Clinical Context

Eating disorders are psychiatric disorders characterized by abnormal eating or weight control behaviors. They have serious morbidity and are among the most life-threatening of all mental health conditions.

In most mid- and high-income countries, eating disorder prevalence in young people has markedly increased over the past 50 years, creating a public health concern. Eating disorders are likely underdiagnosed and undertreated, as shame or stigmatization may lead to underreporting and delay in seeking specialized care.

Study Synopsis and Perspective

A multicenter study, published in the April 1 issue of JAMA Pediatrics^[1] indicated that an elevated proportion of children and adolescents around the world, particularly girls or youths with high body mass indices (BMIs), experience disordered eating. The high figures are concerning from a public health perspective and highlight the need to implement strategies for preventing eating disorders.

These disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision,^[2] include anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder-not otherwise specified. The prevalence of these disorders in young people has markedly increased globally over the past 50 years.^[3] Eating disorders are among the most life-threatening mental disorders; they were responsible for 318 deaths worldwide in 2019.^[4]

Because some individuals with eating disorders conceal core symptoms and avoid or delay seeking specialist care because of feelings of embarrassment, stigma, or ambivalence toward treatment, most cases of eating disorders remain undetected and untreated.^[5]

Brazilian researchers have conducted studies to assess risky behaviors and predisposing factors among young people.^[5] The researchers observed that the probability of experiencing eating disorders was higher among young people who had an intense fear of gaining weight, who experienced thin-ideal internalization, who were excessively concerned about food, who experienced compulsive eating episodes, or who used laxatives. As previously reported, most participants in these studies had never sought professional help.

A group of researchers from several countries, including Brazilians connected to the State University of Londrina, Londrina, Paraná, Brazil, conducted a systematic review and meta-analysis to study the global proportion of disordered eating in children and adolescents.^[1]

José Francisco López-Gil, PhD, of the University of Castilla–La Mancha, Spain, coordinated the study. The investigators determined the rate of disordered eating among children and adolescents using the Sick, Control, One, Fat, Food (SCOFF) questionnaire,^[7] which is the most widely used screening measure for eating disorders.

Methods and Results

Investigators systematically searched 4 databases (PubMed, Scopus, Web of Science, and the Cochrane Library), with date limits from January 1999 to November 2022. Studies were required to meet the following criteria: (1) participants: studies of community samples of children and adolescents aged 6 to 18 years, and (2) outcome: disordered eating assessed by the SCOFF questionnaire. The exclusion criteria were (1) studies conducted with young people who had been diagnosed with physical or mental disorders; (2) studies that were published before 1999 because the SCOFF questionnaire was designed in that year; (3) studies in which data were collected during the COVID-19 pandemic because of the possibility of selection bias; (4) studies that employed data from the same surveys/studies, to avoid duplication; and (5) systematic reviews and/or meta-analyses and qualitative and case studies.^[1]

In all, the systematic review and meta-analysis included 32 studies, which involved a total of 63,181 participants from 16 countries, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.^[8] The overall proportion of children and adolescents with disordered eating was 22.36% (95% CI: 18.84%, 26.09%); P < .001.^[1] According to the researchers, girls were significantly more likely to report disordered eating (n = 27,548; 30.03% [95% CI: 25.61%, 34.65%]) than boys (n = 26,170; 16.98% [95% CI: 13.46%, 20.81%]); P < .001. It was also observed that disordered eating became more elevated with increasing age (B, 0.03 [95% CI: 0, 0.06]; P = .049) and BMI (B, 0.03 [95% CI: 0.01, 0.05]; P < .001).

Translation of Outcomes

According to the authors, this was the first meta-analysis that comprehensively examined the overall proportion of children and adolescents with disordered eating in terms of gender, mean age, and BMI. They identified 14,856 (22.36%) children and adolescents with disordered eating in the population analyzed. A relevant consideration made by the researchers is that, in general, disordered eating and eating disorders are not similar.

"Not all children and adolescents who reported disordered eating behaviors (for example, selective eating) will necessarily be diagnosed with an eating disorder," commented the authors.

Still, disordered eating in childhood or adolescence may predict outcomes associated with eating disorders in early adulthood.

"For this reason, this high proportion found is worrisome and calls for urgent action to try to address this situation," the authors advised.

The study also found that the proportion of children and adolescents with disordered eating was higher among girls than boys. The reasons for the difference in the prevalence with respect to the sex of the participants are not well understood. Boys are presumed to underreport the problem because of the societal perception that these disorders mostly affect girls and because disordered eating has usually been thought by the general population to be exclusive to girls and women.^[9] In addition, it has been noted that the current diagnostic criteria for eating disorders fail to detect disordered eating behaviors more commonly observed in boys than in girls, such as intensely engaging in muscle mass gain and weight gain with the goal of improving body image satisfaction. On the other hand, the proportion of young people with disordered eating increased with increasing age and BMI. This finding is in line with the scientific literature worldwide.

The study has certain limitations. First, only studies that analyzed disordered eating using the SCOFF questionnaire were included. Second, because of the cross-sectional nature of most of the included studies, a causal relationship cannot be established. Third, owing to the inclusion of binge eating disorder and other eating disorders specified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, there is not enough evidence to support the use of SCOFF in primary care and community-based settings for screening for the range of eating disorders. Fourth, the meta-analysis included studies in which self-report questionnaires were used to assess disordered eating, and consequently, social desirability and recall bias could have influenced the findings.^[1]

Quick Measures Required

Identifying the magnitude of disordered eating and its distribution in at-risk populations is crucial for planning and executing actions aimed at preventing, detecting, and treating them. Eating disorders are a global public health problem that healthcare professionals, families, and other community members involved in caring for children and adolescents must not ignore, said researchers. In addition to diagnosed eating disorders, parents, guardians, and healthcare professionals should be aware of symptoms of disordered eating, which include behaviors such as weight loss dieting, binge eating, self-induced vomiting, excessive exercise, and the use of laxatives or diuretics without medical prescription.

Clinical Implications

• Disordered eating occurred in > 1 in 5 youths and was even more prevalent among girls and with increasing age and BMI.
• These high figures are a public health concern, highlighting the need to implement strategies for preventing eating disorders, including screening for them in primary care.
• Members of the healthcare team should keep in mind that behaviors related to eating disorders may lead to greater risk or damage to health, significant distress, or significant impairment of functioning.

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