emotion dysregulation and the probability of engaging in binge eating and driven exercise, whereby the strongest association between emotion dysregulation and these behaviors were observed among adolescents with the lowest levels of weight and shape concerns. Regarding the frequency of eating disorder behaviors, emotion dysregulation had a unique association with severity of binge eating and fasting. Weight and shape concerns were uniquely associated with severity of fasting and driven exercise (community sample only). Findings suggest that emotion dysregulation is a distinct factor of eating disorder behaviors among adolescents.

Correlates and impact of DSM-5 binge eating disorder, bulimia nervosa and recurrent binge eating: a representative population survey in a middle-income country

PURPOSE

Binge eating disorder (BED), bulimia nervosa (BN) and recurrent binge eating (RBE) are binge eating spectrum conditions causing a significant impact in individual's health and functioning. Information regarding those conditions came mostly from high-income countries. The objective of this study was to assess the prevalence of DSM-5 BED, BN and RBE and correlates in a representative sample from a metropolitan area of a middle-income country.

METHODS

The data were obtained from a cross-sectional population-based household survey in two stages in Rio de Janeiro, Brazil. Noninstitutionalized residents aged 18-60 years were assessed by lay interviewers using the Questionnaire of Eating and Weight Patterns-5 (QEWP-5). Positive cases and a paired sample screen-negative cases were reassessed by phone with the Eating Disorders Section of SCID-I-P (adapted for DSM-5). The data were collected from September 2019 to February 2020.

RESULTS

Overall, 2297 individuals were interviewed. Prevalence of BED was 1.4%, BN 0.7%, RBE 6.2%. Psychiatric comorbidities, such as depression, anxiety and ADHD were significantly more prevalent in people with BED, BN and RBE than in people without these eating problems. Several medical conditions, when controlling for body mass index, were significantly more prevalent in people with BED, BN and RBE. People with BED and BN had marked impairments in work/school, social and family life, reduced mental and physical HRQoL and under half had sought treatment.

CONCLUSION

As in high income countries, in Rio de Janeiro, Brazil, BED, BN and RBE are prevalent conditions and are associated with elevated BMI, functional impairment, psychiatric and medical comorbidity and poorer HRQoL.

Beyond Refeeding: The Effect of Including a Dietitian in Eating Disorder Treatment. A Systematic Review

Eating disorders are potentially life-threatening mental health disorders that require management by a multidisciplinary team including medical, psychological and dietetic specialties. This review systematically evaluated the available literature to determine the effect of including a dietitian in outpatient eating disorder (ED) treatment, and to contribute to the understanding of a dietitian’s role in ED treatment. Six databases and Google Scholar were searched for articles that compared treatment outcomes for individuals receiving specialist dietetic treatment with outcomes for those receiving any comparative treatment. Studies needed to be controlled trials where outcomes were measured by a validated instrument (PROSPERO CRD42021224126). The searches returned 16,327 articles, of which 11 articles reporting on 10 studies were included. Two studies found that dietetic intervention significantly improved ED psychopathology, and three found that it did not. Three studies reported that dietetic input improved other psychopathological markers, and three reported that it did not. One consistent finding was that dietetic input improved body mass index/weight and nutritional intake, although only two and three studies reported on each outcome, respectively. A variety of instruments were used to measure each outcome type, making direct comparisons between studies difficult. Furthermore, there was no consistent definition of the dietetic components included, with many containing psychological components. Most studies included were also published over 20 years ago and are now out of date. Further research is needed to develop consistent dietetic guidelines and outcome measures; this would help to clearly define the role of each member of the multidisciplinary team, and particularly the role of dietitians, in ED treatment.

Concurrent validity of the Brazilian Portuguese version of the Questionnaire on Eating and Weight Patterns-5 (QEWP-5) in the general population

The Questionnaire on Eating and Weight Patterns-5 is a self-report instrument developed for the screening of Binge Eating Disorder (BED) and Bulimia Nervosa (BN) according to DSM-5. The present study aimed to examine the concurrent validity of the Brazilian version of QEWP-5 to assess BED and BN in the general population. The Brazilian version of QEWP-5 was administered to 2297 subjects, aged from 18 to 60 years. All screen-positive and a subset of screen-negative participants were also interviewed by telephone using the eating disorders (ED) module of Structured Clinical Interview for DSM-IV - Patients Version (SCID-I-P) for the assessment of BED, BN, and their subthreshold forms. For the assessment of BED, the sensitivity of QEWP-5 was 0.41 and its specificity was 0.90. The positive and negative predictive values were 0.48 and 0.87, respectively. Regarding the assessment of BN, QEWP-5 showed a sensitivity of 0.56, a specificity of 0.90, a positive predictive value of 0.35, and a negative predictive value of 0.95. For the global screening of ED (BED, BN, and subthreshold forms), QEWP-5 showed a sensitivity of 0.71, a specificity of 0.83, a positive predictive value of 0.64 and a negative predictive value of 0.87. QEWP-5 can be a useful instrument for the initial screening of diagnostic threshold ED psychopathology in general population samples. However, it has less utility in identifying cases of BED and BN independently.

A cross-sectional examination of executive function and its associations with grazing in persons with obesity with and without eating disorder features compared to a healthy control group

PURPOSE

The current study aimed to investigate associations between grazing and different facets of executive functioning in persons with obesity with and without significant eating disorder psychopathology, compared to a healthy-weight control group.

METHODS

Eighty-nine participants (of which 20 had obesity and marked eating disorder symptomatology, 25 had obesity but without marked eating disorder symptoms, and 44 were healthy-weight age- and sex-matched participants; N = 89; 66.3% female, age = 28.59 (8.62); 18.18-58.34 years) completed a battery of neuropsychological tests and demographic and eating disorder-related questionnaires. Poisson, Negative Binomial, and Ordinary Least Squares regressions were performed to examine group differences and the associations of grazing with executive functioning within the three groups.

RESULTS

Significantly lower inhibitory control and phonemic fluency were observed for the obesity group without ED features compared to healthy-weight controls. Increasing grazing severity was associated with improved performance in inhibitory control in both groups with obesity, and with phonemic fluency in the obesity group with marked eating disorder features.

CONCLUSION

Although there is mounting evidence that specific cognitive domains, especially inhibition, are affected in obesity, evidence of further detrimental effects of eating disorder psychopathology remains mixed; additionally, for persons with obesity, there may be a weak but positive link between executive functioning and grazing behaviour.

LEVEL OF EVIDENCE

III, comparative cross-sectional observational study with a concurrent control group.

"I'm still here, but no one hears you": a qualitative study of young women's experiences of persistent distress post family-based treatment for adolescent anorexia nervosa

BACKGROUND

Family-based treatment (FBT) is the current treatment of choice for adolescent AN based on positive outcomes that include weight restoration in around two-thirds of adolescents. Nevertheless around a quarter drop-out from treatment, particularly in the earlier phases, and a notable proportion of treated adolescents are reported to experience ongoing psychological distress during and post-treatment. This study explores the under-researched experiences of these adolescents.

METHOD

Fourteen participants from Australia, New Zealand and the United Kingdom were interviewed about their experiences of FBT. An inductive thematic analysis of interview transcript data generated key themes related to their experiences, identity negotiations and the discursive materials these used to construct these.

RESULTS

The participants identified working as a family unit as key to their recovery, highlighting the importance of family therapy interventions for adolescent AN. However, they perceived an almost exclusive focus on weight restoration in the first phase of FBT was associated with experiences that included a relative neglect of their psychological distress and a loss of voice. Key within these experiences were processes whereby the adolescent engaged in identity negotiation and (re)claiming of their voice and implicit in their family standing with them in the treatment was that their life was worth saving. What was noted as most helpful was when therapists advocated and took into consideration their unique needs and preferences and tailored treatment interventions to these.

CONCLUSIONS

There is a need to develop and research treatments that address, from the outset of treatment, the adolescents' psychological distress (including as experienced in the context of their weight restoration). This should be with priority accorded to the adolescent's voice and identity negotiations, as they and their families take steps to address the physical crisis of AN and in doing so, support more holistic and durable recovery.

Emotion dysregulation across the span of eating disorder symptoms: Findings from a community sample of adolescents

OBJECTIVE

Emotion dysregulation is proposed as a key factor within eating disorder pathology. However, less is known about specific emotion regulation difficulties experienced by adolescents with varying levels of eating disorders symptoms. The present study examined the relationship between eating disorder behaviors and specific facets of emotion dysregulation, and differences in emotion dysregulation between eating disorder diagnostic groups.

METHOD

Participants were 2,783 adolescents, 11-19 years (M = 14 years, 9 months, SD = 1 year, 6 months), who completed self-report measures as part of the EveryBODY study. Adolescents were identified as not having eating disorder symptoms (n = 2,122) or meeting diagnostic criteria for symptoms of specific eating disorder, including: anorexia nervosa or atypical anorexia nervosa (n = 57), bulimia nervosa (n = 136), binge-eating disorder (n = 57), other specified feeding or eating disorder characterized by binge eating or purging (n = 381), and unspecified feeding or eating disorder (n = 30).

RESULTS

Binge eating, driven exercise, and fasting were each uniquely associated with emotion dysregulation, whereas purging was not. Similar findings were obtained within specific domains of emotion dysregulation. Findings from diagnostic groups showed a significant main effect of diagnosis on overall emotion dysregulation and most domains of emotion dysregulation. Adolescents with eating disorder symptoms consistently reported higher emotion dysregulation compared to those without these symptoms.

DISCUSSION

Findings indicate that emotion dysregulation is a key factor across eating disorder pathology, and potential treatment target across the spectrum of eating disorder diagnoses in adolescents.

Disordered Eating among People with Schizophrenia Spectrum Disorders: A Systematic Review

Disordered eating, or abnormal eating behaviours that do not meet the criteria for an independent eating disorder, have been reported among people with schizophrenia. We aimed to systemati-cally review literature on disordered eating among people with schizophrenia spectrum disorder (SSD). Seven databases were systematically searched for studies that described the prevalence and correlates of disordered eating among patients with SSD from January 1984 to 15 February 2021. Qualitative analysis was performed using the National Institutes of Health scales. Of 5504 records identified, 31 studies involving 471,159 subjects were included in the systematic review. The ma-jority of studies (17) rated fair on qualitative analysis and included more men, and participants in their 30s and 40s, on antipsychotics. The commonest limitations include lack of sample size or power calculations, poor sample description, not using valid tools, or not adjusting for con-founders. The reported rates were 4.4% to 45% for binge eating, 16.1% to 64%, for food craving, 27% to 60.6% for food addiction, and 4% to 30% for night eating. Positive associations were re-ported for binge eating with antipsychotic use and female gender, between food craving and weight gain, between food addiction and increased dietary intake, and between disordered eating and female gender, mood and psychotic symptoms. Reported rates for disordered eating among people with SSD are higher than those in the general population. We will discuss the clinical, treatment and research implications of our findings.

Supported online cognitive behavioural therapy for bulimia nervosa: a study protocol of a randomised controlled trial

BACKGROUND

Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions.

METHODS

A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness.

DISCUSSION

There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145 .