Pragmatic clinical trials to advance research in children and adolescents with eating disorders.

OBJECTIVE: To discuss the utility of pragmatic clinical trials (PCTs) to help advance research in eating disorders (EDs). METHODS: We describe challenges associated with traditional explanatory research trials and examine PCTs as an alternative, including a review of the PRECIS-2 tool. RESULTS: There are many challenges associated with the design and completion of traditional RCTs within the field of EDs. Pragmatic clinical trials are studies that closely align with conditions available in everyday practice and focus on outcomes that are relevant to patients and clinicians. Results of PCTS maximize applicability and generalizability to clinical settings. DISCUSSION: Available therapies established for the treatment of EDs provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In addition to a general overview of PCTs, we draw upon published literature and our own experiences involving adjunctive olanzapine for the treatment of children and youth with anorexia nervosa to help highlight challenges associated with randomized controlled trial (RCT) design and implementation, and offer pragmatic suggestions that would allow patients greater choice in treatment trials, while at the same time capturing outcomes that are most likely to advance treatment efforts. CONCLUSIONS: Pragmatic clinical trials provide alternatives to RCT design that can help bolster research in EDs that aims to explore real-world effects of interventions. PUBLIC SIGNIFICANCE: Available therapies established for the treatment of eating disorders (EDs) in children and adolescents provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In this article, we discuss the utility of pragmatic trials to help promote research that can help advance knowledge that is relevant to clinical care settings.

Examining the role of artificial intelligence to advance knowledge and address barriers to research in eating disorders.

OBJECTIVE: To provide a brief overview of artificial intelligence (AI) application within the field of eating disorders (EDs) and propose focused solutions for research. METHOD: An overview and summary of AI application pertinent to EDs with focus on AI's ability to address issues relating to data sharing and pooling (and associated privacy concerns), data augmentation, as well as bias within datasets is provided. RESULTS: In addition to clinical applications, AI can utilize useful tools to help combat commonly encountered challenges in ED research, including issues relating to low prevalence of specific subpopulations of patients, small overall sample sizes, and bias within datasets. DISCUSSION: There is tremendous potential to embed and utilize various facets of artificial intelligence (AI) to help improve our understanding of EDs and further evaluate and investigate questions that ultimately seek to improve outcomes. Beyond the technology, issues relating to regulation of AI, establishing ethical guidelines for its application, and the trust of providers and patients are all needed for ultimate adoption and acceptance into ED practice. PUBLIC SIGNIFICANCE: Artificial intelligence (AI) offers a promise of significant potential within the realm of eating disorders (EDs) and encompasses a broad set of techniques that offer utility in various facets of ED research and by extension delivery of clinical care. Beyond the technology, issues relating to regulation, establishing ethical guidelines for application, and the trust of providers and patients are needed for the ultimate adoption and acceptance of AI into ED practice.

A framework for conceptualising early intervention for eating disorders.

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

Appearance satisfaction mediates the relationship between recreational screen time and depressive symptoms in adolescents.

BACKGROUND: Research suggests there is an association between high levels of recreational screen time and depression among adolescents; however, mechanisms driving this association remain unknown. The present study examined appearance and weight satisfaction and disordered eating behaviors as mediators in the relationship between recreational screen time and depressive symptoms in adolescents. METHOD: Longitudinal data on screen time, depressive symptoms, disordered eating behaviors, and appearance and weight satisfaction from 304 adolescents (194 females, Mage = 13.40) were analyzed through a moment structure model. RESULTS: Results revealed appearance dissatisfaction mediated the direct effect of recreational screen time on depressive symptoms (Estimate = 0.48, SE = .18, 95% CI [0.12, 0.84]), and that recreational screen time was significantly related to lower appearance satisfaction (Estimate = -0.06, SE = .02, 95% CI [-0.10, -0.01]), which was significantly predictive of more severe depressive symptoms (Estimate = -1.49, SE = .62, 95% CI [-2.71, -0.28]). CONCLUSIONS: These findings suggest that modulating screen time may be an efficacious strategy to reduce appearance dissatisfaction and depressive symptoms during adolescence.

Asceticism, perfectionism and overcontrol in youth with eating disorders.

PURPOSE: Personality traits such as perfectionism and asceticism, and combinations of these traits (i.e., overcontrol) have been related to eating disorder (ED) diagnosis, symptoms, and chronicity in adult patients with EDs. However, as limited evidence exists in adolescents, the aim of the present study was to examine these links in a clinical sample of adolescents with EDs. METHOD: A retrospective chart review was conducted on 178 adolescents (91% females; Mage = 15.73 years, SD = 1.31) receiving services at a tertiary care pediatric ED program. An examination of variability in mean levels of perfectionism, asceticism, and overcontrol across ED symptom groups (restrictive and binge/purge ED subtypes) was conducted to learn of diagnostic differences, while correlations were used to explore the association of these personality traits with comorbid anxiety and depressive symptoms. Hierarchical linear regression was used to assess whether overcontrol was related to length of stay (LOS) in an inpatient program. RESULTS: Results indicated that adolescents with binge-purge symptoms had higher levels of perfectionism, asceticism and overcontrol compared to those with restrictive symptoms, and that greater levels of perfectionism, asceticism and overcontrol were associated with elevated depression and anxiety symptoms. Additionally, overcontrol predicted greater LOS in the inpatient ED program. CONCLUSION: Results suggest the importance of assessing, monitoring and targeting overcontrol in treatment for adolescents with EDs given its impact on comorbid symptoms and LOS. LEVEL OF EVIDENCE: Level III, evidence obtained from case-control analytic studies.

Cocreating research priorities for anorexia nervosa: The Canadian Eating Disorder Priority Setting Partnership.

OBJECTIVE: The Canadian Eating Disorder Priority Setting Partnership was established to identify and prioritize the top 10 research priorities for females, 15 years or older, with anorexia nervosa, by incorporating equal input from those with lived experience, families, and healthcare professionals. METHOD: This project, which closely followed the James Lind Alliance guidelines, solicited research priorities from the Canadian eating disorder community by means of a five-step process including use of a survey, response collation, literature checking, interim ranking survey, and in-person prioritization workshop. RESULTS: The initial survey elicited 897 priorities from 147 individuals, with almost equal representation from all three stakeholder groups. From this, 603 responses aligned with the project objectives and were collapsed into 71 broader indicative questions. Based on available systematic reviews, 18 indicative questions were removed as they were considered answered by existing literature while 8 indicative questions were added from the recommendations of the reviews. In total, 61 indicative questions were ranked in an interim ranking survey, where 21 questions were prioritized as important by at least 20% of respondents. As a final step, 28 individuals from across Canada attended the prioritization workshop to coestablish the top 10 research priorities. DISCUSSION: Top priorities were related to treatment gaps and the need for more surveillance data. This systematic methodology allowed for a transparent and collaborative approach to identifying current priorities from both the service user and provider perspective. Wide dissemination is anticipated to promote work that is of high relevance to patients, families, and clinicians.

Mediating role of disordered eating in the relationship between screen time and BMI in adolescents: longitudinal findings from the Research on Eating and Adolescent Lifestyles (REAL) study.

OBJECTIVE: This study investigated whether the duration and type of screen time (ST) (TV viewing, recreational computer use, video gaming) is longitudinally associated with z-BMI and if these relationships are mediated by disordered eating (emotional, restrained). DESIGN: At baseline, participants were n 1197 (T1; 60 % female) adolescents (mean age = 13·51 years) who completed surveys over 2 years. ST was assessed by a self-reported measure created by the investigative team, while emotional and restrained eating was measured by the Dutch Eating Behaviour Questionnaire (DEB-Q). Height and weight were objectively measured to quantify z-BMI. SETTING: Thirty-one public and two private schools from the region of Ottawa, Canada. PARTICIPANTS: Students in grades 7-12. RESULTS: Parallel multiple mediation analyses revealed that more time spent watching TV at baseline is associated with higher z-BMI at T3 (total effect; B = 0·19, se = 0·07, P = 0·01, 95 % CI 0·05, 0·34), but no relationships were observed for total ST exposure or other types of ST and z-BMI. Disordered eating did not mediate the positive association between baseline TV viewing and z-BMI at T3. CONCLUSIONS: TV viewing was longitudinally associated with higher z-BMI in a community-based sample of adolescents, but disordered eating behaviours did not mediate this relationship. However, other non-pathological eating behaviours may mediate the association between ST and obesity and warrant further investigation. Finding suggests that targeting reduction in youth's TV viewing may be an effective component in the prevention of childhood obesity.

Characteristics and clinical trajectories of patients meeting criteria for avoidant/restrictive food intake disorder that are subsequently reclassified as anorexia nervosa.

OBJECTIVE: To examine the initial assessment profiles and early treatment trajectories of youth meeting the criteria for avoidant/restrictive food intake disorder (ARFID) that were subsequently reclassified as anorexia nervosa (AN). METHOD: A retrospective cohort study of patients assessed and treated in a tertiary care eating disorders (ED) program was completed. RESULTS: Of the 77 included patients initially meeting criteria for ARFID, six were reclassified as having AN (7.8%) at a median rate of 71 days after the first assessment. Patients in this cohort presented at very low % treatment goal weight (median 71.6%), self-reported abbreviated length of illness (median 6 months), and exhibited low resting heart rates (median 46 beats per minute). Nutrition and feeding focused worries related more to general health as opposed to specific weight and shape concerns or fears at assessment in half of those reclassified with AN. Treatment at the 6-month mark varied among patients, but comprised family and individual therapy, as well as prescription of psychotropic medication. CONCLUSION: Prospective longitudinal research that utilizes ARFID-specific as well as traditional eating disorder diagnostic measures is required to better understand how patients with restrictive eating disorders that deny fear of weight gain can be differentiated and best treated.

Binge eating and social anxiety in treatment-seeking adolescents with eating disorders or severe obesity.

PURPOSE: Binge eating is a common behavior in children and adolescents who suffer from either eating disorders (EDs) or from severe obesity. The purpose of the current study was to explore the association between social anxiety and binge eating and compare prevalence rates of social anxiety between youth with severe obesity or EDs who did or did not engage in binge eating. METHODS: Retrospective data on treatment-seeking youth's (n = 490) eating behaviors and social anxiety at assessment were analyzed. RESULTS: Results indicate that those who engage in binge eating have higher rates of social anxiety; frequency of binges does not predict severity of social anxiety, though social anxiety predicts presence of binge eating. Adolescents with EDs had higher rates of social anxiety than those with obesity, and for both groups, rates of social anxiety were highest in those who binge. CONCLUSIONS: Clinicians who treat youth with EDs and with obesity should be aware of the relationship between binge eating and social anxiety and of the need for treatment to address both these disorders. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Bingeing, Purging, and Suicidal Ideation in Clinical and Non-Clinical Samples of Youth.

Suicidal ideation is a serious mental health concern reported by adolescents. Despite understanding of increased suicidal ideation in patients with eating disorders (EDs) and obesity, few studies have compared how disordered eating (bingeing, vomiting and over exercising) is associated with suicidal ideation in clinical and non-clinical samples of youth across the ED and weight spectrum. The present study aimed to 1) comparatively examine rates of suicidal ideation and disordered eating behaviors in clinical samples of youth with EDs, complex obesity, or from the community, and 2) examine whether disordered eating was associated with suicidal ideation above and beyond age, body mass index, diagnosis, treatment-seeking status, and depressive symptoms in large samples of males vs. females in an attempt to understand whether these behaviors should lead to concern regarding suicidal ideation. Data from charts on treatment-seeking adolescents diagnosed with either an ED (N = 315), severe complex obesity (N = 212), and from the community (N = 3036) were pooled together for comparative purposes. Results showed that suicidal ideation was higher in youth seeking treatment for an ED (50.2%) and obesity (23.7%) as compared to youth from the community (13%). Binary logistic regression analyses revealed that vomiting (OR = 1.73 for females, 8.17 for males) and over-exercising (OR = 1.47 for females, 1.68 for males) was significantly associated with suicidal ideation in both males and females. Findings underscore the importance of screening for suicidal ideation in youth who report vomiting or over-exercising despite diagnostic presentation, age, weight, or treatment setting.

Development of the Ottawa Disordered Eating Screen for Youth: The ODES-Y.

OBJECTIVE: To develop a concise screening tool that allows for early identification of disordered eating in youth. STUDY DESIGN: In this 2-step classification accuracy study, questions for the Ottawa Disordered Eating Screen-Youth, a 2-question screening tool (index test), were conceptualized by clinician-scientists from tertiary care pediatric eating disorder and weight-related clinics, and was validated using retrospective data (2004-2010) from a community-based study, the Research on Eating and Adolescent Lifestyles (REAL) study. RESULTS: Analyses of contrast between the index test and the reference standard using data from 2892 (1714 females) students between grade 7 and grade 12 revealed classification statistics of 67.1% for sensitivity, 85.9% for specificity, 4.7 for positive likelihood ratio, 0.38 for negative likelihood ratio, 50.6% for positive predictive value, and 92.4% for negative predictive value for females and 61.1% for sensitivity, 93.9% for specificity, and 9.9 for positive likelihood ratio, 0.41 for negative likelihood ratio, 32.3% for positive predictive value, and 98.0% for negative predictive value for males. CONCLUSIONS: Our findings suggest that the index test has utility as a short and accurate screening tool for earlier detection of disordered eating thoughts and behaviors in youth. Additional research is needed to best determine how the index test can be administered to youth across various health care, school, public health, and surveillance settings in clinically sensitive pragmatic ways.

Building evidence for the use of descriptive subtypes in youth with avoidant restrictive food intake disorder.

OBJECTIVE: To examine characteristics of patients with Avoidant/Restrictive Food Intake Disorder (ARFID) in an effort to identify and describe subtypes of the disorder. METHOD: A retrospective chart review was completed for patients aged 8-17 years assessed over a 17-year period. RESULTS: Seventy-seven patients were included in the study, the majority of whom were female (n = 56, 73%). The average age of patients was 13.7 years (SD = 2.4 years). Three specific subtypes of ARFID (aligning with example presentations outlined in the DSM-5) were identified: (a) those with weight loss and/or medical compromise as a consequence of apparent lack of interest in eating (n = 30, 39%); (b) restriction arising as a result of sensory sensitivity (n = 14, 18%); and (c) restriction based upon food avoidance and/or fear of aversive consequences of eating (n = 33, 43%). Clinical characteristics of patients varied depending on the assigned subtype. DISCUSSION: Our findings highlight the need for further research into the relative merit of subtype-assignment in patients with ARFID and whether such practice would aid in the recommended treatment. Further research is required to understand whether these categories are generalizable and applicable to other samples such as young children or adults with ARFID, and how treatment options might differ according to subtype.

Examining the bidirectional relationship between physical activity, screen time, and symptoms of anxiety and depression over time during adolescence.

More physical activity (PA) and less screen time (ST) are positively associated with mental health in adolescents; however, research is limited by short-term designs and the exclusion of ST when examining PA. We examined: (a) changes in PA, ST, symptoms of depression, and symptoms of anxiety over four assessments spanning 11years, and (b) bidirectional relationships between initial PA, ST, and symptoms of depression and anxiety as predictors of change in each other during adolescence. Between 2006 and 2010, participants from Ottawa Canada (Time1; N=1160, Mean age=13.54years) completed questionnaires at four points covering the ages from 10 to 21years. Latent growth modeling was used. PA decreased over time whereas ST and symptoms of depression and anxiety increased over time. Controlling for sex, ethnicity, school location, zBMI, birth year, and parents' education, initially higher anxiety was associated with initially higher ST (covariance=.88, p<.05) and initially lower PA (covariance=-6.84, p=.07) independent of initial symptoms of depression. Higher initial depression was associated with higher initial ST (covariance=2.55, p<.05). Increases in anxiety were associated with increases in ST (covariance=.07, p=.06) and increases in depression (covariance=.41, p<.05). Examining bidirectional relationships, higher initial symptoms of depression predicted greater decreases in PA (b=-.28, p<.05). No other significant findings between initial PA, ST, anxiety, or depression were found as predictors of change in each other. Interventions targeting depression around age 13 may be useful to prevent further declines in PA. Similarly, interventions to reduce ST may be beneficial for concurrent reductions in symptoms of depression and anxiety, irrespective of PA.

Screen time is associated with depression and anxiety in Canadian youth.

OBJECTIVE: This study examined the relationships between screen time and symptoms of depression and anxiety in a large community sample of Canadian youth. METHOD: Participants were 2482 English-speaking grade 7 to 12 students. Cross-sectional data collected between 2006 and 2010 as part of the Research on Eating and Adolescent Lifestyles (REAL) study were used. Mental health status was assessed using the Children's Depression Inventory and the Multidimensional Anxiety Scale for Children-10. Screen time (hours/day of TV, video games, and computer) was assessed using the Leisure-Time Sedentary Activities questionnaire. RESULTS: Linear multiple regressions indicated that after controlling for age, sex, ethnicity, parental education, geographic area, physical activity, and BMI, duration of screen time was associated with severity of depression (ß=0.23, p<0.001) and anxiety (ß=0.07, p<0.01). Video game playing (ß=0.13, p<.001) and computer use (ß=0.17, p<0.001) but not TV viewing were associated with more severe depressive symptoms. Video game playing (ß=0.11, p<0.001) was associated with severity of anxiety. CONCLUSION: Screen time may represent a risk factor or marker of anxiety and depression in adolescents. Future research is needed to determine if reducing screen time aids the prevention and treatment of these psychiatric disorders in youth.

Systematic review of the effects of family meal frequency on psychosocial outcomes in youth.

OBJECTIVE: To conduct a systematic review of the effects of frequent family meals on psychosocial outcomes in children and adolescents, and to examine whether there are differences in outcomes between males and females. DATA SOURCES: Studies were identified through a search of MEDLINE (1948 to fifth week of June 2011) and PsycINFO (1806 to first week of July 2011) using the Ovid interface. The MeSH terms and key words used both alone and in combination were family, meal, food intake, nutrition, diets, body weight, adolescent attitudes, eating behaviour, feeding behaviour, and eating disorders. Bibliographies of papers deemed relevant were also reviewed. STUDY SELECTION: The original search yielded 1783 articles. To be included in the analysis, studies had to meet the following criteria: have been published in a peer-reviewed journal in English; involve children or adolescents; discuss the role of family meals on the psychosocial outcomes (eg, substance use, disordered eating, depression) of children or adolescents; and have an adequate study design, including appropriate statistical methods for analyzing outcome data. Fourteen papers met inclusion criteria. Two independent reviewers studied and analyzed the papers. SYNTHESIS: Overall, results show that frequent family meals are inversely associated with disordered eating, alcohol and substance use, violent behaviour, and feelings of depression or thoughts of suicide in adolescents. There is a positive relationship between frequent family meals and increased self-esteem and school success. Studies show substantial differences in outcomes for male and female children and adolescents, with females having more positive results. CONCLUSION: This systematic review provides further support that frequent family meals should be endorsed. All health care practitioners should educate families on the benefits of having regular meals together as a family.

Comparative distribution and validity of DSM-IV and DSM-5 diagnoses of eating disorders in adolescents from the community.

OBJECTIVES: DSM-5 changes for eating disorders (EDs) aimed to reduce preponderance of non-specified cases and increase validity of specific diagnoses. The objectives were to estimate the combined effect of changes on prevalence of EDs in adolescents and examine validity of diagnostic groupings. METHOD: A total of 3043 adolescents (1254 boys and 1789 girls, Mage = 14.19 years, SD = 1.61) completed self-report questionnaires including the Eating Disorder Diagnostic Scale. RESULTS: Prevalence of full-threshold EDs increased from 1.8% (DSM-IV) to 3.7% (DSM-5), with a higher prevalence of bulimia nervosa (1.6%) and the addition of the diagnosis of purging disorder (1.4%); prevalence of binge eating disorder was unchanged (0.5%), and non-specified cases decreased from 5.1% (DSM-IV) to 3.4% (DSM-5). Validation analyses demonstrated that DSM-5 ED subgroups better captured variance in psychopathology than DSM-IV subgroups. DISCUSSION: Findings extend results from previous prevalence and validation studies into the adolescent age range. Improved diagnostic categories should facilitate identification of EDs and indicate targeted treatments.

A psycho-education intervention for parents of adolescents with eating disorders: a randomized controlled trial.

This study evaluated the efficacy of a 2-hour psycho-education session combined with bi-weekly telephone support in increasing parent/caregiver knowledge about eating disorders, increasing self-efficacy by empowering parents to support their child's recovery, and decreasing the impact of eating disorder symptoms on the family. The intervention was targeted at parents/caregivers whose child was waiting to be assessed for an eating disorder. Participants included 51 parents/caregivers and 36 youths. The brief intervention successfully increased parent/caregiver knowledge of the illness, feelings of self-efficacy, and help-seeking behaviors. These findings are clinically useful as waiting lists are common in Canada.

Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study.

OBJECTIVE: To assess and compare clinical characteristics of patients with avoidant/restrictive food intake disorder (ARFID) to those with anorexia nervosa (AN). METHOD: A retrospective review of adolescent eating disorder (ED) patients assessed between 2000 and 2011 that qualified for a diagnosis of ARFID was completed. A matched AN sample was used to compare characteristics between groups. RESULTS: Two hundred and five patients met inclusion criteria and were reviewed in detail. Of these, 34 (5%) patients met criteria for ARFID. A matched sample of 36 patients with AN was used to draw comparisons. Patients with ARFID were younger than those with AN, more likely to present before age 12, and more likely to be male. Patients in both groups presented at low weights. Common eating-specific behaviors and symptoms in the ARFID group included food avoidance, loss of appetite, abdominal pain, and fear of vomiting. Rates of comorbid psychiatric diagnoses and medical morbidity were high in both groups. Almost 80% of AN patients and one-third of ARFID patients required hospital admission as a result of medical instability. Symptom profiles in 4/34 ARFID patients resulted in eventual reclassification to AN. DISCUSSION: This study supports the notion that a small percentage of adolescent patients presenting with restrictive eating disorders meet criteria for ARFID. Patients are younger than average, more likely to be male compared to adolescent AN samples, and have high rates of psychiatric and medical morbidity. The study also suggests that a proportion of patients evolve into AN as treatment progresses.

A family-based eating disorder day treatment program for youth: examining the clinical and statistical significance of short-term treatment outcomes.

This article describes an innovative family-based day treatment program (DTP) for youth with moderate to severe eating disorders. A sample of 65 youth completed a battery of psychological measures pre- and post-treatment and 6 months after program completion. Treatment outcomes were assessed in three main domains: (a) medical stabilization, (b) normalization of eating behavior, and (c) improved psychological functioning. Overall, patients demonstrated statistically significant and clinically meaningful improvements on all outcome measures. Findings indicate that a comprehensive DTP can successfully facilitate positive outcomes in youth with eating disorders and that these improvements can be maintained 6 months post-treatment.

Peer support for eating disorders in Canada: program user perspectives.

Evidence for the value of peer support for eating disorders (EDs) is growing. Peer support is not a replacement for treatment, but can provide hope for recovery, enhance motivation for treatment, and increase feelings of connectedness and belonging for those experiencing EDs. In this study, we explored peer mentees' experiences of peer support for EDs to better understand the impact of peer support and its role in the Canadian treatment and support continuum. We conducted semi-structured interviews with 20 people who had received peer support (group, one-on-one, or chat) and conducted a reflexive thematic analysis through a critical realist lens. We developed four themes. Participants described the importance of connecting with others who had "been there," which helped generate a sense of belonging and connectedness. They also highlighted aspects of the peer support "container" that needed to be in place, such as guidelines for groups and agreements for one-on-one mentoring. When peer support was delivered well, participants described how it helped them help themselves through increasing motivation, communication skills, and other coping skills. Finally, participants described the unique role of peer support within the treatment continuum, as a modality that was accessible, free, and delivered in a way that focused on the whole person. Together, our findings illustrate the value of peer support and considerations for enabling effective and safe peer support delivery.

Peer support can provide hope for recovery, help people feel more motivated to engage in treatment, and generate a sense of belonging for those experiencing EDs. In this study, we sought to understand how peer mentees experienced peer support for EDs. We also wanted to know what role(s) they thought peer support served within the Canadian treatment and support continuum. We conducted semi-structured interviews with 20 people who had received peer support (group, one-on-one, or chat). We developed four themes using a qualitative analysis approach called reflexive thematic analysis. Participants described the importance of connecting with others who had "been there." This helped them feel less isolated and more connected to others with lived experience. They also described several things that needed to be in place for peer support to work, including guidelines for groups and agreements for one-on-one mentoring. If these things were in place, peer support could help people learn to help themselves; for instance, participants shared that they felt more motivated and developed stronger coping and communication skills. In terms of the role of peer support, participants shared that it was an accessible and free option, and one that made them feel seen as a whole person. Together, our findings illustrate the value of peer support and considerations for enabling effective and safe peer support delivery.