Abstract
Background
The prevention and treatment of eating disorders relies on an extensive body of research that includes various foci and methodologies. This scoping review identified relevant studies of eating disorders, body image, and disordered eating with New Zealand samples; charted the methodologies, sample characteristics, and findings reported; and identified several gaps that should be addressed by further research.
Methods
Using scoping review methodology, two databases were searched for studies examining eating disorders, disordered eating, or body image with New Zealand samples. Snowball methods were further used to identify additional relevant articles that did not appear in initial searches. Two independent reviewers screened the titles and abstracts of 473 records. Full text assessment of the remaining 251 records resulted in 148 peer-reviewed articles being identified as eligible for the final review. A search of institutional databases yielded 106 Masters and Doctoral theses for assessment, with a total of 47 theses being identified as eligible for the final review. The included studies were classified by methodology, and the extracted information included the study foci, data collected, sample size, demographic information, and key findings.
Results
The eligible studies examined a variety of eating disorder categories including binge-eating disorder, bulimia nervosa, and anorexia nervosa, in addition to disordered eating behaviours and body image in nonclinical or community samples. Methodologies included treatment trials, secondary analysis of existing datasets, non-treatment experimental interventions, cross-sectional observation, case-control studies, qualitative and mixed-methods studies, and case studies or series. Across all of the studies, questionnaire and interview data were most commonly utilised. A wide range of sample sizes were evident, and studies often reported all-female or mostly-female participants, with minimal inclusion of males and gender minorities. There was also an underrepresentation of minority ethnicities in many studies, highlighting the need for future research to increase diversity within samples.
Conclusion
This study provides a comprehensive and detailed overview of research into eating disorders and body image in New Zealand, while highlighting important considerations for both local and international research.
Plain English summary
Research into eating disorders should include different methods, and should be relevant to people of different ages, gender identities, and ethnicities. We completed a scoping review of research into eating disorders, disordered eating, and body image in New Zealand samples. We searched academic databases for relevant articles, and then screened the articles for eligibility. We then hand-searched key articles, and searched databases again using the names of key authors. A total of 148 peer reviewed articles and 47 theses were eligible for the review, and from these we extracted data on the study method, sample characteristics, and the focus and results. A wide range of methods and sample sizes were reported, and the studies explored several different eating disorders, as well as disordered eating and body image in nonclinical samples. However, the studies often involved all or mostly female samples, few to no gender minority participants, and an underrepresentation of minority ethnicities. Funders should provide adequate time and financial resources to fund recruitment from historically under-represented groups, emphasising their involvement as active researchers. In addition, funders should consider financing the use of novel or underutilised methods to advance knowledge in this field.
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Introduction
Eating disorders such as binge-eating disorder (BED), bulimia nervosa (BN), and anorexia nervosa (AN) are complex and potentially life-threatening psychiatric illnesses. Research in the New Zealand population suggests a lifetime prevalence of 1.9% for BED, 1–1.3% for BN, and 0.6% for AN [1, 2]. These disorders create a significant burden upon the lives of those affected, with many individuals facing prolonged periods of inpatient treatment or multiple relapses. Although research into eating disorders has made substantial progress in recent years, the limited success of available treatments underscores the need for a more complete picture of how to best understand and approach this cluster of disorders.
In addition to the more commonly acknowledged eating disorders noted above, there is a growing awareness surrounding those whose symptoms fall within the Diagnostic and Statistical Manual (DSM-5) [3] other specified feeding and eating disorders (OSFED) diagnostic category. These disorders include atypical or subthreshold forms of BN, AN, and purging disorder which previously were included in the DSM-IV eating disorder not otherwise specified (EDNOS) category, and the newly included night eating syndrome. Despite this group of disorders having been identified as being the most prevalent [4], research surrounding them is comparatively sparse.
At a sub-threshold level, eating disorder psychopathology is common in New Zealand, and has been reported in adolescents, university students, and middle-aged samples [5,6,7]. Disordered eating is often tightly intertwined with body dissatisfaction—a core symptom in the diagnostic criteria for AN and BN [3], which is also suggested to be relevant for BED [8]. Body dissatisfaction is regarded as a significant risk factor for the development of eating disorders [9, 10], with etiological models commonly citing the relationship between body dissatisfaction and subthreshold disordered eating. Body dissatisfaction can be seen as almost normative among young women and, increasingly, young men [11]. In light of this, our understanding of disordered eating can be supplemented by research into body dissatisfaction at both a clinical and subthreshold level.
Although many aspects of eating disorders, subthreshold disordered eating, and body dissatisfaction are studied extensively internationally, it is often unclear whether findings generalise to a New Zealand population. Moreover, even where such findings are applicable, there remains a need to understand these issues in a manner consistent with New Zealand’s unique sociocultural context [12, 13]. Achieving this requires a comprehensive body of research to be conducted within New Zealand, ideally with a range of study designs to ensure a detailed and broad understanding of these issues. Moreover, this research should adequately cover the range of issues pertaining to body image and eating disorders, and include samples that are representative of the population as a whole (such as Indigenous Māori and Pasifika populations). To this end, it is critical that local researchers are aware of what is available within the literature and what is lacking, thus informing the direction for future research and methodologies. However, we were unable to identify any comprehensive reviews of relevant studies involving New Zealand-based participants, thereby hindering progression of research into the issues at hand.
In an effort to bridge the gap between extant research and future projects, the present review scopes and synthesises the foci reported by studies examining eating disorders, disordered eating, and body image within studies that include New Zealand samples. This review was informed by scoping methodology outlined by the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Review (PRISMA-ScR) [14]. It involved: (a) the identification of relevant journal articles and theses; (b) charting the foci, methodologies, sample characteristics, and findings reported in the identified literature; and (c) a descriptive review of what was included, as well as gaps and areas which may be expanded upon.
Methods
Research question
The scoping review was informed by the research question: “To date, what are the methodologies and results reported by studies that have examined eating disorders, disordered eating, and body image in clinical and non-clinical samples in New Zealand?”.
Eligibility
Meeting initial eligibility criteria was dependent on (1) the full text being available, (2) some portion of the sample living in New Zealand during the research, (3) the article or thesis being available in English, (4) the record not being a duplicate, and (5) the topic or a part of the focus being within scope. The scope was informed by the overarching research question of this review, and research items needed to include an examination of eating disorders, disordered eating, or body image in New Zealand samples.
Included eating disorder diagnoses were BED, BN, and AN in addition to disorders in the Other Specified Feeding and Eating Disorder (OSFED) category (DSM-5) or the former Eating Disorder Not Otherwise Specified (EDNOS) category (DSM-IV-TR) [15]. Also included were studies where only symptoms of these disorders (e.g. binge eating, purging) were assessed. Not included were Avoidant/Restrictive Food Intake Disorder (ARFID), pica and rumination disorder; categories shifted to the eating disorders section of DSM-5 from the DSM-IV-TR Feeding and Eating Disorders of Early Childhood Section [3, 15]. Body image in the context of this review included perceptions of one’s own body shape and size, but excluded research items that focused only on concerns such as perceived facial flaws [16], which are often a feature of body dysmorphic disorder. Lastly, research on samples of clinicians working in eating disorder treatment were included, given that this adds considerably to knowledge surrounding eating disorders and their treatment in New Zealand.
Both qualitative and quantitative studies were deemed in scope, as were case studies and case series. International studies that included original data from one or more New Zealand participants were included; however, meta analyses and systematic reviews were not, given that relevant data were likely already published elsewhere. It was decided that conference abstracts would be excluded, given that the findings were either published elsewhere, or the abstracts did not include sufficient information to meet basic eligibility criteria. Lastly, any trials that were in progress but unpublished were also excluded, as it would not be possible to chart the findings of those studies.
Initial database search
To locate references for journal articles from a wide range of sources, relevant search terms were entered into Ovid (EMBASE, psychINFO). The search terms “eating disorder*.kw”, “anorexia nervosa.kw”, “bulimia nervosa.kw”, “binge eating disorder.kw”, “disordered eating.kw”, and “body image.kw” were combined using the “OR” function. This result was then combined with “new zealand.af” using the AND function, and the results were deduplicated. No additional search limitations were used in Ovid. The cut-off date for this and subsequent searches was set to 20 May, 2021.
Snowball searches
During the initial screen of records returned in Ovid, seven authors known to publish research within this scope frequently appeared as first authors. Publications from these authors were further searched in Ovid by entering the search terms “jordan jennifer.au”, “carter frances a.au”, “gendall kelly a.au”, “mcintosh virginia v w or mcintosh virginia violet williams or mcintosh virginia vw).au”, “bulik cynthia m.au”, “wilksch simon m or wilksch sm.au”, “latner janet d or latner jd.au”. These searches were combined using the OR function, and the result was then combined with “new zealand.af” using the AND function. The results were deduplicated within Ovid before being merged with the initial OVID search records, and the combined results were again deduplicated.
The citations within key papers were also hand-searched by two reviewers (HK and LC) for additional relevant publications within New Zealand. Key papers included relevant epidemiological studies and treatment trials known among New Zealand eating disorders researchers. Referenced papers were then located and screened using the same criteria and checklist. Furthermore, when papers reporting secondary analyses referred back to publications which described original study samples, those publications were identified and screened for inclusion.
Grey literature search
To locate Master’s and Doctoral theses, institutional research archives were searched for each of the University of Otago (OURArchive), University of Waikato (Research Commons), University of Canterbury (College of Science, College of Arts), Massey University (Massey Research Online), Auckland University of Technology (Open Repository), and Victoria University of Wellington (Open Access), and University of Auckland (ResearchSpace). A total of 29 potentially relevant theses, including 25 from the University of Auckland, were unavailable online or were only accessible only to staff and students at the relevant institutions. As such, full-text screening was unable to be completed for these records.
The terms “binge eating disorder”, “bulimia nervosa”, “anorexia nervosa”, and “body image” were entered into each university research archive and limited to thesis where possible. The terms “eating disorder” and “disordered eating” were also entered into the same archives. In some instances, these latter terms returned the same results as one of the initial four search terms, such as the results for “eating disorder” being the same as those for “binge eating disorder” in one database. In such cases, results were not added to the final number of records to be screened. In addition, when a very large number of unrelated results were returned for thesis search terms, the results for those terms were limited to “title contains”.
In some cases, the findings from grey literature had already been published in peer reviewed journals. To avoid overlap in these situations, the grey literature record was removed as a duplicate in favour of the published article. Further journal articles identified during this process were labelled as being found via snowball search.
Record screening and eligibility
Search results from OVID were exported into EndNote, and then entered into an Excel spreadsheet to be screened separately by two blind reviewers (HK and LC). The reviewers first pre-screened the titles and abstracts of each record for relevance. Journal articles that were eligible for full-text searching were then located where possible, and the reviewers filled out a checklist to determine whether predetermined eligibility criteria were met. Following blind review, authors HK and LC met to discuss a small number of cases where the decision to include or exclude a record was inconsistent. In these cases, the records were further assessed and a final decision was agreed upon for each, with a total of 10 papers being discussed and 7 of these being excluded from the review.
Data extraction and study classification
For each included research item, a range of data were extracted. The relevant population(s) or construct(s) of interest were identified, including any specific eating disorders being examined, disordered eating among nonclinical (NC) populations, or clinicians working within eating disorder treatment settings. The focus of each study was also briefly summarised, as were the key data collection instruments or measures. Gender and ages of participants were recorded as specified in the research article or thesis, however gender data were converted to percentages where applicable, and age ranges were favoured where available. Ethnicities were also recorded as specified, however for consistency, terms such as “Caucasian” and “New Zealand European” were recorded as “European” for the purposes of this review, and these data were also converted to percentages where applicable. The key findings were summarised based upon information within abstracts and full texts. Lastly, each study was categorised according to the primary methodology used, while those that analysed data from existing treatment trial and survey datasets were labelled as secondary analyses.
The scoping review has been registered on OSF (https://osf.io/c8jwn). No ethical approval was required for this review.
Results
Total records included
The total number of records identified and excluded at each step of the literature search are detailed in Fig. 1. A total of 195 records were included in the final review, with 148 journal articles and 47 theses (13 Doctoral, 34 Master’s) having met full eligibility criteria for the study. Journal articles were published between December 1978 and May 2021, while theses were completed between 1990 and 2021. The specific completion dates for two theses finalised in 2021 were unable to be verified, however the decision was made to include those in the review. The number of publications per year, in addition to the cumulative total of publications, is shown in Fig. 2.
PRISMA flowchart depicting record identification process and number of records included or removed at each stage
Number of included theses or journal articles published each year and cumulative totals
Study classifications
Study methodologies across the journal articles and theses fell into seven broad categories of treatment trials (18 records, Table 1), secondary analyses of existing datasets (50 records, Table 2), non-treatment experimental interventions (17 records, Table 3), cross-sectional research (63 records, Table 4), case control studies (9 records, Table 5), qualitative or mixed-methods (28 records, Table 6), or case studies and series (10 records, Table 7).
Foci and wider studies
The groups examined included binge-eating disorder (BED), bulimia nervosa (BN), anorexia nervosa (AN), Eating Disorder Not Otherwise Specified (EDNOS) or Other Specified Feeding and Eating Disorders (OSFED), orthorexia, and disordered eating or body image among non-clinical (NC) groups. Many publications reported data on a range of variables from larger studies or datasets, including the Anorexia Treatment Study (ATS) [17]; Bulimia Treatment Study (BTS) [18]; the Binge Eating Psychotherapy study (BEP) [19]; Te Rau Hinengaro (TRH) [20]; The Costs of Eating Disorders in New Zealand (COSTS) study, the Survey of Nutrition, Dietary Assessment and Lifestyles (SuNDiAL), Youth Health Surveys [21], Programme for the Integration of Mental Health Data (PRIMHD), The Collaborative Psychiatric Epidemiology Surveys (CPES) [22], and the Global Burden of Disease Study (GBDS) [23].
Sample characteristics
A wide range of sample sizes existed within the quantitative research, with the smallest sample recorded at 5 participants [24] and the largest being 12,992 participants [20]. Within the qualitative research, the sample sizes ranged from 1 to 69 participants. The majority of publications reported all-female (137 studies) or mostly female (14 studies) participant groups. A small number focused on male participants, and on sexual minority individuals. The age range of participants was large, with the lowest age being 12 months [25] and the highest being 98 years [26]. Of the 123 studies that provided age ranges for their samples, seven included children under the age of 13 years, with two focusing specifically on children. Thirty-five included participants over 45 years, though none focused specifically on this age group. A total of 133 studies reported ethnicity data or included samples for which ethnicity was previously reported; ethnicity data were unavailable for the remaining 62 studies. Two of the records within the scope of this review focused primarily on eating disorders or body image among Māori—the Indigenous New Zealand minority population.
Types of data collected
The majority of studies used interviews or self-report measures. Data collection instruments that were commonly used to examine eating pathology included the Eating Disorder Inventory (EDI; 24 studies) [30], EDI-2 (19 studies), [31] EDI-3 (3 studies) [32], Eating Disorder Examination (EDE) [33] or the related questionnaire EDE-Q (29 studies) [34], and the Eating Attitudes Test (EAT-26 or EAT-40) [35] questionnaires (10 studies). Various versions of the Structured Clinical Interview for the Diagnostic and Statistical Manual (SCID) [36] were also used (35 studies). Other commonly identified instruments included the Beck Depression Inventory (BDI) [37] in 18 studies, Rosenberg Self Esteem Scale (RSES) [38] in 9 studies, Hamilton Depression Rating Scale (HDRS; 31 studies) [39], and the Temperament and Character Inventory (TCI) [40] in 14 studies. Among the qualitative studies, individual interviews were most common, while the use of focus groups was minimal. With the exception of physical measures such as weight and height, other physiological methods of data collection and analysis such as blood testing (8 studies), neuroimaging, genetic testing, and other biological assessments were less common.
Discussion
This scoping review identified studies that examined disordered eating and body image in clinical and non-clinical samples from New Zealand, and outlined the methodologies and results reported for each study. A large number of records were located and assessed, and these involved a wide range of methodologies and vastly different foci highlighting considerable progress in understanding disordered eating and body image within New Zealand.
Methodology Most of the literature identified in this review described quantitative research, however a smaller number of exploratory qualitative studies and case studies were also identified, with the majority being identified during grey literature searches. Longitudinal studies and follow up studies of eating disorder treatments, particularly those of five years or more, were also uncommon, which may be attributable to the high cost and attrition rates associated with this type of research. Studies included participants from both clinical samples and non-clinical samples; however, large clinical samples were uncommon, which is likely underpinned by limited funding for larger studies (given that New Zealand allocates a much smaller portion of its GDP to funding research, relative to other countries) [41]. In addition, the relatively small New Zealand population makes it difficult to recruit large samples of individuals with eating disorders, which are relatively low prevalence conditions. Self-report and interview measures were identified as being most frequently used, whereas the analysis of biological data such as blood samples, which can be helpful in understanding the impact of disordered eating, was uncommon. This may be attributable to the relative ease and affordability of survey and interview data, whereas other methods tend to require more financial and research infrastructure, resources, and expertise.
Sex and gender Although some of the studies included males or gender minorities, most focussed on samples that were predominantly or exclusively female. The identification of only two all-male samples [42, 43] is consistent with reports that less than 1% of all published eating disorder research focused specifically on males with these disorders [44, 45]. Several of the identified New Zealand studies of eating disorders excluded potential male participants, or excluded data provided by male survey respondents. This may be partly because the prevalence of these disorders, with the exception of BED, tends to be lower among males [46], leading to low recruitment numbers that generally preclude statistical analyses. The inclusion of male participants also necessitates adapting treatment packages or prevention strategies for these individuals, which provides further logistical challenges for researchers [47]. Although females may be an easier group to recruit from, differences in the presentation of eating disorders and body image concerns in males need to be examined further [48]. In addition, the consistently low recruitment of male participants perpetuates the notion that eating disorders primarily afflict females, while reducing the likelihood that men will come forward to participate in future research on eating disorders, or to seek treatment. There is also evidence to suggest differences in body image concerns, as well as eating disorder risk factors and presentation, among sexual minority and LGBTQIA + individuals [28]; however, very few of the identified studies explored these differences. As such, there is a need for context-specific information to assist healthcare providers in furthering their knowledge of the presentation and treatment options for men, gender minority, and LGBTQIA + individuals in New Zealand.
Age There was a tendency for studies to recruit adolescents and younger adults. This may be partly attributable to convenience, with university aged students being the most readily available population for non-clinical studies, while the higher prevalence of eating disorders among young people can make other age groups more difficult to sample from. We identified very few studies that included participants under the age of 13, which is of particular concern given reports that eating disorders are being increasingly identified among children [49]. Conversely, there were also fewer studies involving middle-aged or older participants, despite middle-age being associated with increased eating disorder risk for women in particular, in part related to the menopause transition [50, 51]. With increased knowledge surrounding the risk and development of eating and body image issues across different age groups in New Zealand, more targeted and effective prevention and treatment strategies may be established.
Ancestry Many studies did not report ethnicity data, and Māori and Pasifika peoples were typically under-represented where these data were available. The lack of Māori and Pasifika representation and inclusion marginalises these groups further, while the extent and ways they are impacted by eating disorders, disordered eating, and body image concerns remain unclear. A lack of research into eating disorders within Indigenous and minority ethnicity populations is common within international literature, which limits our understanding of how to best understand, detect, and approach the treatment of eating disorders among these groups [52]. The results of this review suggest that New Zealand is no exception to this pattern, despite the prevalence of anorexia nervosa and bulimia nervosa in Māori being similar to or higher than in the general population [53]. Food and rituals surrounding food are central to Māori and Pasifika cultures, and are important to consider when assessing and treating eating disorders in Māori and Pasifika participants [13]. It is important to assess all eating disorders in future studies, given subthreshold eating disorders and disordered eating have been found to be highly prevalent in Indigenous peoples in Australia, suggesting current diagnostic criteria may not adequately capture eating problems in underrepresented minority identity groups [54]. Therefore, future studies of eating disorders and related issues within New Zealand need to actively seek participation from Māori and Pasifika people, and explore these issues from a culturally inclusive viewpoint.
Strengths and limitations This review has a number of strengths. Firstly, it captures research spanning a 43-year timeframe, allowing for a thorough investigation into the nature of research on disordered eating and body image within New Zealand. Furthermore, the review has included not only peer-reviewed journal articles, but also grey literature in the form of Masters and Doctoral theses. The addition of postgraduate research has allowed for a pragmatic and inclusive examination of the work conducted using New Zealand based samples, whereas a traditional style of review may exclude valuable data present in grey literature. The present review also has several limitations, with one being that a portion of the relevant grey literature, was unavailable for screening. Some of these theses could have added to the breadth of research methodologies, participants, and foci reported in the review. Although all Medline records are indexed in Embase, it may have been beneficial to also include Medline in the search strategy, as the indexing is unique to each of these databases. In addition, although every attempt was made to pre-define which topics would be included or excluded in the search, there is still a chance of reviewer bias in choosing whether to include research that fit less clearly within the margins of the scope. This is a risk particularly with the inclusion of research on body image. For example, other reviewers might have included studies with questionnaire items that alluded to body image, e.g. “how I look” without specifying weight and shape. However, the involvement of two independent reviewers reduced the risk of bias, as any inconsistencies in the inclusion of records were carefully addressed.
Recommendations Given the data presented in this review, a number of recommendations have been formulated for New Zealand research in the area of eating disorders, disordered eating, and body image. Firstly, although studies of a short term and non-experimental nature are less time-consuming and cheaper, the relapsing nature of eating disorders indicates that more longitudinal studies and long-term psychotherapy follow-ups would be valuable. Future research will also benefit from utilising different assessment methods to better understand the mechanisms underlying eating disorders. These may include physiological methods such as neuroimaging, or other biometric or biological, and genomic and other—omic approaches [55,56,57]. This in turn would allow for a more complete physiological picture of eating disorders in New Zealand, and would aid local research in keeping pace with international research methods. A second recommendation is to include more studies of body image and eating behaviours among males and LGBTQIA + communities. As mentioned earlier, this would further contribute to an understanding of how to responsibly and appropriately approach eating disorders in these groups. Future research should also examine eating disorders and body image concerns before adolescence, and beyond the age of 45, to better address the needs of individuals affected at different life stages. Finally, the paucity of research using a representative proportion of Māori and Pasifika participants was of particular concern. Although it may be more difficult to recruit participants from ethnic minority groups, it is vitally important that researchers make every effort to do so. This should involve engaging these communities from the outset, rather than only studying them as research participants [58].
Funders should be aware of considerable need for eating disorders research to be able to better serve ill individuals and their families in New Zealand. Proposal requirements should require inclusion of men and minoritized gender and ethnic groups, even specifying a minimum percentage of males and individuals from minority ethnicity groups. Funding should be allocated and timed in a way that supports recruitment from more difficult to reach groups, such as providing budgets specifically for targeted advertising and allowing more time to focus on engaging with these participant communities. In addition, funded research should be encouraged to include these groups as active researchers, building capacity in these communities and enabling them to provide guidance throughout the study. Lastly, budgets should be sufficient to support controlled treatment trials, particularly for groups that have been understudied, and research involving techniques and methods that are novel or underutilised.
Conclusions This scoping review is the first comprehensive examination of research into disordered eating and body image conducted in New Zealand. By summarising the foci, methods, and results for each of these studies, the review has also highlighted many gaps and areas where further funding and research is needed, including more treatment trials and longitudinal research, more advanced methods of data collection and analysis, and the inclusion of more diverse sample groups. While it may be more difficult to recruit individuals from minority groups, the greater social connectivity provided by the internet may assist researchers in recruiting, surveying, or interviewing such groups with less difficulty than previously. This study has identified a considerable body of research, and provides important information to assist funders and researchers in benchmarking findings against samples from New Zealand.
Availability of data and materials
All data generated during this study are included in this published article and were extracted from existing publications.
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All authors were supported in part by the Eating Disorders Genetics Initiative (EDGI) grant (NIMH R01MH120170). The funder has no input into this scoping review.
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LC: conceptualisation, methodology, formal analysis, writing—original draft. HLK: methodology, formal analysis, writing—review and editing. MAP: writing—review and editing. MAK: writing—review and editing. CMB: writing—review and editing. JJ: conceptualisation, formal analysis, methodology, supervision, writing—review and editing. All authors read and approved the final manuscript.
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CM Bulik reports: Shire (grant recipient, Scientific Advisory Board member); Lundbeckfonden (grant recipient); Pearson (author, royalty recipient); Equip Health Inc. (Clinical Advisory Board).
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Cleland, L., Kennedy, H.L., Pettie, M.A. et al. Eating disorders, disordered eating, and body image research in New Zealand: a scoping review. J Eat Disord 11, 7 (2023). https://doi.org/10.1186/s40337-022-00728-1
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DOI: https://doi.org/10.1186/s40337-022-00728-1