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• An estimated 9% of the U.S. population , or 28.8 million Americans, will have an eating disorder in their lifetime. 2
• 15% of women will suffer from an eating disorder by their 40s or 50s, but only 27% receive any treatment for it. 64
• Fewer than 6% of people with eating disorders are medically diagnosed as “underweight.” 7, 16 . In fact,  people in larger bodies are at the highest risk  of having developed an eating disorder in their lives, and among people in larger bodies,  the higher the BMI, the higher the risk . 60, 59
• In a sample from an American emergency room,  16% of adult patients screened positive for an eating disorder . 37
• Anorexia has the highest case mortality rate and second-highest crude mortality rate of any mental illness. 2
• 10,200 deaths each year are the direct result of an eating disorder—that’s one death every 52 minutes. 2
• Eating disorder sufferers with the highest symptom severity are  11 times more likely to attempt suicide than their peers without eating disorder symptoms, and even those with sub-threshold symptoms are 2 times more likely. 60   Patients with anorexia have a risk of suicide 18 times higher  than those without an eating disorder. 120
• The economic cost of eating disorders is $64.7 billion every year. 2

BIPOC* Eating Disorder Statistics

• While  BIPOC people are affected by eating disorders at similar rates  overall as their white peers,  they are about half as likely to be diagnosed . 63, 93
• BIPOC patients with eating and weight concerns are  significantly less likely to be asked about eating disorder symptoms by their doctors  than are non-minority patients.  3
• When therapists were presented with descriptions of a fictional patient—identical except for race—they were  less likely to recognize eating disorder symptoms in the Black and Hispanic patient  compared to the white patient.  66
• In a study of adolescents age 11 to 25 who were suffering malnutrition from an eating disorder,  only 40% received the recommended treatment , and patients who  used public insurance   were   only one third as likely to receive the recommended mental health treatment  for their eating disorders as youth with private insurance. Latinx patients were about  half as likely to receive the necessary treatment  as their white peers.  30
• Asian American college students report higher rates of restriction  compared with their white peers and higher rates of purging, muscle building, and cognitive restraint than their white or non-Asian BIPOC peers.  5
• Asian American college students report higher levels of body dissatisfaction  and negative attitudes toward obesity than their non-Asian BIPOC peers.  5
• Members of the LGBTQ+ community are at a  higher risk of having an eating disorder  than heterosexual people. Overall,  LGBTQ+ youth are three times more likely to have an eating disorder  when compared to their straight peers with homosexual and bisexual girls at 2.5 times and homosexual and bisexual boys at 6 times higher rates. 69, 71, 72
• About  1 in 3 sexual minority teenagers say they engaged in dangerous weight control behaviors  within the past month.  Gay and bisexual boys are four times more likely , and  lesbian and bisexual girls are twice as likely , to do so than their heterosexual peers.  70
• About  75% of transgender college students with eating disorders attempt suicide .  56
• Transgender college students are diagnosed with eating disorders at four times the rate  of their cisgender classmates.  73
• 32% of transgender people report using their eating disorder to modify their body  without hormones, such as to reduce curves or halt menstruation. Even so, 56% of transgender people with eating disorders  believe their disorder is not related to their physical body .  8

People with Co-Occurring Conditions Eating Disorder Statistics

• Over 70% of people with eating disorders also have other conditions , most commonly anxiety and mood disorders.  74
• People with disabilities  may have body image concerns related to their disability  that lead to developing and sustaining an eating disorder.  77
• Women with certain physical disabilities may be more likely to have  eating disorder behavior.  75
• People with diet-related chronic conditions —like diabetes and irritable bowel disease— may be at a higher risk of disordered eating.  112
• In a study, girls with type 1 diabetes aged 9-13 were evaluated for 14 years, and  by the time they were in their 20s, 40.8% met criteria for a full- or sub-threshold eating disorder , and 59.2% took part in dangerous disordered eating behavior.  113
• Eating disorders in people with type I diabetes are associated with a significantly higher risk of severe medical complications , including more frequent and longer hospitalizations, and a greater risk of ketoacidosis and retinopathy.  124
• People with eating disorders typically have between one and four other psychiatric disorders . Indeed, the majority of adolescents with eating disorders have at least one other psychiatric disorder, ranging from a low of 55% for anorexia to a high of 88% for bulimia.  21, 35
• Between  13 to 58% of ARFID patients also have Autism Spectrum Disorder . In a study of children with ASD and severe food limitations,  78% ate a diet that put them at risk for five or more nutritional deficiencies.  79, 80, 81, 82
• Between 6 and 17%  of eating disorder patients  also have ADHD.  86-87
• Girls with ADHD are 3.6 times more likely to have an eating disorder  in general and 5.6 times more likely to have bulimia in particular.  88
• Between  10 and 35% of patients with eating disorders have OCD  unrelated to the eating disorder.  118
• In a study of college and university students,  just 2% of those who met criteria for eating disorders were “underweight.”  93
• For the overall populace, the figure is usually  estimated to be less than 6% .  60
• People in larger bodies  are at higher risk of using unhealthy weight control behaviors.  21, 52, 98
• About  40% of “overweight“ girls and 20% of “overweight“ boys use disordered eating behaviors.   99
• Patients meeting the standard diagnostic criteria for anorexia were 14 times more likely to receive the recommended treatment  than those with  atypical anorexia . 30
• Among those who experience weight stigma,  two-thirds were stigmatized by doctors , leading many to avoid seeking healthcare.  102
• People who experience weight discrimination  are 60% more likely to die.  94
• Athletes report higher rates of excessive exercise  than non‐athletes.  14
• Female athletes are twice as likely to engage in eating disorder behavior than male athletes; however,  both men (77%) and women (80%) participating in weight-dependent sports report using compensatory behaviors.  43
• Eating disorders may be particularly hard to detect among athletes  due in part to secretiveness, stigma, and symptom presentation.  47
• Athletes may be less likely to seek treatment  for an eating disorder due to stigma, accessibility, and sport‐specific barriers.  14
• Certain aspects of military life are thought to contribute to developing or exacerbating eating disorders,  including weight and fitness requirements, the stress of combat exposure, and sexual trauma.  62
• Body dysmorphic disorder affects   13.0% of male military members and 21.7% of female military members , more than  five times the rates for the overall population .  107
• One-third of overweight military personnel engage in unhealthy weight loss behavior to “make weight”  while in the service, and  they are more likely to suffer from eating disorder behavior later in life  as veterans.  39
• Over 16% of female military personnel and veterans have suffered from an eating disorder , with associations between the eating disorder and sexual trauma and PTSD.  108
• In the five years studied—from 2017 to 2021– the incidence rates of eating disorders among active service  members increased by 79% .  61
• In a study of military personnel from Iraq and Afghanistan, an estimated  32.8% of female and 18.8% of male veterans showed signs of probable eating disorders , highest being atypical anorexia nervosa (13.6% of women and 4.9% of men), bulimia nervosa (6.1% of women and 3.5% of men), and binge-eating disorder (4.4% of women and 2.9% of men).  109
• At age 6 to 10, girls start to worry about their weight, and by 14,  60 to 70% are trying to lose weight .  35
• A survey found that  77% of children and adolescents as young as 12 dislike their bodies , and  45% say they are regularly bullied about how they look .  128
• Weight-related teasing is  a primary way kids are bullied , and  kids in bigger bodies are significantly more likely to be bullied  than their smaller-bodied classmates. 103, 104
• Girls who were teased about their weight were  two times more likely to be “overweight,”  1.5 times more likely to binge eat, and 1.5 times more likely to use extreme methods of weight control five years later.  99
• 22% of children and adolescents have unhealthy eating behaviors  that could lead to or indicate an eating disorder.  89
• A study found  8% of 15-year-old girls diet at a severe level , and their risk of developing an eating disorder was  18 times greater  than her non-dieting peers. 90
• About  12% of adolescent girls have some form of eating disorder .  126
• Just  20% of adolescents with eating disorders disorders seek treatment .  38
• Men represent up to 25% of people with eating disorders .  45
• Even so,  women are up to five times more likely to be diagnosed  and 1.5 times more likely to be treated for an eating disorder than men are.  93
• Men with eating disorders tend not to recognize their symptoms as problematic , in part due to the stereotype of eating disorders as being a “woman’s problem.”  110
• By the time men with eating disorder symptoms present in healthcare settings, their cases tend to be more severe , in part due to their denial of symptoms, anticipated or encountered prejudice, and even denial of treatment because of their gender.  44
• Healthcare professionals tend to minimize the symptoms of men with eating disorders.  46

Older Adults Eating Disorder Statistics

• While most older adults with eating disorders have had symptoms since adolescence,  life transitions and stressors common in older adulthood —such as children leaving the home and menopause— can make eating disorders much worse .  70
• Among women age 50 and over,  71.2% say they are currently trying to lose weight , and 79.1% said their weight or shape had a “moderate” effect on or was “the most important” part of their self-esteem.  125
• 41% of women over 50 have current or previous core eating disorder symptoms , divided into 13.3% who have current and 27.7% with past symptoms.  125
• Compare to other patients, eating disorder patients who receive mentorship  report significant improvement in 7 of 12 areas related to quality of life, and greater psychological, emotional, and physical well-being. 129
• Patients in eating disorder treatment are  119% more likely to attend appointments  with their providers when they also receive mentorship. 129
• Eating disorder patients who receive mentorship from peers who have recovered from an eating disorder  see greater reduction in body dissatisfaction and anxiety  than those who received support from people without lived experience. 130
• Parents and families  supporting someone with an eating disorder got  significant value out of connecting with a mentor . They benefited greatly from the support, information, and compassion received. 131
• Research suggests that using trained mentors to deliver mental health care  could increase the number of youth receiving evidence-based mental health care.   132

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Eating Disorders

Eating disorders are serious and sometimes fatal illnesses that cause severe disturbances to a person’s eating behaviors. Obsessions with food, body weight, and shape may also signal an eating disorder. Common eating disorders include binge eating disorder, bulimia nervosa, and, less common but very serious, anorexia nervosa.

Additional information about eating disorders can be found on the NIMH Health Topics page on Eating Disorders .

Definitions

Binge eating disorder.

• Binge eating disorder is characterized by recurrent binge eating episodes during which a person feels a loss of control and marked distress over his or her eating. Unlike bulimia nervosa, binge eating episodes are not followed by purging, excessive exercise or fasting. As a result, people with binge eating disorder often are overweight or obese.

Bulimia Nervosa

• Bulimia nervosa is characterized by binge eating (eating large amounts of food in a short time, along with the sense of a loss of control) followed by a type of behavior that compensates for the binge, such as purging (e.g., vomiting, excessive use of laxatives, or diuretics), fasting, and/or excessive exercise. Unlike anorexia nervosa, people with bulimia can fall within the normal range for their weight. But like people with anorexia, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape.

Anorexia Nervosa

• Anorexia nervosa is characterized by a significant and persistent reduction in food intake leading to extremely low body weight in the context of age, sex, and physical health; a relentless pursuit of thinness; a distortion of body image and intense fear of gaining weight; and extremely disturbed eating behavior. Many people with anorexia see themselves as overweight, even when they are starved or severely malnourished.

Age of Onset

Based on diagnostic interview data from the National Comorbidity Survey Replication (NCS-R), median age of onset was 21 years-old for binge eating disorder and 18 years-old for both bulimia nervosa and anorexia nervosa. 1

Prevalence of Eating Disorders in Adults

Based on diagnostic interview data from the NCS-R, the data below indicate the past year prevalence of each type of eating disorder among U.S. adults aged 18 and older. 1

• The overall prevalence of binge eating disorder was 1.2%.
• Prevalence of binge eating disorder was twice as high among females (1.6%) than males (0.8%).
• Based on Sheehan Disability Scale associated with past year behavior, 62.6% of people with binge eating disorder had any impairment and 18.5% had severe impairment.
• The lifetime prevalence of binge eating disorder was 2.8%.
• The overall prevalence of bulimia nervosa was 0.3%.
• Prevalence of bulimia nervosa was five times higher among females (0.5%) than males (0.1%).
• Based on Sheehan Disability Scale* associated with past year behavior, 78.0% of people with bulimia nervosa had any impairment and 43.9% had severe impairment.
• The lifetime prevalence of bulimia nervosa was 1.0%.
• The lifetime prevalence of anorexia nervosa in adults was 0.6%.
• Lifetime prevalence of anorexia nervosa was three times higher among females (0.9%) than males (0.3%).
• A past year prevalence estimate for anorexia nervosa was not generated in the NCS-R sample of respondents. 1

Co-morbidity with Other Mental Disorders in Adults

• More than half (56.2%) of respondents with anorexia nervosa, 94.5% with bulimia nervosa, and 78.9% with binge eating disorder met criteria for at least one of the core DSM-IV disorders assessed in the NCS-R.
• All three eating disorders had the highest comorbidity with any anxiety disorder.
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Treatment of Eating Disorders in Adults

• Approximately one-third (33.8%) of respondents with anorexia nervosa, 43.2% with bulimia nervosa, and 43.6% with binge eating disorder sought treatment specifically for their eating disorder.
• Females with bulimia nervosa and binge eating disorder sought treatment more than males. However, males with anorexia nervosa sought treatment more often than females.
• A majority of respondents with anorexia nervosa, bulimia nervosa, and binge eating disorder (50.0%–63.2%) received treatment for emotional problems at some time in their lives (data not shown).

Prevalence of Eating Disorders in Adolescents

• The lifetime prevalence of eating disorders was 2.7%.
• Eating disorders were more than twice as prevalent among females (3.8%) than males (1.5%).
• Prevalence increased modestly with age.
• In the NCS-A, eating disorders included anorexia nervosa, bulimia nervosa, and binge eating disorder.

Data Sources

• Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58. PMID: 16815322 
• Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9. PMID: 20855043 

Statistical Methods and Measurement Caveats

This webpage presents data from the following sources.

National Comorbidity Survey Replication (NCS-R)

Diagnostic Assessment and Population:

• The NCS-R is a nationally representative, face-to-face, household survey conducted between February 2001 and April 2003 with a response rate of 70.9%. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview (WMH-CIDI), a fully structured lay-administered diagnostic interview that generates both International Classification of Diseases, 10 th Revision, and DSM-IV diagnoses. The DSM-IV criteria were used here. Participants for the main interview totaled 9,282 English-speaking, non-institutionalized, civilian respondents. Eating disorders were assessed in a subsample of 2,980 respondents. The Sheehan Disability Scales (SDS) assessed disability in work role performance, household maintenance, social life, and intimate relationships on 0–10 scales. The NCS-R was led by Harvard University.

Survey Non-response:

• In 2001-2002, non-response was 29.1% of primary respondents and 19.6% of secondary respondents. Reasons for non-response to interviewing include: refusal to participate (7.3% of primary, 6.3% of secondary); respondent was reluctant- too busy but did not refuse (17.7% of primary, 11.6% of secondary); circumstantial, such as intellectual developmental disability or overseas work assignment (2.0% of primary, 1.7% of secondary); and household units that were never contacted (2.0%).
• For more information, see PMID: 15297905  .

National Comorbidity Survey Adolescent Supplement (NCS-A)

• The NCS-A was carried out under a cooperative agreement sponsored by NIMH to meet a request from Congress to provide national data on the prevalence and correlates of mental disorders among U.S. youth. The NCS-A was a nationally representative, face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States. The survey was based on a dual-frame design that included 904 adolescent residents of the households that participated in the adult U.S. National Comorbidity Survey Replication and 9,244 adolescent students selected from a nationally representative sample of 320 schools. The survey was fielded between February 2001 and January 2004. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview.
• The overall adolescent non-response rate was 24.4%. This is made up of non-response rates of 14.1% in the household sample, 18.2% in the un-blinded school sample, and 77.7% in the blinded school sample. Non-response was largely due to refusal (21.3%), which in the household and un-blinded school samples came largely from parents rather than adolescents (72.3% and 81.0%, respectively). The refusals in the blinded school sample, in comparison, came almost entirely (98.1%) from parents failing to return the signed consent postcard.
• For more information, see PMID: 19507169  .

• Open access
• Published: 30 May 2023

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

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

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

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

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

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

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

Plain English summary

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

Introduction

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

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

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

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

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

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

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

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

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

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

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

Overall outcomes

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

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

Remission, recovery, and relapse

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

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

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

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

Diagnostic crossover

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

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

Anorexia nervosa (AN)

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

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

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

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

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

Bulimia nervosa (BN)

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

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

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

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

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

Binge eating disorder (BED)

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

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

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

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

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

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

EDNOS, OSFED and UFED

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

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

Avoidant/Restrictive Food Intake Disorder (ARFID)

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

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

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

Community outcomes

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

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

Factors relating to outcomes

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

Age of presentation

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

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

Clinical features and co-occurring conditions

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

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

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

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

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

Psychosocial, environmental and health factors

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

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

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

Treatment factors

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

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

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

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

Self-esteem, self-compassion, and motivation

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

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

Relapse prevention programs

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

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

Online relapse prevention programs

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

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

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

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

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

Standardised, weighted, and crude mortality

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

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

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

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

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

Years of life lost/years lived with disability

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

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

Risk factors

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

Cause of death

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

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

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

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

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

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

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

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

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

Key findings

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

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

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

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

Strengths and limitations

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

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

Availability of data and materials

Not applicable—all citations provided.

Abbreviations

Atypical anorexia nervosa

Adolescent focused therapy

• Anorexia nervosa

Anorexia nervosa binge/purge subtype

Anorexia nervosa restricting subtype

Avoidant restrictive food intake disorder

• Binge eating disorder

Body mass index

• Bulimia nervosa

Behavioural weight loss therapy

Cognitive behaviour therapy

Enhanced cognitive behavioural therapy

Crude mortality rate

Diagnostic and statistical manual of mental disorders

Expected body weight

• Eating disorders

Eating disorder examination questionnaire

Eating disorder not otherwise specified

Eating disorder not otherwise specified-anorectic type

Eating disorder not otherwise specified-bulimic type

End of treatment

Family-based therapy

Healthcare management advisors

Health related quality of life

Integrative cognitive-affective therapy

InsideOut Institute

Interpersonal therapy

Major depressive disorder

Objective binge eating

Obsessive compulsive disorder

Other specified feeding or eating disorder

Quality of life

Randomised controlled trial

National eating disorder research & translation strategy rapid review

Standardised mortality ratio

Substance use disorder

Treatment as usual

Unspecified feeding or eating disorder

Weighted mortality ratio

Years of life lost

Years lived with a disability

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Acknowledgements

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

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

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

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

Sydney Local Health District, Sydney, Australia

Healthcare Management Advisors, Melbourne, Australia

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

Robert Boakes, Rebecca Pinkus & Paul Rhodes

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

Leah Brennan & Eleanor Wertheim

School of Psychology, Perth, Western Australia, Australia

Susan Byrne

Eating Disorders Victoria, Victoria, Australia

Belinda Caldwell

Perth, Australia

Shannon Calvert

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

David Castle

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

Ian Caterson

Eating Disorders Queensland, Brisbane, QLD, Australia

Belinda Chelius

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

Westmead Hospital, Sydney, NSW, Australia

Simon Clarke

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

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

Brisbane, Australia

Lexi Crouch

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

Jasmine Fardouly & Lenny Vartanian

University of Sydney, Sydney, NSW, Australia

Carmen Felicia & Amber-Marie Firriolo

New South Wales Health, Sydney, NSW, Australia

John Feneley & Karen Rockett

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

Mathew Fuller-Tyszkiewicz & Ross King

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

Anthea Fursland

Hollywood Clinic, Ramsay Health Care, Perth, Australia

Bethanie Gouldthorp & Jake Linardon

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

Scott Griffiths & Isabel Krug

Queensland Eating Disorder Service, Brisbane, QLD, Australia

Amy Hannigan

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

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

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

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

Francis Kay-Lambkin

Westmead Hospital, Sydney, Australia

Michael Kohn

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

Randall Long

Exchange Consultancy, Redlynch, NSW, Australia

Amanda Long

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

Sloane Madden

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

Sian McLean

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

Thy Meddick

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

Richard O’Kearney & Elizabeth Rieger

ADHD and BED Integrated Clinic, Melbourne, VIC, Australia

Roger Paterson

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

Susan Paxton

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

Genevieve Pepin

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

Andrea Phillipou

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

Judith Piccone

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

Bronwyn Raykos

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

Janice Russell

Ramsay Health Care, Perth, Australia

Fiona Salter

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

Susan Sawyer

National Eating Disorders Collaboration, Victoria, Australia

Beth Shelton

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

Urvashnee Singh

Sydney, Australia

Sophie Smith

The Butterfly Foundation, Sydney, Australia

Sarah Squire, Juliette Thomson & Ranjani Utpala

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

Andrew Wallis

Department of Psychiatry, University of Queensland, Brisbane, Australia

Warren Ward

University of Tasmania, Hobart, TAS, Australia

Sarah Wells

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

Simon Wilksch

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

Michelle Williams

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National Eating Disorder Research Consortium

• Phillip Aouad
• , Sarah Barakat
• , Robert Boakes
• , Leah Brennan
• , Emma Bryant
• , Susan Byrne
• , Belinda Caldwell
• , Shannon Calvert
• , Bronny Carroll
• , David Castle
• , Ian Caterson
• , Belinda Chelius
• , Lyn Chiem
• , Simon Clarke
• , Janet Conti
• , Lexi Crouch
• , Genevieve Dammery
• , Natasha Dzajkovski
• , Jasmine Fardouly
• , Carmen Felicia
• , John Feneley
• , Amber-Marie Firriolo
• , Nasim Foroughi
• , Mathew Fuller-Tyszkiewicz
• , Anthea Fursland
• , Veronica Gonzalez-Arce
• , Bethanie Gouldthorp
• , Kelly Griffin
• , Scott Griffiths
• , Ashlea Hambleton
• , Amy Hannigan
• , Susan Hart
• , Phillipa Hay
• , Ian Hickie
• , Francis Kay-Lambkin
• , Ross King
• , Michael Kohn
• , Eyza Koreshe
• , Isabel Krug
• , Jake Linardon
• , Randall Long
• , Amanda Long
• , Sloane Madden
• , Sarah Maguire
• , Danielle Maloney
• , Peta Marks
• , Sian McLean
• , Thy Meddick
• , Jane Miskovic-Wheatley
• , Deborah Mitchison
• , Richard O’Kearney
• , Shu Hwa Ong
• , Roger Paterson
• , Susan Paxton
• , Melissa Pehlivan
• , Genevieve Pepin
• , Andrea Phillipou
• , Judith Piccone
• , Rebecca Pinkus
• , Bronwyn Raykos
• , Paul Rhodes
• , Elizabeth Rieger
• , Sarah-Catherine Rodan
• , Karen Rockett
• , Janice Russell
• , Haley Russell
• , Fiona Salter
• , Susan Sawyer
• , Beth Shelton
• , Urvashnee Singh
• , Sophie Smith
• , Evelyn Smith
• , Karen Spielman
• , Sarah Squire
• , Juliette Thomson
• , Stephen Touyz
• , Ranjani Utpala
• , Lenny Vartanian
• , Sabina Vatter
• , Andrew Wallis
• , Warren Ward
• , Sarah Wells
• , Eleanor Wertheim
• , Simon Wilksch
•  & Michelle Williams

Contributions

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

Corresponding author

Correspondence to Jane Miskovic-Wheatley .

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Not applicable.

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Competing interests.

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

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Supplementary Information

Additional file 1: fig. s1..

PRISMA flow diagram.

Additional file 2: Table S1.

Studies included in the Rapid Review.

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

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Anorexia nervosa.

Christine A. Moore ; Brooke R. Bokor .

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Last Update: August 28, 2023 .

• Continuing Education Activity

Anorexia nervosa is defined by the restriction of nutrient intake relative to requirements, which leads to significantly low body weight. Patients with this eating disorder will have a fear of gaining weight along and a distorted body image with the inability to comprehend the seriousness of their condition. This activity reviews the evaluation and management of anorexia nervosa and highlights the role of the interprofessional team in improving care for patients with this condition.

• Outline the epidemiology of anorexia nervosa.
• Explain the pathophysiology of anorexia nervosa.
• Describe the management of anorexia nervosa.
• Summarize the importance of improving care coordination among the interprofessional team members to enhance the delivery of care for those with anorexia nervosa.
• Introduction

Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight. Patients will have an intense fear of gaining weight and distorted body image with the inability to recognize the seriousness of their significantly low body weight. [1] [2] [3]

The success of many professions depends on a person's weight. Models and actors portray a level of thinness that is difficult to attain, and it is enhanced by make-up and photographic alterations. Athletes in sports such as ballet, long-distance running, and martial arts are pressured to maintain lean body weights to outperform the competition. Media outlets promote diet secrets and weight loss tips in excess. Populations such as maturing females identify thin body types with increased self-esteem and link weight loss with self-control. [4] [5]

• Epidemiology

Anorexia nervosa is more common in females than males. Onset is late adolescence and early adulthood. Lifetime prevalence is 0.3% to 1% (European studies have demonstrated a prevalence of 2% to 4%), irrespective of culture, ethnicity, and race. Risk factors for eating disorders include childhood obesity, female sex, mood disorders, personality traits (impulsivity and perfectionism), sexual abuse, or weight-related concerns from family or peer environments. [6] [7] [8]

• Pathophysiology

Studies demonstrate biological factors play a role in the development of anorexia nervosa in addition to environmental factors. Genetic correlations exist between educational attainment, neuroticism, and schizophrenia. Patients with anorexia nervosa have altered brain function and structure there are deficits in neurotransmitters dopamine (eating behavior and reward) and serotonin (impulse control and neuroticism), differential activation of the corticolimbic system (appetite and fear), and diminished activity among the frontostriatal circuits (habitual behaviors). Patients have co-morbid psychiatric disorders such as major depressive disorder and generalized anxiety disorder.

• History and Physical

Patients will report symptoms such as amenorrhea, cold intolerance, constipation, extremity edema, fatigue, and irritability. They may describe restrictive behaviors related to food like calorie counting or portion control, and purging methods, for example, self-induced vomiting or use of diuretics or laxatives. Many exercise compulsively for extended periods of time. Patients with anorexia nervosa develop multiple complications related to prolonged starvation and purging behaviors.

Workup includes a thorough medical history (comprehensive review of systems, family and social history, medications including nonprescribed, past medical and psychiatric history, prior abuse) and physical exam (looking for complications above). Basic labs include coagulation panel, complete blood count, complete metabolic profile, 25-hydroxyvitamin D, testosterone (males), thyroid-stimulating hormone, and urine testing (beta-hCG [females] and drugs, either illicit or prescription). An electrocardiogram is recommended to assess for life-threatening arrhythmias. Additional studies may be necessary if BMI is less than 14 kg/m, for example, echocardiogram in patients with hemodynamic compromise (dyspnea, murmurs, syncope) or computed tomography of the abdomen to rule out superior mesenteric artery syndrome or amenorrhea more than 9 months (dual-energy x-ray absorptiometry). [9] [8]

Complications of anorexia nervosa are listed:

• Cardiovascular: bradycardia, dilated cardiomyopathy, electrolyte-induced arrhythmias, hypotension, mitral valve prolapse, pericardial effusion
• Constitutional: arrested growth, hypothermia, low body mass index (BMI), muscle wasting
• Dermatologic: carotenoderma, lanugo, xerosis
• Endocrine: hypothalamic hypogonadism, osteoporosis
• Gastrointestinal: constipation (laxative abuse), gastroparesis
• Hematologic: cytopenias (inc. normocytic anemia), bone marrow hypoplasia/aplasia
• Neurologic: brain atrophy, peripheral neuropathy (mineral and vitamin deficiencies)
• Obstetric: antenatal and postnatal complications
• Psychiatric: depression, impaired concentration, insomnia, irritability
• Renal and electrolytes: hypokalemic metabolic acidosis or alkalosis (laxative or diuretic abuse, resp.), prerenal renal failure, refeeding syndrome.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides the diagnostic criteria for anorexia nervosa (A-C). It classifies the disease by type, status, and severity.

Of note, amenorrhea has been removed from the DSM-5 criteria. Patients who meet the new criteria and continue to menstruate have similar outcomes as those who do not.

Other eating disorders have similar features to anorexia nervosa. Avoidant or restrictive food intake disorder involves food restriction with failure to meet the nutritional need. While patients are often underweight, this disturbance does not meet diagnostic criteria for anorexia nervosa. Individuals with binge eating disorder eat excessive amounts of calories in a short period with a lack of self-control but do not display compensatory behaviors such as purging or restriction. Patients with bulimia nervosa will binge and purge without a corresponding low BMI. Pica refers to chronic ingestion of nonfood substances and may be a manifestation of underlying medical or psychiatric condition. For example, patients with anorexia nervosa may eat toilet paper when they are hungry. Rumination disorder occurs when patients repeatedly regurgitate food for one month when no other medical condition can be identified and does not occur solely during the course of another eating disorder. Other specified feeding or eating disorder refers to conditions with symptoms that impair functioning but do not meet criteria for a specific eating disorder, for example, patients who meet criteria for anorexia nervosa but have BMI more than 18.5 kg/m are classified as “atypical anorexia nervosa.”

Major depressive disorder can cause anorexia and weight loss. However, patients are not obsessed with body habitus. Patients with obsessive-compulsive disorder may have food rituals but maintain a normal weight. Patients who abuse stimulants such as cocaine and methamphetamine experience weight loss through increased metabolism and concentrated efforts to obtain illicit substances rather than consume calories.

Medical conditions can cause weight loss. Examples are celiac disease, hyperthyroidism, inflammatory bowel disease, malignancy, poorly controlled diabetes mellitus, primary adrenal insufficiency, and tuberculosis. The diagnosis will come from the history and physical examination. Order labs as dictated by the clinical picture.

• Treatment / Management

Treatment for anorexia nervosa is centered on nutrition rehabilitation and psychotherapy. Patients who need inpatient treatment have the following characteristics:

• Existing psychiatric disorders requiring hospitalization
• High risk for suicide (intent with highly lethal plan or failed attempt)
• Lack of support system (severe family conflict or homelessness)
• Limited access (lives too far away to participate in a daily treatment program)
• Medically unstable (bradycardia, dehydration, hypoglycemia or poorly controlled diabetes, hypokalemia or other electrolyte imbalances indicative of refeeding syndrome, hypothermia, hypotension, organ compromise requiring acute treatment)
• Poorly motivated to recover (uncooperative, preoccupied with intrusive thoughts)
• Purging behaviors that are persistent, severe, and occur multiple times a day
• Severe anorexia nervosa (less than 70% of ideal body weight or acute weight loss with food refusal)
• Supervised feeding and/or specialized feeding (nasogastric tube) required
• Unable to stop compulsively exercising (not a sole indication for hospitalization).

Outpatient treatment includes intensive therapy (2 to 3 hours per weekday) and partial hospitalization (6 hours per day). Pediatric patients benefit from family-based psychotherapy to explore underlying dynamics and restructure the home environment.

Refeeding syndrome can occur following prolonged starvation. As the body utilizes glucose to produce molecules of adenosine triphosphate (ATP), it depletes the remaining stores of phosphorus. Also, glucose entry into cells is mediated by insulin and occurs rapidly following long periods without food. Both cause electrolyte abnormalities such as hypophosphatemia and hypokalemia, triggering cardiac and respiratory compromise. Patients should be followed carefully for signs of refeeding syndrome and electrolytes closely monitored.

Pharmacotherapy is not used initially. For acutely ill patients who do not respond to initial treatment, olanzapine is a first-line medication. Other antipsychotics have not demonstrated similar effects on weight gain. For patients who are not acutely ill but have co-morbid psychiatric conditions such as generalized anxiety disorder or major depressive disorder, combination therapy with selective serotonin reuptake inhibitors (SSRIs) and therapy is best. Patients who do not respond to SSRIs may need a second-generation antipsychotic. Tricyclic antidepressants (TCAs) are less preferred due to concerns about cardiotoxicity, especially in malnourished patients. Bupropion is contraindicated in patients with eating disorders due to the increased risk of seizures. [10] [11] [12]

• Differential Diagnosis
• Chronic mesenteric ischemia
• Malabsorption
• Hyperthyroidism
• Irritable bowel syndrome
• Celiac disease

Remission in AN varies. Three-fourths of patients treated in out-patient settings remit within 5 years and the same percentage experience intermediate-good outcomes (including weight gain). Relapse is more common in patients who are older with a longer duration of disease or lower body fat/weight at the end of treatment, have co-morbid psychiatric disorders, or receive therapy outside of a specialized clinic. Patients who achieve partial remission often develop another form of eating disorder (ex. bulimia nervosa or unspecified eating disorder).

All-cause mortality is greater in AN compared to the rest of the population. It has one of the highest mortality rates of all eating disorders due to medical complications, substance abuse, and suicide. Patients with AN have increased rates of suicide and this accounts for 25% of deaths associated.

• Complications
• Delayed puberty
• Hypercarotenemia
• Hypothermia
• Hypoglycemia
• Osteoporosis
• Failure to thrive 
• Cardiomyopathy
• Bradycardia
• Arrhythmias
• Renal failure
• Constipation
• Peripheral neuropathy
• Pancytopenia
• Infertility
• Deterrence and Patient Education

Anorexia nervosa is a psychiatric disease in which patients restrict their food intake relative to their energy requirements through eating less, exercising more, and/or purging food through laxatives and vomiting. Despite being severely underweight, they do not recognize it and have distorted body images. They can develop complications from being underweight and purging food. Diagnose by history, physical, and lab work that rules out other conditions that can make people lose weight. Treatment includes gain weight (sometimes in a hospital if severe), therapy to address body image, and management of complications from malnourishment.

• Enhancing Healthcare Team Outcomes

Anorexia nervosa is a serious eating disorder that has very high morbidity. The disorder is usually managed with an interprofessional team that consists of a psychiatrist, dietitian, social worker, internist, endocrinologist, gastroenterologist, and nurses.  The disorder cannot be prevented and there is no cure. Hence patient and family education is key to preventing high morbidity. The dietitian should educate the family on the importance of nutrition and limiting exercise. The mental health nurse should educate the patient on changes in behavior, easing stress, and overcoming any emotional issues. The pharmacist should educate the patient and family on the use of drugs like laxatives and weight loss pills. Only through close follow-up and monitoring can patient outcomes be improved. [13] [14]  [Level 5]

Evidence-based Outcomes

Remission in anorexia nervosa varies. Three-fourths of patients treated in out-patient settings remit within five years and the same percentage experience intermediate-good outcomes, including weight gain. Relapse is more common in patients who are older with a longer duration of disease or lower body fat/weight at the end of treatment, have co-morbid psychiatric disorders, or receive therapy outside of a specialized clinic. Often, patients who achieve partial remission develop another form of eating disorders like bulimia nervosa or unspecified eating disorder.

All-cause mortality is greater in anorexia nervosa compared to the rest of the population. It has one of the highest mortality rates of all eating disorders due to medical complications, substance abuse, and suicide. Patients with anorexia nervosa have increased rates of suicide, and this accounts for 25% of deaths associated with the disorder. [15] [16] [9]  [Level 5]

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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Criteria for Anorexia Nervosa Contributed by Christine Moore, D.O.

Disclosure: Christine Moore declares no relevant financial relationships with ineligible companies.

Disclosure: Brooke Bokor declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Moore CA, Bokor BR. Anorexia Nervosa. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Anorexia Statistics – Gender, Race & Socioeconomics 

An estimated 30 million people in the United States have had an eating disorder at some point in their lifetime. This equates to about 20 million women and 10 million men.

Further Reading

Anorexia Stats About Men and Boys Calling a Hotline for Help The Underlying Causes of Anorexia Am I Anorexic? Symptoms of AN Mortality Rates of Anorexia

Eating disorders impact around 9% of the global population. They result in more than 10,000 deaths in the U.S. every year, representing one of the deadliest mental illnesses. Anorexia can impact people of every gender identity, race, and socioeconomic status. It is one of the most common eating disorders involving food and calorie restriction, fear of gaining weight, and distorted body image.

Gender Statistics on Anorexia

Anorexia is a mental health disorder that can impact anyone at any age. Men, women, and people of any gender identity can develop anorexia. 

Anorexia is more common in women than men. As a result, it is often stigmatized, overlooked, and underdiagnosed in men. Anorexia is likely very underreported in men. 

Women with anorexia regularly restrict calories and food intake in an attempt to look very thin. They will still believe they are “fat” regardless of how much weight they lose. 

Men can also have restrictive diets and deprive themselves of the necessary nutrition to maintain a healthy weight, but they are more likely to exercise excessively and take steroids and/or supplements to achieve their version of a “masculine” lean and muscular body type.

• Women have anorexia at rates three times higher than males : 0.9% of the population versus 0.3% of the population.
• An estimated 0.5% to 3.7% of women will develop anorexia at some point in their lifetime.
• Around 10 million men in the United States will develop an eating disorder within their lifetime.
• Men make up approximately 20% of all people with anorexia.

Anorexia also affects the LGBTQ+ population. Gender dysmorphia and body dissatisfaction are often contributing factors to the onset of an eating disorder. 

Nearly a third of transgender people with an eating disorder report using the disorder to modify their bodies without the use of hormones. 

Adult and adolescent LGBT individuals experience disordered eating and eating disorders at higher rates than their heterosexual or cisgender peers.

Race Statistics & Anorexia

Just as anorexia can impact people of different gender and sexual orientations, it can also affect people across different races and ethnicities. 

While previous studies have shown a higher prevalence in white females than women of color, recent research has shown that there are likely similar risk factors and prevalence of an eating disorder across these racial and ethnic lines. Ethnic minorities are then just as likely to develop an eating disorder as white individuals are. 

Asian American women often have lower body weights and a higher thin-ideal internalization. Exposure to Western media has likely elevated the risk for disordered eating and body image, which can increase the rate of potential eating disorders in this group. 

In contrast, African American women tend to have higher BMIs and a lower thin-ideal internalization, which can then be a protective factor for developing an eating disorder. It is also important to note that a higher BMI with an eating disorder can elevate the mortality risk for the disorder.

Socioeconomic Statistics on Eating Disorders

It has been falsely believed that eating disorders like anorexia are mainly limited to white upper-class women. Research has challenged this belief, showing that people across all socioeconomic statuses are equally prone to developing an eating disorder. 

Historical studies that reported a higher prevalence of anorexia in those with higher socioeconomic status have been shown to be too narrow and not indicative of the entire picture. 

Low-income populations also have eating disorders and risk factors that can lead to anorexia. Anorexia can impact people of all socioeconomic levels.

Other At-Risk Groups

There are a variety of factors that can contribute to the onset of anorexia that can put some populations and people at a higher risk for developing the eating disorder. Statistics on at-risk groups are as follows:

• Athletes: Studies have shown that more than a third of female NCAA Division I athletes exhibit symptoms and attitudes that place them at risk for anorexia. Many sports (especially individual sports such as gymnastics, swimming, wrestling, track and field, bodybuilding, diving, and dancing) put a lot of emphasis on a specific body type or weight, which can increase the risk of an eating disorder to achieve that ideal body type. Studies show that 35% of female college athletes and 10% of males have an elevated risk for anorexia.
• People with autism: Around 20% of people with autism also have anorexia . Autism can elevate the risk for anorexia since people with autism often already exhibit restrictive eating patterns, have a desire to exhibit some sense of control, and often want to fit an ideal body image to “fit in” with peers.
• Teens: Young females are at the highest risk, and anorexia often begins in adolescence. The vast majority ( 95% ) of people with an eating disorder are between the ages of 12 and 25. About 1 out of every 100 young women between the ages of 10 and 20 have anorexia.
• People with co-occurring mental illnesses: Anorexia commonly co-occurs with other mental health conditions. Studies have shown that in people with anorexia, there is also a lifetime prevalence of substance abuse (12%–21%), anxiety disorders (20%–60%), and depression (15%–60%)
• Eating Disorder Statistics . (February 2020). U.S. News & World Report .
• Eating Disorder Statistics . (2021). National Association of Anorexia Nervosa and Associated Disorders (ANAD).
• Eating Disorders . (n/a). National Institute of Mental Health (NIMH). 
• Eating Disorder Statistics . (October 2020). GenPsych .
• Eating Disorders in Men & Boys . (2022). National Eating Disorders Association (NEDA).
• Eating Disorders in Males . (November 2021). National Eating Disorders Collaboration (NEDC).
• Parker LL. (2020). Eating Disorder and Disordered Eating Behaviors in the LGBT Population: A Review of the Literature . Journal of Eating Disorders , 8 (51).
• Cheng ZH, Perko VL, Fuller-Marashi L, Gau JM, Stice E. (2019). Ethnic Differences in Eating Disorder Prevalence, Risk Factors, and Predictive Effects of Risk Factors Among Young Women . Eating Behaviors , 32:23-30.
• Mulders-Jones B, Mitchison D, Girosi F, Hay P. (2017). Socioeconomic Correlates of Eating Disorder Symptoms in An Australian Population-Based Sample . PLOS ONE , 12 (1). 
• Huryk KM, Drury CR, Loeb KL. (2021). Diseases of Affluence? A Systematic Review of the Literature on Socioeconomic Diversity in Eating Disorders . Eating Behaviors , 43 .
• Eating Disorders & Athletes . (2022). National Eating Disorders Association (NEDA).
• Anorexia’s Link to Autism, Explained . (December 2020). Spectrum News .
• Eating Disorder Facts . (2021). Johns Hopkins All Children’s Hospital.
• Statistics: How Many People Have Eating Disorders? Anorexia Nervosa & Associated Eating Disorders (ANRED).
• What Is the Prevalence of Psychiatric Comorbidities with Anorexia Nervosa? (June 2019). Medscape .

Last Update | 09 - 22 - 2022

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Key research and statistics

On this page, overview of eating disorders today, key diagnostic statistics, eating disorders and gender, eating disorders and age, eating disorders and lgbtiqa+ communities, eating disorders and cultural and ethnic diversity, eating disorders and aboriginal and torres strait islander people, eating disorders and co-occurring conditions, eating disorder mortality and suicidality, eating disorder treatment and recovery, eating disorders and economic impact, body image, dieting and social media.

This page provides key research and statistics on issues relating to eating disorders.

Please be aware that some of these statistics relate to confronting issues regarding eating disorder risk factors, suicide/mortality rates and mental illness susceptibility.

It is important to remember that these figures provide a statistical overview only – eating disorders are highly individual and varied and not all research will be applicable to all.  

Please always attribute the statistic to the original source, not Eating Disorders Victoria.  

Eating disorders, when combined with disordered eating, are estimated to affect 16.3% of the Australian population (Hay et al., 2015).   

Latest data estimates that the number of people in Australia with an eating disorder aged over 5 years old is around 1.1 million, or approximately 4.45% of the population (Deloitte Access Economics, 2024, p.27). This number indicates that 286,069 Victorians had an eating disorder in 2023.  

A concerning trend in age distribution shows that 27% of eating disorder cases in Australia are among those aged 10-19. This is has nearly doubled since 2012, highlighting a significant increase in eating disorders among younger age groups (Deloitte Access Economics, 2024, p.10).  

According to the latest data, the most prevalent eating disorders in Australia were Unspecified Feeding and Eating Disorders and Other Specified Feeding and Eating Disorders , affecting approximately 1.5% and 1.1% of the Australian population respectively. In contrast, Anorexia Nervosa and Bulimia Nervosa each occurred in less than 0.5% of the general population (Deloitte Access Economics, 2024, p.27).   

The lifetime prevalence for eating disorders is approximately 10.46% of the Australian population. This estimates that 2,754, 446 Australians had an eating disorder at any time within their life (Deloitte Access Economics, 2024, p.30). This is an increase of 1.46% from conservative estimates in 2012 (NEDC, 2017).  

A recent review found that worldwide, lifetime prevalence of eating disorders was 8.4% (3.3-18.6%) for women and 2.2% (0.8-6.5%) for men. The results also showed that the prevalence has been increasing over time (Galmiche et.al., 2019).   

Eating disorders are serious mental illnesses.

Learn about the different types of eating disorders and signs and symptoms to look out for.

Binge Eating Disorder   

• Based on Australian data, the lifetime prevalence of Binge Eating Disorder is the second highest of all eating disorders at 2.2% (Deloitte Access Economics, 2024, p.30).  
• Binge Eating Disorder has the latest average age of onset of all eating disorders estimated to be about 25 years old (Butterfly Foundation, 2012).   

Learn more about binge eating disorder  

Anorexia Nervosa  

• The lifetime prevalence of Anorexia Nervosa in the Australian population is 1.8% (Deloitte Access Economics, 2024, p.30).  
• The average onset of Anorexia Nervosa is 16-17 years, although more and more younger children are becoming affected (Keski-Rahkonen at al., 2018).   

Learn more about anorexia nervosa  

Bulimia Nervosa    

• The lifetime prevalence of Bulimia Nervosa in the Australian population is estimated to be 1.85% (Deloitte Access Economics, 2024, p.30).  
• The average age of onset of Bulimia Nervosa is 18 years (Volpe et.al., 2016).   

Learn more about bulimia nervosa  

Eating disorders are the third most common chronic illness in young women (Yeo & Hughes, 2011).   

• 67% of people with eating disorders in Australia are female and 33% male (Deloitte Access Economics, 2024, p.28).   
• Women and girls are more likely to experience all types of eating disorders than men and boys, where Binge Eating Disorder prevalence is almost double in women compared to men, and more than doubled for Bulimia Nervosa (Deloitte Access Economics, 2024, p.28).  
• Approximately 80-85% of individuals diagnosed with Anorexia Nervosa or Bulimia Nervosa are female and 15-20% are male (Hay et al., 2008).    
• Eating disorders and disordered eating behaviours in boys and men may present differently than in girls and women, particularly with muscularity-oriented disordered eating (Nagata et al., 2020).   
• Research suggests that transgender people, whose assigned sex at birth does not match their gender identity, are more likely than cisgender people, whose assigned sex at birth matches their gender identity, to have been diagnosed with an eating disorder or to engage in disordered eating (Watson et al., 2017).   
• Research indicates that both transfeminine spectrum (TFS; those assigned male at birth and identifying as women or on the feminine spectrum) and transmasculine spectrum (TMS; those assigned female at birth and identifying as men or on the masculine spectrum) individuals had higher levels of disordered eating and body dissatisfaction than cisgender participants (Witcomb et.al., 2015).    
• An Australian study found that 23% of transgender young people have a current or previous diagnosis of an eating disorder (Strauss et.al., 2017).   

Did you know?

Research indicates that over one third of people experiencing an eating disorder are men ( Koreshe et al., 2023). Many experts believe that this number is likely to be even higher due to underreporting due to gender stereotyping and misdiagnosis.  

Eating disorders can affect people of all ages and have been diagnosed in those younger than 5 years and older than 80 years (NEDC, 2017).   

• Research shows that adolescents are at greatest risk, with the average age of onset for an eating disorder between 12 and 25 years (Volpe et al., 2016).   
• The highest prevalence is found in 15 – 19 year olds, where up to 12% of adolescents in this age bracket had an eating disorder in 2023 (Deloitte Access Economics, 2024, p.29).  
• 75% of people diagnosed with Anorexia Nervosa and 83% of people diagnosed with Bulimia Nervosa are between 12 and 25 years (Volpe et al., 2016).   
• 57% of contacts to the Butterfly Foundation National Helpline in 2018-2019 were from young people aged up to 25 years (Butterfly Foundation, 2020a).  

People who are LGBTIQA+ are at a greater risk for disordered eating behaviours (Calzo et al, 2017).  

• Gay, lesbian and bisexual teens may be at higher risk of binge eating than their heterosexual peers (Austin et al., 2009).  
• A review from the United States found that lifetime prevalence for eating disorders is higher among sexual minority adults compared with cisgender heterosexual adults however, more detailed research is required (Nagata et al., 2020).  

Eating disorders occur in all ethnicities, nationalities and cultural backgrounds (Schamberg et al., 2017).  

• A 2019 review found that at any point in time (one-time prevalence) eating disorders occur all over the world, specifically, 4.6% in America, 2.2% in Europe and 3.5% in Asia (Galmiche et al., 2019).  
• It is important to recognise unique cultural nuances and sensitivities, and varied sociocultural factors that influence an individual’s relationship with food, body image, and mental health.  

Though research is limited, it has been estimated that eating disorders incidence is much higher in Indigenous populations with estimates that up to 27% are affected (Burt, et al., 2020).    

• A recent research study found that 28% of Indigenous high school students have an eating disorder compared to 22% of other Australian teens (Burt et al., 2020).   
• Binge eating disorders are as common, if not more common, among Aboriginal and Torres Strait Islander youth (Hay & Carriage, 2012).   
• Research suggests that 30% of Aboriginal and Torres Strait Islander young people are extremely or very concerned about their body image (Hall et al., 2020).   

Eating disorders are frequently associated with other psychological and physical disorders such as depression, anxiety disorders, substance abuse and personality disorders (Hudson et.al, 2007).   

• Approximately 55- 97% of people diagnosed with an eating disorder have a mental illness comorbid condition (NEDC, 2017).   
• Approximately 45-86% of individuals diagnosed with an eating disorder have co-existing depression (O’Brien & Vincent, 2003).   
• Approximately 64% of individuals diagnosed with an eating disorder have co-existing anxiety disorder (Kaye et al., 2004).   
• Approximately 58% of individuals diagnosed with an eating disorder have co-existing personality disorder (NEDC, 2017).   
• Among adolescents, approximately 88% of individuals with Bulimia Nervosa , 84% of individuals with Binge Eating Disorder , and 55% of individuals with Anorexia Nervosa have had one or more co-existing mental illness at some point in their lives (NEDC, 2017).    
• Research indicates that anxiety disorder (especially social anxiety) can precede the onset of an eating disorder (Swinbourne & Touyz, 2007).   
• Higher rates of disordered eating have been described in chronic health conditions that require dietary modification, including Celiac disease, Cystic Fibrosis and Diabetes (Wabich et al., 2020).   
• People with Diabetes (both Type 1 and Type 2) may be two times as likely to develop disordered eating and/or an eating disorder likely due to the nature of the illness including factors such as weight-gain, obsession with food and feelings of loss of control (Pereira and Alvarenga, 2007).   
• Gastrointestinal conditions such as Irritable Bowel Syndrome (IBS) are more prevalent in those diagnosed with an eating disorder though research is unclear if symptoms are resulting from or precede the eating disorder (Marie et al., 2019).   
• Research findings suggest that patients with inflammatory bowel disease (IBD) including Crohn’s disease and Ulcerative Colitis, may struggle with maladaptive attitudes toward eating making them at higher risk for developing disordered eating and/or an eating disorder however more research specific to these conditions is required (Wabich et al., 2020).   

Eating disorders, along with substance use disorders, have the highest mortality rate of all psychiatric disorders (Chesney, Goodwin & Fazel, 2014).   

• The mortality rate of those with Anorexia Nervosa is higher than other eating disorders (Fichter & Quadflieg, 2016).   
• Cardiovascular complications is the leading cause of death among people with Anorexia Nervosa, followed by suicide (Smith, Zuromski & Dodd, 2018).   
• The rate of mortality of individuals with Bulimia Nervosa and Binge Eating Disorder is lower than those with Anorexia Nervosa, but still significantly higher than the general population (NEDC, 2017).   
• People with Anorexia Nervosa are more than 31 times more likely to attempt suicide and those with Bulimia Nervosa 7.5 times more likely to attempt suicide than the general population (Preti et.al, 2011).   
• People with Anorexia Nervosa are 18 times more likely to die by suicide and those with Bulimia Nervosa are 7 times more likely to die by suicide relative to gender and aged matched comparison groups (Smith, Zuromski & Dodd, 2018).   
• Suicidal behaviour is elevated in Binge Eating Disorder relative to the general population (Smith, Zuromski & Dodd, 2018).    
• Suicide risk is higher when eating disorders occur with other psychological conditions (Smith et.al., 2018).   

When skilled and knowledgeable health professionals deliver treatment, full recovery and good quality of life can be achieved for most people with eating disorders (Butterfly Foundation, 2016).  

• It is estimated that 75% of people with an eating disorder don’t seek professional help (Hart et.al., 2011).   
• The reasons/ barriers for not accessing treatment include stigma, shame, denial, failure to perceive the severity of the illness, cost of treatment, low motivation to change, lack of encouragement and lack of knowledge about how to access help resources (Ali et.al, 2017).    
• The most effective treatment for eating disorder is person-centred care, tailored to suit the individual’s illness, situation and needs (Hay et.al., 2014).   
• The average time taken to recover from all types of eating disorders, after seeking treatment, is 1-6 years (Deloitte Access Economics, 2015).  

Learn more about treatment for eating disorders  

Accessing professional, evidence-based treatment for an eating disorder will give you the best possible recovery outcomes.  

• The economic cost has increased by 36% in the last decade, exceeding $66.9 billion in 2023 – this equates to a cost per person of $60,654 (Deloitte Access Economics, 2024).  
• Health system costs (public and private) attributed to eating disorders in 2023 was $251.4 million. Importantly this does not account for all out-of-pocket health system expenses incurred by those impacted by eating disorders (Deloitte Access Economics, 2024).  
• Anorexia nervosa accounts for 75% of the total health system costs, also accounting for the highest per person costs ($4,859) followed by BN ($163) (Deloitte Access Economics, 202
• Body image has been listed in the top four concerns for young Australians from 2009-2018 with 30% concerned about body image (Carlisle et al, 2018).   
• Research shows that up to 80% of young teenage girls report a fear of becoming ‘fat’ (Kearney-Cooke & Tieger, 2015).   
• Nearly 23% of Australian women report a self over evaluation of weight and shape – meaning they think they are larger than they are according to BMI (Mitchison et.al., 2013).   
• It has been reported that more than 55% of Australian girls and 57% boys aged 8 to 9 years are dissatisfied with their body t (Daragnova, 2013).    
• Nearly half of Australian women and one third of Australian men are dissatisfied with their body (NEDC, 2017).   
• Weight related teasing in children is associated with disordered eating, weight gain, binge eating, and extreme weight control measures (Golden, Schneider & Wood, 2016).   
• Social media use has been linked to self-objectification, and using social media for merely 30 minutes, a day can change the way you view your own body (Fardouly & Vartanian, 2015).   
• A study of teen girls reported that social media users were significantly more likely than non-social media users to have internalized a drive for thinness and to engage in body surveillance (Fardouly et.al., 2015).    
• Weight-loss dieting is a risk factor for the development of an eating disorders and. Dieting frequently precedes the onset of an eating disorder (Butryn & Wadden, 2005).   
• Dietary restraint influences binge-eating behaviour (Andres & Saldana, 2014).   
• High frequency dieting and early onset of dieting are associated with poorer physical and mental health, more disordered eating, extreme body dissatisfaction, and more frequent general health problems (Tucci et al., 2007).   

Learn more about dieting and eating disorders

Engaging in weight-loss dieting is the a key behavioural risk factor for developing an eating disorder.

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Eating disorders are serious mental health conditions. They can impact people of all ages, sexes, ethnicities, and cultures. Early treatment and intervention provide the best success rates.

• Types of Eating Disorders

Eating disorders are extremely common, as nearly 1 out of every 10 Americans is expected to develop one in their lifetime. 

Eating disorders involve distorted feelings and behaviors related to food and eating. They can have serious and often fatal consequences. 

What Are the Different Eating Disorders?

Eating disorders are not a lifestyle choice. They are serious mental health conditions involving disturbances in eating behaviors, emotions, and thoughts about food and eating. 

There are four main eating disorders.

• Anorexia nervosa: Anorexia involves serious restriction of food and/or calorie intake and a distorted vision of self as overweight even if underweight. 
• Bulimia nervosa: Bulimia generally follows a binge-purge pattern of eating where an individual eats a large amount of food in a binge and then compensates for this with laxatives or diuretics, forced vomiting, excessive exercise, or a combination of these actions.
• Binge eating disorder: Unlike with bulimia, binge eating disorder is not followed by purging behaviors and involves a loss of control over eating.
• Avoidant-restrictive food intake disorder (ARFID): ARFID involves severely restricting the amount or type of food eaten, but unlike with anorexia, this is not due to a distorted body image.

People with eating disorders are not always severely underweight. Eating disorders are often overlooked and under diagnosed. 

Eating disorders are commonly life-threatening , leading to medical complications related to starvation as well as high rates of suicide.

Eating Disorder Statistics

Eating disorders are common around the globe, impacting a wide range of populations and demographics. They commonly develop during adolescence, but they can impact children and older adults as well. 

While eating disorders have commonly been considered to mainly impact women and those in Western countries, studies show that men also develop eating disorders, and there is a high prevalence of eating disorders in Asia and developing Middle Eastern countries. 

Anorexia Nervosa

Anorexia more commonly impacts women than men, but both men and women can develop it. Women have a lifetime prevalence of up to 4 percent , while men have a lifetime prevalence of up to 0.3 percent. The rate of anorexia is also increasing in adolescents and young teens (those under the age of 15). 

Bulimia Nervosa

Rates of bulimia nervosa are declining over time. Currently, up to 3 percent of women and up to 1 percent of men have a lifetime incidence of bulimia. The overall prevalence of bulimia is estimated at 0.3 percent with women being five times more likely to have bulimia than men with rates of 0.5 percent and 0.1 percent respectively.

Binge Eating Disorder

Binge eating disorder impacts an estimated 1.5 percent of women and 0.3 percent of men globally. The disorder is commonly overlooked and likely underreported. 

Binge eating disorder is nearly always (94 percent of the time) accompanied with lifetime mental health symptoms and health conditions, including these:

• Mood disorders
• Substance use disorders
• Anxiety disorders
• Post-traumatic stress disorder (PTSD)
• Borderline personality disorder
• Suicidal ideations
• Type 2 diabetes
• Hypertension

Avoidant Restrictive Food Intake Disorder (ARFID)

ARFID is most common in children and adolescents. It is highly comorbid with anxiety disorders (around 75 percent), mood disorders (close to 33 percent), and autism spectrum disorders (close to 20 percent). 

It is considered a relatively new eating disorder, and lifetime prevalence is estimated to be between 5 percent and 13 percent . Young males most commonly struggle with ARFID. 

ARFID is often related to a fear of choking or vomiting or due to sensory issues with certain foods. 

Adolescents

Most eating disorders begin in the teen years or early adulthood, with 95 percent of first-time cases occurring by age 25. Nearly half report an onset of an eating disorder between the ages of 16 and 20. 

About half of teenage girls and a third of teenage boys engage in unhealthy behaviors and disordered eating to try and control weight. In adolescents, anorexia is one of the top three chronic illnesses. 

The mortality rate for females between the ages of 15 and 24 is 12 times higher for anorexia than any other cause of death.

College Students

Nearly all women (91 percent) surveyed on a college campus tried to control their weight through dieting, and a quarter of college-aged women binge and purge to manage their weight. Transgender college students engage in disordered eating behaviors quadruple the rate of their cisgender peers. 

The lifetime prevalence for eating disorders among teens between the ages of 13 and 18 is nearly 3 percent. Eating disorders are twice as common in females than males.

Athletes are a specialty category of people that commonly struggle with eating disorders, especially those in sports that have a heavy emphasis on body shape, size, weight, or appearance, such as swimming, gymnastics, bodybuilding, wrestling, dancing, figure skating, horse racing, rowing, and diving. In these types of sports, more than 60 percent of women have eating disorders, and a third of male athletes do. 

Minority populations are often at a higher risk for eating disorders, which can include marginalized racial and cultural groups, members of the LGBTQ+ population, and those with lower socioeconomic status. 

Studies have shown that African American teenage girls are nearly twice as likely to engage in bulimic behaviors than their Caucasian peers. Girls from low-income families struggle with bulimia more often than their peers from middle- and high-income families. Hispanic adolescents are also more likely to have bulimia than non-Hispanic teenagers. All minority groups are shown to have a higher incidence of binge eating disorder.

Members of the LGBTQ+ population commonly engage in disordered eating and have dysfunctional body images, often in an effort to fit into a specific stereotype that they believe to be “ideal.” Eating disorders are more common in gay men than in heterosexual men, for instance. Bisexual and gay boys are more likely than their peers to take laxatives, diet pills, vomit, or fast to control their weight. 

Nonbinary people also regularly restrict eating to maintain their perceived optimal androgynous stereotype reflected in popular culture. 

Although women are more commonly diagnosed with eating disorders than men, and men are less likely to seek treatment for an eating disorder, nearly 10 million men will develop an eating disorder in their lifetime. Close to 20 percent of those with anorexia are men. Around a third of men with an eating disorder also have a history of sexual abuse. 

Gay men are 12 times more likely to report purging behaviors and 7 times more likely to report binge eating behaviors than straight men.

Mortality Rates

Over 10,000 people die from an eating disorder each year. More than one person dies every hour, and eating disorders have the highest mortality rate out of all mental illnesses. The mortality rate for men is twice that of women even though women more commonly have anorexia than men. 

The following are common causes of death for eating disorders:

• Cardiac complications
• Organ failure
• Dehydration

Nearly 8.5 percent of women and 2.5 percent of men have a lifetime weighted mean rate of an eating disorder diagnosis. It is estimated that nearly 30 million people in the United States have an eating disorder, and eating disorders impact around 9 percent of the world’s population. 

The 12-month prevalence of any eating disorder is 0.43 percent . More recently defined types of eating disorders, such as binge eating disorder, are more prevalent than anorexia and bulimia today. 

Eating disorder rates are also likely underreported, as many statistics only include anorexia nervosa and bulimia nervosa. Research shows that 41.9 million cases of eating disorders were underrepresented in 2019, with 17.3 million people having binge eating disorder and 24.6 million people having OSFED (other specified feeding or eating disorder) globally.

The onset of the COVID-19 pandemic has increased the onset of eating disorder behaviors, diagnoses, and the severity of symptoms and comorbidities around the world, including in North America, Europe, and Australia. Studies show that the incidence of eating disorders rose 15.3 percent in 2020 over previous years. This could be attributed to the isolation related to the pandemic, as eating disorders are often solitary conditions. 

Eating Disorder Treatment 

Early intervention and treatment for an eating disorder are key for lowering potential medical and mental health complications and improving outcomes and recovery rates. 

People with eating disorders have high rates of depression, suicide, medical complications, and additional co-occurring disorders like substance abuse and addiction. Treatment for an eating disorder should be comprehensive and include a variety of modalities aimed at treating the whole person. 

Comprehensive treatment should include the following methods:

• Individual, group, and family therapies: Behavioral therapies can help to investigate the root cause of the eating disorder to positively modify harmful and disordered patterns of thinking that lead to an unhealthy relationship with food and negative body image.
• Medical care and monitoring: People with eating disorders often have health issues related to disordered eating or food restriction. These will need to be addressed and managed during treatment by medical professionals. This can often involve refeeding, which will need to be monitored and managed with care.
• Medications: Since eating disorders commonly co-occur with other mental health disorders, such as anxiety and depression, mood stabilizers, antidepressants, and antipsychotics can be beneficial when used in conjunction with therapeutic means.
• Nutritional counseling: Eating disorders involve unhealthy relationships with food and eating behaviors. It can be helpful to include education and counseling on nutrition to reorganize thoughts and the way a person views food.

Support groups made up of peers who also have eating disorders or who are in recovery can provide a sense of community and resources. ANAD (National Association of Anorexia Nervosa and Associated Disorders) hosts a variety of Eating Disorder Peer Support Groups .

If you or someone you know struggles with an eating disorder, NEDA (National Eating Disorders Association) provides the NEDA Helpline . They offer referrals and information on how to get help and support.

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• A Systematic Scoping Review of Research on COVID‐19 Impacts on Eating Disorders: A Critical Appraisal of the Evidence and Recommendations for the Field. (January 2022). International Journal of Eating Disorders.
• The Impact of the COVID‐19 Pandemic on Eating Disorder Risk and Symptoms. (July 2020). International Journal of Eating Disorders.
• Eating Disorder Peer Support Groups. (2021). National Association of Anorexia Nervosa and Associated Disorders.
• Contact the Helpline. (2022). National Eating Disorders Association.

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

Affiliations.

• 1 Department of Psychiatry, University of Campania L. Vanvitelli, Naples, Italy. Electronic address: [email protected].
• 2 Department of Psychiatry, University of Campania L. Vanvitelli, Naples, Italy.
• 3 Neurosciences Department, University of Padua, Padua, Italy.
• 4 Integrated Research and Treatment Center AdiposityDiseases, Behavioral Medicine Research Unit, Department of Psychosomatic Medicine and Psychotherapy, University of Leipzig Medical Center, Leipzig, Germany.
• 5 King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
• 6 Flinders Institute for Mental Health and Well-Being, the Blackbird Initiative, Flinders University, South Australia, Australia.
• 7 Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, USA; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, USA.
• 8 Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital, Tuebingen, Germany; Centre of Excellence for Eating Disorders Tuebingen (KOMET), Germany.
• 9 Translational Health Research Institute, School of Medicine, Western Sydney University, Australia.
• 10 Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy.
• 11 Department of Psychiatry, Bellvitge University Hospital-IDIBELL and CIBERobn, ISCIII, Barcelona, Spain.
• 12 Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea.
• 13 Schoen Clinic Roseneck, Prien am Chiemsee, Germany; Clinic for Psychiatry and Psychotherapy, University Hospital Freiburg, Freiburg, Germany; Clinic for Psychiatry and Psychotherapy, University Hospital of Munich, Munich, Germany.
• 14 Eating Disorders Center for Treatment and Research, Department of Neuroscience, University of Turin, Turin, Italy.
• 15 Department of General Psychology, University of Padova, Padova, Italy.
• 16 Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neurosciences, University of Salerno, Salerno, Italy.
• 17 Department of Mental Health, Asl Salerno, Salerno, Italy.
• 18 Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.
• 19 Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada; Department of Mental Health, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany.
• PMID: 36084848
• PMCID: PMC9813802
• DOI: 10.1016/j.neubiorev.2022.104857

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).

Keywords: Eating disorders; Psychopharmacology; Psychotherapy; Randomized controlled trials; Treatment; Umbrella review.

Copyright © 2022 Elsevier Ltd. All rights reserved.

Publication types

• Research Support, N.I.H., Extramural
• Research Support, Non-U.S. Gov't
• Systematic Review
• Antidepressive Agents / therapeutic use
• Binge-Eating Disorder* / drug therapy
• Binge-Eating Disorder* / psychology
• Bulimia Nervosa*
• Bulimia* / drug therapy
• Feeding and Eating Disorders* / drug therapy
• Meta-Analysis as Topic
• Network Meta-Analysis
• Antidepressive Agents

Grants and funding

• R01 MH119084/MH/NIMH NIH HHS/United States
• DH_/Department of Health/United Kingdom
• R01 MH118278/MH/NIMH NIH HHS/United States
• R01 MH120170/MH/NIMH NIH HHS/United States
• R01 MH124871/MH/NIMH NIH HHS/United States

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NHS treating record number of young people for eating disorders

• Children and young people
• Mental health

More young people than ever before are receiving treatment for eating disorders according to the latest figures, the NHS said today. Almost 10,000 children and young people started treatment between April and December with record demand for services – an increase of a quarter compared to the same period last year and up by almost two thirds since before the pandemic.

NHS chiefs today said that young people and their families should seek help without delay if they were concerned, with community services now available in every part of the country.

Professor Prathiba Chitsabesan, NHS Associate Clinical Director for Children and Young People’s Mental Health and psychiatrist advised young people and their loved ones to use trusted online resources if they had concerns and wanted to seek help.

Professor Chitsabesan added that some of the signs to look out for included behaviours such as making rules about what or how they eat, eating a restricted range of foods or having a negative self-image about their weight and appearance. Young people’s problems with food can begin as a coping strategy or a way of feeling in control but may lead to more restrictive patterns of eating and behaviours. The rise could be attributed to the unpredictability of the COVID-19 pandemic, feeling isolated, disruption to routines and experiences of loss and uncertainty.

The NHS is investing an additional £79 million into children’s mental health services because of increased demand during the pandemic, with funding being used to ensure at least 2,000 more children and young people start eating disorder treatment.

Mental health services, including eating disorder services, are being backed by an additional £2.3 billion every year in additional funding until 2023/24 as part of the NHS Long Term Plan’s commitment to improving mental health services .

Claire Murdoch, NHS Mental Health Director said: “NHS services remained open throughout the pandemic as hard-working mental health staff worked to deliver care to more people than ever before.

“The NHS continues to see record-high numbers of young people for eating disorders and it is vital anybody who might need care comes forward as quickly as possible so the NHS can get you any care you may need.

“Parents can find information on potential symptoms, such as binge eating, feeling guilty after eating, and negative self-image, and other signs of a potential eating disorder are available on the NHS website and they should not hesitate to contact the NHS if they think their child might need some support”.

One of the people that the NHS has helped is Alice who was 17 years of age when her mother referred her to NHS eating disorder services, with an initial conversation with the NHS taking place the day after referral.

Alice said: “I felt so anxious when my Mum had made the referral as I didn’t know if I could be helped – those fears soon disappeared after speaking to my clinician over the phone only a day after the referral was made. If it wasn’t for the call so soon after, I don’t know if I would have answered my phone; I would have probably tried to pretend it wasn’t happening and disengage. The assessment was gentle and informative, I felt understood by my clinician. It wasn’t so scary after all”.

Following the assessment, it was determined cognitive behavioural therapy was the best way forward for Alice who says she is now doing much better.

Alice said: “I couldn’t believe that my treatment began only six days after my assessment. I was expecting to wait weeks or even months. I truly believe that if it wasn’t for the rapid intervention so soon after referral, I would be in a very different position. Thankfully, with the support from my clinician, I can report that I am doing much better. I was hesitant to seek support but I’m glad I did, I would say to anyone else in a similar position to take that step as it could save your life”.

In the guidance, Professor Chitsabesan recommends helpful support from charities doing important work in this area including BEAT which has designated pages to help young people who may be struggling with an eating problem, including an eating disorder, and provide advice.

The signs and symptoms of eating problems can vary from person to person. However, a combination of the below symptoms could be a sign that a child might need additional support:

• preoccupation with checking calorie or other ingredient content in food
• eating a restricted amount or range of foods
• binge eating
• more controlling behaviours such as rules about eating, insisting on making their own meals or only using certain utensils and cutlery
• negative self-image about their weight and/or appearance
• secretiveness or avoiding eating with others
• feeling guilty after eating
• repeatedly weighing themselves
• vomiting after eating, or going to the toilet immediately after eating
• compulsive or excessive exercising
• abnormally low or high weight or changes in weight or body shape
• long-term weight stagnation or failure to grow
• complaining of poor concentration, dizziness, tiredness or feeling cold
• getting stressed at mealtimes
• low mood, anxiety or irritability
• social withdrawal.

Professor Prathiba Chitsabesan advised parents over the pandemic on steps they can take to support their child which includes:

• Take time to talk to with the child or young person you care for: young people may find it difficult to accept that they have a problem or that they may need help. Some young people may find it easier to talk while doing something together such as playing a board game or engaging in a craft or other activity. Find a time when you will not be disturbed and both of you feel calm. If they find it difficult to talk to you, encourage them to talk to another trusted adult such as a family member, teacher or GP.
• Make time to listen to them: create a calm safe space where they can communicate how they are feeling without judgement. Try to avoid saying things that could feel accusatory, critical or dismissive.
• Try to understand the problems and provide reassurance that you have heard them and are there to help: ask how they are feeling rather than focussing all the conversation on their eating or weight as this can often be more productive. Complimenting them on things other than their appearance can help the young person feel valued and is less likely to be interpreted negatively.
• Encourage regular mealtimes as a family: sitting down together for regular mealtimes as a family can help encourage social and healthy eating behaviours and help monitor any concerns about eating problems. Keep the conversation neutral.
• Keep an eye on the young person you care for. Consider if eating problems persist, deteriorate and/or are impacting on the young person’s day to day living: seek specialist health advice and support and increase vigilance, including checking if the young person is losing weight, developing secondary physical health symptoms (see list above) or accessing websites/social media content that is pro-eating disorders.
• Help the child or young person you care for do positive activities which means they aren’t isolating themselves: positive activities including safe contact with family and friends can provide a distraction from negative and intrusive thoughts and may help the young person open up about their feelings.
• Provide structure and routine (including for sleep): frequent changes to routine and restrictions can cause some children and young people to feel more anxious and upset. Many children and young people may also experience difficulties with their sleep. Providing structure through the development of daily and weekly timetables, including bedtime routines can be helpful in providing some predictability for young people in this unsettled time and distraction from negative thoughts.
• Support children and young people with disabilities: children and young people with disabilities including those with autism spectrum disorder or learning disabilities may find the impact of COVID-19 particularly difficult to manage. It is important to explain change and manage any anxiety and distress they may be experiencing as this may impact on their eating behaviours including restrictive patterns of eating or overeating. Seek advice if they are already in contact with specialist health and social care services or contact your GP. The National Autistic Society have helpful advice on their website on how to deal with this uncertain time .
• Seek specialist advice and support quickly if you think the young person you care for has physical symptoms secondary to weight loss, suicidal thoughts or are self-harming: It is important that you do not ignore these and that you speak to a GP or crisis mental health help line urgently to get the right help and support – or contact some of the services detailed below.
• Finally, as a parent or carer, look after your own mental health too: this will help you to best support yourself and those you care about. Remember to talk to your family and friends about how you are feeling and seek help for yourself from the NHS and other support services if it’s all getting too much .

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Anorexia Nervosa Statistics 2023: 12 Shocking Facts

March 1, 2023 By Dr Jake Linardon Leave a Comment

Anorexia nervosa is an eating disorder characterized by extremely low body weight due to persistent and chronic energy restriction, and body image distortions comprised of an intense fear of weight gain.

In 2023, anorexia nervosa continues to be a devastating mental health condition that affects millions of individuals worldwide. As we begin this year, it’s critical to understand the current state of anorexia nervosa and its alarming impact on individuals, families, and communities. Here are 12 shocking statistics that shed light on the reality of anorexia nervosa in 2023.

This article will have ideally provided you with additional insight into anorexia and its impact.

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About Dr Jake Linardon

Dr Jake Linardon, PhD, is the founder of Break Binge Eating and a Research Fellow and Lecturer of Psychology at Deakin University, Melbourne Australia. He studies the causes, consequences, and treatments for eating disorders. He has published numerous peer-reviewed journal articles and book chapters on eating disorders, and serves as an editorial board member for the International Journal of Eating Disorders.

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Number of new hospitalized young male patients due to anorexia Japan FY 2019-2022

In fiscal year 2022, there were 24 male patients under 20 years old in Japan who were hospitalized for anorexia nervosa who attempted suicide, and 48 male patients who reported suicidal thoughts. The number of male patients who had suicidal thoughts increased from the previous year, with 48 male patients.

Number of new hospitalized male patients under 20 years due to anorexia nervosa in Japan in fiscal year 2019 to 2022

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November 2023

Asia, Japan

fiscal years 2019 to 2023; the Japanese fiscal year starts on April 1 of the stated year and ends on March 31 of the following year

16 hospitals

20 years and younger

16 hospitals from 31 cooperating hospitals that responded for all years 2019 to 2022

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