Tan et al.

Journal of Eating Disorders (2023) 11:51 Journal of Eating Disorders

https://doi.org/10.1186/s40337-022-00725-4

REVIEW Open Access

The association between eating disorders

and mental health: an umbrella review
Eng Joo Tan1, Tejeesha Raut2, Long Khanh‑Dao Le1*, Phillipa Hay3,4, Jaithri Ananthapavan2,5, Yong Yi Lee1,6,7 and
Cathrine Mihalopoulos1

Abstract
Objective There have been an increasing number of systematic reviews indicating the association between eating
disorders (ED), including its risk factors, with mental health problems such as depression, suicide and anxiety. The
objective of this study was to conduct an umbrella review of these reviews and provide a top-level synthesis of the
current evidence in this area.
Method A systematic search was performed using four databases (MEDLINE Complete, APA PyscInfo, CINAHL
Complete and EMBASE). The inclusion criteria were systematic reviews (with or without meta-analysis), published in
the English language between January 2015 and November 2022. The quality of the studies was assessed using the
Joanna Briggs Institute Critical Appraisal tools for use of JBI Systematic reviews.
Results A total of 6,537 reviews were identified, of which 18 reviews met the inclusion criteria, including 10 reviews
with meta-analysis. The average quality assessment score for the included reviews was moderate. Six reviews inves‑
tigated the association between ED and three specific mental health problems: (a) depression and anxiety, (b)
obsessive-compulsive symptoms and (c) social anxiety. A further 3 reviews focused on the relationship between ED
and attention deficit hyperactivity disorder (ADHD) while 2 reviews focused on ED and suicidal-related outcomes.
The remaining 7 reviews explored the association between ED and bipolar disorders, personality 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.
Discussion Mental health problems such as depression, social anxiety and ADHD were found to be more prevalent
among people suffering from eating disorders. Further research is necessary to understand the mechanism and
health impacts of potential comorbidities of ED.
Keywords Eating disorders, Mental health, Depression, Anxiety, Suicide, Risk factors, Systematic review, Umbrella
review

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,

*Correspondence:
Long Khanh‑Dao Le
[email protected]
Full list of author information is available at the end of the article

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Tan et al. Journal of Eating Disorders (2023) 11:51 Page 2 of 14

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.

Introduction and substance use disorder, there is no existing review

Eating disorders (ED) such as anorexia nervosa, bulimia that provides a top-level summary of these associations
nervosa and binge eating disorders lead to higher physical by using a broader definition of mental health. Conse-
and psychological morbidity, disabilities, and mortality quently, there is a lack of comparative analyses of the var-
rates [1]. The prevalence of eating disorder is increas- ious mental health problems and their associations with
ing, with the lifetime prevalence between 3.3 and 18.6% ED. Addressing this gap in current research can assist
among women and between 0.8 and 6.5% among men [2]. researchers and clinicians to develop a suite of inter-
Risk factors such as dieting and body dissatisfaction have ventions that has the most impact on reducing the ED-
been considered predictors of ED onset for many years mental health co-morbidity. In this context, an umbrella
[3]. Other predisposing factors of ED also include family review is useful because it allows the findings of exist-
history of EDs, having close relatives with a mental health ing reviews to be compared and contrasted. Therefore,
problem, personal history of anxiety disorder, and behav- this umbrella review aims to synthesize contemporary
ioural inflexibility and sociocultural issues such as weight evidence in order to better understand the relation-
stigma, bullying or teasing and limited social networks ship between eating disorders and various mental health
[4]. problems across demographic and clinical factors.
Many studies have linked EDs to various mental health
problems. For example, personality disorders can be Methods
found in a portion of patients with anorexia nervosa This review adhered to the Joanna Brigg Institute (JBI)
(AN) and bulimia nervosa (BN), and were encountered guidelines for umbrella reviews [14] and the PRISMA
in the treatment of EDs [5]. Binge eating disorder (BED) (Preferred Reporting Items for Systematic Reviews and
has been found to impact mental health problems such Meta-Analyses) standards [15]. An ethics exemption
as anxiety and depression which worsens health-related for this research was approved by the Deakin University
quality of life (HRQL) of an individual [6]. In a study of Human Research Ethics Committee (DUHREC) (ref.
a nationally representative sample of 36,309 adults, all 202–1030). The protocol was registered with PROS-
three EDs were associated with more than one comorbid PERO: International Prospective Register of Systematic
somatic condition, which can range from lifetime mood Reviews (ref. CRD42021232372).
disorders, anxiety disorders, major depressive disorder
and alcohol and drug use disorders [7]. It has been widely Search strategies and databases
recognized that individuals with EDs show higher rates In consultation with an experienced librarian, a literature
of suicidality, which includes complete suicide, suicidal search to identify potentially eligible publications was
attempt, and suicidal ideation [8]. The negative percep- performed by the second author (TR) on 16 November
tion of body image, a risk factor for ED, has also been 2020. A second literature search was performed by the
linked to depression and obesity [9]. Individuals suffer- first author (EJT) on 8 November 2022 to include poten-
ing from anorexia nervosa or bulimia nervosa also exhibit tial studies published from 16 November 2020 onwards.
social anxiety disorders, have low self-esteem and more Both searches were conducted via the EBSCOhost plat-
likely to feel nervous about their appearances in public form on four databases: MEDLINE Complete, APA
places [10–12]. PyscInfo, CINAHL Complete and EMBASE. The Interna-
The significant burden of mental health problems tional Classification of Diseases version 10 (ICD-10) was
necessitates a more comprehensive understanding of used to define the mental health problems relevant to this
the relationship between mental health and ED. Recent review. For the purpose of this review, the disease cat-
evidence suggested that the burden of mental health egory of disorders of psychological development, which
problems has increased, with suicide as the second lead- included disorders related to speech, language, scholastic
ing cause of death among 15–29 years and the annual skills, motor function and autism were not considered.
global cost of depression and anxiety was estimated to be The search terms used in the study were various combi-
USD 1 trillion [13]. While previous studies and reviews nations of eating disorder keywords (e.g., “anorexi*”) and
have investigated the association between EDs and spe- mental health keywords (e.g., “addiction”) using Boolean
cific mental health problems such as anxiety, depression operators (or/and). Further details of the search terms
Tan et al. Journal of Eating Disorders (2023) 11:51 Page 3 of 14

can be found in Table S1 in the supplementary informa- Quality assessment

tion file. The bias and quality of the included reviews were
assessed using the Joanna Briggs Institute Critical
Appraisal tools for systematic reviews (The Joanna Briggs
Inclusion and exclusion criteria Institute, 2017). The purpose of this appraisal tool is to
The aim of this umbrella review was to identify reviews assess the methodological quality of the included stud-
of studies that investigated the association between eat- ies and to determine the extent of the possibility of bias
ing disorders and mental health problems. Therefore, in design, conduct and analysis. The tool consists of 11
reviews that reported the association or consequences items (further details are available Table S2 in the sup-
of EDs or ED risk factors and mental health problems plementary information file) include three choices - “Yes”,
such as depression, anxiety, substance use disorders were “No” and “Unclear”. The total score on the scale is 11.
included. The inclusion criteria required studies to be
systematic reviews with or without meta-analyses while Results
scoping reviews, narrative reviews, or literatures reviews A total of 7,275 potentially relevant studies were iden-
without quality assessment were excluded. For the pur- tified from the database search. After duplicates were
pose of this umbrella review, a study is considered a removed, 6,537 studies were available for screening. After
systematic review if it had a clearly formulated research title and abstract screening, 94 studies were progressed
question, reported systematic and reproducible methods to full-text screening. Full-text screening resulted in 18
to identify, select and critically appraise relevant research studies meeting the inclusion criteria and being included
studies. The studies were limited to the general popula- in the umbrella review. The PRISMA diagram shown in
tion although there were no age or gender restrictions Fig. 1 reports the reason for exclusion for the remaining
on the participants. All the articles included in the study 76 studies with full-text review.
were human studies, published in the English language
published in peer-reviewed journals within the last seven
Characteristics of included studies
years i.e. from January 2015 to November 2022. Non-
Out of the 18 systematic reviews, ten included a meta-
review studies such as cohort, prevalence, case-control or
analysis component. There were six reviews investigat-
cross-sectional studies were excluded from this review.
ing the association between ED or ED risk factors (e.g.
Reviews with the wrong setting, study design, outcomes
body dissatisfaction) and three specific mental health
or the patient population were excluded. Further details
problems: (a) depression and anxiety, (b) obsessive-com-
of the inclusion and exclusion criteria can be found in
pulsive symptoms and (c) social anxiety. Another three
Table S2 in the supplementary information file.
reviews focused on the relationship between ED and
attention deficit hyperactivity disorder (ADHD) while
Identification of relevant studies and data extraction two reviews focused on ED and suicidal-related out-
All studies from the database search results were comes. The remaining seven reviews explored the asso-
imported into Endnote and duplicates were removed. ciation between ED and bipolar disorders, personality
The remaining studies were then uploaded to Covi- disorders, and non-suicidal self-injury. Further details of
dence, an online systematic review management tool, the included studies are presented in Table 1. The num-
for screening [16]. A two-stage screening process apply- ber of individual studies included within the reviews
ing the inclusion and exclusion criteria was conducted: ranged from five to 122 studies with the majority of
(a) title and abstract screening and (b) full-text screen- included studies being conducted using a cross-sectional
ing. Both screening processes were done independently study design. All but one review investigated the general
by two reviewers (TR, EJT) and any discrepancies were population, including males and females, and the sample
discussed and resolved by the third reviewer (LL). The size ranged from 1,792 to 2,321,441 participants.
following data were extracted from reviews that ful-
filled the inclusion criteria: year of publication, number ED, depression and anxiety, obsessive compulsive
of included studies, type of eating disorders or risk fac- symptoms and social anxiety
tors of eating disorders, mental health problem, presence The evidence from two reviews [17–19] suggest that
of meta-analysis component, study design, population individuals afflicted with BED or disordered eating have
description, country and effect size (if available). Data a higher risk of experiencing negative mood, tension,
extraction was performed by TR and independently sadness and emotional instability [19], which can fur-
checked by EJT and LL. ther develop into depressive and anxiety symptoms [17].
However, limited evidence was found to support any link
between disordered eating and obsessive-compulsive
Tan et al. Journal of Eating Disorders (2023) 11:51 Page 4 of 14

Fig. 1 PRISMA flow diagram of included studies

symptoms [17]. There is evidence to suggest that the rela- AN or BN have high levels of social anxiety compared to
tionship between anxiety and AN can be bi-directional. healthy controls.
For example, the review by Lloyd et al. [18] demon- Several reviews have indicated that certain ED risk fac-
strated that the risk of anorexia is predicted to increase tors can potentially contribute to depression. The system-
in adolescents and young adults diagnosed with an anxi- atic review and meta-analysis conducted by Puccio et al.
ety disorder. Meanwhile, Kerr-Gaffney et al. [11] con- [20] suggested that eating pathology is one of the risk
ducted a systematic review and meta-analysis and found factors for depression and vice-versa. The effect of eat-
that both BN and AN were associated with social anxi- ing pathology on depression among 18,641 females aged
ety with a medium effect size of 0.71 [95% CI 0.47, 0.95; 6–50 years was shown to be significant with an effect
p < 0.001] and a large effect size of 1.65 [95% CI 1.03, 2.27; size of 0.13 (95% CI: 0.09 to 0.17, p < 0.001), which was
p < 0.001], respectively as estimated using the Cohen’s d conducted on r values [19]. A systematic review of body
statistic. The authors concluded that individuals with image dissatisfaction and depression found that in men
the perception of being underweight or dissatisfaction
Table 1 Summary of included reviews
Author (year) Type of eating Mental health Review type Number of Population Effect size of meta- Overall findings Quality score*
disorder/ risk problem included studies description (total analysis
factors (and study design sample size, age (95% CI)
if available) range and sex)

Álvarez Ruiz et al., Eating disorder (ED) Bipolar disorders Systematic review 18 studies on ED in General population N/A High comorbidity of 45%
[25] particularly bulimia (BD) patients with BD, (n = 7,750, age bipolar disorder and
nervosa and binge 8 studies on BD in range = not ED, particularly of
eating disorder patients with ED reported, bulimia nervosa and
binge eating disor‑
Tan et al. Journal of Eating Disorders

sex = males and

females) der. However, further
research needed to
determine assess‑
ment, treatment and
disease etiology.
Baskin & Galligan, Disordered eating Depressive and Systematic review 11 prospective Pregnant and N/A Strong evidence for 81%
(2023) 11:51

[17] anxiety symptoms, cohort and 14 cross post-partum period association between
obsessive compul‑ sectional / retrospec‑ women (n = 318,049, disordered eating
sive symptoms tive studies age range = not and depression and
reported, anxiety symptoms
sex = females) during pregnancy.
Limited evidence for
association between
disordered
eating and obses‑
sive-compulsive
symptoms during
pregnancy for asso‑
ciation between
disordered eating
and depressive
symptoms during
the post-partum
period.
Conti et al., [8] Binge eating disor‑ Suicidality (i.e. Systematic review 12 cross-sectional General population N/A BED was significantly 72%
der (BED) suicidal ideation or studies (n = 71,610, associated with
attempted and/or 5 longitudinal age range = not higher risk of suicidal
committed suicide) studies reported but gener‑ behaviors (SB) and
ally involved adoles‑ suicidal ideation
cents and adults, (SI). The correla‑
sex = males and tion between BED
females) and suicide risk is
important but there
was a lack of studies
investigating the size
impact of BED on
suicide risk.
Page 5 of 14
Table 1 (continued)
Author (year) Type of eating Mental health Review type Number of Population Effect size of meta- Overall findings Quality score*
disorder/ risk problem included studies description (total analysis
factors (and study design sample size, age (95% CI)
if available) range and sex)

Cucchi et al., [28] Eating disorders (ED), Non-suicidal self- Systematic review 29 studies General population Any ED diagnosis: Lifetime history 72%
anorexia nervosa injury (NSSI) with meta-analysis (n = 6,575, Prevalence of of NSSI is highly
(AN) and bulimia component age range = 16–30 NSSI = 27.3% prevalent among
nervosa (BN) years old, (23.8–31.0%) adolescents and
Tan et al. Journal of Eating Disorders

sex = males and AN diagnosis young adults with

females) only: Prevalence ED, and correlates
of NSSI = 21.8% positively with a
(18.5–25.6%) history of suicidal
BN diagnosis attempt.
only: Prevalence
(2023) 11:51

of NSSI = 32.7%
(26.9–39.1%)
Drakes et al., [31] Eating disorders Obsessive-compul‑ Systematic review 59 studies General population Aggregate lifetime Obsessive-com‑ 72%
sive disorder with meta-analysis (n = unclear, and current preva‑ pulsive disorder is
component age range = 12–60 lence of obsessive- prevalent among
years, compulsive disorder individuals with a
sex = males and was 13.9% [95% CI primary diagnosis of
females) 10.4, 18.1] and 8.7% eating disorder.
[95% CI 5.8, 11.8]
respectively across
EDs
Farstad et al., [29] Eating disorders, Personality disorders Systematic review 14 studies General popula‑ Pooled prevalence Avoidant and obses‑ 63%
including anorexia (PDs) with meta-analysis tion (nn= 1,884, rates ranged from sive-compulsive
nervosa (AN), component age range = not 0% (0–4%) (schizoid) PDs were associated
bulimia nervosa (BN) reported, to 30% (0–56%) with restricting AN
sex = males and (obsessive-compul‑ and binge-eating
females) sive) in individuals disorder while bor‑
with ED derline and paranoid
PDs were associated
with binge-eating/
purging AN, BN and
other EDs.
Page 6 of 14
Table 1 (continued)
Author (year) Type of eating Mental health Review type Number of Population Effect size of meta- Overall findings Quality score*
disorder/ risk problem included studies description (total analysis
factors (and study design sample size, age (95% CI)
if available) range and sex)

Fornaro et al., [26] Eating disorders, Bipolar disorder (BD) Systematic review 47 studies General population BED occurred in The comorbidity 72%
including anorexia with meta-analysis (n = 15,146, 12.5% (95%C.I.=9.4– between ED and
nervosa (AN), component age range = not 16.6%) of BD cases. BD was present in a
bulimia nervosa (BN) reported, BD occurred in 9.1% considerable num‑
Tan et al. Journal of Eating Disorders

and binge eating sex = males and (95%C.I.=3.3–22.6%) ber of patients.

disorder (BED) females) of BED cases.
BN occurred in 7.4%
(95%C.I.=6–10%) of
BD cases. BD
occurred in 6.7%
(2023) 11:51

(95%C.I.=12-29.2%)
of BN cases.
AN occurred in 3.8%
(95%C.I.=2–6%)
of BD cases. BD
occurred in 2%
(95%C.I.=1–2%) of
AN cases.
Goldstein & Gvion, Anorexia nervosa Suicidality (i.e. Systematic review 36 cross sectional General population N/A AN and BN were 63%
[27] (AN) and bulimia suicidal ideation or studies (nn= 2,321,441, associated with an
nervosa (BN) attempted and/or 2 longitudinal age range = not increased risk of
death by suicide) studies reported, suicidal behaviours
sex = males and and ideation.
females)
Kaisari et al., [22] Disordered eating Attention Deficit Systematic review 72 studies including General population N/A Positive association 90%
behavior Hyperactivity Disor‑ 37 cross sectional (n = 115,418, age between ADHD
der (ADHD) studies, 11 case- range = unclear but and disordered
control studies, 6 includes children, eating. Impulsivity
cohort studies, 7 adolescents and symptoms of ADHD
longitudinal studies, adults, sex = males were positively
2 secondary analysis and females) associated with over‑
of the National Lon‑ eating in anorexia
gitudinal study of nervosa and bulimia
Adolescent Health, 3 nervosa. Further
experimental stud‑ research is needed
ies, 3 retrospective to determine the
studies, 5 prospec‑ direction of relation‑
tive studies and 1 ship and underlying
epidemiological mechanisms.
study
Page 7 of 14
Table 1 (continued)
Author (year) Type of eating Mental health Review type Number of Population Effect size of meta- Overall findings Quality score*
disorder/ risk problem included studies description (total analysis
factors (and study design sample size, age (95% CI)
if available) range and sex)

Kerr-Gaffney et al. Eating disorders (ED), Social anxiety disor‑ Systematic review 38 cross-sectional General population AN diagnosis: Significant differ‑ 81%
[11] including anorexia der (SA) with meta-analysis studies, 12 included (n = 8,501, d = 1.65 (1.03–2.27) ences of AN and BN
nervosa (AN) and component in meta-analysis age range = 12–45 BN diagnosis: between ED groups
bulimia nervosa (BN) years old, d= 0.71 (0.47–0.95) and healthy controls.
Tan et al. Journal of Eating Disorders

sex = males and High levels of SA

females) are associated with
more severe form
of ED.
Levin & Rawana, [12] Eating disorders (ED), Attention-deficit/ Systematic review 37 studies, including General popula‑ N/A Childhood ADHD 72%
including hyperactivity disor‑ 27 cross sectional increases the risk of
(2023) 11:51

tion (n = 74,852
disordered eating, der (ADHD) studies. participants, age disordered eating
anorexia nervosa range = 5–49 years or developing ED in
(AN), bulimia ner‑ old, sex = males and later life.
vosa (BN) and binge females)
eating disorder (BED)
Lloyd et al., [18] Anorexia Nervosa Anxiety Systematic review 8 studies, including General population N/A Anxiety disor‑ 81%
(AN) 4 retrospective case (n = 1,670,312, age der diagnosis in
control studies and range = unclear, general may predict
4 prospective cohort sex = males and increased ano‑
studies females) rexia nervosa risk.
However, longitu‑
dinal associations
between specific
anxiety disorders
and subsequent AN
onset unclear.
Mandelli et al., [32] Eating disorders, Obsessive-compul‑ Systematic review 32 studies General population Lifetime and current OCD comorbidity in 81%
including anorexia sive disorder with meta-analysis (n = unclear, comorbidity rates: EDs is a significant
nervosa (AN), component mean age 19% and 14% in AN phenomenon,
bulimia nervosa (BN) range = 15–45 years, patients; 13% and 9% affecting almost one
and binge eating sex = males and in BN patients. fifth of the patients
disorder (BED) females Higher lifetime in cross-sectional
estimates based on observations and
prospective follow up to nearly 40% in
up studies: 44% in prospective follow-
AN patients; 19% in up studies.
BN patients.
Page 8 of 14
Table 1 (continued)
Author (year) Type of eating Mental health Review type Number of Population Effect size of meta- Overall findings Quality score*
disorder/ risk problem included studies description (total analysis
factors (and study design sample size, age (95% CI)
if available) range and sex)

Miller et al., [30] Eating disorders, Border personal‑ Systematic review 122 studies General population Affective instability Nine symptoms of
including anorexia ity disorder (BPD) with meta-analysis (n = unclear, was the BPD symp‑ borderline personal‑
nervosa (AN), symptoms component age range = 12 tom most elevated, ity disorder were
bulimia nervosa (BN) years and above, while anger was the significantly elevated
Tan et al. Journal of Eating Disorders

and binge eating sex = males and BPD symptom least in patients with EDs
disorder (BED) females elevated, in patients compared to con‑
with EDs compared trols. Certain symp‑
to controls. toms of BPD play a
more prominent role
in the comorbidity
(2023) 11:51

between BPD and

EDs than others.
Nazar et al., [24] Eating disorders (ED), Attention-Deficit/ Systematic review 17 studies General population Pooled effect The risk having 90%
including anorexia Hyperactivity disor‑ with meta-analysis (n = 38,421, age ED diagnosis in an ED for indi‑
nervosa (AN), der (ADHD) component range = 9–44 years ADHD: OR = 3.82 viduals with ADHD is
bulimia nervosa (BN) old, sex = males and (2.34–6.24) increased three-
and binge eating females) AN diagnosis in fold and the risk of
disorder (BED) ADHD: OR = 4.28 having ADHD for
(2.24–8.16) individuals with
BN diagnosis in ED is increased by
ADHD: OR = 5.71 two-fold.
(3.56–9.16)
BED diagnosis in
ADHD: OR = 4.13
(3-5.67)
ADHD diagnosis
in ED: OR = 2.57
(1.30–5.11)
Nicholls et al., [19] Binge eating disor‑ Emotions and eating Systematic review 15 studies, with General population N/A Depression was con‑ 72%
der (BED) behavior 13 studies reported (n = 2,858, sistently associated
on adults and 2 age range = 10–47 with binge eating.
studies reported on years old, Negative mood
children sex = males and was found to be
females) an antecedents of
binge eating within
an adult BED-obese
sample. However,
findings were mixed
regarding the role
of stress, anger, and
positive emotions.
Page 9 of 14
 Tan et al. Journal of Eating Disorders

Table 1 (continued)
Author (year) Type of eating Mental health Review type Number of Population Effect size of meta- Overall findings Quality score*
disorder/ risk problem included studies description (total analysis
factors (and study design sample size, age (95% CI)
(2023) 11:51

if available) range and sex)

Puccio et al., [20] Eating pathology Depression Systematic review 42 studies assessing General population Correlation value for Eating pathology is 63%
with meta-analysis longitudinal relation‑ (n = 73,115, eating pathology on one of the risk fac‑
component ship between eating age range = 6–50 depression = 0.13 tors for depression
pathology and years old, (0.09–0.17) with and vice-versa.
depression sex = males and p < 0.001
females) Correlation value
for depression
predicting eating
pathology = 0.16
(0.10–0.22), p < 0.001.
Silva et al., [9] Body image Depression Systematic review 5 cross-sectional General population N/A Depression or 63%
studies (n = 35,518, depressive symp‑
age range = 18 years toms were associ‑
and older, ated with body
sex = males and image for both men
females) and women.
SMD = standardized mean difference; OR = odds ratio
*The quality score was calculated from the total score out of 11 based on the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews questionnaire
Page 10 of 14
Tan et al. Journal of Eating Disorders (2023) 11:51 Page 11 of 14

due to low weight was observed by idealizing a larger ED and non‑suicidal self‑injury
body, whereas women perceived their body larger than it A systematic review and meta-analysis by Cucchi et al.
was by idealizing a lean body [21]. Both of these condi- [28] reported that, among patients with various EDs,
tions were associated with the presence of depression or the prevalence of a lifetime history of non-suicidal self-
depressive symptoms although the review was unable to injury (NSSI) was 27.3% (95% CI 23.8–31.0%) for ED,
conclude whether more severe body image dissatisfaction 21.8% (95% CI 18.5–25.6%) for AN, and 32.7% (95% CI
increased chances of also having depressive symptoms or 26.9–39.1%) for BN. Based on 29 studies and 6,575 par-
both conditions co-exist. ticipants, the review concluded that NSSI is a significant
correlate of ED and prevalent among adolescents and
ED and attention deficit hyperactivity disorder young adults with ED.
A systematic review conducted by Kaisari et al. [22] on
disordered eating behaviour and (ADHD) among 115,418 ED and personality disorders
participants (including both male and female popula- The systematic review and meta-analysis conducted by
tions) suggested that the impulsivity symptoms of ADHD Farstad et al. [29] on ED and personality disorders (PD)
were positively associated with overeating in AN and BN. included 14 studies and showed that pooled prevalence
Similarly, Levin & Rawana [23] explored the association rates of PD ranged from 0% (95% CI: 0–4%) (for schiz-
between AN, BN and BED and ADHD among 74,852 oid) to 30% (95% CI 0–56%) (for obsessive-compulsive)
participants and showed that childhood ADHD increases in individuals with ED. The authors concluded that
the risk of disordered eating or developing ED in later increases in perfectionism, neuroticism, low extraver-
life. The systematic and meta-analysis of ED on ADHD sion, sensitivity to social rewards, avoidance motivation,
by Nazar et al. [24] showed that the pooled odds ratio of negative urgency and high-self-directedness was found in
diagnosing any ED in ADHD populations was 3.82 (95% the people presenting with EDs. This finding is consist-
CI 2.34–6.24). BN has the highest odds ratio (5.71, 95% ent with another review that investigated the association
CI 3.56–9.16) followed by AN (4.28, 95% CI 2.24–8.16) between EDs and symptoms of borderline personality
and BED (4.13, 95% CI 3.00–5.67). On the other hand, disorder [30]. The authors found that nine symptoms of
the pooled odds ratio of diagnosing ADHD in people borderline personality disorder were significantly ele-
with eating disorders was 2.57 (95% CI 1.30–5.11) [24]. vated in patients with EDs compared to controls.
In a meta-analytic review of 59 studies, the lifetime
ED and bipolar disorder and current prevalence of obsessive-compulsive disor-
The systematic review by Álvarez Ruiz & Gutiérrez-Rojas der was reported to be 13.9% [95% CI 10.4–18.1%] and
[25] found that the severity of BN and BED in women 8.7% [95% CI 5.8–11.8%] respectively across EDs, which
was higher among patients with bipolar disorder. The evi- included all ED subtypes [31]. Another meta-analysis
dence from their review suggested that there is a comor- review reported lifetime comorbidity rates for obsessive-
bidity between ED and bipolar disorder, with prevalence compulsive disorder of 19% in AN patients and 14% in
rate of EDs in bipolar disorder patients ranging from 5.3 BN patients based on cross-sectional studies [32]. These
to 31%. In addition, a more recent meta-analytic review rates increased to 44% in AN patients and 18.5% in BN
of 47 studies reported the lifetime prevalence of AN, BN patients when longitudinal studies were considered.
and BED as 3.8% (95% CI 2–6%), 7.4% (95% CI 6–10%)
and 12.5% (95% CI 9.40–16.6%) among individuals with
bipolar disorder, respectively [26]. Quality of included systematic reviews
The scores achieved by the included reviews ranged from
45% (i.e. 5 out of 11 questions) to 100% (i.e. 11 out of 11
ED and suicidal factors
questions). On average, the reviews met 72% of the JBI
A systematic review of 12 cross-sectional and 5 longi-
criteria. The details of the score are presented in Table S3
tudinal studies on BED and suicidal factors among ado-
in the supplementary information file. Overall quality
lescents and adults found that BED is associated with a
was acceptable and most reviews performed well in the
higher risk of suicide, including suicidal behaviours and
design of review question, inclusion criteria, search strat-
ideation [8]. Similarly, the systematic review by Goldstein
egy and criteria used for study appraisal. The main loss
& Gvion [27], which included 36 cross-sectional stud-
of scores were from the criteria of methods to minimize
ies and 2 longitudinal studies, suggested that eating dis-
errors in data extraction and assessment of publication
orders with purging behaviour, impulsivity and specific
bias.
interpersonal features were associated with greater risk
of suicidal behaviours.
Tan et al. Journal of Eating Disorders (2023) 11:51 Page 12 of 14

Discussion eating pathology due to childhood ADHD was observed

To the best of our knowledge, this is the first umbrella to be stronger in males compared to females [23]. Fur-
review to examine the overall evidence of the association thermore, restrictive eating behaviour has been linked to
between eating disorders and mental health across the ADHD-related hyperactivity symptoms in boys although
age spectrum. While previous reviews were focused on the causal pathway is still not fully understood [34, 35]
investigating the relationship between eating disorders As the population group investigated by the reviews
and specific mental health problems, our review captured included in this study was predominantly females, the
all relevant mental health problems, including mental association between ED and mental health may be under-
disorders, personality disorders and suicide-related out- estimated in males. A balanced representation of the two
comes. The findings of this review were synthesized from sexes should be considered in future studies and will lead
contemporaneous systematic reviews (i.e. in the last 7 to an improved understanding of the function of gender
years) and highlighted the growing body of evidence in in this emerging comorbidity.
this area, particularly the frequency of comorbidity of Our umbrella review also reported that most of the
ED and mental health problems. In addition, our review research were undertaken in high-income countries,
provides a top-level summary of the strength of the asso- whereas limited studies have been conducted in low-
ciation between the various mental health problems and middle-income countries. This is not surprising
and eating disorders, and the direction of effect where given that previous evidence have indicated a severe
possible. scarcity of mental health research resources in low- and
A total of 643 individual studies were reviewed by the 18 middle-income countries, especially in Asian and Afri-
systematic reviews included in this umbrella review. The can countries [36]. Furthermore, ED-related epidemiol-
synthesis of evidence revealed that there is a significant ogy research in low- and middle-income countries often
association between ED and mental health problems in focused on prevalence studies and less on comorbidity
general. However, among the various mental health prob- between ED and mental health problems [37]. Therefore,
lems investigated, only reviews focusing on depression, there is a need to address this gap in the literature and
social anxiety and ADHD reported an effect size or odds investigate the generalizability of present evidence across
ratio from their respective meta-analysis. Therefore, based different regions.
on quantitative evidence, the association between these One of the limitations of our umbrella review is that it
three mental health problems and ED is more prominent did not include reviews published in languages other than
compared to other mental health problems. There is also English. In addition, our literature search was limited to
evidence to suggest that depression and anxiety are signifi- the last 7 years, therefore, reviews published before 2015
cantly associated with different types of EDs and their risk were not considered. However, it is likely that the more
factors. For example, symptoms of depression and anxi- recent reviews in our study have included previous evi-
ety were often observed in individuals suffering from AN, dence. Another limitation is that no recent individual
BN and BED or those with ED risk factors such as body studies were included. Although this omission may have
dissatisfaction [16, 21]. Interestingly, existing research an impact on the findings of our study, it is unlikely to
shows that childhood ADHD increased the risk of disor- change the overall conclusion.
dered eating or developing ED in later life and vice versa Overall, there may be several clinical implications
while the risk of ADHD in individuals with ED is increased from our findings. First, there is a need to increase
three-fold, compared to control groups [24]. This phenom- awareness and screening for ED in general mental
enon is particularly relevant for prevention efforts given health settings and broader demographics. Compared
that diagnosis of ADHD in young girls or women can be to general mental health, ED is often underdiagnosed
delayed or missed [33]. As such, there are potential shared in primary care and therefore the health burden of ED
benefits to be gained when addressing both conditions. is largely hidden even though it is substantial [38, 39].
Further research is required to explore the underlying Second, it is necessary to address the unmet need for
mechanisms and comorbidity between EDs and mental treatment of ED. Evidence has shown that although a
disorders. The prevention or treatment of this comorbidity majority of community cases with a diagnosable ED
also needs to be addressed by future intervention studies. who seek treatment received treatment for weight loss,
While females continue to be disproportionately only a small proportion received appropriate mental
affected by ED, including through its association with health care [40]. There is a need to promote supported
other mental health problems, there is also growing evi- integrated treatments such as the introduction of mood
dence to indicate the adverse impacts of the ED-men- intolerance module in temperament based therapy with
tal disorder comorbidity on the male population. For supports [41].
example, the correlation between the risk of developing
Tan et al. Journal of Eating Disorders (2023) 11:51 Page 13 of 14

Conclusion Competing interests

Dr Long Le is a Guest Editor for the collection of “Environmental Influences
The outcome of the umbrella review suggests that eating on Eating disorders, Disordered eating and Body Image” in Journal of Eating
disorders and mental health problems are significantly Disorders. All other authors do have any competing interest to declare.
associated with each other. Mental health problems such
Author details
as depression, anxiety, suicidal attempts are found to be 1
School of Public Health and Preventive Medicine, Monash University Health
more prevalent among people suffering from eating dis- Economics Group (MUHEG), Monash University, Melbourne, VIC 3004, Aus‑
orders. EDs also arise from impulsive behaviours, poor tralia. 2 Deakin Health Economics, Institute for Health Transformation, School
of Health and Social Development, Deakin University, Burwood, VIC 3125,
emotion regulation, history of childhood physical and Australia. 3 Translational Health Research Institute (THRI), School of Medicine,
emotional abuse, pain tolerance and interpersonal fears Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia.
4
such as perceived burdensomeness [16, 27]. Our findings Camden and Campbelltown Hospital, SWSLHD, Campbelltown, NSW
2560, Australia. 5 Global Obesity Centre, Institute for Health Transformation,
suggest that there is a need for further research to under- School of Health and Social Development, Deakin University, Burwood, VIC
stand the health impacts of eating disorder and mental 3125, Australia. 6 School of Public Health, The University of Queensland, QLD
disorder comorbidities. For instance, there is a limited 4006 Herston, Australia. 7 Policy and Epidemiology Group, Queensland Centre
for Mental Health Research, QLD 4076 Wacol, Australia.
assessment of risk factors of suicide in people with ED
and, therefore, historical and contemporary data need Received: 29 June 2022 Accepted: 18 December 2022
to be collected in order to better understand the risk
of suicide in ED. Further efforts should also be made to
identify effective and cost-effective interventions for the
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