Disentangling binge eating disorder and food addiction: a systematic review and meta-analysis

Early life adversity impacts alterations in brain structure and food addiction in individuals with high BMI

Obesity and food addiction are associated with distinct brain signatures related to reward processing, and early life adversity (ELA) also increases alterations in these same reward regions. However, the neural mechanisms underlying the effect of early life adversity on food addiction are unknown. Therefore, the aim of this study was to examine the interactions between ELA, food addiction, and brain morphometry in individuals with obesity. 114 participants with high body mass index (BMI) underwent structural MRIs, and completed several questionnaires (e.g., Yale Food Addiction Scale (YFAS), Brief Resilience Scale (BRS), Early Traumatic Inventory (ETI)). Freesurfer 6 was applied to generate the morphometry of brain regions. A multivariate pattern analysis was used to derive brain morphometry patterns associated with food addiction. General linear modeling and mediation analyses were conducted to examine the effects of ELA and resilience on food addiction in individuals with obesity. Statistical significance was determined at a level of p < 0.05. High levels of ELA showed a strong association between reward control brain signatures and food addiction (p = 0.03). Resilience positively mediated the effect of ELA on food addiction (B = 0.02, p = 0.038). Our findings suggest that food addiction is associated with brain signatures in motivation and reward processing regions indicative of dopaminergic dysregulation and inhibition of cognitive control regions. These mechanistic variabilities along with early life adversity suggest increased vulnerability to develop food addiction and obesity in adulthood, which can buffer by the neuroprotective effects of resilience, highlighting the value of incorporating cognitive appraisal into obesity therapeutic regimens.

Ultra-Processed Food Addiction: A Research Update

PURPOSE OF REVIEW

Detail recent advancements in the science on ultra-processed food (UPF) addiction, focusing on estimated prevalence rates and emerging health disparities; progress towards identifying biological underpinnings and behavioral mechanisms; and implications for weight management.

RECENT FINDINGS

Notable developments in the field have included: (1) estimating the global prevalence of UPF addiction at 14% of adults and 15% of youths; (2) revealing health disparities for persons of color and those with food insecurity; (3) observing altered functioning across the brain-gut-microbiome axis; (4) providing early evidence for UPF withdrawal; and (5) elucidating poorer weight management outcomes among persons with UPF addiction. The breadth of recent work on UPF addiction illustrates continued scientific and public interest in the construct and its implications for understanding and treating overeating behaviors and obesity. One pressing gap is the lack of targeted interventions for UPF addiction, which may result in more optimal clinical outcomes for this underserved population.

Using latent class analysis to identify different clinical profiles according to food addiction symptoms in obesity with and without binge eating disorder

Background and aims

Existing research suggests that food addiction (FA) is associated with binge eating disorder (BED) and obesity, but the clinical significance of this relationship remains unclear. This study aims to investigate the different clinical profiles of FA symptoms among patients who have obesity with/without BED using latent class analysis (LCA).

Methods

307 patients (n = 152 obesity and BED, n = 155 obesity without BED) completed a battery of self-report measures investigating eating psychopathology, depression, emotional dysregulation, alexithymia, schema domains, and FA. LCA and ANOVAs were conducted to identify profiles according to FA symptoms and examine differences between classes.

Results

LCA identified five meaningful classes labeled as the "non-addicted" (40.4%), the "attempters" (20.2%), the "interpersonal problems" (7.2%), the "high-functioning addicted" (19.5%) and the "fully addicted" (12.7%) classes. Patients with BED and obesity appeared overrepresented in the "high-functioning addicted" and "fully addicted" classes; conversely, patients with obesity without BED were most frequently included in the "non-addicted" class. The most significant differences between the "high-functioning addicted" and "fully addicted" classes versus the "non-addicted" class regarded heightened severity of eating and general psychopathology.

Discussion and conclusions

The results bring to light distinct clinical profiles based on FA symptoms. Notably, the "high-functioning addicted" class is particularly intriguing as its members demonstrate physical symptoms of FA (i.e., tolerance and withdrawal) and psychological ones (i.e., craving and consequences) but are not as functionally impaired as the "fully addicted" class. Identifying different profiles according to FA symptoms holds potential value in providing tailored and timely interventions.

Co-occurrence of habit-forming risk behaviors and their socio-demographic, health status and lifestyle determinants: a population-based cross-sectional study

BACKGROUND

Although habit-forming risk behaviors frequently co-occur, determinants of concurrent risk behaviors have rarely been investigated. The aim of the present study was to investigate socio-demographic, health status, and lifestyle determinants of single versus concurrent risk behaviors in general-population adults.

METHODS

We analyzed data from 32,622 participants (74.5% female; mean age = 57.9 ± 14.2 years) of the NutriNet-Santé cohort who completed the Alcohol Use Disorders Identification Test, the 12-item Cigarette Dependence Scale, the modified Yale Food Addiction Scale 2.0, and the Internet Addiction Test in 2021-2022. Using established cutoffs, participants were first split into 2 groups (presence versus absence) for each risk variable (alcohol use disorders, nicotine dependence, food addiction, Internet addiction) and were then divided into 3 groups (no risk behavior, 1 risk behavior (reference), and ≥ 2 risk behaviors). The association between socio-demographic, health status, and lifestyle exposures and individual/concurrent risk behaviors were investigated with polytomous logistic regression.

RESULTS

Younger age (Odds Ratio (OR) = 2.04; 95% Confidence Interval (CI: 1.62-2.56), current financial difficulties (OR = 1.29; CI: 1.08-1.54), self-perceived poor health (OR = 1.70; CI: 1.32-2.20), overall poor dietary quality (OR = 2.88; CI: 2.06-4.02), being underweight (OR = 1.46; CI: 1.05-2.04), having obesity (OR = 1.62; CI: 1.31-1.99), lack of affection during childhood (OR = 1.41; CI: 1.18-1.69), and a lifetime prevalence or medication use for a mental disorder (OR = 1.46; CI: 1.24-1.73) were positively associated with having ≥ 2 versus 1 risk behavior (all p < 0.05). The comparison of none versus 1 risk behavior revealed the same determinants in addition to having a higher education, being physically active at work, and being overweight.

CONCLUSIONS

We investigated determinants of concurrent habit-forming risk behaviors among adults in a large, population-based study. The findings could serve as impetus for future research in this domain and ultimately help guide addiction prevention efforts.

Assessing Discriminant Validity through Structural Equation Modeling: The Case of Eating Compulsivity

Food addiction (FA) and disordered eating behaviors related to obesity are gaining attention in clinical and research fields. The modified Yale Food Addiction Scale 2.0 (mYFAS2.0) is the gold standard questionnaire to measure FA, while another tool is the Measure of Eating Compulsivity 10 (MEC10). Discriminant validity is present when two measures of similar but distinct constructs show a correlation that is low enough for the factors to be regarded as distinct. However, the discriminant validity of these measures has never been tested. Through a cross-sectional study design, 717 inpatients (females: 56.20%, age: 53.681 ± 12.74) with severe obesity completed the MEC10, Binge Eating Scale (BES), and mYFAS2.0. A structural equation model (SEM) was fitted, freely estimating latent correlations with 95% confidence intervals (95% CI). The results confirmed the scales' excellent psychometric properties. Importantly, latent factor correlations between MEC10 and mYFAS2.0 (est = 0.783, 95% CI [0.76, 0.80]) supported their discriminant validity. In contrast, the latent correlation of MEC10 and BES (est = 0.86, 95% CI [0.84, 0.87]) exceeded the recommended thresholds, indicating the absence of discriminant validity and suggesting a potential overlap, consistent with previous evidence. In conclusion, MEC10 demonstrates excellent psychometric properties but is more a measure of BED and not FA.

Plasma concentration of leptin is related to food addiction in gambling disorder: Clinical and neuropsychological implications

Background

Data implicate overlaps in neurobiological pathways involved in appetite regulation and addictive disorders. Despite different neuroendocrine measures having been associated with both gambling disorder (GD) and food addiction (FA), how appetite-regulating hormones may relate to the co-occurrence of both entities remain incompletely understood.

Aims

To compare plasma concentrations of ghrelin, leptin, adiponectin, and liver-expressed antimicrobial peptide 2 (LEAP-2) between patients with GD, with and without FA, and to explore the association between circulating hormonal concentrations and neuropsychological and clinical features in individuals with GD and FA.

Methods

The sample included 297 patients diagnosed with GD (93.6% males). None of the patients with GD had lifetime diagnosis of an eating disorder. FA was evaluated with the Yale Food Addiction Scale 2.0. All patients were assessed through a semi-structured clinical interview and a psychometric battery including neuropsychological tasks. Blood samples to measure hormonal variables and anthropometric variables were also collected.

Results

From the total sample, FA was observed in 23 participants (FA+) (7.7% of the sample, 87% males). When compared participants with and without FA, those with FA+ presented both higher body mass index (BMI) (p < 0.001) and leptin concentrations, after adjusting for BMI (p = 0.013). In patients with FA, leptin concentrations positively correlated with impulsivity, poorer cognitive flexibility, and poorer inhibitory control. Other endocrine measures did not differ between groups.

Discussion and conclusions

The present study implicates leptin in co-occurring GD and FA. Among these patients, leptin concentration has been associated with clinical and neuropsychological features, such as impulsivity and cognitive performance in certain domains.

Risk of binge eating disorder in patients with metabolic dysfunction-associated steatotic liver disease

PURPOSE

Very few data exist on the association between metabolic dysfunction-associated steatotic liver disease (MASLD) and eating disorders. The study aimed to evaluate the presence of binge eating disorder (BED), in MASLD subjects.

METHODS

Demographic, clinical investigation, anthropometric measurements and laboratory were collected in 129 patients with MASLD (34.1% males; age, 53.7 years; BMI, 34.4 kg/m2) addressed by general practitioners to a hospital-based unit of metabolic disorders. The risk of binge eating was tested by the binge eating scale (BES); values in the range 17-26 were considered "possible" BED, values > 26 were considered "probable" BED. Hepatic steatosis and fibrosis were tested by surrogate biomarkers and imaging (transient elastography). Calorie intake and lifestyle were self-assessed by questionnaires.

RESULTS

Possible BED was present in 17.8% of cases, probable BED in another 7.6%, and were neither associated with gender, obesity class, diabetes, features of metabolic syndrome, nor with presence and severity of hepatic steatosis and fibrosis. Also steatosis grade by CAP and fibrosis stage by liver stiffness did not correlate with BES. However, an association was present between the daily caloric intake and "possible" BED (odds ratio, 1.14; 95% confidence interval, 1.05-1.24; "probable" BED, 1.21; 1.07-1.37), after adjustment for confounders.

CONCLUSION

Binge eating, as scored by BES, is present in a significant proportion of MASLD cases screened for metabolic disorders in a specialized center. It may impact behavioral treatment, reducing the chance of weight loss without systematic psychological support.

LEVEL OF EVIDENCE

Level III, cohort analytic study.

Reactive hypoglycemia in binge eating disorder, food addiction, and the comorbid phenotype: unravelling the metabolic drive to disordered eating behaviours

BACKGROUND

Impaired metabolic response such as blood glucose fast fluctuations may be hypothesized in binge eating disorder (BED) and food addiction (FA) by virtue of the repetitive consumption of highly processed food. Conversely, rapid changes in plasma glucose (i.e., hypoglycemia) may trigger craving for the same food products. The investigation of early glycemic disturbances in BED and FA could enhance the understanding of the metabolic mechanisms involved in the maintenance of the disorders. Present study investigated hypoglycemia events during a 5-h-long oral glucose tolerance test (OGTT) in people with BED, FA, and the comorbid phenotype. Further, the association between the severity of eating psychopathology and the variability in hypoglycaemia events was explored.

METHODS

Two-hundred participants with high weight and no diabetes completed the extended OGTT and were screened for BED, FA, BED-FA, or no-BED/FA. The four groups were compared in hypoglycemia events, OGTT-derived measures, and eating psychopathology. The association between predictors (eating psychopathology), confounders (demographics, metabolic features), and the outcomes (hypoglycemia, early/late hypoglycemia, severe hypoglycemia, reactive hypoglycemia) was examined through logistic regression.

RESULTS

Hypoglycemia in general, and reactive hypoglycemia were highly frequent (79% and 28% of the sample, respectively). Hypoglycemia events (< 70 mg/dL) were equally experienced among groups, whilst severe hypoglycemia (< 54 mg/dL) was more frequent in BED at the late stage of OGTT (5 h; χ2 = 1.120, p = .011). The FA and BED groups exhibited significantly higher number of reactive hypoglycemia (χ2 = 13.898, p = .003), in different times by diagnosis (FA: 210'-240'; BED: at the 270'). FA severity was the only predictor of early and reactive hypoglycemia.

CONCLUSIONS

People with BED or FA are prone to experiencing reactive hypoglycemia; FA severity may predict early and symptomatic hypoglycemia events. This can further reinforce disordered eating behaviours by promoting addictive responses, both biologically and behaviourally. These results inform professionals dealing with eating disorders about the need to refer patients for metabolic evaluation. On the other hand, clinicians dealing with obesity should screen for and address BED and FA in patients seeking care for weight loss.

Features of Addiction in Binge-Eating Disorder: Considerations for Screening and Treatment

Similarities have been reported between the diagnostic and associated characteristics of binge-eating disorder (BED) and substance-related and non-substance-related disorders. This has resulted in interest in using addiction models to inform clinical care for people with BED. The purpose of this paper was to review features of addiction in BED with a focus on clinical implications. First, we briefly summarize similarities and differences in diagnostic and mechanistic features and symptoms for BED and food addiction, substance-related disorders, and non-substance-related disorders. Then we review aspects of addiction in BED that have clinical implications for screening and treatment of this condition. Similarities in diagnostic criteria between BED and substance-related and non-substance-related disorders include loss of control, greater use than intended, continued use despite adverse consequences, and marked distress. Addiction models may help inform aspects of clinical care of BED, particularly for shared antecedents and mechanisms underlying both disorders and to enhance engagement in treatment. Yet, there are large gaps in evidence regarding the effects of many aspects of addiction models to BED. More research is needed to examine the safety and efficacy of using addiction theories and frameworks for clinical strategies for BED.

Current Discoveries and Future Implications of Eating Disorders

Eating disorders (EDs) are characterized by severe disturbances in eating behaviors and can sometimes be fatal. Eating disorders are also associated with distressing thoughts and emotions. They can be severe conditions affecting physical, psychological, and social functions. Preoccupation with food, body weight, and shape may also play an important role in the regulation of eating disorders. Common eating disorders have three major types: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). In some cases, EDs can have serious consequences for an individual's physical and mental health. These disorders often develop during adolescence or early adulthood and affect both males and females, although they are more commonly diagnosed in young adult females. Treatment for EDs typically involves a combination of therapy, nutrition counseling, and medical care. In this narrative review, the authors summarized what is known of EDs and discussed the future directions that may be worth exploring in this emerging area.

Behavioural biases in the interaction with food objects in virtual reality and its clinical implication for binge eating disorder

Cognitive processes play a central role in the development, maintenance and remission in mental disorders, like in Binge Eating Disorder (BED). Insights into cognitive mechanisms reflected by embodied interaction with food and its connections to clinically relevant psychopathology offer new possibilities for translational diagnostics and interventions. We longitudinally investigated the manual interaction with food in a virtual reality (VR) in 31 patients with BED. Patients were assessed at baseline before participating in a randomized-controlled trial (RCT) investigating a computer-based inhibitory control training programme enhanced by transcranial direct current stimulation (tDCS) and at a 6-week follow-up. At both assessments, an experimental VR paradigm was conducted and patients were characterized concerning eating disorder psychopathology, eating behaviour, general impulsivity and food craving. In the experimental task, one of two simultaneously presented objects (food vs. office tools) had to be collected. Food was recognized faster than office tools and subsequent approach behaviour was initiated faster, whereas thereafter, food was collected slower than office tools. Exploratory, we could not find a modulatory effect of applied tDCS on the interaction with food. No relationship between behavioural biases and sample characterizations could be detected. Two different stages in the manual interaction with food were found: a faster first stage that comprises recognition and movement initiation and a slower second stage that comprises controlled handling and may reflect aversive motivational processes. As the behavioural patterns do not change with an ameliorated BED-psychopathology at the second assessment, the task seems insensitive in detecting translational interconnections between behavioural biases and BED-characteristics.Level of evidence: Level I, experimental study.

Dissociative experiences of compartmentalization are associated with food addiction symptoms: results from a cross-sectional report

PURPOSE

Studies have shown significant associations of dissociative symptoms with both eating and addictive disorders; however, the different forms of dissociation have been relatively understudied in relation to food addiction (FA). The main aim of this study was to investigate the association of certain forms of dissociative experiences (i.e., absorption, detachment and compartmentalization) with FA symptoms in a nonclinical sample.

METHODS

Participants (N = 755; 543 women; age range: 18-65; mean age: 28.22 ± 9.99 years) were evaluated using self-report measures of FA, dissociation, eating disturbances, and general psychopathology.

RESULTS

Compartmentalization experiences (defined as pathological over-segregation of higher mental functions) were independently associated with FA symptoms (β = 0.174; p = 0.013; CI = [0.008; 0.064]) even when confounding factors were controlled for.

CONCLUSION

This finding suggests that compartmentalization symptoms can have a role in the conceptualization of FA, with such two phenomena possibly sharing common pathogenic processes.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Early life influences on the development of food addiction in college attending young adults

PURPOSE

There is little investigation into the causes of food addiction. The aim of this study was to determine the impact of early life influences on the development of food addiction in college-attending young adults aged 18-29.

METHODS

This study utilized a sequential explanatory mixed-methods research design. College-attending young adults were invited to complete an online survey measuring Adverse Childhood Experiences (ACEs), food addiction, depression, anxiety, stress, and demographic information. Correlations between food addiction and the other variables were analyzed and significant variables were placed into a nominal logistic regression model to predict the development of food addiction. Participants who met the criteria for food addiction were invited to participate in interviews to examine their childhood eating environment and when their symptoms emerged. Interviews were transcribed and thematically analyzed. Quantitative analysis was conducted using JMP Pro Version 16.0 and qualitative analysis was conducted using NVIVO Software Version 12.0.

RESULTS

Survey respondents (n = 1645) had an overall 21.9% prevalence of food addiction. Significant correlations were observed between food addiction and ACEs, depression, anxiety, stress, and sex (p < .01 for all). Depression was the only significant predictor of the development of food addiction (OR = 3.33 95% CI 2.19, 5.05). The most common eating environment described by interview participants (n = 36) was an emphasis on diet culture, ideal body image, and restrictive environments. Symptoms frequently emerged after transitioning into college and having the ability to make their own food choices.

CONCLUSION

These results show the impact of early life eating environments and young adulthood mental health on the development of food addiction. These findings contribute to the understanding of underlying causes of food addiction.

LEVEL OF EVIDENCE

Level V, Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Diet quality and eating behaviors of college-attending young adults with food addiction

BACKGROUND

College students are heavily influenced by their food environment and are an important population in which to study food addiction. This mixed-methods study aimed to examine diet quality and eating behaviors of college students with food addiction.

METHODS

Students attending a large university in November 2021 were invited to complete an online survey that measured food addiction, eating styles, eating disorder symptoms, diet quality, and anticipated feelings after eating. Kruskal-Wallis H determined differences between those with and without food addiction in mean scores of quantitative variables. Participants who met the symptom threshold for the presence of food addiction were invited to participate in an interview that elicited more information. Quantitative data was analyzed using JMP Pro Version 16.0 and qualitative data was thematically analyzed using NVIVO Pro Software Version 12.0.

RESULTS

Respondents (n = 1645) had a 21.9 % prevalence of food addiction. Individuals with mild food addiction had the highest scores in cognitive restraint. Those with severe food addiction had the highest scores in uncontrolled eating, emotional eating, and eating disorder symptoms. Individuals with food addiction showed significantly higher negative expectancies for healthy and junk food, lower intake of vegetables, higher intakes of added sugars and saturated fat. Interview participants had problems with sweets and carbohydrates most often and described eating until physically ill, eating in response to negative emotions, dissociation while eating, and strong negative feelings after eating.

CONCLUSION

Findings contribute to the understanding of the behaviors, emotions, and perceptions surrounding food by this population, providing potential behaviors and cognitions to target for treatment.

Disordered Eating Behaviors Related to Food Addiction/Eating Addiction in Inpatients with Obesity and the General Population: The Italian Version of the Addiction-like Eating Behaviors Scale (AEBS-IT)

PURPOSE

The purpose of this research is to test the psychometric properties and factorial structure of the Addiction-like Eating Behaviors Scale (AEBS) in an Italian sample of adults with severe obesity seeking treatment for weight reduction and the general population, and to examine the measurement invariance of the tool by comparing a clinical and a nonclinical sample.

METHODS

A confirmatory factor analysis (CFA) was initially conducted to test the factorial structure of the Italian version of the AEBS (AEBS-IT) on a total of 953 participants. Following this, the measurement invariance and psychometric properties of the tool AEBS-IT were assessed on both inpatients with severe obesity (n = 502) and individuals from the general population (n = 451). Reliability and convergent validity analysis were also run.

RESULTS

CFA revealed a bi-factor structure for the AEBS-IT, which also showed good reliability and positive correlations with food addiction (through the mYFAS2.0 symptom count), binge-eating symptoms, compulsive eating behavior, and dysfunctional eating patterns and the individuals' body mass index (BMI). Moreover, the tool was invariant across populations.

CONCLUSION

This study provided evidence that the AEBS-IT is a valid and reliable measure of FA in both clinical and nonclinical samples.

Associations Between Food Addiction and Substance-Use Disorders: A Critical Overview of their Overlapping Patterns of Consumption

Purpose of Review

Research on patterns of overconsumption in individuals with food addiction (FA) has focused largely on binge eating. However, compulsive overeating can be varied and dimensional. This review focuses on the similarities between the patterns of consumption in FA and in other clinically established substance-use disorders, such as alcohol and nicotine dependence. It also highlights features that make FA unique to other addiction disorders.

Recent Findings

Overall, there is substantial evidence that binge-like overconsumption is a characteristic of various substance-use and eating disorders. Likewise, it appears that different overeating patterns can reflect addictive-like eating. One pattern may be compulsive grazing — defined as the repetitive inability to resist consumption of small amounts of food.

Summary

This review adds to the increasingly compelling picture that FA and binge-eating disorder are unique conditions, and that FA resembles other substance-use disorders. We conclude that a variety of overeating patterns can reflect addictive eating behaviours in vulnerable individuals, one of which may be compulsive grazing.

Risk of somatic diseases in patients with eating disorders: the role of comorbid substance use disorders

AIMS

Eating disorders (EDs) and substance use disorders (SUDs) often co-occur, and both involve somatic diseases. So far, no study has considered whether comorbid SUDs may impact somatic disease risk in patients with EDs. Therefore, this study aimed to examine the impact of comorbid SUDs on the risk of 11 somatic disease categories in patients with anorexia nervosa (AN), bulimia nervosa (BN) and unspecified eating disorder (USED) compared to matched controls.

METHODS

A retrospective cohort study was conducted using Danish nationwide registries. The study population included 20 759 patients with EDs and 83 036 controls matched on month and year of birth, sex and ethnicity. Hazard ratios (HRs) were calculated to compare the risk of being diagnosed with a somatic disease (within 11 categories defined by the ICD-10) following first ED diagnosis (index date) between ED patients and controls both with and without SUDs (alcohol, cannabis or hard drugs).

RESULTS

The ED cohort and matched controls were followed for 227 538 and 939 628 person-years, respectively. For ED patients with SUDs, the risk pattern for being diagnosed with different somatic diseases (relative to controls without SUDs) varied according to type of ED and SUD [adjusted HRs ranged from 0.95 (99% CI = 0.57; 1.59) to 4.17 (2.68, 6.47)]. The risk estimates observed among ED patients with SUDs were generally higher than those observed among ED patients without SUDs [adjusted HRs ranged from 1.08 (99% CI = 0.95, 1.22) to 2.56 (2.31, 2.84)]. Abuse of alcohol only had a non-synergistic effect on six disease categories in AN patients and five in BN and USED patients. Abuse of cannabis (with/without alcohol) had a non-synergistic effect on five disease categories in AN and BN patients and two in USED patients. Abuse of hard drugs (with/without alcohol or cannabis) had a non-synergistic effect on nine disease categories in AN patients, eight in BN patients and seven in USED patients.

CONCLUSIONS

The present study documents non-synergistic but not synergistic harmful somatic consequences of SUDs among patients with different EDs, with AN and hard drugs being the most predominant factors. Hence, EDs and SUDs did not interact and result in greater somatic disease risk than that caused by the independent effects. Since EDs and SUDs have independent effects on many somatic diseases, it is important to monitor and treat ED patients for SUD comorbidity to prevent exacerbated physical damage in this vulnerable population.