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The prospective relationship between anxiety symptoms and eating disorder symptoms among adolescents: a systematic review and meta-analysis of a bi-directional relationship
Anxiety symptoms and eating disorder symptoms commonly co-occur in adolescents. However, there is divergent evidence on the prospective relationship between the two factors. This systematic review and meta-analysis summarises the existing literature on the prospective and bi-directional relationship between anxiety symptoms and eating disorder symptoms in adolescence. A systematic search across six databases was conducted on the 11th June 2024. Studies were included if they assessed the prospective relationship between anxiety symptoms and eating disorder symptoms, or vice versa, in adolescence. 19,591 studies were screened, of which 54 studies met inclusion criteria and were included in the full review. Four meta-analyses were conducted. Anxiety symptoms were associated with subsequent eating disorder symptoms, increases in eating disorder symptoms, and higher odds of eating disorders, including their onset. Conversely, eating disorder symptoms were associated with subsequent anxiety symptoms, increases in anxiety symptoms, and higher odds of subsequent anxiety disorders. Current evidence suggests that anxiety symptoms and eating disorder symptoms do not merely co-occur during adolescence, but are prospectively and bi-directionally linked. Further research is needed to understand the underlying mechanisms of this relationship, as well as individual differences in symptom trajectories.
Anxiety symptoms and eating disorder symptoms are frequently experienced by adolescents [1‐3]. Both are linked with heightened distress and increased risk of developing clinical full-blown disorders (i.e., anxiety disorders and eating disorders) and are highly likely to co-occur [4, 5]. Indeed, young women who experience eating disorder symptoms are 3–4 times more likely to also experience clinical levels of anxiety symptoms [6]. Despite this common co-occurrence, it is not clear whether symptoms share a common aetiology or have a causal link with one another [7]. Identifying the temporal relationship of symptoms, especially during adolescence, is critical for informing early intervention and prevention efforts that could target anxiety or eating disorder symptoms to prevent the onset of both anxiety disorders and eating disorders [8]. The current systematic review aimed to examine the prospective evidence linking anxiety symptoms and eating disorder symptoms to establish whether: a) anxiety symptoms temporally predict eating disorder symptoms, and/or b) eating disorder symptoms temporally predict anxiety symptoms.
Anxiety symptoms and subsequent eating disorder symptoms
Most research to date has explored whether anxiety disorders predict the future onset of eating disorders [9‐11], based on converging evidence within clinical samples that anxiety disorders tend to occur before eating disorder onset [4, 12]. This research suggests that the presence of any anxiety disorder, rather than a specific type of anxiety, is predictive of an increased risk for eating disorder development. While the examination of the anxiety and eating comorbidity at a diagnostic level has highlighted the co-occurrence of disorders, this approach lacks nuanced information on symptomatic associations that may further our understanding of the underlying aetiology of this comorbidity. More recent models of comorbidity in mental illness suggest that symptoms of multiple disorders could be explained by latent liability that influences the symptoms presentation of those disorders (e.g., behavioural symptoms), as well as their progression over time [13]. As such, it is pertinent to extend this line of research by investigating the comorbidity between anxiety disorders and eating disorders at the symptom level as well, to gain a deeper understanding of this comorbidity.
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Additionally, many studies have relied on clinical samples and focused on adults retrospectively reporting the time-ordering of their disorder onset [5]. Such approaches may be biased due to recall and selection bias, questioning whether findings from adult clinical samples apply to adolescents experiencing sub-clinical symptoms of anxiety or eating pathology. Among adolescents, research suggests that the temporal relationship between anxiety symptoms and eating disorder symptoms may be more complicated than suggested by adult clinical studies. For example, research has found links between anxiety symptoms and eating disorder symptoms for some age groups (e.g., early adolescence and late adolescence/emerging adults), but not others (e.g., mid-adolescence) [14]. Indeed, a systematic review on eating disorder symptom trajectories in adolescents suggests that anxiety symptoms during middle childhood/early adolescence are associated with later onset of eating disorders [11]. Additionally, some anxiety symptoms, like worry and anxiety sensitivity, appear to be more predictive of future eating disorder symptoms compared to others [14]. Thus, a comprehensive overview of the existing literature is needed to gain a more complete understanding of how anxiety symptoms and eating disorder symptoms relate to one another over time.
Eating disorder symptoms and subsequent anxiety symptoms
In contrast to cumulative research on investigating anxiety as a predictor for eating disorders, relatively few studies have examined whether eating disorder symptoms predict anxiety symptoms. Indeed, in previous reviews on the clinical comorbidity of anxiety disorders and eating disorders, only one study was identified that examined the prevalence of eating disorders within individuals with an anxiety disorder [15]. Within clinical populations, research suggests that adults with an anxiety disorder have higher odds of also meeting criteria for an eating disorder compared to adults without an anxiety disorder [16]. Further, eating disorders in adolescents have been linked with anxiety disorders in adulthood in the general population [17]. Emerging research is pointing to a bi-directional relationship, whereby anxiety disorders during adolescence predict eating disorders in adulthood and vice versa [18]. However, different patterns emerge for different disorders. Thus, a clearer understanding of the symptomatic associations is needed.
Current review
In sum, current research indicates that (a) anxiety disorders and eating disorders are highly comorbid, (b) both anxiety symptoms and eating disorder symptoms are commonly experienced by adolescents, and (c) anxiety symptoms and eating disorder symptoms are positively associated.
Given these findings, this review aimed to provide a comprehensive and objective synthesis of the current literature on how anxiety symptoms and eating disorder symptoms relate to one another over time in adolescents. Such an overview may elucidate whether focusing on both anxiety symptoms and eating disorder symptoms as focal points for psychosocial interventions and preventive strategies is supported by evidence. In particular, the current review focused on adolescence as a key developmental period for the onset of eating disorder symptoms and heightened prevalence of anxiety symptoms [19].
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Methods
Study protocol
The PRISMA guidelines for reporting systematic reviews and meta-analyses were followed [20]. The PRISMA checklist is listed in Supplementary Material 1. The review protocol was pre-registered with the PROSPERO database of systematic review protocols (#CRD42023425811) and on the open-science framework (https://doi.org/https://doi.org/10.17605/OSF.IO/CE8D3). All deviations from the protocol are clearly outlined below.
Study selection and literature search
Eligible studies were required to: (1) have quantitative data on at least two timepoints, (2) be conducted among adolescents from the general population (mean age 12–21 years), and (3) examine the prospective associations between anxiety and eating disorder symptoms. We considered studies that examined both general levels of anxiety or eating disorders, symptoms of specific disorders (e.g., anorexia nervosa, generalised anxiety disorder), and specific symptoms (e.g., binge eating, rumination). Studies were excluded if they: (1) included an intervention or clinical trial, (2) included cross-sectional data only, (3) did not include measures on anxiety or eating disorder symptoms, or (4) did not test the association between anxiety and eating disorder symptoms prospectively. Further decisions were made to exclude studies that included concepts relating to both anxiety and eating disorder symptoms (e.g., social appearance anxiety) in the absence of other anxiety or eating disorder measures. Studies in languages other than English were assessed by members of the research team with suitable language expertise, where possible. Remaining studies were excluded based on language as translation was deemed inappropriate. References for these studies are provided in Supplement 1.
Search terms listed below were combined using the Boolean AND operator:
i)
Anxiety terms: “anxi*” OR “fear” OR “ruminat*” OR “worry*” OR “PTSD” OR “OCD” OR “generalized anxiety” OR “phobi*” OR “obsessi*” OR “compulsi*” OR “intrusive th*” OR “shyness” OR “nervousness”
ii)
Eating disorder terms: “eating habits” OR “disordered eating” OR “eating disorder*” OR “eating pathology” OR “body image” OR “body dissatisfaction” OR “shape concerns” OR “weight concerns” OR “excessive exercise” OR “diet*” OR “restrictive eat*” OR “dietary restraint” OR “fast*” OR “intention to lose weight” OR “bulimi*” OR “binge*” OR “overeat*” OR “night eat*” OR “purg*” OR “laxative” OR “diuretic” OR “vomit*” OR “loss of control eat*” OR “emotional eat*”
iii)
Adolescence terms: “teen*” OR “youth*” OR “adolescen*” OR “juvenile*” OR “young adult*” OR “young person*” OR “young people*” OR “young m#n” OR “young wom#n” OR “high school*”
The initial search on the databases was conducted on 12th May 2023 and updated on 11th June 2024. The search did not include a set start date, thus articles from the databases' inception were included. The search was conducted in MEDLINE, PsycINFO, Scopus, Web of Science, Embase, and ProQuest. We had originally planned to also include a systematic search in PsyArXiv to identify further grey literature. However, due to issues with using the exact search terms importing references into Covidence, and identifying duplicates based on peer-reviewed studies, a manual search was conducted on PsyArXiv to identify further relevant papers. The search and study selection was conducted by one author (NT), two authors (SD & ABT) screened 20% of studies. Screening was conducted independently, and conflicts were resolved among the authors. To avoid conflicts of interest, authors did not screen any published papers on which they were listed as authors.
Assessment of study quality
The NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies checklist [21] was used to assess study quality of all included studies. Quality assessments were carried out independently and blindly by two authors (NT and MO). Any discrepancies were resolved through discussion between the two authors. To avoid conflicts of interest, authors did not rate any published papers on which they were listed as authors.
Data extraction
All data extraction and coding was performed by the first author (NT) and two independent authors (SD & ABT) who extracted 100% of data for quality control. The following study information variables were extracted: author/s, date of publication, title of publication, publication type, number of participants, sample description (e.g., age, gender, ethnicity), length of follow-up, type of anxiety measure, type of eating disorder measure, association between anxiety and eating disorder symptoms and effect size(s).
Meta-analysis
In addition to the planned narrative synthesis of all reviewed studies, four random effects meta-analyses were conducted as more papers than expected were identified in the systematic review. These meta-analyses were not part of the pre-registration and should be noted as a change from the original plan. Studies were included in the meta-analysis if they included broad anxiety measures (e.g., overall symptoms) rather than specific symptoms (e.g., rumination) to allow for meaningful comparisons. Studies reporting on generalised anxiety or social anxiety were included, whereas studies reporting on obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), or panic symptoms were excluded from the meta-analysis due to symptom-specificity, but are discussed in the narrative synthesis. Studies reporting on either broad eating disorder symptoms (e.g., overall symptoms) or specific behaviours (e.g., dietary restraint) were included in the meta-analysis.
To account for differences in measurement types, we conducted four different meta-analyses: 1. anxiety symptoms predicting eating disorder symptoms (dichotomous), 2. anxiety symptoms predicting eating disorder symptoms (continuous), 3. eating disorder symptoms predicting anxiety symptoms (dichotomous), 4. eating disorder symptoms predicting anxiety symptoms (continuous).
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Random effects models were used, due to the variation across study characteristics meaning that no single effect size could be assumed. Effect sizes (Odds ratios/risk ratios or Pearson’s r) were directly obtained from studies or calculated based on frequencies in the case of odds ratios. For studies reporting continuous measures, the pooled effect size included un-adjusted bi-variate correlations only (i.e., Pearson’s r). For studies reporting dichotomous measures, the pooled effect size included both adjusted and un-adjusted estimates (i.e., odds ratios/risk ratios).
Studies not reporting sufficient information to obtain effect sizes were not included in the meta-analysis (e.g., reporting results of regression models only). If studies reported multiple effect sizes, we chose to retain effect sizes with the longest delay between measurements. If effect sizes were reported for separate outcomes or by gender, multiple effect sizes per study were included. Sensitivity analyses using a multi-level meta-analysis clustering by study were conducted to account for study dependence.
Statistical analysis was performed with R version 3.6.0, using the metafor package. Heterogeneity was examined using the I2 and Cochran’s Q statistics [22]. In general, I2 values of 25% reflect low heterogeneity, 50% moderate heterogeneity and > 75% high heterogeneity [22]. Cochran’s Q is the weighted sum of squared differences between observed effects and weighted average effect, whereby a significant Cochran’s Q statistic indicates heterogeneity. In case of high heterogeneity, we examined the moderating effects of age at baseline and length of follow-up using meta-regressions treating both constructs as a continuous variable. Other potential moderators that were considered, but ultimately not included due to high degrees of heterogeneity in measures or reporting included eating disorder type, different anxiety symptoms and gender. Small study bias was examined using funnel plots and Egger’s regression test (Egger et al., 1997). Study outliers were tested to determine potentially influential studies. Overlap of included studies within each meta-analysis is shown in Supplementary Fig. 1.
Results
Study selection
The searches of the online databases generated 35,568 records. Following de-duplication, the abstracts and titles of 19,591 records were screened. 714 full-text studies were screened. Two additional studies were identified as suitable through PsyArXiv or references of studies which met the eligibility criteria. See Fig. 1 for PRISMA flowchart. Agreement between raters was acceptable in both the title/abstract screening stage (86.2–88.7% agreement; Cohen’s kappa: 0.35–0.44), and full-text screening stage (78.8–93.2% agreement; Cohen’s kappa: 0.27–0.63).
Several eligible studies used the same study sample and were assessed for overlap. LeGrange et al. [23] and Linardon et al. [24] both used data from the Australian Temperament Project. LeGrange et al. [23] reported on early anxiety predicting adolescent eating disorder symptoms, whereas Linardon et al. [24]reported on adolescent eating disorder symptoms predicting adult anxiety. As both studies used different waves of participant data and examined different relationships, both studies were retained. Lloyd et al. [25], Micali et al. [26], Micali et al. [17], and Schaumberg et al. [14] all used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Lloyd et al. [25], used anxiety diagnosis data at ages 13/14 and 15/16 to predict fasting at ages 15/16 & 17/18. Micali et al. [26] examined latent classes of eating disorder symptoms at ages 14 and 16 to predict anxiety diagnosis at ages 16 and 18. Micali et al. [17] examined eating disorder diagnoses at age 14 and how they predict anxiety disorders at age 16. Lastly, Schaumberg et al. [14] used anxiety symptom clusters at age 10 to predict disordered eating at age 14. Given the overlap of waves and measures between the two Micali et al. studies, we chose to retain only Micali et al. [17] for the purpose of the review, as it provided more detailed information on different eating disorder symptoms. We further chose to retain Lloyd et al. [25] and Schaumberg et al. [14] due to different measures and waves of data collection used. Lastly, Levinson and Rodebaugh [27], Levinson et al. [28], & Sala and Levinson [29] all used data from the same US undergraduate sample. As the sample and outcome measures were identical for all three studies, we decided to merge study findings into one single study subsequently referred to as Levinson & Sala, et al. (2016). After this consolidation, 54 studies were included in the review.
Study characteristics and quality assessment
Table 1 shows the study characteristics of the included studies. Most studies were conducted in Western countries in mixed-gender samples. Studies covered a range of age groups and varied in delays between measurement points. In terms of study quality, all included studies were rated as either ‘good’ or ‘fair’ and no studies were excluded from the review based on study quality. Full information on quality ratings can be found in Table 2. Overall, methodological gaps were identified in the reporting of power analyses and participant retention over time.
9.9% Hispanic or Latino, 90.1% not Hispanic or Latino
Child Behavior Questionnaire (CBQ) & Preschool Age Psychiatric Assessment (PAPA)
Body dissatisfaction subscale from the Minnesota Eating Behavior Survey (MEBS) & Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K- SADS-PL)
56.5% White, not of Hispanic origin, 17.2% Hispanic, 16.9% Black, not of Hispanic origin, 5.3% other or unknown, 0.2% American Indian or Alaskan Native, 4% Asian or Pacific Islander
White (81.9%), Asian (6.4%), Middle Eastern (1.5%), or other (10.2%; Eurasian 4.4%, European 2.1%, The Americas 1.3%, Indian 1.1%, Maori/Islander 0.9%, unknown 0.4%)
Social anxiety subscale of the Spence Children’s Anxiety Scale (SCAS-C)
1For the daily diary studies, only data at Wave 1 (2019) was included due to acute COVID-19 pandemic at Wave 2. For the longitudinal comparison, both waves were included
In total, 47 of the 54 studies examined the prospective association between anxiety symptoms and eating disorder symptoms. A majority of studies (24 of 46, 51.1%) found evidence for a link between anxiety symptoms and subsequent eating disorder symptoms, with some studies (16 of 47, 34.0%) reporting mixed findings, and few studies (7 of 47, 14.9%) reporting no significant association. Studies varied greatly in terms of age ranges covered (baseline age range: 3–20.9 years), and the domains of anxiety or eating disorder measured. In terms of gender, there were 26 mixed gender studies, 15 female-only studies, 1 male-only study, and 5 not reported.
Eleven studies reported on 21 separate effect sizes investigating the relationship between anxiety symptoms and subsequent eating disorder symptoms using dichotomous measures. Having anxiety symptoms was associated with significantly higher odds of subsequent eating disorder symptoms, with a pooled effect size of OR = 1.58 (95% CI: 1.23–2.03, p < 0.001), see Fig. 2. Heterogeneity was significant and high (Q = 112.63, p < 0.001; I2 = 96.70%). Egger's regression test showed significant funnel plot asymmetry (z = 2.76, p = 0.006). Age of participants at baseline was a significant moderator accounting for 28.23% of heterogeneity (tau2 = 0.13, SE = 0.08; test for residual heterogeneity: QE(df = 15) = 81.76, p < 0.001; test of moderators: QM(df = 1) = 4.01, p = 0.045), whereby the relationship between anxiety symptoms and subsequent eating disorder symptoms was stronger for studies with older participants at baseline. Length of follow-up was not a significant moderator (tau2 = 0.15, SE = 0.09; test for residual heterogeneity: QE(df = 16) = 91.86, p < 0.001; test of moderators: QM(df = 1) = 1.92, p = 0.166).
Fig. 2
Random effects meta-analysis: Forest plots comparing odds ratios for anxiety symptoms and subsequent eating disorder symptoms (95% CI). Observed outcome = log odds. Estimate = Odds ratio
Sensitivity analysis using a multi-level meta-analysis accounting for study dependence found a similar relationship, with a pooled effect size of OR = 1.58 (95% CI: 1.21–2.07, p = 0.002).
Twelve studies reported on 22 separate effect sizes investigating the relationship between anxiety symptoms and subsequent eating disorder symptoms using continuous measures. Anxiety symptoms were associated with significantly higher subsequent eating disorder symptoms, with a pooled effect size of r = 0.18 (95% CI: 0.13–0.23, p < 0.001), see Fig. 3. Heterogeneity was significant and high (Q = 108.05, p < 0.001; I2 = 84.09%). Egger's regression test showed no significant funnel plot asymmetry (z = 1.52, p = 0.130). Age of participants at baseline was a significant moderator accounting for 58.54% of heterogeneity (tau2 = 0.01, SE = 0.00; test for residual heterogeneity: QE(df = 18) = 55.07, p < 0.001; test of moderators: QM(df = 1) = 17.05, p < 0.001), whereby the relationship between anxiety symptoms and subsequent eating disorder symptoms was stronger for studies with older participants at baseline. Length of follow-up was a significant moderator accounting for 43.52% of heterogeneity (tau2 = 0.01, SE = 0.00; test for residual heterogeneity: QE(df = 20) = 66.15, p < 0.001; test of moderators: QM(df = 1) = 10.98 p < 0.001), whereby the relationship between anxiety symptoms and subsequent eating disorder symptoms was stronger for studies with shorter delays.
Fig. 3
Random effects meta-analysis: Forest plots comparing correlation coefficients for anxiety symptoms and subsequent eating disorder symptoms (95% CI)
Sensitivity analysis using a multi-level meta-analysis accounting for study dependence found a similar relationship, with a pooled effect size of r = 0.20 (95% CI: 0.13–0.27, p < 0.001).
Narrative synthesis: Childhood anxiety to adolescent eating disorder symptoms
Eight studies reported on the association between childhood anxiety symptoms and eating disorder symptoms in adolescence. Of these, five found significant associations, two mixed findings, and one did not find a significant association between childhood anxiety symptoms and adolescent eating disorder symptoms.
Most studies focused on general anxiety symptoms. These studies found that childhood anxiety symptoms predicted subsequent binge eating [14], fasting [14], emotional eating [14, 51], body image concerns [14, 36], and overall disordered eating [75] in adolescence. However, there were mixed findings around eating disorder diagnosis. Buffered et al. [36] found that meeting criteria for an anxiety disorder in childhood was not associated with meeting criteria for either anorexia nervosa or bulimia nervosa. Similarly, Tanofsky-Kraff et al. [69] found that anxiety at age 10 did not predict onset of binge eating disorder. Mixed findings were reported by Schaumberg et al. [14], who found that physical symptoms of anxiety at age 10 predicted higher odds of meeting criteria for bulimia nervosa at age 16, but not for anorexia nervosa. In contrast, van Eeden et al. [71] found that anxiety disorders in childhood, especially generalised anxiety disorder or social anxiety disorder, predicted having an eating disorder in late adolescence. Regarding specific symptoms, Dworschak et al. [38] reported that rumination in a mixed child/adolescent sample (ages 8–15) was related to more frequent weight concerns and more frequent restrictive eating at the person-level (i.e., more frequent rumination than normal was associated with more frequent weight concerns and restrictive eating than normal) over a 21-day period. Additionally, more frequent rumination predicted higher frequency of restrictive behaviours, but not weight concerns one year later.
Taken together, the reviewed evidence suggests that childhood anxiety is linked with broad eating disorder pathology in adolescence. More research on whether this extends to an increased risk for meeting criteria for an eating disorder is required.
Narrative synthesis: Adolescent anxiety to adolescent eating disorder symptoms
Most studies (33 of 46, 69.6%) reported on the association between anxiety symptoms and subsequent eating disorder symptoms in adolescence. Of these, 17 (51.5%) found significant associations, 11 (33.3%) mixed findings, and 5 (15.2%) did not find a significant association between anxiety symptoms and subsequent eating disorder symptoms in adolescence.
Overall, anxiety symptoms were found to predict both subsequent eating disorder symptoms, including general eating pathology [33, 45, 58], bulimic symptoms [48], binge eating [59], and fasting [25], and increases in eating disorder symptoms, such as bulimic symptoms [48], general eating pathology [53] and weight control behaviours in girls only [44]. In particular, Lacroix et al. [52] showed that trait anxiety at age 11 predicted membership of a high-risk eating disorder trajectory throughout adolescence and year adulthood compared to a low-risk membership. However, findings did not seem to hold in studies controlling for depression [23, 35, 41, 63]. Further, no significant relationship was found when looking at daily anxious affect predicting binge eating [67]. Mixed findings were also evident when distinguishing between-person from within-person changes. Fitzsimmons-Craft et al. [40] found that while anxiety predicted both between-person differences in dietary restraint and binge eating, anxiety only predicted within-person binge eating and not dietary restraint in a university sample (i.e., emerging adults). However, among early adolescents Parker et al. [61] found anxiety to only predict between-person differences in loss of control eating and not within-person changes. Focusing on within-person changes, Lim et al. [55] reported no significant findings for binge eating, uncontrolled eating, or emotional eating, but did find a significant stress and anxiety interaction that predicted within-person changes in dietary restraint. That is, both lower than usual stress and anxiety predicted greater than usual increases in dietary restraint.
Symptoms of specific anxiety disorders showed mixed findings for social anxiety symptoms. Social anxiety symptoms were positively related to subsequent eating disorder symptoms, such as bulimic symptoms [64], eating disorder pathology [57], binge eating [65], emotional eating [73], and dietary restraint [65], but not subsequent symptoms of anorexia nervosa [64], or purging [65]. Further, there was no evidence that social anxiety predicted increases in eating disorder symptoms (Levinson & Sala, et al., 2016; 64]. A similar pattern was evident for symptoms of generalised anxiety. Findings showed that generalised anxiety predicted subsequent eating disorder diagnosis [68], dietary restraint [65], purging [65], and binge eating [65]. However, there were mixed findings when predicting increases in eating disorder symptoms. Levinson and Sala, et al. (2016) found that generalised anxiety predicted increases in drive for thinness, but not bulimic symptoms or body image concerns. Limited studies examined other anxiety disorders. Of these, OCD symptoms were found to predict increases in driven exercise among boys, but not girls [42], and predicted subsequent binge eating, but not increases in binge eating [66]. Further, PTSD symptoms predicted increases in binge eating [37], eating disorder thoughts [49] and compensatory behaviours [49].
Turning to more mechanistic research, a limited number of studies investigated specific anxiety symptoms. Among these, two key symptoms were examined in the literature: fear of negative evaluation, a core feature of social anxiety, and rumination, a core feature of generalised anxiety. There were mixed findings regarding fear of negative evaluation. Two studies found that fear of negative evaluation predicted increases in bulimic symptoms [41, 43], whereas one did not (Levinson & Sala, et al., 2016). All three were conducted among undergraduate women (i.e., emerging adults). Further, two studies found that among undergraduate women fear of negative evaluation did not predict increases in body image concerns [41, 70]. No gender differences were found in the associations. Regarding rumination, there appears to be evidence implicating rumination in bulimic symptoms. Findings show that rumination predicted both subsequent bulimic symptoms [47], and increases in bulimic symptoms [60, 72]. More specifically, rumination was shown to predict the onset of binge eating, but not compensatory behaviours [60]. Further, rumination was shown not to be related to subsequent overall eating symptoms [58].
Taken together, the reviewed evidence suggests that anxiety is linked with subsequent eating disorder pathology in adolescence, however, this association is not independent of depression. Further research is also required to distinguish between-person changes from within-person changes in the prospective relationship between anxiety and eating disorder symptoms. Of note, few studies investigated specific anxiety symptoms that may be implicated in the relationship between anxiety and eating disorder symptoms. Within these limited studies, there is converging evidence that rumination is linked to bulimic symptoms, but more work is needed regarding fear of negative evaluation.
Narrative synthesis: Adolescent anxiety to adult eating disorder symptoms
Six studies reported on the association between adolescent anxiety symptoms and eating disorder symptoms in adulthood. Of these, two found significant associations, three mixed findings, and one did not find a significant association between anxiety symptoms and eating disorder symptoms in adulthood.
Most studies focused on associations at a disorder-level and found that associations may be disorder-dependent. When looking at disorders overall, no association was found between meeting criteria for an anxiety disorder in adolescence and meeting criteria for an eating disorder in adulthood [34]. More nuanced findings emerged when looking by criteria. Meeting criteria for OCD in adolescence predicted the onset of anorexia nervosa in adulthood [18], and PTSD symptoms in adolescence predicted the onset of bulimia nervosa in adulthood [74]. Meeting criteria for a specific phobia predicted increased odds of meeting criteria for an eating disorder [54], but not onset of either anorexia nervosa or bulimia nervosa [18]. No significant findings were noted for social anxiety or generalised anxiety [18]. At a symptom level, overall anxiety predicted subsequent eating pathology [46], and increases in bulimic symptoms [30], but not overall eating pathology [46].
Taken together, the reviewed evidence suggests that there is a tentative link between adolescent anxiety and eating disorder symptoms in adulthood that requires further research. Of note, most studies focused on diagnostic groups rather than overall anxiety which may hinder detection of significant associations.
In conclusion, the reviewed evidence suggests that there is a link between anxiety and eating disorder symptoms that requires further research. Findings from the meta-analysis show that symptoms of anxiety are associated with higher odds of experiencing eating disorder symptoms and with high levels of eating disorder symptoms in the future. However, effect sizes were small, and studies were highly heterogenous. The narrative synthesis further showed that anxiety symptoms may predict the onset of eating disorder symptoms, as well as the increase in symptoms. However, more research is needed to further elucidate this relationship. For example, few studies examined gender differences or differentiated within-person from between-person associations.
In total, 25 of the 54 studies examined the prospective association between eating disorder symptoms and subsequent anxiety symptoms. Most studies (15 of 25, 60.0%) found evidence for a link, with some studies (7 of 25, 28.0%) reporting mixed findings, and few studies (3 of 25, 12%) reporting no significant association. Studies varied greatly in terms of age ranges covered (baseline age range: 10.4–19.8 years), and the domains of anxiety or eating disorder measured. In terms of gender, there were 15 mixed gender studies, 5 female-only studies, 1 male-only study, and 4 not reported.
Seven studies reported on 21 separate effect sizes investigating the relationship between eating disorder symptoms and subsequent anxiety symptoms using dichotomous measures. Having eating disorder symptoms was associated with significantly higher odds of subsequent anxiety symptoms, with a pooled effect size of OR = 2.25 (95% CI: 1.83–2.76, p < 0.001), see Fig. 4. Heterogeneity was significant and moderate (Q = 41.22, p = 0.004; I2 = 53.80%). Egger's regression test showed no significant funnel plot asymmetry (z = 1.34, p = 0.179). Neither age of participants at baseline (tau2 = 0.13, SE = 0.08; test for residual heterogeneity: QE(df = 18) = 38.76, p = 0.003; test of moderators: QM(df = 1) = 0.23, p = 0.628) or length of follow-up were significant moderators (tau2 = 0.15, SE = 0.09; test for residual heterogeneity: QE(df = 18) = 20.27, p = 0.002; test of moderators: QM(df = 1) = 0.36, p = 0.551).
Fig. 4
Random effects meta-analysis: Forest plots comparing odds ratios for eating disorder symptoms and subsequent anxiety symptoms (95% CI). Observed outcome = log odds. Estimate = Odds ratio
Sensitivity analysis using a multi-level meta-analysis accounting for study dependence found a similar relationship, with a pooled effect size of OR = 2.21 (95% CI: 1.64–2.99, p < 0.001).
Seven studies reported on 14 separate effect sizes investigating the relationship between eating disorder symptoms and subsequent anxiety symptoms using continuous measures. Eating disorder symptoms were associated with significantly higher subsequent anxiety symptoms, with a pooled effect size of r = 0.25 (95% CI: 0.19–0.32, p < 0.001), see Fig. 5. Heterogeneity was significant and high (Q = 55.12, p < 0.001; I2 = 78.26%). Egger's regression test showed no significant funnel plot asymmetry (z = 0.64, p = 0.520). Neither age of participants at baseline (tau2 = 0.01, SE = 0.01; test for residual heterogeneity: QE(df = 11) = 47.97, p < 0.001; test of moderators: QM(df = 1) = 0.29, p = 0.590) or length of follow-up were significant moderators (tau2 = 0.01, SE = 0.01; test for residual heterogeneity: QE(df = 12) = 53.46, p < 0.001; test of moderators: QM(df = 1) = 0.01, p = 0.916).
Fig. 5
Random effects meta-analysis: Forest plots comparing correlations for eating disorder symptoms and subsequent anxiety symptoms (95% CI)
Sensitivity analysis using a multi-level meta-analysis accounting for study dependence found a similar relationship, with a pooled effect size of r = 0.26 (95% CI: 0.18–0.33, p < 0.001).
Narrative synthesis: Adolescent eating disorder symptoms to adolescent anxiety symptoms
Most studies (19 of 25) reported on the association between eating disorder symptoms and subsequent anxiety symptoms in adolescence. Of these, 12 found significant associations, 5 mixed findings, and 2 did not find a significant association between eating disorder symptoms and subsequent anxiety symptoms in adolescence.
Overall eating pathology in adolescence predicted subsequent overall anxiety symptoms [31, 33, 58], social anxiety [57], and rumination [58]. Meeting criteria for any eating disorder in adolescence predicted higher odds of meeting criteria for an anxiety disorder [17], but not subsequent social anxiety [64].
Turning to specific eating disorder symptoms, body image concerns predicted subsequent anxiety symptoms [39] as well as increases in anxiety symptoms [63] and fear of negative evaluation [70]. Body image concerns did not predict subsequent anxiety in late adolescent boys [59], or increases in worry in late adolescent girls (Levinson & Sala, et al., 2016). Bulimic symptoms predicted subsequent rumination [47], as well as increased overall anxiety [48] and increased rumination [60, 72]. However, bulimic symptoms did not predict increases in worry (Levinson & Sala, et al., 2016). Binge eating predicted subsequent overall anxiety [59, 69], OCD symptoms [66], and increased anxiety [69], but not onset of anxiety [65]. When distinguishing between and within-person associations, there was a significant between-person associations between loss of control eating and subsequent anxiety, but not within-person association [61]. Mixed findings emerged for dietary restraint. Dietary restraint predicted the onset of generalised anxiety but not social anxiety [65], nor did it predict subsequent overall anxiety or increases in overall anxiety [63]. Only one study examined purging, whereby purging predicted the onset of generalised anxiety but not social anxiety [65]. No study examined driven exercise specifically.
Taken together, the reviewed evidence supports a link between eating disorder symptoms and subsequent anxiety symptoms in adolescence. Further, evidence suggests that eating disorder symptoms predict increases in anxiety symptoms. In particular, overall eating pathology appears to be related to subsequent anxiety symptoms. More research is needed to understand within-person and between-person association, as well as specific symptom associations.
Narrative synthesis: Adolescent eating disorder symptoms to adult anxiety symptoms
Six studies reported on the association between adolescent eating disorder symptoms and anxiety symptoms in adulthood. Of these, three found significant associations, two mixed findings, and one did not find a significant association between adolescent eating disorder symptoms and anxiety symptoms in adulthood.
Most studies examined the association at a diagnostic-level and found mixed results. Two studies found a significant association between meeting criteria for an eating disorder in adolescence and meeting criteria for an anxiety disorder in adulthood [50, 62], whereas another did not [34]. When looking at specific diagnoses, meeting criteria for anorexia nervosa in adolescence did not predict meeting criteria for any anxiety disorder in adulthood, but meeting criteria for bulimia nervosa in adolescence precited the onset of panic disorder and social anxiety disorder [18]. At a more symptomatic level, overall eating disorder symptoms predicted subsequent generalised anxiety in adulthood, and increased generalised anxiety in men but not women [56]. Similarly, both bulimic symptoms and body image concerns in adolescence predicted subsequent overall anxiety in both men and women, but the relationship between bulimic symptoms and subsequent anxiety was stronger in men compared to women.
Taken together, the reviewed evidence supports a link between eating disorder symptoms in adolescence and anxiety symptoms in adulthood. More research is needed to examine potential gender differences, and differences by diagnoses.
In conclusion, the reviewed evidence suggests that there is a link between anxiety and eating disorder symptoms. Findings from the meta-analysis show that symptoms of eating disorder are associated with higher odds of experiencing anxiety symptoms in the future and higher levels of anxiety symptoms. However, effect sizes were small, and studies were highly heterogenous. The narrative synthesis further showed that anxiety symptoms may predict an increase in symptoms. However, more research is needed to further elucidate this relationship. For example, few studies examined gender differences or differentiated within-person from between-person associations.
Findings: Bi-directional relationship between anxiety and eating disorder symptoms
In total, 6 of the 54 studies specifically examined the prospective bi-directional association between anxiety and eating disorder symptoms. Of these, four found evidence for a bi-directional relationship whereas two did not.
Specifically, Holm found a bi-directional relationship between rumination and bulimic symptoms, whereby rumination predicted increased bulimic symptoms and bulimic symptoms predicted increased rumination. The same pattern was observed by Nolen et al. in adolescent girls. Similarly, Hou found a bi-directional relationship between overall anxiety and bulimic symptoms, whereby anxiety symptoms predicted increased bulimic symptoms and bulimic symptoms predicted increased anxiety symptoms. However, in their cross-lag panel model the first path of bulimic symptoms predicting subsequent anxiety symptoms was not significant, suggesting that the bi-directional nature of the association is established only after increases in anxiety symptoms are experienced. In contrast, Levinson & Sala, et al. (2016) found no evidence of a bi-directional relationship when examining bulimic symptoms among other eating disorder symptoms in young women. In their study, worry predicted increases in drive for thinness, but not body dissatisfaction or bulimic symptoms. No links between eating disorder symptoms and subsequent worry were found.
Regarding other eating disorder symptoms, Trompeter found a bi-directional relationship between fear of negative evaluation and body image concerns [41], whereby fear of negative evaluation predicted increased body image concerns and body image concerns predicted increased fear of negative evaluation. However, Puccio found no evidence of a bi-directional relationship when examining body image concerns among other symptoms. Instead, findings showed that both body image and eating concerns predicted increased anxiety symptoms during late adolescence, but not vice versa. Interestingly, no significant associations were found earlier in adolescence or for dietary restraint, a behavioural eating disorder symptom. Of note, unlike other studies, this study controlled for depression which may account for some discrepancies between results.
In conclusion, there is some evidence that anxiety and eating disorder symptoms exhibit a bi-directional relationship, especially concerning rumination and bulimic symptoms. However, more research needs to test this relationship explicitly.
Discussion
The current review synthesised evidence from 54 studies to examine the prospective relationship between anxiety symptoms and eating disorder symptoms in adolescence, including four meta-analyses. Overall, evidence suggests that there is a prospective and bi-directional relationship between anxiety symptoms and eating disorder symptoms. Anxiety symptoms were shown to be associated with subsequent eating disorder symptoms, increases in eating disorder symptoms, and higher odds of eating disorders, including the onset of such disorders. Conversely, eating disorder symptoms were also associated with subsequent anxiety symptoms, increases in anxiety symptoms, and higher odds of anxiety disorders.
Findings are in line with previous reviews highlighting a high co-morbidity between anxiety disorders and eating disorders [4, 76], showing that this extends beyond clinical samples and is prospective in nature. Extending findings to both community samples and prospective designs is critical in further developing our understanding of the co-morbidity between anxiety disorders and eating disorders. However, whilst findings from the current review show a clear bi-directional relationship between anxiety symptoms and eating disorder symptoms, the longitudinal relationship between these is less clear. For example, there is some evidence to suggest that anxiety symptoms might first be associated with eating disorder symptoms, after which time, a bi-directional relationship becomes evident. That is, in the absence of eating disorder symptoms, anxiety symptoms are linked to later onset of eating disorder symptoms [54, 71]. Further, Hou et al. [48] found that in a cross-lag panel model, anxiety symptoms were associated with subsequent bulimic symptoms across timepoints (i.e., from T1 to T2, and T2 to T3), whereas bulimic symptoms were only associated with anxiety symptoms at later timepoints (i.e., not from T1 to T2, but from T2 to T3). As such, anxiety symptoms may trigger eating disorder symptoms, which then maintain and potentially exacerbate existing anxiety symptoms. However, this could in part be due to the respective age of onset of anxiety disorders and eating disorders. While anxiety disorders typically have an onset in childhood, eating disorder frequently develop in adolescence or early adulthood [19]. Thus, anxiety symptoms may be early signs of later eating disorders rather than being causally related to the onset of symptoms. There is a genetic correlation between anxiety and anorexia nervosa [77], therefore the bi-directional relationship between anxiety symptoms and eating disorder symptoms could point towards a shared vulnerability factor, such as genetic predisposition [7, 78]. However, this research should be extended to clarify shared and specific genetic vulnerabilities. Further research should examine in detail the temporal relationship between anxiety symptoms and eating disorder symptoms to understand the mechanisms implicated in their relationship. Additionally, limited research has examined individual differences in symptom trajectories or identified different pathways through which symptoms are related to one another. Thus, further exploration of how anxiety and eating disorder symptoms relate to one another and how this varies between individuals is required.
Research implications
Our review suggests several avenues for future research. Firstly, few studies differentiated between-person from within-person changes. Of the studies that did differentiate, most found significant between-person changes but only limited within-person changes. However, studies were limited with small sample sizes. Thus, more research is needed to distinguish these differences and determine whether associations exist at both a between-person and within-person level, or purely on a between-person level. This distinction is important to advance our understanding of the underlying mechanisms linking anxiety and eating disorder symptoms and improve early intervention and prevention methods. The current understanding from the reviewed evidence shows that adolescents with high anxiety symptoms (compared to others) are at risk for increased eating disorder symptoms (and vice versa; a between-person relationship), however it is still unclear whether adolescents who experience higher levels of anxiety than they would usually experience are also at risk of increased eating disorder symptoms and vice-versa (i.e., a within-person relationship). If only a between-person relationship existed, this would imply that adolescents with heightened anxiety symptoms can effectively be identified as being “at risk” for future eating disorder symptoms, and vice versa, but targeting these symptoms may not decrease this risk. However, if a within-person relationship existed, targeting existing levels of anxiety and/or eating disorder symptoms would likely reduce the risk of future anxiety and/or eating disorder symptoms.
Secondly, more research on mechanisms underlying the relationship between anxiety symptoms and eating disorder symptoms, and vice versa is needed. Evidence from this review suggests, that rumination may be particularly implicated in the development and maintenance of bulimic symptoms [47, 60, 72], however, more research is needed to support this link. Further, mixed evidence was evident for fear of negative evaluation as a specific mechanism. Studies with late adolescent girls found no significant relationship between fear of negative evaluation and body image concerns (Gilbert and Meyer [41]; Levinson & Sala, et al., 2016), whereas research among mixed-gender mid-adolescents found a significant bi-directional relationship [70]. Relatedly, few studies investigated gender differences and many studies were conducted in female-only samples. Of the studies that did investigate gender differences, there were mixed findings with evidence pointing towards a stronger relationship amongst boys. For example, Linardon et al. [24] found that the relationship between bulimic symptoms and subsequent anxiety was stronger for boys compared to girls. Loose et al. [56] found that while eating disorder symptoms predicted subsequent generalised anxiety symptoms in both boys and girls, increases in generalised anxiety symptoms (i.e., controlling for baseline levels) were only significant for boys. Lastly, Goodwin et al. [42] found that OCD symptoms predicted increases in excessive exercise among boys, but not girls. However, some studies found no gender differences in associations between anxiety symptoms and eating disorder symptoms, and vice versa [70, 72]. Thus, more research is needed to understand potential gender differences.
Clinical implications
Findings from this review provide important clinical implications, particularly concerning prevention and early intervention for both anxiety and eating disorder symptoms. Understanding the prospective relationship between anxiety and eating disorder symptoms may assist the early detection of either anxiety symptoms in those with eating disorder symptoms or eating disorder symptoms in those with anxiety symptoms. Further, the bi-directional nature between anxiety and eating disorder symptoms may point towards a vicious cycle, in which symptoms may maintain one another. As such, effective treatments for adolescents with co-occurring anxiety symptoms and eating disorder symptoms should target both groups of symptoms, whether this is within the context of anxiety disorder or eating disorder treatment. While current treatments are likely to target some overlapping features (e.g., fear of weight gain in eating disorders, or appearance anxiety in anxiety disorders), to our knowledge there are not many specific treatments that target both anxiety and eating disorders, nor specific prevention programs. Greater focus on overlapping mechanisms (e.g., avoidance) may be beneficial both for prevention and treatment (see [8] for review).
Limitations
This study has some limitations which should be considered when interpreting our results. Firstly, there were a limited number of studies in the meta-analyses, with high levels of heterogeneity. Secondly, included studies were largely based in Western countries and cultural differences in the examined associations should be considered. Thirdly, our review focused on clearly defined measures of both anxiety symptoms and eating disorder symptoms and excluded shared concepts such as ‘fear of weight gain’ or ‘appearance anxiety’. Given the natural overlap in symptoms and definitions of many psychological constructs, this may have introduced an artificial separation between anxiety symptoms and eating disorder symptoms.
Conclusion
The current systematic review and meta-analysis have shown evidence for a bi-directional prospective relationship between anxiety symptoms and eating disorder symptoms in adolescence. However, the reviewed research has a range of limitations, which require attention in future research. Findings from this review have potential clinical implications in terms of prevention and early intervention for both anxiety symptoms and eating disorder symptoms.
Declarations
Conflict of interest
Nora Trompeter receives an honorarium from Wiley as Associate Editor for Mental Health Science. Francisco Diego Rabelo-da-Ponte receives royalties from Springer Nature. Nadia Micali receives an honorarium for her services as Associate Editor for European Eating Disorders Review.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The prospective relationship between anxiety symptoms and eating disorder symptoms among adolescents: a systematic review and meta-analysis of a bi-directional relationship
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Nora Trompeter
Ștefana Dârvariu
Anna V. Brieva-Toloza
Marie-Christine Opitz
Francisco Diego Rabelo-da-Ponte
Helen Sharpe
Sylvane Desrivieres
Ulrike Schmidt
Nadia Micali
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