Search

Abstract Background Despite the high prevalence of disordered eating and eating disorders amongst elite athletes, it remains unclear whether risk factors and psychological processes align with those in the general population or if there are unique sport-factors associated with heightened risk. This cross-sectional study investigated if sport-specific factors (including pressures and psychological processes) explained additional variance in elite athletes’ disordered eating symptoms, controlling for established population-general risk factors. Current elite athletes (N = 178, 72.4% female, mean age = 23.9, standard deviation age = 7.0) completed online surveys assessing disordered eating, body dissatisfaction, perfectionistic traits, population-general and sport-specific pressures, as well as general (thin-ideal, muscular-ideal) and athlete-specific (drive for leanness for performance, athletic identity) psychological processes. Results Disordered eating was highly prevalent, with 78.2% of athletes reporting at least moderate risk, 46.4% at least high risk, and 20.6% very high risk. Controlling for demographic covariates and population-general pressures, sport-specific pressures explained significant additional variance (13.5%) in disordered eating. Even when controlling for perfectionistic traits, greater weight pressures in sport (β = .35) was uniquely associated with greater disordered eating. In a separate multivariate analysis controlling for covariates and general psychological processes, athlete-specific psychological processes explained significant additional variance (15.5%) in disordered eating. Even when controlling for body dissatisfaction, greater drive for leanness for performance (β = .17) and athletic identity (β = .13) were uniquely associated with greater disordered eating. Conclusions These findings support evidence that elite athletes may experience dual pressures and psychological processes associated with disordered eating: those congruent with appearance-oriented models and others independent of appearance. This duality should be considered in the modification of interventions for disordered eating in elite athletes. Key points 1. Disordered eating was highly prevalent in a sample of 178 elite adult athletes, with 78.2% reporting at least moderate risk for having related symptoms or behaviours. 2. Greater weight pressures in sport was significantly associated with greater disordered eating, even when controlling for demographic covariates and population-general appearance-related pressures from family and the media. 3. Both appearance-based (drive for thinness, body dissatisfaction) and non-appearance (drive for leanness for performance, athletic identity) psychological processes were uniquely associated with greater disordered eating.

Abstract Recent trials have shown promising results for the use of psychedelic-assisted therapies in treating severe refractory psychiatric illnesses, and there has been growing interest in examining the effectiveness of these therapies in treating eating disorders. To move forward in a safe, ethically sound, and scientifically rigorous manner, the field must address critical considerations. In this Comment article, we outline important risks and ethical considerations, along with methodological aspects that require careful consideration in the design of psychedelic-assisted therapy trials. We conclude by providing provisional guidelines for clinical research trials to help shape the future of this work, with the aim of investigating and employing the use of psychedelics for treating eating disorders in a manner that protects clients and research participants while maximizing methodological rigour.

Abstract Introduction This Rapid Review (RR) aimed to assess the current literature over the past decade to determine the prevailing evidence regarding compulsory treatment* in eating disorders (ED). It is hoped that the review will help inform a consensus opinion as to whether this course of action confers significant clinical benefit, and importantly, to whom it should apply. The review also explores alternative options to involuntary care. Methods Four indexing databases (OVID; ProQuest; Web of Science; PubMed/MedLine) were searched using variations of the following keywords: “coercive/detained/involuntary/least restrictive care” “treatment refusal” “incarcerated/forced/compulsory admission” “moral/ethic/legal/mental health act” “eating disorder”. Research was restricted to articles published between 2013 and 2023 and included grey literature. Results Of 9911 articles retrieved, 34 were included for final analyses, exploring ethical, legal, and physical and mental health outcomes of compulsory treatment. Studies comprised review papers, cohort studies, cross sectional research, case series reports, ethnography, commentary papers and grey literature. The majority of studies focused on individuals with anorexia nervosa (AN). Only two papers considered compulsory treatment in individuals with other eating disorders (EDs) Findings largely align with previous reviews suggesting compulsory treatment saves lives but comes at a therapeutic and personal cost. It remains unknown as to who may benefit from compulsory treatment. The decision to invoke compulsory treatment remains with the clinician and is a responsibility that is likely to be faced by most in their care of individuals with EDs. Conclusions Significant gaps remain in the published literature and a clear road map for a clinician-informed decision on the submission of a compulsory treatment for a person with ED does not yet exist. Further, there is little evidence as to who is most likely to benefit from compulsory treatment. There is consensus that efforts should be concentrated on reducing instances of compulsory treatment and minimising coercion through the development of open, transparent and trusting relationships between individuals and their treating clinician. Co-produced research and the development of clinical guidelines guided by the voices of individuals with lived experience are needed to ensure minimisation of potential harm.

Abstract Purpose Developing personal goals beyond weight and shape, and promoting the agency to pursue those goals, could aid in treatment and recovery from anorexia nervosa (AN). This research explores the strengths, interests and goals of individuals currently receiving treatment for AN and evaluates how treatment services are supporting them to work towards personal goals across all areas of everyday life. Method A total of 58 community-dwelling adults currently receiving treatment for anorexia nervosa at any stage of recovery completed the Client Assessment of Strengths, Interests and Goals Self-Report (CASIG-SR). Participants reported their goals for accommodation, work and study, interpersonal relationships, recreational activities, spirituality, religion or life purpose, physical health and mental health, and the personal strengths and supports needed to achieve those goals. Concordance scores were calculated between importance of personal goals and level of support from current services regarding these goals. Results Themes identified across goals, strengths and supports were Connection, Independence & Confidence, Meaning & Self: The Real Me, and Stability & Balance. Work and study goals and strengths were identified strongly. The key support needed was stability from the current treatment team to provide a stable base for change. Concordance scores indicate support provided for personal goals was less than the importance of the goal to the individual. Conclusion Results suggest goals for everyday living are critical to recovery in anorexia nervosa. Specific clinical considerations to increase motivation and hope are increased access to peer support, a focus on increasing positive affect, supporting safe exercise and promoting outdoor experiences and connection with nature. Level III Evidence obtained from well-designed cohort or case–control analytic studies.

Individuals with eating disorders often face difficulty accessing sufficiently intensive, recovery-focused treatment. Residential treatment may fill a gap in the spectrum of care, offering 24-h support in a more home-like environment than a hospital and using a holistic approach including individual and group psychological therapy, meal support, and lived experience staff. As residential treatment has not previously been examined in Australia, the current study aimed to document the development, treatment components, and structure of this first Australian residential service for eating disorders and provide a pilot of its treatment outcomes. Preliminary outcomes are included from a sample of 19 individuals from the first six months of admissions, including eating disorder symptoms, eating disorder-related impairment, anxiety, and depression. Significant pre- to post-treatment improvement was found in total eating disorder psychopathology, dietary restraint, eating concerns, body mass index, eating disorder-related impairment, and depression, but not from pre-treatment to a six-month follow-up. Pilot outcomes were positive at end-of-treatment but require further clinical evaluation to examine follow-up effects. Clinical insights are discussed from the establishment of this new treatment service, including recommendations for clinicians involved in the current roll-out of residential programs across Australia.

The efficacy of two different online treatment programs for people with binge eating disorder (BED) was compared. One hundred and nineteen adults with BED were randomized to treatments based on the Healthy Approach to Weight Management and Food in Eating Disorders (HAPIFED) or cognitive behavioural therapy (CBT). The treatments were delivered via videoconferencing in 10 groups with approximately 12 participants in each group. Each group included 13 treatment sessions and two follow-up sessions. Participants’ self-reported eating disorder behaviours/psychopathology, general mental health, and weight were assessed at pre-treatment, the end of treatment, a 3-month follow-up, and a 6-month follow-up. The participants in both treatments similarly reduced objective and subjective binge eating episodes from pre-treatment to the end of treatment. There were no significant differences in weight loss for the participants in either treatment. The participants in both treatments had reduced levels of loss of control over eating, eating disorder psychopathology, depression, psychological stress, and difficulties in emotion regulation from pre-treatment to the end of treatment. Treatments based on the HAPIFED or CBT delivered via videoconferencing can reduce binge eating and improve mental health in people with BED.

Abstract Background Lisdexamfetamine dimesylate (LDX) has demonstrated safety and efficacy for treatment of Binge Eating Disorder (BED). However, to date, trials have not included participants with co-occurring psychiatric disorders. This study explores how LDX affects eating disorder psychopathology, symptoms of common psychiatric comorbidities of BED (ADHD, depression, anxiety), and psychological quality of life, in people with moderate to severe BED. Methods These are secondary analyses of an open-label LDX trial conducted in 41 adults (18–40 years) over eight-weeks. Participants received LDX titrated to 50 or 70 mg. Clinical assessments and self-report questionnaires were conducted at baseline and 8-week follow-up. Results Eating disorder psychopathology and psychological quality of life improved after 8-weeks of LDX. No significant group-level changes in depression, anxiety or ADHD severity scores were observed. However, the majority within the small subsets with elevated depression and ADHD symptoms experienced reduced depressive and inattentive symptom severity, respectively. Conclusions We provide proof-of-concept evidence that LDX may provide broader psychological benefits to individuals with BED, beyond reducing their BE frequency. Effects of LDX on anxiety should be monitored closely by clinicians. Early indications suggest that LDX may be effectively used in people with BED, with and without co-occurring psychiatric conditions, however tolerability may be lower in highly complex cases. Trial registration: Australian and New Zealand Clinical Trials Registry (anzctr.org.au) #ACTRN12618000623291.

This study aimed to explore the dietetic treatment experiences of individuals with high eating disorder (ED) symptomatology attending a metabolic and bariatric clinic. An exploratory mixed methods cross-sectional study was conducted. Eighteen participants completed the survey, which included an adapted version of the Eating Disorders Treatment Experience Survey (EDTES), the Eating Disorder Examination Questionnaire Short (EDE-QS), and quantitative and qualitative questions relating to the roles and helpfulness of a dietitian in treatment. Data regarding the most and least helpful dietitians were collected. Differences between groups were tested with the Wilcoxon signed ranks test. A reflexive thematic analysis was used to analyse open-ended responses. The mean EDE-QS score reported by participants was 20.9 (SD = 6.0). The dietitians who were perceived as the most helpful were those who took into consideration an individual’s treatment preferences and choices (Z = −1.96, p = 0.05). Three themes were constructed: (1) nutrition knowledge and skills, (2) person-centred care, and (3) roles of the multidisciplinary team. Although further research is required, our findings suggest that the role of a dietitian in this setting may extend beyond weight-loss advice, and with additional training, could include individualised and collaborative supportive care that overlaps with ED treatment.

Background: The majority of research on the relationship between anorexia nervosa (AN) and trauma has been cross-sectional and quantitative. This study aimed to qualitatively explore how this relationship may shift over time. Methods: A community sample of nine women with a lived experience of AN and trauma were interviewed three times over ten years (1997–2007). Thematic analysis and narrative emplotment were utilised to construct themes both within and across interview transcripts. Results: AN was found to function as a way of coping with trauma (Theme 1), and also became a traumatic experience in and of itself (Theme 2). Longitudinal shifts were identified where the women moved away from AN as a way of coping to loosen the stronghold it had over their lives. Conclusions: This study illuminated how the women’s relationship with AN shifted over time, including the functions and meanings ascribed to AN, and the resilience of women to exit critical stages of AN and achieve meaningful change in their lives over the long term. A further novel finding was that the coping function AN served in early years of life shifted over time as they navigated additional traumas in adulthood and new and diverse ways of coping.

Abstract Background Women experiencing pregnancy after stillbirth experience high levels of anxiety, fear and depression. Standard antenatal care may be emotionally unsuitable for many women at this time, and there is a lack of evidence on what interventions or approaches to care might benefit these women. Therapeutic massage may assist women after stillbirth by decreasing anxiety, worry and stress. Objective This paper outlines the objectives, methodology, outcome and assessment measures for the Helping suppOrt individuals Pregnant after Experiencing a Stillbirth (HOPES) feasibility trial which evaluates massage as an adjunct approach to care for pregnant women who have experienced a prior stillbirth. It also outlines data collection timing and considerations for analysing the data. Methods HOPES will use a convergent parallel mixed-methods, single-arm repeated measures trial design in trained massage therapists’ private clinics across Australia. HOPES aims to recruit 75 individuals pregnant after a previous stillbirth. The intervention is massage therapy treatments, and participants will receive up to five massages within a 4-month period at intervals of their choosing. Primary quantitative outcomes are the feasibility and acceptability of the massage intervention. Secondary outcomes include determining the optimal timing of massage therapy delivery and the collection of measures for anxiety, worry, stress and self-management. A thematic analysis of women’s experiences undertaking the intervention will also be conducted. A narrative and joint display approach to integrate mixed-methods data is planned. Discussion The HOPES study will determine the feasibility and preliminary evidence for massage therapy as an intervention to support women who are pregnant after a stillbirth. Trial registration. ClinicalTrials.gov NCT05636553. Registered on December 3, 2022, and the trial is ongoing.

This study aimed to examine whether early change in self-reported quality of life (QoL) was a predictor of outcomes in the treatment of anorexia nervosa (AN). Given suggestions that people with AN overestimate their QoL when unwell, we hypothesised that any early change in self-reported QoL, be it an early improvement or early worsening, would predict better outcomes in terms of end-of-treatment body mass index (BMI), eating disorder (ED) psychopathology, and QoL. Participants were 78 adult outpatients engaged in cognitive behaviour therapy for anorexia nervosa (CBT-AN) either with or without the embedded compulsive exercise module “compuLsive Exercise Activity TheraPy” (LEAP). Polynomial regression was utilised to examine the effects of varying combinations of baseline and 10-week self-reported physical-health-relatedr QoL (SF-12; PHRQoL subscale), mental-health-related QoL (SF-12; MHRQoL subscale), and eating-disorder-specific QoL (EDQoL; global, psychological, cognitive/physical, financial, and school/work subscales) on end-of-treatment BMI, ED psychopathology, and QoL. Greater magnitudes of early change in global EDQoL scores, both positive and negative, predicted better MHRQoL but not BMI or ED psychopathology at the end of treatment. Psychological EDQoL ratings also accounted for 38.1% of the variance in end-of-treatment ED psychopathology, although tests examining the 6ratings may be meaningful in predicting treatment outcomes. The positive impact of early worsening in QoL ratings suggests that early QoL ratings are inflated due to denial and poor insight. Clinicians should be reassured that early QoL decline does not indicate treatment failure.

Abstract Background Exploration of client identity negotiations during treatment for Anorexia Nervosa (AN) is a relatively new area of research. Research suggests that difficulties with identity negotiations may present as a barrier to treatment. This study sought to explore individuals’ identity negotiations during therapy sessions using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN). Analysis focused on moments in therapy where individuals’ identities were dominated or defined by AN and where alternative identities could be generated. Method 40 in-session transcripts from sessions at early, mid and end points of the CBT-AN (with LEAP) treatment were qualitatively analysed for nine of the 78 participants in the original randomised control trial. Through a constructivist framework, thematic analysis was used to identify surface and latent meanings and discursive material participants used to negotiate their identities in the context of therapy sessions. Results Analysis of in-therapy transcripts generated two themes pertaining to identity negotiations: (1) troubled identities and (2) rebuilding identities and lives outside of AN. Early therapy sessions explored fragmented and AN dominated identities, including how AN was troubling to participants’ sense of self, contributed to conflicted identities, positioned them outside of normality, and was associated with isolated and othering identities. Within therapy sessions, participants engaged in a recursive process of shifting relationships with AN and themselves and building identities and lives outside of the AN identity. This included generating hopes for recovery and the future more frequently in mid- to late- therapy sessions. Conclusion Identity negotiations evident in the therapeutic conversations aligned with the key components of the CBT-AN intervention, including addressing (1) the characterisation of oneself as ‘an anorexic’ and (2) the diversification of roles and activities to broaden and enhance self-concepts. Future developments of therapeutic interventions for AN would benefit from greater consideration of ways to assist individuals to more comprehensively address problematic identities, including uncovering identities hidden by the AN identity and generating preferred identities. Trial Registration: Ethics approval was obtained at the time of the initial study and for this embedded research by the HREC at the Western Sydney University (HR777332).

Abstract Background Severe and enduring anorexia nervosa (SE-AN), is a serious and persistent illness, despite ‘state of the art’ treatment. Criteria have been theoretically proposed, but not tested, and may not adequately capture illness complexity, which potentially inhibits treatment refinements. The clinical reality of death as an outcome for some people who experience SE-AN (1 in 20) and broadening access to voluntary assisted dying, further complicates the field, which is undeveloped regarding more fundamental concepts such as nosology, treatment, recovery definitions and alternative conceptualisations of SE-AN. The present paper is in response to this and aims to build upon qualitative literature to enhance phenomenological understandings of fatal SE-AN. Method A published book, being the legacy of a 32-year-old professional artist offers a rich account of a life lived with AN, for 18 years with continuous treatment. A polysemous narrative via the interrelationship between the languages of the artist’s words and visual art is translated via interpretative phenomenological analysis (IPA), offering rich insight into the SE-AN experience. Findings The process of analysis induced three superordinate themes (1) Disappearing Self (2) Dialectical Dilemma (3) Death and Dying: Finding Meaning. Two cross cutting themes traversed these themes: (a) Colour and (b) Shifting Hope, where the former produced a visual representation via the ‘SE-AN Kaleidoscope’. Collectively the themes produce a concept of SE-AN, grounded in the data and depicted visually through the artist’s paintings. Conclusions The picture of SE-AN revealed in the analysis extends upon conceptualisations of SE-AN, highlighting key processes which are thus far under explored. These factors are implicated in illness persistence eliciting opportunities for further research testing including diagnostic considerations and treatment directions. In SE-AN, distorted body image extends to a global distortion in the perception of self. Additional criteria for the severe and enduring stages of illness related to (1) self and identity processes (2) measures of ‘global impoverishment’ across life domains are proposed for consideration in the future testing of putative defining features of SE-AN.

Abstract Objectives This systematic review aimed to compare the weight change in people with or without binge eating who underwent various weight loss treatments. Methods We searched for studies in PubMed, American Psychological Association, and Embase from inception to January 2022. The studies selected included assessment of binge eating and body weight before and after weight loss treatment in people of any age. The meta-analyses were conducted using Comprehensive Meta-Analysis (CMA). We used Egger’s regression test, the funnel plot, and the Trim and Fill test to assess the risk of publication bias. Results Thirty-four studies were included in the systematic review, with a total of 10.184 participants. The included studies were divided into three categories according to types of weight loss treatments, namely, (1) bariatric surgery; (2) pharmacotherapy isolated or combined with behavioral interventions; and (3) behavioral and/or nutritional interventions. The meta-analyses showed no significant difference in weight loss between people with or without binge eating engaged in weight loss treatments, with an overall effect size of − 0.117 (95% CI − 0.405 to 0.171; P = 0.426). Conclusions Our findings showed no difference in weight loss in people with or without pre-treatment binge eating who received various weight loss treatments. Weight loss treatments should not be withheld on the basis that they will not be effective in people with pre-treatment binge eating, albeit their safety and longer term impacts are unclear. Level of evidence: Level I, at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies.

Abstract Background Night eating syndrome (NES) is a unique eating disorder characterised by evening hyperphagia and nocturnal ingestions which cause significant distress and/or impairment in functioning. Despite the growing literature, NES remains poorly understood and under diagnosed. As such, this study aims to compare the prevalence of physical health conditions in participants with NES when compared to participants without an eating disorder (ED) and participants with other eating disorders (including anorexia nervosa (AN), binge eating disorder (BED) and bulimia nervosa (BN)) in a general population Australian sample of adults. Methods The data for this study were obtained from the 2017 Health Omnibus Survey (HOS) a multi-stage, cross-sectional survey, conducted by Harrison Research in South Australia. This current study focused on 2547 participants over 18 years of age and specific questions from this population survey including those related to participant demographics and health. Results This study identified that participants who screened positive for night eating syndrome (spNES) when compared to participants with other eating disorders (ED) or no ED diagnosis, were significantly more likely to have an increased age, be female, have lower levels of education and have lower household income. Additionally, the spNES group was significantly associated with sleep apnoea (p = 0.031), insomnia or other sleep problems (p

Abstract Background Severe and enduring anorexia nervosa (SE-AN) is amongst the most impairing of all mental illnesses. Collective uncertainties about SE-AN nosology impacts treatment refinement. Qualitative research, particularly lived experience literature, can contribute to a process of revision and enrichment of understanding the SE-AN experience and further develop treatment interventions. Poor outcomes to date, as evidenced in clinical trials and mortality for people with SE-AN (1 in 20) demonstrate the need for research that informs conceptualisations and novel treatment directions. This interpretative, meta-ethnographic meta-synthesis aimed to bridge this gap. Methods A systematic search for qualitative studies that explored the AN experiences of people with a duration of greater than 3 years was undertaken. These studies included those that encompassed phenomenology, treatment experiences and recovery. Results 36 papers, comprising 382 voices of SE-AN experiences informed the meta-ethnographic findings. Four higher order constructs were generated through a synthesis of themes and participant extracts cited in the extracted papers: (1) Vulnerable sense of self (2) Intra-psychic processes (3) Global impoverishment (4) Inter-psychic temporal processes. Running across these meta-themes were three cross cutting themes (i) Treatment: help versus harm, (ii) Shifts in control (iii) Hope versus hopelessness. These meta-themes were integrated into conceptualisations of SE-AN that was experienced as a recursive process of existential self-in-relation to other and the anorexia nervosa trap. Conclusions The alternative conceptualisation of SE-AN proposed in this paper poses a challenge to current conceptualisations of AN and calls for treatments to engage with the complex intra and inter-psychic processes of the SE-AN, more fully. In doing so, clinicians and researchers are asked to continue to be bold in testing novel ideas that may challenge our own rigidity and attachment to dominant paradigms to best serve the individual person with SE-AN. The ‘global impoverishment of self’, found in this synthesis of AN experiences, should inform proposed diagnostic criteria for SE-AN.

Abstract Background Little is known about the prevalence and impairment associated with possible Avoidant/restrictive food intake disorder (ARFID) in community adolescent populations. We aimed to investigate the prevalence, health-related quality of life (HRQoL), and psychological distress associated with possible ARFID in a sample of adolescents from the general population in New South Wales, Australia. Methods A representative sample of 5072 secondary school students aged between 11 and 19 years completed the online EveryBODY survey in 2017. The survey included demographic data, eating behaviours, psychological distress and both physical and psychosocial health-related quality of life. Results The prevalence of possible ARFID was 1.98% (95% CI 1.63–2.41) and did not differ significantly across school years 7–12. The weight status of participants with possible ARFID did not differ significantly from those without possible ARFID. When measuring gender identity, the ratio of males to females with possible ARFID was 1:1.7. This was statistically significant, however, the effect size was very small. Psychological distress and HRQoL did not differ significantly between the possible ARFID and non-ARFID group. Conclusions The prevalence of possible ARFID was found to be similar to that of anorexia nervosa and binge eating disorder in the general adolescent population. Adolescents who identify as girls rather than boys may be more likely to develop ARFID, replication with new samples is required to confirm these findings. The impact of ARFID on HRQoL may be minimal in adolescence and become more significant in adulthood, further research using longitudinal design, healthy control groups and/or diagnostic interviews is required.

Abstract Background Treatment for anorexia nervosa (AN) is typically delivered on a continuum of care, starting with outpatient treatment, and moving onto intensive outpatient, day or residential treatment and/or inpatient hospitalisation. However, minimal attention has been afforded to the lived experiences of persons undergoing inpatient treatment for AN. In particular, qualitative literature pertaining to the lived experiences of specialist inpatient or residential treatment of AN remains fragmented and incomplete. The aim of this review was to synthesise current literature exploring patients’ lived experiences of residential and inpatient treatment for AN within eating disorder-specific treatment services. Methods Five databases were searched and a qualitative thematic systematic review and meta-synthesis of 11 studies were conducted. Results Eleven studies of 159 participants were included. Four meta-themes were constructed from the data: (1) a medical discourse—“I don’t think it’s individualised here”; (2) restrictive practice—living in a “bubble”; (3) myself, others and “a similar demon”; and (4) I am “not just another anorexic”. The data also revealed two cross-cutting themes: (1) more than a single experience; and (2) meaning making and identity. Conclusions These findings highlight the complex and multifaceted nature of the inpatient treatment experience as well as the inherent conflicts in balancing the necessity of medical and psychological intervention with person-centred treatment approaches in the treatment of AN.

Abstract Objective Grazing is a disturbed eating pattern that has been associated with eating disorders and obesity. One of the new measures to investigate this eating behavior is the Short Inventory of Grazing (SIG), a two-item questionnaire that assesses grazing in general and grazing associated with the feeling of loss of control over eating (LOC grazing). However, the psychometric properties of the SIG have not been assessed in the Brazilian population. The present study aimed to cross-culturally adapt and validate a Brazilian version of the SIG. Methods The SIG was adapted to the Brazilian context following international guidelines. Then, 90 undergraduate students completed an online survey including questions from the SIG, the Binge Eating Scale (BES), the Patient Health Questionnaire-9 (PHQ9), the Generalized Anxiety Disorder-7 (GAD7), and a question related to self-reported health status. The internal consistency, test-retest reliability, and convergent validity of the questionnaire were assessed. Results The prevalence rates of at least one weekly episode of grazing in general and LOC grazing were 71.1 and 54.5%, respectively. The internal consistence of the SIG was acceptable (0.81). In addition, SIG scores on both items were positively and significantly associated with BES, GAD7, and PHQ9 scores, and with poorer self-rated health. However, SIG test and retest scores differed significantly. Conclusion Overall, the Brazilian version of the SIG demonstrated adequate psychometric properties. The instrument had adequate internal consistency, with both items exhibiting good convergent validity with related measures.

Plain English Summary This review aimed to investigate the association between eating disorders (ED) and mental health problems. A review of existing systematic reviews was conducted to provide a top-level synthesis of the current evidence in this area. Our review found a total of 18 systematic reviews, which investigated the association between ED and a wide range of mental health problems. These conditions include depression and anxiety, obsessive-compulsive symptoms, attention deficit hyperactivity disorder (ADHD), social anxiety, personality disorders, suicidal-related outcomes, bipolar disorders and non-suicidal self-injury. Depression, social anxiety and ADHD are likely to have a stronger strength of association with ED relative to other mental health problems.

Plain English summary Our understanding of the prevalence and impact of eating disorders has improved significantly over the past 20-years. Research highlights that rates of eating disorders are increasing. To inform the development of the Eating Disorder Research and Translation Strategy 2021–2031 this review aimed to better understand the global change in prevalence and impact of eating disorders to inform policy decision-making. Three scholarly databases were systematically searched for related research published between 2009 and 2021. Searches identified 135 studies which met our inclusion criteria. Estimates in lifetime eating disorder prevalence varied from 2.58 to 8.4% in women and girls. Findings indicated that eating disorders appeared more prevalent in young people and adolescents, particularly young women, while sexuality diverse (LGBTQI +) individuals were six-times more likely to have an eating disorder compared to the general male population. The little research suggests moderate to high prevalence of eating disorders in First Australian peoples, Australia’s spending on eating disorders was estimated at ~ $84 billion due to disability or death. There is no doubt that eating disorder prevalence and impact are on the rise. Future research should include more diverse populations to increase estimate accuracy and improve care for all.

Abstract Purpose Since the term orthorexia nervosa (ON) was coined from the Greek (ὀρθός, right and ὄρεξις, appetite) in 1997 to describe an obsession with “correct” eating, it has been used worldwide without a consistent definition. Although multiple authors have proposed diagnostic criteria, and many theoretical papers have been published, no consensus definition of ON exists, empirical primary evidence is limited, and ON is not a standardized diagnosis. These gaps prevent research to identify risk and protective factors, pathophysiology, functional consequences, and evidence-based therapeutic treatments. The aims of the current study are to categorize the common observations and presentations of ON pathology among experts in the eating disorder field, propose tentative diagnostic criteria, and consider which DSM chapter and category would be most appropriate for ON should it be included. Methods 47 eating disorder researchers and multidisciplinary treatment specialists from 14 different countries across four continents completed a three-phase modified Delphi process, with 75% agreement determined as the threshold for a statement to be included in the final consensus document. In phase I, participants were asked via online survey to agree or disagree with 67 statements about ON in four categories: A–Definition, Clinical Aspects, Duration; B–Consequences; C–Onset; D–Exclusion Criteria, and comment on their rationale. Responses were used to modify the statements which were then provided to the same participants for phase II, a second round of feedback, again in online survey form. Responses to phase II were used to modify and improve the statements for phase III, in which statements that met the predetermined 75% of agreement threshold were provided for review and commentary by all participants. Results 27 statements met or exceeded the consensus threshold and were compiled into proposed diagnostic criteria for ON. Conclusions This is the first time a standardized definition of ON has been developed from a worldwide, multidisciplinary cohort of experts. It represents a summary of observations, clinical expertise, and research findings from a wide base of knowledge. It may be used as a base for diagnosis, treatment protocols, and further research to answer the open questions that remain, particularly the functional consequences of ON and how it might be prevented or identified and intervened upon in its early stages. Although the participants encompass many countries and disciplines, further research will be needed to determine if these diagnostic criteria are applicable to the experience of ON in geographic areas not represented in the current expert panel. Level of evidence Level V: opinions of expert committees

Plain English summary Narrative therapy has been proposed as a promising intervention for the treatment of eating disorders. However, the treatment outcomes of narrative therapy for eating disorders are under-researched. This systematic review of the literature has demonstrated limited support for narrative therapy through practice-based evidence in clinician reports and transcripts of therapy sessions. These reports demonstrated how narrative therapy was associated with identity shifts, some symptom reduction, reduced hospitalisations, improved agency over the problem and improvements in quality of life. There is a need for future research to systematically report treatment outcomes. This will fill a gap in research evidence-base for narrative therapy in the treatment of eating disorders.

Plain English summary Exercise is an important feature of most eating disorders. Researchers have found that people with an eating disorder exercise because they feel driven to do so, or because it helps them cope with negative emotions. This type of exercise is called ‘compulsive exercise’, and it can have detrimental physical and mental effects. There is some disagreement in the literature about how to define compulsive exercise, and there are many ways to measure and treat it. The aim of this study is to collect expert researchers’ and clinicians’ views of compulsive exercise, and elicit suggestions regarding how to reliably measure this behaviour in order to promote consensus in the field.

Abstract Background There are presently a number of eating disorder treatment interventions that have a research-evidence base to support their effectiveness. However, rates of attrition and treatment outcomes demonstrate that there is no one-size fits all for the treatment of eating disorders. Narrative therapy is a promising, but under-researched, intervention for the treatment of eating disorders (EDs). The aim of this study was to conduct a narrative synthesis of the literature to explore the content and use of narrative therapy in the treatment of EDs. Method Data were extracted from 33 eligible included studies following systematic search of five data bases. Data included aims and objectives, sample characteristics, treatment details and components of narrative therapy, which informed the narrative synthesis. The study is reported according to the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results Narrative therapy interventions for EDs consisted of several components including the narrative worldview; unpacking the problem story; finding, thickening the meaning and performance of stories hidden by the problem story; and safety considerations. A notable proportion of the extracted articles discussed components of unpacking problem stories, and finding and re-authoring openings (or unique outcomes) that were hidden by problematic stories. Relatively fewer papers discussed the processes by identity shifts were performed or lived out, including in the eating practices of those with a lived ED experience. Furthermore, few papers addressed how therapists established client safety within the narrative framework when working with EDs. Conclusion This narrative synthesis found that narrative practitioners utilise a variety of narrative therapy techniques in working with individuals with a lived ED experience. The current literature has emphasis on specific narrative therapy techniques used in ED treatments, with some aspects of the narrative worldview and safety considerations left undiscussed. Additional research is needed to explore how identity shifts in narrative therapy are performed and lead to measurable behavioural changes, and to consider how safety considerations can be established within the narrative worldview. Plain English summary There are a number of psychological therapies for eating disorders that have research evidence-base. These treatments, however, do not work for everyone as indicated by drop-out rates and eating disorders running a severe and enduring course for some people. Narrative therapy is a therapeutic intervention that has been reported as a promising intervention for people with an eating disorder. The focus of narrative therapy is to engage the person in finding identities hidden by problem-saturated identities and in the performance of these hidden identities. In this review, we have explored the use of narrative therapy for eating disorders to identify what aspects of this therapy are currently being used and which components are less referenced in the literature. Findings from this study support the need for further research into narrative therapy components in the treatment of eating disorders, particularly how hidden identities are performed and safety considerations are integrated into this therapeutic intervention.

Plain English summary The objective of this project was to develop recommendations and clinical considerations to guide clinicians in the management of people experiencing eating disorders who also have higher weight. A Guideline Development Group was formed containing members with academic and/or clinical expertise and people with a lived experience of eating disorder. The guideline was not only informed by reviews of the scientific literature but also clinical expertise and lived expertise. This guideline has undergone extensive review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical, academic and/or lived expertise. The guideline outlines a set of recommendations for clinical practice including the strong recommendation for psychological treatment to be offered as the first treatment for an eating disorder in people who are of higher weight. Considerations in clinical practice including weight stigma, care by professionals from disparate disciplines, and cultural considerations are also discussed. The Guideline Development Group acknowledges a lack of available research evidence specific to people experiencing an eating disorder who are also of higher weight and consequently some recommendations relied on consensus of group members taking into account the expert reviews. The Group also identified areas where additional research is necessary such as research evaluating weigh-neutral and other more recent approached in the field.

Plain English Summary Anorexia Nervosa (AN) is notable for the individual’s conviction that they need to lose weight—even when they are dangerously underweight- or to prevent weight gain. However, how these beliefs relate to the emotional experience of the body, in the presence of AN need to be explored further. This study begins to examine this relationship. Twenty-one adults (95% women; average age 27 years) receiving in-patient treatment for AN were asked a series of questions related to beliefs about their body. To allow a comparison between the level-of-insight and body shape dissatisfaction, participants were also asked to rate how satisfied or dissatisfied they were about their body shape. Almost 25% of the sample had beliefs of delusional intensity about their body shape. Further, it was also found that people with AN who had stronger beliefs of delusional intensity were more likely to be dissatisfied with their body shape. This pilot study appears to support previous research that suggests that some individuals with AN have stronger beliefs of delusional intensity. The findings from the current study should be extended with future research looking at the impact of beliefs on illness and treatment.

Plain English Summary People with anorexia nervosa often have difficulty thinking flexibly and in terms of the big picture. We investigated whether these thinking styles (1) change over treatment, (2) influence response to treatment, or (3) predict whether people gain weight or overcome the eating disorder. We found that people were able to think more flexibly after treatment. We also found that people who had more difficulty seeing the big picture prior to treatment had a more rapid decrease in eating disorder symptoms and clinical impairment in treatment. Thinking styles did not predict whether people gained weight early in treatment or overcame the eating disorder. Our findings suggest that the detail-focused thinking style commonly observed among people with anorexia nervosa can be both a vulnerability and a strength.

Plain English Summary Eating disorders can cause a large impact to the lives of those living with them and their loved ones. There is a need for research from the perspective of the individual with lived eating disorder experience to shape treatment for these conditions. This study aimed to address this need by investigating features of therapy and how they impacted the overall perception of treatment helpfulness. It was found that therapist related factors, such as providing freedom of choice around change and instilling hope, accounted for a large contribution to helpfulness. It was also found that motivation may not necessarily have to be high when commencing treatment to result in better ratings of treatment helpfulness.

Abstract Background Despite being the first validated measure of grazing, the Grazing Questionnaire (GQ) has not been investigated among individuals with obesity. Therefore, the current study aimed to examine the psychometric properties of the GQ in an obesity sample. Methods Participants (N = 259) were recruited from community and clinical settings in Australia. The sample comprised adults with normal weight (n = 77) and obesity (n = 182). A portion of individuals with obesity (n = 102) had binge eating disorder (BED). Data from the obesity group was examined to establish the factor structure, validity, and reliability of the GQ. A one-way ANOVA with planned contrasts was conducted to compare scores on the GQ across groups. Results Confirmatory factor analysis revealed that the 2-factor model of the GQ was the best model fit for individuals with obesity. The GQ demonstrated high internal consistency, test–retest reliability over 3 months, and convergent and divergent validity. As hypothesised, the obesity group had significantly higher scores on the GQ than the normal weight group, while the obesity with BED group had significantly higher scores than the obesity without BED group. Conclusion This was the first study to investigate the psychometric properties of the GQ in an obesity sample. Overall, findings indicated that the GQ is a psychometrically sound measure of grazing among individuals with obesity. These findings provide further support for two distinct subtypes of grazing and highlight the importance of increased assessment and management of grazing behaviours for individuals with obesity and eating disorders. Plain English summary Maintaining a healthy weight is one of the greatest challenges for individuals with obesity. Certain eating patterns such as grazing may contribute to difficulties in weight management. Grazing is the repetitive and unplanned eating of small amounts of food that is not related to feeling hungry. Researchers and clinicians often use self-report questionnaires to measure grazing. However, the first validated questionnaire of grazing has not been investigated among individuals with obesity. Therefore, the goal of this study was to examine and validate the Grazing Questionnaire in individuals with obesity. Overall, our results showed that the Grazing Questionnaire is a valid and reliable self-report measure of grazing in individuals with obesity. Similar to previous research, we found that there are two subtypes of grazing. The first subtype involves continuous, unplanned eating. The second subtype is associated with a sense of loss of control over eating. We also found that people with obesity and binge eating disorder graze more than people with obesity that do not have binge eating disorder, while both groups graze more than individuals with normal weight. We recommend that clinicians routinely assess and treat unhelpful grazing patterns when working with individuals with obesity and eating disorders.

Objectives: Approximately 5.4 million parents worldwide are affected by stillbirth each year. There are limited therapeutic options for bereaved parents to manage their grief. A questionnaire was developed to learn more about parents' experience with complementary medicine after stillbirth. Design: An online questionnaire-based study was conducted. Setting: Australian and American parents, 18 years or over, and who had experienced a stillbirth in the past 36 months were recruited. The study was open for participation for 11 months. Main outcome measures: The authors developed the questionnaire based on existing survey instruments used for researching prenatal loss and complementary medicine. The complementary and alternative medicines included in the questionnaire include acupuncture, Ayurveda, biofeedback, Chinese Medicine, energy healing, exercise, homeopathy, massage therapy, meditation, mindfulness, naturopathy, Shamanism, tai chi, and yoga. The questionnaire included 43 questions in 5 sections: demographics, complementary medicine use over time, impact of the loss, preferences for coping with grief, and utilization of and experience of complementary medicine for coping with grief. Results: Almost 30% (29.8%) of respondents used complementary medicine to help manage their grief. Themes for how complementary medicine was perceived by help respondents included (1) helping them cope, (2) a self-care tool, and (3) a sense of control. The most popular complementary medicines used after a stillbirth were massage (n?=?36/72; 50%) and exercise (n?=?37/72; 51.4%). Respondents who used complementary medicine to help manage their grief had significantly slightly lower impact of event scale scores than those who did not use complementary medicine [r(213)?=??0.16, p?=?0.021). The study identified several barriers to complementary medicine use after a stillbirth, including not knowing much about it (n?=?85/103; 82.5%), cost (n?=?40/103; 38.8%), and a lack of confidence (n?=?23/103; 22.3%). Conclusions: The study found a desire for complementary medicine therapies to help manage grief especially massage and exercise.

Abstract Background Bulimia nervosa (BN) and binge eating disorder (BED) are eating disorders (EDs) characterized by recurrent binge eating. They are associated with medical complications, impaired adaptive function and often a high BMI, for which a multidisciplinary treatment approach may be needed. This study explored the efficacy of a novel intervention integrating Cognitive Behavioural Therapy- Enhanced (CBT-E) and weight management for people with recurrent binge eating episodes and high BMI with respect to physical, psychopathological and quality of life outcomes. Methods Ninety-eight adults diagnosed with BN, BED, or Other Specified/Unspecified Feeding or Eating Disorder (OSFED/UFED) and BMI ≥ 27 to 75%) had blood test results for glucose, insulin, triglycerides and cholesterol within the normal range, and 52% were within the normal range for the physical component of quality of life at baseline with no change during the trial period. Conclusion Integrating weight and ED management resulted in comparable outcomes to ED therapy alone. Although adding weight management to an ED intervention had no adverse effects on psychological outcomes, it also had no beneficial effect on metabolic outcomes. Therefore, more intense weight management strategies may be required where indicated to improve metabolic outcomes. Safety will need to be concurrently investigated. Trial registration US National Institutes of Health clinical trial registration number NCT02464345 , date of registration 08/06/2015. Changes to the present paper from the published protocol paper (Trials 18:578, 2015) and as reported in the Trial registration (clinicaltrials.gov) are reported in Supplementary File 1.

Abstract Background Many people with an eating disorder (ED) never engage with an evidence-based ED treatment. Of the few studies that have qualitatively explored barriers to receiving treatment, some do so in relation to mental health conditions in general, and others focus on participants who have already undergone treatment. This study aims to address this gap in the literature by exploring the barriers to ED treatment engagement from the perspectives of individuals in the community with an ED (either self-identified or professionally diagnosed) and had not received ED treatment/s. Method Fifty-six of 772 participants in an online Eating Disorders Treatment Experience survey had self-identified as having symptoms consistent with an ED, or had received a diagnosis of an ED and indicated that they had never undergone treatment for an ED. They were asked to share the reasons for which they did not receive treatment with an open-ended question. Qualitative analysis of survey responses was completed using the Framework Method to generate overarching themes that encapsulated the diverse participant accounts. Results The thematic analysis generated two main themes, each with two subthemes. The first theme was the negotiation of the need for treatment within oneself (intrapersonal factors; theme 1). The second theme explored interpersonal contexts that shaped the participant’s decision not to seek treatment (interpersonal/external factors; theme 2). Two cross-cutting subthemes of fear and health literacy were also generated that demonstrated a high degree of overlap with the aforementioned main themes. Conclusions The process by which individuals decide whether or not to engage with ED treatment services is complex and involves intra- and interpersonal negotiations intertwined with health literacy and fear. A factor not prominent in previous research was negative self-perceptions and the belief of being undeserving of treatment. These factors have implications for ongoing community and clinical interventions to further address barriers to ED treatment engagement.

Abstract Background Eating disorders (EDs) are highly complex mental illnesses associated with significant medical complications. There are currently knowledge gaps in research relating to the epidemiology, aetiology, treatment, burden, and outcomes of eating disorders. To clearly identify and begin addressing the major deficits in the scientific, medical, and clinical understanding of these mental illnesses, the Australian Government Department of Health in 2019 funded the InsideOut Institute (IOI) to develop the Australian Eating Disorder Research and Translation Strategy, the primary aim of which was to identify priorities and targets for building research capacity and outputs. A series of rapid reviews (RR) were conducted to map the current state of knowledge, identify evidence gaps, and inform development of the national research strategy. Published peer-reviewed literature on DSM-5 listed EDs, across eight knowledge domains was reviewed: (1) population, prevalence, disease burden, Quality of Life in Western developed countries; (2) risk factors; (3) co-occurring conditions and medical complications; (4) screening and diagnosis; (5) prevention and early intervention; (6) psychotherapies and relapse prevention; (7) models of care; (8) pharmacotherapies, alternative and adjunctive therapies; and (9) outcomes (including mortality). While RRs are systematic in nature, they are distinct from systematic reviews in their aim to gather evidence in a timely manner to support decision-making on urgent or high-priority health concerns at the national level. Results Three medical science databases were searched as the primary source of literature for the RRs: Science Direct, PubMed and OVID (Medline). The search was completed on 31st May 2021 (spanning January 2009–May 2021). At writing, a total of 1,320 articles met eligibility criteria and were included in the final review. Conclusions For each RR, the evidence has been organised to review the knowledge area and identify gaps for further research and investment. The series of RRs (published separately within the current series) are designed to support the development of research and translation practice in the field of EDs. They highlight areas for investment and investigation, and provide researchers, service planners and providers, and research funders rapid access to quality current evidence, which has been synthesised and organised to assist decision-making.

Plain English summary The few established treatments for anorexia nervosa have limited success rates with high patient dropout. Specialist Supportive Clinical Management (SSCM) is a promising treatment for eating disorders. It would be beneficial to understand SSCM better and how and why it may work, which this paper proposes. SSCM is collaborative and flexible to people’s needs, offering them treatment choices and to progress at their own pace. It is less prescriptive than other manualised therapies and therefore could be offered to people more than once, building hopefulness. It requires an experienced psychotherapist to deliver it as SSCM addresses both the symptom of the ED (food and exercise behaviours) as well as life issues causing difficulty to a person (psychotherapy), as presented by the patient. Grounded in a sound scientific basis, SSCM is a promising treatment that would benefit from further development, in line with evolving understandings of AN, and some ideas for this are offered within the paper.

Plain English summary Adolescence is a time of rapid emotional and physical development when beliefs about one’s weight and shape are established. Parents are key influencers of adolescent beliefs and behaviours. This study aimed to consider associations between perceived positive and negative parental comments on weight/shape and eating, with sons’ and daughters’ psychological distress and behaviours associated with eating disorders. We found all perceived negative comments from either parent were associated with poorer adolescent mental health, both specific to behaviours associated with eating disorders and general distress. When we considered the strength of the relationship between parental comments and different influences such as biological sex, developmental stage, BMI percentile and psychological distress, we expected to find that BMI percentile and psychological distress would influenced the findings, and they did. When we considered the relationship with them included, perceived maternal negative comments continued to have a negative influence on behaviours related to eating disorders. Therefore, our findings highlight the importance of raising awareness of potential negative impacts within family systems of comments around weight/shape and eating in these key formative years.

Dietitians are included in eating disorder (ED) treatment teams for their expertise in nutrition. However, little is known about an individual’s experience of dietetic intervention as part of their ED treatment and what they value as part of dietetic care. Therefore, the aim of this review was to synthesise the available qualitative literature to understand the role and value of a dietitian in ED treatment from the perspective of individuals with lived experience. Six databases and Google Scholar were searched and a thematic synthesis and meta-synthesis of fifteen studies were conducted. Four themes were constructed from the data: (1) “guidance and structure”—Provision of nutrition knowledge and skills; (2) “having all my bases covered”—Dietitians as part of a multidisciplinary team; (3) Challenges in nutritional treatment; and (4) “it was my treatment and my recovery”—Person-centred dietetic treatment. Across all identified themes was the cross-cutting theme of a shared treatment journey between the dietitian and the individual receiving treatment. These findings support dietitians having a role that is not limited only to the provision of nutrition treatment in ED care and illustrates the importance of dietitians engaging with clients by centring on the individual’s needs and preferences. Further understanding helpful dietetic treatment components and identifying gaps in training is needed to develop these broader roles for dietetic care.

Plain English summary Family-Based Treatment (FBT) is a well-established, intensive approach to the treatment of adolescent anorexia nervosa (AN). The first phase of treatment focuses on eating and weight restoration, where parents are given responsibility for the adolescent’s home-based refeeding. This is followed by handing over of this responsibility to the adolescent with the final-phase a focusing on adolescent-specific psychological issues. While the majority of adolescents gain weight with this treatment, a substantive proportion experience ongoing psychological distress and around a quarter of families drop out in the first phase. Little is known about these adolescents’ experiences. In this project, we interviewed 14 individuals who, with their family, had either dropped out of FBT and/or experienced ongoing psychological distress post-treatment. The participants noted that their parents’ stance in supporting them was life-saving and contributed to a sense that their life was worth saving. However, they also noted a relative absence of focus on their psychological distress, particularly in the early stages of treatment. Most helpful for participants was when therapists took into consideration and tailored treatments to them. Future treatments need to consider ways to support an adolescent’s psychological distress more comprehensively, prioritise their voice and support them in finding an identity outside of the AN identity.

Abstract Background Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions. Methods A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness. Discussion There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145 .

Abstract Background There is preliminary evidence to suggest that yoga can be beneficial in reducing anxiety, depression and general eating disorder symptoms in people with Anorexia Nervosa (AN). It is unclear whether the therapeutic benefits of yoga are supported or utilised in the treatment of AN amongst clinical experts. The present study aimed to explore and synthesise expert opinion on the use of yoga as an adjunctive therapy in the management of anxiety, depression and over-exercise in individuals with AN. Methods A Delphi methodology was employed, with clinicians considered experts in the treatment of AN recruited internationally to form the panel (n = 18). The first iteration of questionnaires comprised of four open-ended questions concerning the experts’ understanding of the term yoga and opinions on its’ use in therapy generally and more specifically in the treatment of AN. Using content analysis, statements were derived from this data and included as Likert-based items in two subsequent rounds where panellists rated their level of agreement on each item. Seventeen out of 18 respondents completed all three iterations. Results Consensus (level of agreement defined at ≥ 85%) was achieved for 36.47% of the items included in the second and third rounds. The panel reached consensus on items defining yoga and pertaining to its’ general benefits. The panel agreed that yoga is a adjunct therapy for various problems, consensus was not achieved on the specific use of yoga as an adjunct therapy in the treatment of comorbid anxiety, depression or trauma in patients with AN. Although the expert panel acknowledged a number of benefits for use of yoga in AN, they strongly endorsed that future research should evaluate the potential risks of using yoga as an embodied practice. Conclusions It is possible that yoga could be considered for inclusion in future guidelines if supported by empirical research. We conclude that there seems to be enough consensus that such further scientific investigation is warranted. Plain English summary This study aimed to explore expert opinion on the use of yoga as an adjunctive therapy in the management of anxiety, depression and over-exercise in individuals with Anorexia Nervosa (AN). Clinicians considered experts in the treatment of AN recruited internationally to form the panel (n = 18). Experts were asked about their understanding of the term yoga and their opinions on its’ use in therapy. The panel reached consensus on items defining yoga and pertaining to its’ general benefits. Although the panel agreed that yoga is a nice additional therapy for various problems, consensus was not achieved on the use of yoga as an additional therapy in the treatment of specific problems like anxiety, depression or trauma in people with AN. The expert panel acknowledged a number of benefits for use of yoga in AN. However the panel strongly considered that future research should evaluate the potential risks of using yoga as an embodied practice. The areas of collective agreement gained in the study can serve as preliminary guidelines for the use of yoga in AN whilst guiding future research directions.

Anorexia nervosa (AN) is a mental health disorder that has serious physical, emotional and social consequences. Whilst cognitive behavioural therapy for AN (CBT-AN) has demonstrated efficacy, there remains a global need to improve AN treatment. Compulsive exercise activity therapy (LEAP) is an active therapy consisting of the addition to CBT-AN of eight specific sessions that focus on exercise and motivation for behavioural change. This paper presents a secondary analysis of 74 female participants in a randomised control trial of LEAP plus CBT-AN versus CBT-AN alone. The main aim of this study was to explore putative predictors and to estimate the magnitude of changes due to LEAP for specific outcome measures. Participants (LEAP: n = 36; CBT-AN: n = 38) were assessed at three successive surveys: baseline, end of therapy, and 6 months post-therapy. The overall effect sizes for changes between baseline to end of therapy and baseline to 6-month follow-up assessment showed large effect sizes (Cohen’s d > = 0.80) for mental-health-related quality of life (MHRQoL), weight concern, dietary restraint, eating concern, AN stage change, and psychological distress (all p < 0.05). The results also indicated that several pre-treatment characteristics, including body mass index (BMI), level of eating disorder (ED) symptoms, and MHRQoL are important for identifying whether a treatment is likely to be effective. Future treatment programs should aim to optimise early improvements in BMI, ED symptoms, and MHRQoL.

Abstract Background Studies into the disordered eating behaviour of chew and spit have alluded to several cohorts more likely to engage in the behaviour, one such group being bariatric surgery candidates and patients. Weight-loss surgery candidates have received little to no attention regarding engaging in chew and spit behaviour. Changes in pre- and post- surgery eating pathology related to chew and spit behaviour has yet to be explored and described in academic literature. Case presentation The current study reports on three cases of individual women, aged 30, 35, and 62 respectively, who indicated engagement in chew and spit. All three cases underwent bariatric surgery (two underwent gastric bypass, one underwent vertical sleeve gastrectomy). Eating pathology—including chew and spit behaviour, anxiety and depression, and adherence to the Norwegian nutritional guidelines were examined pre-operatively and post-operatively (one and two-year follow-up). At baseline (pre-surgery), two participants reported that they engaged in chew and spit, compared to one patient post-surgery. All three cases reported that they, to at least some extent, adhered to dietary guidelines post-surgery. Subjective bingeing frequency appeared to be relatively low for all three cases, further declining in frequency at one-year follow-up. At baseline, one participant reported clinically significant depression and anxiety, with no clinically significant depression or anxiety reported at follow-ups in participants that chew and spit. Conclusions The current study provides a starting point for the exploration of chew and spit as a pathological symptom of disordered eating in bariatric patients. It highlights the need to further explore chew and spit before and after weight-loss surgery.