A systematic review of sociodemographic reporting and representation in eating disorder psychotherapy treatment trials in the United States

Abstract

Objective: Eating disorders (EDs) were once conceptualized as primarily affecting affluent, White women, a misconception that informed research and practice for many years. Abundant evidence now discredits this stereotype, but it is unclear if prevailing "evidence-based" treatments have been evaluated in samples representative of the diversity of individuals affected by EDs. Our goal was to evaluate the reporting, inclusion, and analysis of sociodemographic variables in ED psychotherapeutic treatment randomized controlled trials (RCTs) in the US through 2020.Methods: We conducted a systematic review of ED psychotherapeutic treatment RCTs in the US and examined the reporting and inclusion of gender identity, age, race/ethnicity, sexual orientation, and socioeconomic status (SES) of enrolled participants, as well as recruitment methods, power analyses, and discussion of limitations and generalizability.Results: Our search yielded 58 studies meeting inclusion criteria dating back to 1985.Reporting was at times incomplete, absent, or centered on the racial/gender majority group. No studies reported gender diverse participants, and men and people of color were underrepresented generally, with differences noted across diagnoses. A minority of papers considered sociodemographic variables in analyses or acknowledged limitations related to sample characteristics. Some progress was made across the decades, with studies increasingly providing full racial and ethnic data, and more men included over time. Although racial and ethnic diversity improved somewhat, progress appeared to stall in the last decade.Discussion: We summarize findings, consider context and challenges for RCT researchers, and offer suggestions for researchers, journal editors, and reviewers on improving representation, reporting, and analytic practices.Public Significance: Randomized controlled trials of eating disorder psychotherapeutic treatment in the US are increasingly reporting full race/ethnicity data, but information on SES is inconsistent and sexual orientation absent. White women still

Structural validity of the Eating Disorder Examination—Questionnaire: A systematic review

“…Although most studies ( k = 44, 73.3%) included information on race or ethnicity, sample characteristics were sometimes unclear and, despite the wealth of studies, there remains a need for future research on samples with greater diversity, particularly regarding gender and ethnicity, to enhance generalizability to historically under‐represented groups (Goel, Jennings Mathis, et al, 2022). In line with reporting in treatment trials (Burnette et al, 2022), data on race/ethnicity were often focused on “White,” often including a binary distinction between “White” and “Other.” Moving forward, studies should collect (and report) detailed data rather than broad categories (Burnette et al, 2022), and provide data on all represented races/ethnicities, not just the majority group. Papers not in English were excluded from the review and one highly cited paper in particular (Hilbert et al, 2007) may have been helpful to include as it seems to have influenced several subsequent empirical studies.…”

“…In line with reporting in treatment trials (Burnette et al, 2022), data on race/ethnicity were often focused on "White," often including a binary distinction between "White" and "Other." Moving forward, studies should collect (and report) detailed data rather than broad categories (Burnette et al, 2022), and provide data on all represented races/ethnicities, not just the majority group. Papers not in English were excluded from the review and one highly cited paper in particular (Hilbert et al, 2007) may have been helpful to include as it seems to have influenced several subsequent empirical studies.…”

Gender Differences in Treatment Outcomes for Eating Disorders: A Case-Matched, Retrospective Pre–Post Comparison

“…Speculations persist that men’s underrepresentation may have also facilitated the development of women-centered ED treatments [ 26 ], resulting in suboptimal outcomes for men. Evidence-based therapeutic recommendations for EDs include nutritional rehabilitation and psychotherapy [ 35 ] and primarily derive from interventional trials that average between 7.8 and 16.3% men [ 18 , 36 ]. For example, among the more than 300 trials included in the German ED treatment guidelines [ 37 ], men comprise only 10%, 5%, and less than 1% of treatment samples for BED, AN, and BN, respectively [ 13 ].…”

Epidemiology of eating disorders among US adults

“…Contrary to clinical lore, Udo and Grilo [13] documented that eating disorders are distributed across sex, race/ethnicity, age, and education level, highlighting the need for prevention and early identification efforts and for clinician screening and recognition practices to consider that eating disorders are distributed broadly (i.e., not limited to ‘thin white wealthy women’). These findings also provided further evidence for possible clinic sampling biases in studies of eating disorders based on treatment-seeking individuals which tend to enroll relatively few men and people of color [19,20].…”

“…Across anorexia nervosa, bulimia nervosa, and BED, prevalence of ever seeking help was lower in non-Hispanic Blacks (NHB) and Hispanics relative to non-Hispanic Whites (NHW): 31.8% (NHW), 19.6% (NHB), vs. 14.6% (Hispanics) for anorexia nervosa, 67.4% (NHW), 49.0% (NHB), vs. 44.4% (Hispanics) for bulimia nervosa, and 57.9% (NHW), 23.2% (NHB), vs. 25.9% (Hispanics) for BED. Prevalence of ever seeking treatment for BED was also lower in men relative to women (27.5 vs. 56.8%).…”