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Introduction: Although recent research has focused on the effects of maternal eating disorders (EDs) on children, little is known about the effect of maternal EDs on neurobiological outcomes in newborns and infants. This study is the first to investigate neurobehavioural regulation and cognitive development in newborns and infants of mothers with EDs. Methods: Women with an active and past ED and healthy controls were recruited to a prospective longitudinal study during their first trimester or second trimester of pregnancy. Newborns and infants of mothers with ED were compared with newborns and infants of healthy controls on (a) neurobehavioural dysregulation using the Brazelton Neonatal Behavioural Assessment Scale at 8 days postpartum (active ED, n = 15; past ED, n = 20; healthy controls, n = 28); and (b) cognitive development using the Bayley Scales of Infant and Toddler Development at 1-year postpartum (active ED, n = 18; past ED, n = 19; healthy controls, n = 28). In order to maintain the largest possible sample at each time point, sample size varied across time points. Results: Newborns of mothers with an active ED had worse autonomic stability when compared with newborns of healthy controls [B = -0.34 (-1.81, -0.26)]. Infants of mothers with a past ED had poorer language [B = -0.33 (-13.6, -1.9)] and motor development [B = -0.32 (-18.4, -1.3)] compared with healthy controls. Conclusions: Children of mothers with ED display neurobehavioural dysregulation early after birth and poorer language and motor development at 1 year. These characteristics suggest evidence of early neurobiological markers in children at risk. Differential outcomes in children of women with active versus past ED suggest that active symptomatology during pregnancy might have an effect on physiological reactivity while cognitive characteristics might be more stable markers of risk for ED.

Objective: Fraudulent participation is an escalating concern for online clinical trials and research studies and can have a significant negative impact on findings. We aim to shed light on the risk and to provide practical recommendations for detecting and managing such instances. Methods: The FREED‐Mobile (FREED‐M) study is an online, randomized controlled feasibility trial to assess a digital early intervention for young people (aged 16–25) in England or Wales with eating problems. The trial involved baseline (week 0), post‐intervention (week 4), and follow‐up (week 12) surveys, alongside weekly modules provided over 4 weeks on the study website. Study completers were compensated with £20 shopping vouchers. Despite the complexity of the trial design, two instances of fraudulent sign‐ups occurred in January and March 2023. To counter this, we developed a "fraudulent participants protocol" following internal investigations and discussions with collaborators. Results: The implementation of prevention measures such as reCAPTCHA updates, IP address review, and changes in reimbursement effectively halted further fraudulent sign‐ups. Our protocol facilitated the systematic identification and withdrawal of suspected or clear fraudsters and was demonstrably robust at distinguishing between fraudsters and genuine responders. Discussion: All remote, online trials or studies are at risk of fraudulent participation. Drawing from our experience and existing literature, we offer practical recommendations for researchers considering online recruitment and data collection. Vigilance and the integration of deterrents, and data quality checks into the study design from the outset are advised to safeguard research integrity. Public Significance: Fraudulent participation in digital research can have asignificant impact on research findings, potentially leading to biased resultsand misinformed decisions. We developed an effective protocol for theprevention, identification, and management of fraudulent participants. Bysharing our insights and recommendations, we hope to raise awareness of thisissue and provide other researchers with the knowledge and strategies necessaryto safeguard research integrity moving forward. [ABSTRACT FROM AUTHOR]

Objective: We present the protocol of a feasibility randomised controlled trial (RCT) of intermittent theta burst stimulation (iTBS) for young people with anorexia nervosa (AN). Effective first‐line psychological therapies exist for young people with AN, but little is known about how to treat those who do not respond. Non‐invasive neuromodulation, such as iTBS, could address unmet treatment needs by targeting neurocircuitry associated with the development and/or maintenance of AN. Design: Sixty‐six young people (aged 13–30 years) with persistent AN will be randomly allocated to receive 20 sessions of real or sham iTBS over the left dorsolateral prefrontal cortex in addition to their usual treatment. Outcomes will be measured at baseline, post‐treatment (1‐month post‐randomisation) and 4‐months post‐randomisation (when unblinding will occur). Additional open follow‐ups will be conducted at 12‐ and 24‐months post‐randomisation. The primary feasibility outcome is the proportion of participants retained in the study at 4‐months. Secondary outcomes include AN symptomatology, other psychopathology, quality of life, service utilisation, neurocognitive processes, and neuroimaging measures. Discussion: Findings will inform the development of a future large‐scale RCT. They will also provide exploratory data on treatment efficacy, and neural and neurocognitive predictors and correlates of treatment response to iTBS in AN. HIGHLIGHTS: This paper presents a study protocol of a triple‐blind feasibility randomised controlled trial (RCT) with an open longer‐term follow‐up, using intermittent theta burst stimulation (iTBS) for young people with AN.It provides a clinical and scientific rationale for conducting a neuromodulation RCT in eating disorders.It is hoped that the findings will inform the development of a future large‐scale RCT investigating the clinical efficacy of iTBS for AN. [ABSTRACT FROM AUTHOR]

Background: Timely intervention is beneficial to the effectiveness of eating disorder (ED) treatment, but limited capacity within ED services means that these disorders are often not treated with sufficient speed. This service evaluation extends previous research into guided self-help (GSH) for adults with bulimic spectrum EDs by assessing the feasibility, acceptability, and preliminary effectiveness of virtually delivered GSH using videoconferencing. Method: Patients with bulimia nervosa (BN), binge eating disorder (BED) and other specified feeding and eating disorders (OSFED) waiting for treatment in a large specialist adult ED out-patient service were offered virtually delivered GSH. The programme used an evidence-based cognitive behavioural self-help book. Individuals were supported by non-expert coaches, who delivered the eight-session programme via videoconferencing. Results: One hundred and thirty patients were allocated to a GSH coach between 1 September 2020 and 30 September 2022; 106 (82%) started treatment and 78 (60%) completed treatment. Amongst completers, there were large reductions in ED behaviours and attitudinal symptoms, measured by the ED-15. The largest effect sizes for change between pre- and post-treatment were seen for binge eating episode frequency (d = –0.89) and concerns around eating (d = –1.72). Patients from minoritised ethnic groups were over-represented in the non-completer group. Conclusions: Virtually delivered GSH is feasible, acceptable and effective in reducing ED symptoms amongst those with bulimic spectrum disorders. Implementing virtually delivered GSH reduced waiting times, offering a potential solution for long waiting times for ED treatment. Further research is needed to compare GSH to other brief therapies and investigate barriers for patients from culturally diverse groups. [ABSTRACT FROM AUTHOR]

Introduction: First Episode Rapid Early Intervention for Eating Disorders (FREED) is the leading eating disorder (ED) early intervention model for young people. Research has shown that it reduces the duration of untreated illness, improves clinical outcomes, and has cost savings. However, less is known about the experience of implementing FREED. This study aimed to investigate the views and experiences of adopting, implementing, and sustaining FREED from the perspective of clinical staff. Methods: Seven focus groups were conducted involving 26 clinicians. Thematic analysis was used, with the Non-Adoption, Abandonment and Challenges to Scaleup, Spread and Sustainability (The NASSS framework) framework being applied to organise subthemes and determine facilitators and barriers. The NASSS framework was also used to rate the complexity of themes as either simple (straightforward, predictable, few components), complicated (multiple interrelating components), or complex (dynamic, unpredictable, not easily divisible into constituent components). Results: There were 16 subthemes identified under seven broader themes representing each domain of the NASSS framework. Key barriers and areas of complexity included factors related to EDs as an illness (e.g., high acuity and prevalence), and organisational complexity (e.g., staffing shortages, lack of managerial/team support). Key facilitators included positive clinician/adopter attitudes, a supportive national network, and the ability for FREED to be flexible/adaptable over time. Conclusion: The FREED model appears to be desirable to clinical staff. Wider team and managerial support was perceived to be particularly important to its successful implementation, as were the national network and supervision. Key areas of complexity include staffing issues and high ED acuity/prevalence. These barriers to implementation need to be managed and investment continued to expand and improve early intervention for EDs further. [ABSTRACT FROM AUTHOR]

Background: A significant number of people with bulimia nervosa (BN) or binge‐eating disorder (BED) do not seek professional help. Important reasons include limited knowledge of eating disorders (EDs), feelings of shame, treatment costs, and restricted access to specialized healthcare. In this study, we explored if a novel therapy delivered in a primary care setting could overcome these barriers. We investigated factors such as motivation and expectations and included the patients' and newly trained therapists' perspectives. Method: We interviewed 10 women with BN (n = 2) or BED (n = 8), enrolled in the Physical Exercise and Dietary therapy (PED‐t) program, in a Healthy Life Center (HLC) located in a primary healthcare facility. Interview topics discussed were motivations for and expectations of therapy, and the treatment location. In addition, 10 therapists from HLC's were interviewed on their experiences with the PED‐t training program and expectations of running PED‐t within their service. The semi‐structured interviews were analyzed using reflexive thematic analysis. Results: Most patients had limited knowledge about EDs and first realized the need for professional help after learning about PED‐t. Patients exhibited strong motivations for treatment and a positive perception of both the PED‐t, the new treatment setting, and the therapists' competencies. The therapists, following a brief training program, felt confident in their abilities to treat EDs and provide PED‐t. With minor operational adjustments, PED‐t can seamlessly be integrated into national HLC service locations. Conclusion: PED‐t is an accessible therapeutic service that can be delivered in a primary care environment in a stepped‐care therapy model. Public Significance: This study investigates the views and experiences of patients and newly trained therapists of PED‐t (Physical Exercise and Dietary therapy), a new program‐led primary care therapy for binge‐eating spectrum eating disorders. The treatment and the locations for the intervention, that is, local health care centers, were found to be highly acceptable to both patients and therapists, thus PED‐t could easily be integrated as a first step into a step‐care delivery model. [ABSTRACT FROM AUTHOR]

Introduction: The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has shown promising outcomes for young people with an eating disorder, leading to national scaling and implementation across England. Between 2020 and 2023, the national implementation of FREED was supported by the Academic Health Science Networks (AHSNs), which are publicly funded organisations with the mission to spread innovations at scale and pace. This study aimed to investigate the views and experiences of AHSN programme leads on the national roll-out of FREED and the perceived sustainability of the model. Methods and results: Semi-structured interviews were conducted with 13 programme leads across the AHSNs with direct experience supporting the national implementation of FREED. Thematic analysis was adopted using a critical realist approach. Initial sub-themes were inductively generated and then organised under seven larger themes representing the domains of the Non-adoption, Abandonment, and Challenges to Scale-Up, Spread and Sustainability (NASSS) framework. Each sub-theme was classified as a facilitator and/or barrier and then each larger theme/domain was assessed for its complexity (simple, complicated, complex). Data analysis revealed 28 subthemes, 10 identified as facilitators, 13 as barriers, and five as both. Two domains were classed as simple, three as complicated, and two as complex. Sub-themes ranged from illness-related complexities to organisational pressures. Key facilitators included a high-value proposition for FREED and a supportive network. Key barriers included staffing issues and illness-related factors that challenge early intervention. Discussion: Participants described broad support for FREED but desired sustained investment for continued provision and improving implementation fidelity. Future development areas raised by participants included enlarging the evidence base for early intervention, increasing associated training opportunities, and widening the reach of FREED. Results offer learning for early intervention in eating disorders and the scaling of new health initiatives. [ABSTRACT FROM AUTHOR]

Objective: High eating disorder (ED) relapse rates stress the need for clearer understanding around how recovery is experienced and maintained. Recent research endorses the concept of recovery as a process rather than an endpoint. This study aimed to investigate daily experiences of living in recovery from an ED. Method: Fourteen participants who self‐identified as recovered from a formally diagnosed ED were recruited online. A qualitative diary app was used for data collection. Participants completed written or audio open‐ended diary entries every other day for 2 weeks describing their experiences, thoughts, and feelings. Diaries were analysed using reflexive thematic analysis. Results: Four themes were developed. 'Ever‐present eating disordered thoughts' highlights how pervasive these thoughts remain for participants. 'Impact of social discourses' unpacks the challenges of maintaining recovery while surrounded by unhelpful social discourses about food and body image. 'Recovery is precarious' highlights how a combination of stressors can build up to threaten recovery. 'Finding balance in recovery' illustrates the many ways participants try to manage their recovery each day. Conclusions: The findings make it clear that living in recovery from an ED is a complex process that must be navigated daily. Recommendations for treatment and recovery support are discussed. Highlights: Key findings are: (1) Eating disordered thoughts persist throughout recovery, requiring a substantial amount of time and energy to manage theme; (2) societal attitudes towards food and body image negatively impact recovery; and (3) diaries also illustrated that periods of stress, anxiety, or low mood can trigger more difficult periods of managing recovery, and increase vulnerability to relapse.Limitations of the study include: (1) online recruitment; (2) requiring a formal eating disorder (ED) diagnosis; and (3) no assessment of ED treatment after diagnosis, so the impact of treatment received on recovery experiences is not explored.Qualitative diary methods may capture unique personality and coping styles in the context of everyday lives, as well as aspects of recovery that are similar across the spectrum of experiences of many people. [ABSTRACT FROM AUTHOR]

Objective: There has been no review on eating disorder‐focused psychological interventions in East Asia. The aims of this systematic scoping review were to summarize existing and forthcoming studies and to synthesize the cultural adaptations and effectiveness of the interventions identified. Method: Five databases (PubMed, Embase, Global Health, Medline, PsychInfo) and seven trial registries were searched. Studies examining eating disorder (ED)‐focused psychological interventions in East Asia were included. Narrative synthesis was used for the analysis. Results: Eighteen published studies and 14 ongoing/completed but unpublished studies were included. Most published studies were uncontrolled and five were feasibility studies. Among the ongoing studies, 71% are randomized controlled trials. Cognitive therapies were the main approach used, including individual cognitive behavioral therapy (CBT), internet CBT, group CBT, guided self‐help, and cognitive remediation therapy. Cultural adaptations were mostly related to language, communication style and tailoring the dietary requirements to local diets. Interventions were shortened to increase acceptability and reduce financial and time burden to patients. Overall, studies showed good acceptability, completion rates and positive effects on ED symptoms (indicated by moderate to large effect sizes or statistical significance). Discussion: Studies were underpowered and uncontrolled, thus precluding meaningful interpretations of effectiveness to be made. However, the psychological interventions were acceptable and showed promise in delivery. Digital and group interventions seemed to be the most feasible given barriers in the local health systems. More controlled studies, as well as studies on children and adolescents, are needed in future. Public significance: This is the first systematic scoping review examining psychological interventions for eating disorders in East Asia. Research in eating disorders has largely focused on White people and in Western countries. This review will be helpful for clinicians and researchers to understand the current state of the field through a non‐Eurocentric lens, to identify gaps and plan future research. [ABSTRACT FROM AUTHOR]

EDIFY (Eating Disorders: Delineating Illness and Recovery Trajectories to Inform Personalised Prevention and Early Intervention in Young People) is an ambitious research project aiming to revolutionise how eating disorders are perceived, prevented and treated. Six integrated workstreams will address key questions, including: What are young people's experiences of eating disorders and recovery? What are the unique and shared risk factors in different groups? What helps or hinders recovery? How do the brain and behaviour change from early- to later-stage illness? How can we intervene earlier, quicker and in a more personalised way? This 4-year project, involving over 1000 participants, integrates arts, design and humanities with advanced neurobiological, psychosocial and bioinformatics approaches. Young people with lived experience of eating disorders are at the heart of EDIFY, serving as advisors and co-producers throughout. Ultimately, this work will expand public and professional perceptions of eating disorders, uplift under-represented voices and stimulate much-needed advances in policy and practice. [ABSTRACT FROM AUTHOR]

Objective: The high burden of eating disorders (EDs) and limited availability of treatment speaks of a need to explore new avenues for treatment delivery. To understand if new treatment avenues are helpful and acceptable to patients, we investigated the effectiveness of Physical Exercise and Dietary Therapy (PED‐t) in participants with bulimia nervosa or binge‐eating disorder, and acceptability when the PED‐t was implemented in a Healthy Life Center in a municipal primary healthcare service. Method: Exercise physiologists and one dietitian were trained in ED literacy and to run PED‐t, before screening women for eligibility. Effectiveness (n = 16) of PED‐t and participants' experiences (n = 8) were evaluated by a mixed methods study design. Results were analyzed by relevant statistics and reflexive thematic analysis. Results: Of 19 eligible participants, 16 completed treatment. At post‐treatment, the Eating Disorder Examination Questionnaire global score, binge‐eating frequency, and symptoms of depression were lower, and nine (56% of completers) were in remission. Participants' treatment experiences were classified into two overarching themes: "competence" and "emotional support." Participants reported high acceptance for PED‐t, the local venue and group format, and felt that PED‐t provided them with coping tools and increased mental strength. However, many also spoke of an unmet need to address emotional eating. Discussion: Findings point to a potential for making an effective ED therapy more accessible, and that participants find the local low‐threshold delivery within a group‐format helpful. With small adjustments, the PED‐t could emerge as a promising first‐line treatment for bulimic EDs. Public Significance Statement: Limited access to treatment for EDs, patients' high barriers to help‐seeking, and the high rates of limited efficacy from psychotherapy speak of a need to explore new therapies and avenues for delivery. In this study, we build on findings from a controlled ED treatment trial and replicate the beneficial effects and find a high patient acceptance of "physical exercise and diet therapy" implemented in a real, non‐clinical setting. [ABSTRACT FROM AUTHOR]

Objective: Eating disorders are associated with significant illness burden and costs, yet access to evidence‐based care is limited. Greater use of programme‐led and focused interventions that are less resource‐intensive might be part of the solution to this demand‐capacity mismatch. Method: In October 2022, a group of predominantly UK‐based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme‐led and focused interventions for eating disorders in an attempt to bridge the demand‐capacity gap. Results: Several key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme‐led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal. Conclusions: Programme‐led and focused interventions are a viable option to close the demand‐capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority. Highlights: An expert consensus consortium held a workshop to improve access to, and efficacy of, programme‐led and focused psychological interventions for people with eating disorders across the age range.Consensus statements and recommendations were produced, including changing terminology and misconception that such interventions are only suitable for specific presentations or mild cases.Working together across sectors is needed to close the demand‐capacity gap and integrate programme‐led and focused interventions across care pathways. [ABSTRACT FROM AUTHOR]

Objective: The DAISIES trial, comparing inpatient and stepped‐care day patient treatment for adults with severe anorexia nervosa was prematurely terminated in March 2022 due to poor recruitment. This qualitative study seeks to understand the difficulties faced during the trial by investigating stakeholders' views on and experiences of its implementation. Method: Semi‐structured interview and focus group transcripts, and trial management and oversight group meeting minutes from May 2020‐June 2022 were analysed using thematic analysis. Participants were 47 clinicians and co‐investigators involved with the DAISIES trial. The Non‐Adoption, Abandonment, Scale‐up, Spread, and Sustainability (NASSS) framework was applied to the interpretive themes to classify barriers and facilitators to implementation. Results: Five themes were identified: incompatible participation interests; changing standard practice; concerns around clinical management; systemic capacity and capability issues; and Covid‐19 disrupting implementation. Applying the NASSS framework indicated the greatest implementation challenges to arise with the adopters (e.g. patients, clinicians), the organisational systems (e.g. service capacity), and the wider socio‐political context (e.g. Covid‐19 closing services). Conclusions: Our findings emphasise the top‐down impact of systemic‐level research implementation challenges. The impact of the Covid‐19 pandemic accentuated pre‐existing organisational barriers to trial implementation within intensive eating disorder services, further limiting the capacity for research. Highlights: The paper highlights the particular challenges to research implementation that arise within an NHS intensive service context.Applying an implementation science framework to the interpretive themes indicated that challenges to implementation spanned the individual to the systemic level, with the latter posing greater barriers and impacting implementation success in other areas.The results suggest that future research into intensive treatment needs to better accommodate patient preferences and emphasise clinician‐researcher relationships and the alignment of clinical and research teams. [ABSTRACT FROM AUTHOR]

Background: In a feasibility randomised controlled trial in people with overweight/obesity with and without binge eating disorder (BED) symptoms, we assessed eight weekly sessions of attention bias modification training (ABMT) and mindfulness training (MT) versus waiting list (WL) and explored potential mechanisms. Methods: 45 participants were randomly allocated to one of three trial arms. Primary outcomes were recruitment, retention and treatment adherence rates. Secondary outcomes included measures of eating behaviour, mood, attention and treatment acceptability. Assessments were conducted at baseline, post-intervention (week 8), and follow-up (week 12). Results: Participant retention at follow-up was 84.5% across groups. Session completion rates in the laboratory were 87% for ABMT and 94% for MT, but home practice was much poorer for ABMT. Changes in BMI and body composition were small between groups and there was a medium size BMI reduction in the MT group at follow-up. Effect sizes of eating disorder symptom changes were not greater for either intervention group compared to WL, but favoured ABMT compared to MT. Hedonic hunger and mindful eating scores favoured MT compared to ABMT and WL. ABMT reduced attention biases towards high-calorie food cues, which correlated with lower objective binge eating days at post-intervention. No significant changes were observed in the MT, or WL conditions. Conclusions: Both ABMT and MT have potential value as adjuncts in the treatment of obesity and BED, and a larger clinical trial appears feasible and indicated. Trial registration: ISRCTN Registry, ISRCTN15745838. Registered on 22 May 2018. Plain English summary: In this small research study, people who were classified as overweight or living with obesity (with or without symptoms of binge eating disorder) received either a mindfulness intervention, a "subconscious" attention-based intervention called attention bias modification training (ABMT) or were put on a waiting list for 8 weeks. People in the mindfulness group experienced improvements in emotional eating, mindful eating, and "impulsive" eating. Those who received the attention-based training paid less attention to highly caloric food after the intervention which correlated with fewer binge eating episodes. Results from this study suggest that both types of interventions have potential as add-on treatments for obesity and binge eating disorder, but larger studies are necessary to assess their clinical impact. [ABSTRACT FROM AUTHOR]

Aims: This study aims to investigate the effect of maternal eating disorders (ED) on mother‐infant quality of interaction at 8 weeks and bonding and child temperament at 1 and 2 years postnatally. We also aimed to explore the relationship between maternal ED psychopathology, comorbid psychiatric difficulties, and both mother‐infant quality of interaction and bonding in women with ED. Women were recruited to a prospective longitudinal study. By the time of giving birth, the sample consisted of 101 women of the initial 137 (73.7%). Overall, 62 women (ED = 36; HC = 26) participated in the 8‐week assessment, 42 (ED = 20; HC = 22) at 1 year, and 78 (ED = 34; HC = 44) at 2 years. Mann‐Whitney U Test was used to explore association between maternal ED and mother‐infant quality of interaction and between maternal ED and bonding. Spearman correlations were used to explore associations between maternal ED psychopathology, comorbid psychiatric difficulties, and both mother‐infant quality of interaction and bonding. Results: We found no differences between early mother‐infant interaction and bonding in mothers with ED in comparison to HC. High levels of maternal ED psychopathology were correlated with high anxiety levels, higher negative affectivity, and lower extraversion in children of ED mothers both at 1 and 2 years. Furthermore, high levels of ED psychopathology were also associated with lower effortful control at 1 year. Conclusions: Findings imply that maternal ED have an impact on child temperament. Future research should focus on resilience and on which protective factors might lead to positive outcomes. These factors can be then used as therapeutic and preventative targets. Key points: Our study did not find significant differences in each domain of mother‐infant quality of interaction and bonding between cases and controls.Positive correlations were found between high levels of maternal ED psychopathology, anxiety, and high levels of negative affectivity, and lower extraversion in children at both 1 and 2 years, and ED psychopathology and lower effortful control at 1 year.Children's temperament is compromised in the presence of a maternal eating disorder. Detection and early intervention are recommended to facilitate mother‐child interactions and to prevent any later adverse outcomes. [ABSTRACT FROM AUTHOR]

Objective: This paper outlines the evidence base for early intervention for eating disorders; provides a global overview of how early intervention for eating disorders is provided in different regions and settings; and proposes policy, service, clinician and research recommendations to progress early intervention for eating disorders. Method and Results: Currently, access to eating disorder treatment often takes many years or does not occur at all. This is despite neurobiological, clinical and socioeconomic evidence showing that early intervention may improve outcomes and facilitate full sustained recovery from an eating disorder. There is also considerable variation worldwide in how eating disorder care is provided, with marked inequalities in treatment provision. Despite these barriers, there are existing evidence‐based approaches to early intervention for eating disorders and progress is being made in scaling these. Conclusions: We propose action steps for the field that will transform eating disorder service provision and facilitate early detection, treatment and recovery for everyone affected by eating disorders, regardless of age, socioeconomic status and personal characteristics. Highlights: Early intervention for eating disorders is in its infancy.We summarise existing early intervention approaches for eating disorders from around the globe.We propose key policy, service, clinician, and research recommendations to progress early intervention for eating disorders. [ABSTRACT FROM AUTHOR]

Aim: First Episode Rapid Early Intervention for Eating Disorders (FREED) is an early intervention model for young people with recent‐onset eating disorders (ED). Promising results from a previous single‐centre study and a four‐centre study (FREED‐Up) have led to the rapid national scaling of FREED to ED services in England (FREED‐4‐All). Our aim was to evaluate duration of an untreated ED (DUED), wait time target adherence, and clinical outcomes in FREED‐4‐All and compare these to the (benchmark) findings of the earlier FREED‐Up study. Method: FREED services submit de‐identified data to the central FREED team quarterly. The current study covers the period between September 2018 and September 2021. This FREED‐4‐All dataset includes 2473 patients. These were compared to 278 patients from the FREED‐Up study. Results: DUED was substantially shorter in the FREED‐4‐All dataset relative to the FREED‐Up study (15 vs. 18 months). Adherence to the wait time targets was comparable in both cohorts (~85% of engagement calls attempted in <2 days, ~50%–60% of assessments offered in <14 days, ~40% of treatment offered in <28 days). Patients in the FREED‐4‐All dataset experienced significant improvements in ED and general psychological symptoms from pre‐ to post‐treatment that were comparable to the FREED‐Up study. These findings should be interpreted cautiously as only 6% of FREED‐4‐All patients had post‐treatment data. Conclusions: Data from the FREED‐4‐All evaluation suggest that FREED is replicating at scale. However, these data are flawed, uncertain, proximate, and sparse and should therefore be used carefully alongside other evidence and clinical experience to inform decision making. [ABSTRACT FROM AUTHOR]

Objective: Psychotherapy is the treatment of choice for anorexia nervosa (AN) but mechanisms of action are still largely unknown. Growing research suggests that synchrony between patient and therapist contributes to treatment success. Adding to this literature, this study examined the association between language style matching (LSM) among patient and therapist as an indicator of interpersonal (verbal) synchrony and treatment outcome in AN. Method: Audio recordings of mid‐treatment therapy sessions (n = 25) in a multi‐centre randomized controlled trial on the Maudsley Model of Anorexia Nervosa Treatment for Adults were transcribed and used to calculate LSM for each patient‐therapist dyad. These scores were used to predict treatment outcome at 12‐month follow‐up. Results: LSM did not predict body mass index (primary outcome) at follow‐up. However, higher LSM (M = 0.87, SD = 0.04) was associated with lower eating disorder psychopathology (accounting for 11% of the variance) and higher recovery rates (accounting for 28% of variance) at follow‐up. Conclusions: These preliminary findings suggest that verbal synchrony between patients with AN and their therapists contributes to favourable treatment outcomes. High levels of LSM may reflect therapeutic empathy, cooperation, or mutual positive perception. Further research should explore the mechanisms of linguistic synchrony with larger samples to allow for stronger conclusions. Highlights: Verbal synchrony among patients with anorexia nervosa (AN) and their therapists in mid‐treatment sessions did not predict body mass index but eating disorder symptoms and recovery 12 months after randomisation.These findings advance the idea that verbal synchrony between patients with AN and their therapists contributes to favourable treatment outcomes, possibly through empathy, cooperation, or mutual positive perception.If the findings can be replicated in larger and more heterogeneous samples, these may inform the development of automated clinical support tools for therapists. [ABSTRACT FROM AUTHOR]

Objective: First Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway which aims to provide timely, well‐coordinated, developmentally informed and evidence‐based care for young people with eating disorders (EDs). This article investigates the impact of the COVID‐19 pandemic on FREED patient presentations and service provision in England. Method: Data from three services spanning the pre‐ to post‐pandemic period were included (January 2019–September 2021; n = 502 patients). Run charts were created to analyze changes in monthly baseline patient data (e.g., referral numbers, duration of an untreated ED, diagnostic mix, and average body mass index for patients with anorexia nervosa [AN]). Results: Significant increases in referral numbers were found from September 2020 onward, coinciding with the end of the first UK national lockdown. The percentage of AN presentations significantly increased after the onset of the first national lockdown (April 2020–December 2020). No other significant change patterns were identified. Discussion: There have been substantial increases in referral numbers and presentations of AN to FREED services whereas illness severity seems largely unchanged. Together, this suggests that increased referrals cannot be attributed to milder presentations being seen. Implications for the implementation, funding, and sustainability of the model are discussed. Public Significance: Our research suggests that early intervention eating disorder services across England faced significant increases in patient referrals and presentations of anorexia nervosa over the COVID‐19 pandemic. This increase in referrals is not due to a rise in milder eating disorder cases, as baseline symptom severity remained stable across the pandemic. Investment in early intervention for eating disorders must therefore match increased referral trends. [ABSTRACT FROM AUTHOR]

Background: Binge eating disorder (BED) is a common and disabling problem associated with impaired cognitive control. Preliminary studies show that brain-directed treatments, including transcranial direct current stimulation (tDCS) and attention bias modification training (ABMT), improve cognitive control and alleviate symptoms of BED. When combined, tDCS may enhance the effects of ABMT, and vice versa, thereby improving treatment outcomes. Methods: This protocol describes a feasibility single-blind randomized sham-controlled trial of concurrent self-administered tDCS and ABMT in adults with BED (The TANDEMTrial). Eighty adults with BED will be randomly assigned to one of four groups: ABMT with real or sham self-administered tDCS, ABMT only, or waiting list control. In the treatment arms, participants will complete 10-sessions of their allocated intervention over 2-3 weeks. Outcomes will be assessed at baseline (T0), immediately post treatment (T1), and 6 weeks after end of treatment (T2), and at comparable timepoints for participants in the waitlist control group. Feasibility will be evaluated by assessing recruitment/retention rates and blinding success. Acceptability will be assessed quantitatively via participant ratings and qualitatively via semi-structured interviews. Episodes of binge eating at follow-up will be the primary clinical outcome and rate ratios from Poisson regression will be reported. Secondary outcomes will assess changes in ED and general psychopathology, attention bias toward high calorie foods, and executive function. Discussion: It is hoped that data from the trial will contribute to the development of neurobiologically informed treatments for BED, provide insights into the potential use of at-home variants of tDCS, and inform the design of future large scale trials. [ABSTRACT FROM AUTHOR]

Objective: Repetitive transcranial magnetic stimulation (rTMS) is a promising emerging treatment for anorexia nervosa (AN). However, to date, patients' views and experiences of this treatment have not been fully explored. To assess these, we integrated a qualitative study into a feasibility randomised controlled trial of rTMS in individuals with severe enduring AN. Method: Twenty‐nine (of 34) trial participants contributed to this study. Semi‐structured interviews were conducted 3‐months following the completion of rTMS treatment (4‐months post‐randomisation), prior to unblinding. Transcripts were analysed using content analysis. Results: rTMS was deemed an acceptable but time‐consuming treatment. Many emphasised how their lives had changed to some extent during, but mainly after treatment by making them more positive, open‐minded, flexible and willing to try new things in relation to their AN and other aspects of their lives. Conclusions: These qualitative data will be valuable in shaping participant information, recruitment and planning of future large‐scale trials of rTMS in AN. Trial Registration: ISRCTN14329415, registered 23rd July 2015, https://www.isrctn.com/ISRCTN14329415 Highlights: This study is the first to systematically explore participants' experiences of repetitive transcranial magnetic stimulation (rTMS) treatment for severe enduring anorexia nervosa (AN), as part of a randomised controlled feasibility trial.Participants expressed that rTMS was an acceptable but time‐consuming treatment. Many participants who received real rTMS described positive changes in relation to AN and quality of life.Findings from this qualitative study will help to shape future research of rTMS treatment for AN. [ABSTRACT FROM AUTHOR]

Depression, anxiety and eating disorders ("social-emotional disorders") are common during adolescence/emerging adulthood, periods of intense identity development. Despite this, there are few reviews of existing research on the relationship between symptoms of these disorders and ongoing identity development. This study systematically reviewed, narratively synthesized and meta-analyzed longitudinal investigations of the relationship between identity synthesis/confusion and depression, anxiety and eating disorders symptoms during adolescence/emerging adulthood. Three databases (PsycInfo, Medline, Embase) were searched. Study quality was systematically appraised, findings were qualitatively synthesized and (where possible) meta-analyzed. 20 studies (55% "fair" quality, 45% "poor" quality) were identified, including 13,787 participants (54.2% female, mean age = 14.48 years, range 10–29 years). The narrative synthesis found evidence of bidirectional relationships between identity synthesis/confusion and depression, anxiety and eating disorder symptoms. Meta-analyses and meta-regressions of a sub-sample of studies (N = 9) indicated no significant associations between identity synthesis or confusion and anxiety or depression symptoms. More high-quality research is needed before firm conclusions can be drawn. [ABSTRACT FROM AUTHOR]

Background: First Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway for emerging adults aged 16 to 25‐years with a recent onset eating disorder (ED) of <3 years. A previous single‐site study suggests that FREED significantly improves clinical outcomes compared to treatment‐as‐usual (TAU). The present study (FREED‐Up) assessed the scalability of FREED. A multi‐centre quasi‐experimental pre‐post design was used, comparing patient outcomes before and after implementation of FREED in participating services. Methods: FREED patients (n = 278) were consecutive, prospectively ascertained referrals to four specialist ED services in England, assessed at four time points over 12 months on ED symptoms, mood, service utilization and cost. FREED patients were compared to a TAU cohort (n = 224) of similar patients, identified retrospectively from electronic patient records in participating services. All were emerging adults aged 16–25 experiencing a first episode ED of <3 years duration. Results: Overall, FREED patients made significant and rapid clinical improvements over time. 53.2% of FREED patients with anorexia nervosa reached a healthy weight at the 12‐month timepoint, compared to only 17.9% of TAU patients (X2 [1, N = 107] = 10.46, p <.001). Significantly fewer FREED patients required intensive (i.e., in‐patient or day‐patient) treatment (6.6%) compared to TAU patients (12.4%) across the follow‐up period (X2 [1, N = 40] = 4.36, p =.037). This contributed to a trend in cost savings in FREED compared to TAU (−£4472, p =.06, CI −£9168, £233). Discussion: FREED is robust and scalable and is associated with substantial improvements in clinical outcomes, reduction in inpatient or day‐patient admissions, and cost‐savings. [ABSTRACT FROM AUTHOR]

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Objective: This study explored participants' experience of approach bias modification training (ABM) with transcranial Direct Current Stimulation (tDCS) for binge eating disorder (BED) within a randomised controlled trial (RCT). A subset of participants who completed the RCT were interviewed to attain feedback on treatment experience and outcomes. Method: 15 participants with BED who completed the RCT were recruited, using purposive sampling. Participants received six sessions of concurrent ABM training with either real or sham tDCS. Semi‐structured interviews relating to study experience and treatment outcomes were conducted and data were analysed thematically. Results: The combined ABM and tDCS intervention was deemed acceptable and worthwhile by participants interviewed across both intervention groups. Negative preconceptions of tDCS were an initial deterrent to study participation for some, yet the brain stimulation experience was found to be tolerable. Minor and transient sensations and side effects attributed to tDCS were reported by most participants during and after stimulation, in addition to less pleasant aspects of ABM training, with no significant adverse effects reported by interviewees. Positive outcomes were described by participants across both intervention groups, relating to changes in BED symptoms and to broader beneficial effects on associated cognitive and emotional factors. Two participants experienced a shift in autonomy, attributed to tDCS and the combined intervention respectively. Conclusions: Adults with symptoms of BED found concurrent ABM and tDCS sessions to be acceptable, despite initial apprehension about the safety of tDCS. Findings are relevant to the neuroethics literature and may inform science communication strategies on neuromodulation treatments. Key points: Novel, brain‐targeted treatment adjuncts are needed to improve clinical outcomes for patients with binge eating disorder (BED). This study is the first to explore participants' experience of multi‐session concurrent approach bias modification training (ABM) and transcranial Direct Current Stimulation (tDCS) for BED within a randomised control trial (ICARUS RCT: ISRCTN35717198)All interviewees would recommend study participation to others, which may indicate high rates of acceptability of the combined intervention. Facilitators and potential barriers to study enrolment and engagement were outlined. The perceived impact of tDCS on participants' autonomy and identity was discussed by a minority of participants interviewed. Participants reported an apprehension of, and misconceptions around, tDCS as a safe treatment modality prior to participation in the RCTFindings from this study will complement quantitative findings from the RCT in informing the development and evaluation of future studies. Additionally, participants' feedback is relevant to the discussion of the potential impact of neuromodulation on autonomy and identity, and may inform science communication strategies disseminating information about non‐invasive brain stimulation technologies to the public [ABSTRACT FROM AUTHOR]

Background Digitalizing the healthcare system has been declared a priority by the UK government. People with eating disorders (EDs), especially those with bulimia nervosa (BN) or binge eating disorder (BED), and ED carers may benefit from online self-help programmes, due to the shame and stigma associated with EDs and barriers in accessing treatment, skills-training or support. Qualitative studies are needed to explore stakeholders' needs, attitudes to and views about online self-help, to optimize intervention design and delivery. Methods Focus groups and telephone interviews were conducted with people with BN or BED, and carers of people with anorexia nervosa, between March and September 2018 in the UK. Results People with EDs and carers perceived online self-help positively in the context of barriers to seeking and accessing treatment and support, despite some seeing it as inferior to face-to-face support. Most reported little experience with online interventions. Participants thought the disadvantages of online interventions could be overcome by reminders, progress summaries, regular engagement and engaging with peers. Receiving guidance was seen as an important functionality in the intervention by people with EDs. Conclusions People with EDs and their carers are aware of the potential benefits of online self-help despite having little experience with this form of intervention. A stepped-care approach that utilizes technology-based interventions as a first step and makes such interventions available directly to the consumer may fit the attitudes and needs of stakeholders. The study provides a foundation for future research on design and delivery of ED online self-help. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to evaluate the effectiveness of evidenced‐based psychological treatments (specifically, Cognitive‐Behaviour Therapy for Eating Disorders [CBT‐ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology. Method: Three hundred and seventy‐nine participants meeting criteria for DSM‐5 anorexia nervosa, bulimia nervosa, binge‐eating disorder or other specified feeding or eating disorder completed pre‐ and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging. Results: Ninety seven percent of participants received treatment in line with evidence‐based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m2 over treatment, with similar outcomes for MANTRA and CBT‐ED. Discussion These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence‐based psychotherapies to real‐world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders. [ABSTRACT FROM AUTHOR]

Introduction: Multi-family therapy (MFT) is a recommended treatment for adolescent anorexia nervosa internationally. Despite recent significant advances in single-family therapy, the evidence base for MFT remains relatively small. Several individual and family factors have been associated with poorer outcomes in single-family therapy, many of which may be addressed or ameliorated by MFT if delivered early in treatment. This trial aims to determine the feasibility and acceptability of adding a five-day multi-family therapy group to the early stages of family therapy for anorexia nervosa. Secondary objectives are to explore effect size changes in key individual and family factors across treatment. Methods: This feasibility trial will use a randomised controlled design. Sixty adolescents (age 10–17 inclusive) with anorexia nervosa or atypical anorexia nervosa and their parents will be recruited from a community-based specialist eating disorder service in London, UK. Participants will be randomly allocated to receive six months of eating disorder focussed family therapy with a five-day MFT group (experimental group) or without (control group). Block randomisation will be conducted by the King's Clinical Trials Unit and researchers will be blind to participants' intervention allocation. Feasibility, acceptability and secondary outcomes measures will be collected at baseline, post-MFT, end of treatment, six-month and 12-month follow-up. Feasibility and acceptability will be assessed according to trial sign-up rates, retention, measure completion rates and satisfaction. Secondary outcomes include physical health improvements, changes in psychiatric symptoms, emotion regulation and reflective function capacity, expressed emotion, parental difficulties and therapeutic alliance. Descriptive data and exploration analysis of trends and effect sizes will be reported upon at trial completion. Discussion: The five-day MFT program developed for this study is novel, brief and more accessible than previous MFT models. The inclusion of a data collection point during treatment and follow-up will allow for an investigation of trends during and after treatment. This will allow exploration and comparison of future potential mediators and moderators of MFT and FT-AN outcomes and how these may differ between treatments. Trial registration: ISRCTN registry; ISRCTN93437752, on 27 January 2021. [ABSTRACT FROM AUTHOR]

Background: Eating disorders (EDs) are common in student populations and present formidable challenges as to how best to treat and support these young people, especially at points of transition. Yet research exploring these challenges is lacking, particularly from the perspective of those providing treatment and support. Methods: A qualitative design was used to explore clinicians' perspectives of supporting students with EDs. Twelve clinicians from a large ED service in the United Kingdom participated in one‐to‐one semi‐structured interviews. Data were analysed using thematic analysis. Results: Facilitators and barriers to supporting students with EDs fell into four overarching themes: Health System, University, Patient and Carer Factors. Reported facilitators were; ED service awareness, flexibility and resources, university as a motivator, and carer support. Reported barriers were; poor links and communication between institutions, the primary care system, poor university provision for and awareness of EDs, young people's denial and ambivalence, inconsistent implementation of guidelines, and carer anxiety. Conclusions: The findings revealed challenges unique to the university transition, including the need for more collaborative working between healthcare and education institutions, improved training of non‐specialised ED professionals, and the benefits of a flexible, adapted ED treatment approach specifically tailored to the unique needs of students with EDs. Highlights: Emerging adults are increasingly being recognised as having unique developmental needs relative to adolescence—this study confirms these suggestions, and highlights the need for distinct treatment approaches for students with eating disordersFindings reveal a need to improve joint‐working and open communication between institutions, and institutions and families, to facilitate more consistent monitoring and support for students with EDs in two localitiesFindings also emphasise the need to enhance ED training for all non‐specialist health professionals and university staff, to ensure prompt detection, sign‐posting and management of students with EDsThe value of carers in the university transition is sometimes overlooked—involving carers in the preparation phase of the university transition for emerging adults with EDs is essentialUniversity can be a motivator in recovery for some students with EDsED service flexibility and psychoeducation resources may support students with EDs during their transition to universityAddressing how ED treatment may best be adapted to meet the unique development needs of emerging adults at university remains an avenue for future research. Simultaneous exploration of other ED treatment team, healthcare professional, university professional, carer and student's with EDs perspectives would be beneficial [ABSTRACT FROM AUTHOR]

Background: Duration of untreated eating disorder (DUED), that is, the time between illness onset and start of first evidence‐based treatment, is a key outcome for early intervention. Internationally, reported DUED ranges from 2.5 to 6 years for different eating disorders (EDs). To shorten DUED, we developed FREED (First Episode Rapid Early Intervention for EDs), a service model and care pathway for emerging adults with EDs. Here, we assess the impact of FREED on DUED in a multi‐centre study using a quasi‐experimental design. Methods: Two hundred and seventy‐eight patients aged 16–25, with first episode illness of less than 3 years duration, were recruited from specialist ED services and offered treatment via FREED. These were compared to 224 patients, of similar age and illness duration, seen previously in participating services (treatment as usual [TAU]) on DUED, waiting times and treatment uptake. Results: FREED patients had significantly shorter DUED and waiting times than TAU patients. On average, DUED was reduced by ∼4 months when systemic delays were minimal. Furthermore, 97.8% of FREED patients took up treatment, versus 75.4% of TAU. Discussion: Findings indicate that FREED significantly improves access to treatment for emerging adults with first episode ED. FREED may reduce distress, prevent deterioration and facilitate recovery. Highlights: This study is a large‐scale replication of an earlier single‐centre pilot study of First Episode Rapid Early Intervention for Eating Disorders (FREED). Findings indicate that, as in the pilot study, FREED significantly reduces duration of untreated eating disorder and is associated with significantly shorter wait times for both assessment and treatment when implemented at scaleDifferences between groups were more pronounced when systemic delays were minimalThe proportion of FREED patients taking up treatment was significantly higher than in treatment as usual, suggesting that a shorter interval between help‐seeking from primary care and an offer of specialist assessment/treatment has clear down‐stream benefits [ABSTRACT FROM AUTHOR]

Objective: This systematic review assesses the average duration of untreated eating disorder (DUED) in help‐seeking populations at the time of first eating disorder (ED) treatment and investigates the relationship between DUED and symptom severity/clinical outcomes. Method: PRISMA guidelines were followed throughout. Selected studies provided information on either: (i) length of DUED, (ii) components of DUED, (iii) cross‐sectional associations between DUED and symptom severity, (iv) associations between DUED and clinical outcomes, or (v) experimental manipulation of DUED. Study quality was assessed. Results: Fourteen studies from seven countries were included. Across studies, average DUED weighted by sample size was 29.9 months for anorexia nervosa, 53.0 months for bulimia nervosa and 67.4 months for binge eating disorder. A younger age at time of first treatment was indicative of shorter DUED. Retrospective studies suggest that a shorter DUED may be related to a greater likelihood of remission. Manipulation of DUED by shortening service‐related delays may improve clinical outcomes. Conclusions: Data on length of DUED provide a benchmark for early intervention in EDs. Preliminary evidence suggests DUED may be a modifiable factor influencing outcomes in EDs. To accurately determine the role of DUED, definition and measurement must be uniformly operationalised. HighlightsThis systematic review is the first to examine duration of untreated eating disorder (DUED) across different eating disorders. Definitions and measurement of DUED and its components vary considerably between studies.Across different eating disorders average DUED weighted by sample size ranges from approximately two and a half years (for anorexia nervosa) to nearly 6 years (for binge eating disorder).DUED appears to be related to age such that younger patients have shorter DUED. [ABSTRACT FROM AUTHOR]