The Impact of the COVID-19 Pandemic and Associated Public Health Response on People with Eating Disorder Symptomatology: A National Australian Study

Background Associated with the COVID-19 pandemic is a mental health crisis. People with lived experience of eating disorders (ED) may be particularly vulnerable due to exasperating factors including social isolation, co-occurring conditions, etc. This study investigates the association of the pandemic with ED symptomatology to consider impact and identify risk factors for clinical consideration. with a higher level of illness. Secondarily, it is hypothesised that those with co-occurring mental health conditions, those experiencing higher levels of depression, anxiety and/or stress, those experiencing loneliness, and/or those not actively engaged in treatment during the pandemic will be more negatively impacted, reporting worsening ED symptoms. This study is an open community study to investigate the impact the COVID-19 pandemic has had on people with a lived experience of an eating disorder.


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The coronavirus disease 2019 (COVID- 19) was declared a global pandemic in March 2020 by the World Health Organisation and as of March 2021 had infected over 117 million people and caused over 2.6 million deaths worldwide (WHO, 2020). Along with chronic respiratory abnormalities, longer term health implications have already been reported including cardiovascular (Scutelnic & Heldner, 2020), renal, dermatologic and neurological concerns (CDC, 2020). Research on the impact of acute respiratory epidemics on vulnerable populations have shown neuropsychiatric linkage between outbreaks and mental disorders (Shah et al., 2020).
The COVID-19 pandemic has similarities with past outbreaks in terms of global fear due to the virus itself, nancial insecurity, and modern quarantine strategies such as mandatory lockdowns and 'social distancing' to curtail viral spread.
Isolation signi cantly impacts mental health causing feelings of anxiety, depression, anger and loneliness with increased duration in quarantine directly associated with increased symptoms of Post-Traumatic Stress Disorder (Usher, Bhullar, & Jackson, 2020). Following early warnings from the United Nations about a pandemic-associated mental health crisis (Mohsen, 2020), population-wide mental health concerns have been reported including a 2-fold increase in anxiety disorders, a 3-fold increase in major depressive disorders and suicide risk, and signi cant increases in binge drinking (Winkler et al., 2020). While all communities have been impacted socially, nancially and psychologically, the pandemic may have signi cant impact on those most vulnerable, such as people with pre-existing mental health illnesses (Torales et al., 2020), especially people with lived experience of eating disorders (Touyz, Lacey, & Hay, 2020).
Eating Disorders (ED) are a range of complex psychological disorders which can lead to signi cant physical and psychological impairment and are associated with high rates of mortality and low rates of detection and intervention (Currin & Schmidt, 2005; Ivancic et al., 2020; Keel et al., 2003). Among the EDs, Anorexia Nervosa has the highest reported mortality rate of any psychological illness (Morris & Twaddle, 2007), with approximately 12 times greater risk of death and 57 times greater risk of suicide as compared to peers (Arcelus et al., 2011;Keel et al., 2003). Due to the high level of impairment, chronic health consequence and mortality, people with an ED warrant considered attention during this pandemic.
People with a lived experience of an ED may be particularly vulnerable due to the impact social isolation and loneliness can have on the illness (Levine, 2012). People with EDs have a complex relationship with food, so issues around food shortages and stock-pilling experienced at the panicked start of lockdowns can lead to worsening symptoms (Touyz et al., 2020). As compulsive exercise is a common feature and coping strategy in ED's, closures of health and tness centres can trigger ED symptoms such as binge-eating, purging, body image concern, excessive exercise and diet pill misuse (The Butter y Foundation, 2020). Due to the high co-occurrence of contamination fears and obsessive-compulsive symptomatology with EDs (Jiménez-Murcia et al., 2007), fear of disease contamination and increased hygiene measures may also exasperate anxiety and ED symptoms (Phillipou et al., 2020). Research from the early months of the pandemic reported a signi cant increase in symptoms across all ED diagnoses (Termorshuizen et al., 2020), reactivation of symptoms (Graell et al., 2020), signi cant increase in hospital admission for children (Haripersad et al., 2021), and interference with the recovery process (Castellini et al., 2020). As this pandemic moves from initial crisis to more sustained change in our way of life, it is crucial to understand potential long-term consequences of this pervasive experience for those in our community most at risk, especially for those with pre-existing mental and physical health concerns, such as for those with a lived experience of eating disorders.
This study aims to better understand the pandemic experience for individuals experiencing eating disorder symptomatology within the community to identify risk factors and to re ne clinical understanding. Primarily, it is hypothesised that the COVID-19 pandemic and associated public health response, while necessary, has had a detrimental impact on the mental health of people with an ED, especially for those with a higher level of illness. Secondarily, it is hypothesised that those with cooccurring mental health conditions, those experiencing higher levels of depression, anxiety and/or stress, those experiencing loneliness, and/or those not actively engaged in treatment during the pandemic will be more negatively impacted, reporting worsening ED symptoms. This study is an open community study to investigate the impact the COVID-19 pandemic has had on people with a lived experience of an eating disorder.

Design and Setting
This was a national longitudinal observational study with bi-monthly self-reports of people 16 years and over with diagnosis of an eating disorder (ED) or experiences of ED symptomatology in Australia. A survey design, delivered by a secure online platform REDCap (Research Electronic Data Capture) (Harris et al., 2019) was chosen due to reach, cost-effectiveness and as a safe mode of delivery during public health orders, with recruitment open May to October 2020. The online survey was promoted within mental and general health sectors, via social media advertising and national media coverage. The estimated time to complete the survey was 20 minutes and was only offered in the English language. All participants who completed were entered into a draw to win one of two shopping vouchers worth AUD100 (<.001 probability) as a retention strategy. Collected data was deidenti ed and stored in a secure network data management system compliant with University Research Data Management Policy. This paper presents baseline data analysis.

Participants
Anyone with a self-reported current or previous clinical diagnosis of an eating disorder (APA, 2013) or self-reported ED symptom was invited to participate. Participants gave informed consent and could cease or withdraw at any time. The cohort was drawn nationwide with representation from all states and territories (Table 1), all under restrictions mandated by the Australian Government Department of Health for the duration of the study.

Australia's COVID-19 Public Health Response
From March 2020 with some easement of measures starting in October 2020, Australian borders were closed to all nonresidents, with returning residents required to spend two weeks in supervised quarantine hotels, all state and territory borders were closed within Australia, and social distancing rules were in place. After a surge of cases in March 2020, public health measures saw a signi cant reduction in cases to less than 20 per day by the end of April, and Australia had essentially eradicated the virus by November 2020, excepting quickly contained local outbreaks. As of March 2021, Australia has had 29,000 COVID-19 cases with 909 deaths (Australian Government Department of Health, 2021). Forty-ve percent of the study cohort was from the state of Victoria who experienced an additional stay-at-home order July to October 2020 due to an outbreak in May, signi cant to the survey period.

Measures
Following demographic, co-occurring mental illness, ED treatment and items pertaining to the experience of ED prior to the pandemic (pre-pandemic), participants were asked to rate any change in ED symptom they had experienced during the pandemic (within-pandemic) (i.e., body image concern, food restriction/dieting, binge/over-eating, etc.) and other pandemic experiences (i.e., quality of sleep, alcohol use, etc.) on a 5-point Likert scale (i.e., increased a lot-decreased a lot). Participants Pearson's chi squared tests to explore dichotomous variables. An alpha level of .05 was used for all statistical tests.

Demographics
Of 1723 participants, mode age was 24.9 years (age range collected), range 16-80 years, with 83.1% (n=1431) under 30 years. The majority (97.2%) were assigned the female gender at birth (n=1675; male n=46, prefer not to say n=2), with 91.6% (n=1578) identifying as female. Forty-ve participants (2.6%) identi ed as Aboriginal or Torres Strait Islander. Most participants lived in urban areas (81.5%), over half with their families (55.7%) or partner (16.4%), and 9.3% were parents. The cohort was well educated, with 40.9% having graduated high school and an additional 51.9% higher quali cation or degree, and 68.3% were in paid employment prior to the pandemic. Full demographics in Table 1.

Pre-existing eating disorder illness factors
Thirty-nine percent (n=679) self-reported a current DSM-5 (APA, 2013) eating disorder (ED) diagnosis, 20.1% (n=346) a previous diagnosis, with 40.5% (n=698) not having ever received formal diagnosis but self-identi ed ED symptoms. Table 1 shows the proportion of the sample by diagnostic group, the largest proportion reporting a lifetime experience of Anorexia Nervosa (AN) (42.3%). To note, participants could identify more than one diagnosis, with 33.1% identifying multiple.
Only 100 participants reported diet pill misuse (Table 2) but as reported increase in symptom was low for this group (n=4), no further analysis was interpreted (Table 3).
Participants reported a history of ED symptomatology for a mean (x) 9.28 years (SD=8.45, range 1-53 years, Median 7 and Interquartile range 3-12 years). Prior to the pandemic, the vast majority (95.9%) reported experiencing ED symptoms at least some of the time: 20.5% all the time, 45.0% most of the time, 16.4% half of the time, 14.0% some of the time, with 4.1% none of the time (but previously). Nearly half (47.9%) were receiving some form of ED treatment during the pandemic, 25.7% had received treatment in the past, and 26.5% had never received any treatment. To note, there was a signi cant difference between EDE Global Score for those with a treatment history (x=4.19, SD=1.16) compared to those with none (x=3.78, SD=1.19), t(1265)=5.58, p<.001. One hundred and twenty-seven participants had an inpatient admission within the past twelve months, and an additional 168 reported an admission prior to that, representing 17.1% of the sample reporting receipt of inpatient care.
Pre-existing co-occurring mental health factors Seventy-nine percent reported a current or lifetime co-occurring mental health condition: 71.1% obsessive-compulsive disorder, 70.9% anxiety, 55.2% depression, and 65.2% a history of self-harm, suicidal ideation or at least one suicide attempt (24.7% currently, 40.5% previously), detailed in Table 1

Impact of COVID-19
Participants were asked about the direct impact of COVID-19 on themselves or an immediate family member: 629 selfquarantined after being a close contact with an identi ed case, with 108 of that group falling physically ill with the virus. An additional 65 people were hospitalised, with 20 of those passing away. To note, 107 participants declined to answer.

Impact of COVID-19 on eating disorder symptoms
Participants were asked to rate degree of change of ED symptoms at assessment (within pandemic) compared to before the pandemic (pre-pandemic). Presented in Table 2 are responses by the total cohort and by subgroups dependent on whether the ED symptom was present pre-pandemic or not. As can be seen overall, there is a reported increase across most ED symptoms within pandemic: 88.0% of the total sample reported an increase in body image concern (67.2% a lot, 20.8% somewhat), 74.1% in food restriction/dieting, 66.2% in binge/over-eating, 48.6% in driven/over-exercise and 25.4% in selfinduced vomiting. Of the 1565 who reported body image concern as a current symptom prior to the pandemic, 90.5% reported an increase (70.3% a lot, 20.2% somewhat), of the 1300 who reported food restriction/dieting as a current ED symptom prior to the pandemic, 82.1% reported an increase, and of the 958 who reported binge/over-eating as a current ED symptom prior to the pandemic, 89.2% reported an increase.
Although applying to much smaller proportions of the cohort, reporting re-emergence and rst-time emergence of ED symptoms during the pandemic was not uncommon. As seen in Table 2, 59.3% of participants reporting previous (i.e., a lifetime ED symptom that was not active prior to the pandemic) body image concerns reported symptom return during pandemic. Similarly, 47.7% who reported lifetime food restriction/dieting, 47.2% binge/over-eating and 40.5% driven/overexercise reported re-emergence of those symptoms. For some participants who reported they had never experienced (or the symptom was not applicable) a particular ED symptom prior to the pandemic, they experienced it for the rst time during the pandemic: 65.3% reporting increased body image concerns; 37.5% food restriction/dieting, and 26.8% binge/over-eating.
Independent samples t-tests were used to explore the relationship (Mean Difference; MD) between change in ED symptoms reported during the pandemic with ED severity. For all ED symptoms, participants who reported an increase in ED symptoms during the pandemic (within pandemic) were signi cantly more likely to have a higher eating disorder severity score as indexed by the EDE Global Score, for example, body image concern (MD=0.98; t(1325)=10.05, p<.001) and food restriction/dieting (MD=0.62; t(1325)=8.62, p<.001) ( Table 3).
Pearson's chi-square test of independence with corresponding relative risk (RR) and con dence intervals (CI) were performed to explore relationships between change in ED symptoms within pandemic with ED diagnostic status and ED treatment status ( Table 4). The relationships between ED symptom and presence of ED diagnosis were mixed, for example, participants with current ED diagnosis (39.4%) were 1.6 times more likely to report an increase in self-induced vomiting during the pandemic as those without diagnosis (RR 1.62; 95% CI, 1.442 to 1.811), but 25% less likely to report an increase in binge/over-eating (RR 0.75; 95%CI, 0.667 to 0.842). The relationship between ED treatment status (i.e., whether participants were engaged in active treatment or not) and ED symptom change were also mixed. The 47.9% of the sample engaged in ED treatment were more likely to report an increase in self-induced vomiting (1.3 times), laxative and/or pill misuse (1.4 times) and driven/over-exercise (1.2 times), but 22% less likely to report an increase in binge/over-eating.
Relationship of mental state to eating disorder symptom change Independent samples t-tests were used to explore the relationship between ED symptom change during the pandemic with mental state (DASS-21) and loneliness (UCLA Loneliness Scale) ( Table 3). Higher DASS depression scores were associated with an increase in all ED symptoms within pandemic, such as for body image concern (MD=1.90; t(1216)=3.54, p<.001), food restriction/dieting (MD=1.50; t(1216)=3.84, p<.001), binge/over-eating (MD=0.94; t(1216)=2.63, p=.009), and selfinduced vomiting (MD=2.29; t(1216)=5.84, p<.001) with a moderate to high effect size. Higher DASS anxiety and stress scores were signi cantly associated with increased body image concern, food restriction/dieting, self-induced vomiting, driven/over-exercise and laxative and/or pill misuse. Finally, higher loneliness scores were associated with an increase in all ED symptoms except for driven/over exercise.
Pearson's chi-square test of independence with corresponding relative risks and con dence intervals were performed to examine the relation between the presence of at least one co-occurring mental health condition (79.0%) and change in ED symptom during the pandemic (Table 4). Participants who self-reported a current co-occurring mental health condition were 1.1 times more likely to experience an increase in body image concern (RR 1.11; 95%CI, 1.018 to 1.219) and food restrictions/dieting (RR 1.07; 95%CI, 1.006 to 1.135) within pandemic, noting modest effect sizes. Regarding the impact of the pandemic on other aspects of mental health: 87.5% of participants reported guilt over buying food, 69.3% a poorer quality of sleep, 50.3% increased alcohol use, 34.5% increased use of prescription medication, 32.3% increased smoking and 31.7% increased recreational drug use ( Table 2).

Impact of public health measures
Presented in Table 5, most participants were negatively impacted by a variety of public health measures and pandemic experiences, for example, 83.0% were negatively impacted from change in daily routine, 81.0% from restricted access to family and friends, 68.0% from social media reaction to the pandemic and 62.0% from news coverage. Independent samples t-tests were used to explore the relationship between eating disorder severity as indexed by the EDE Global Score and whether these experiences caused a negative impact, as opposed to a neutral/positive impact. There was a signi cant relationship between higher EDE Global scores in 12 out of 18 experiences, such as promotion of exercise as an essential activity (MD=0.55; t(1243)=8.49, p<.001), change in daily routine (MD=0.54; t(1254)=6.08, p<.001), availability of safe foods on meal plan, increased focus on cleaning/hygiene, and change in access to health professionals/treatment, to name a few.
Residents of the state of Victoria (45.6%) experienced stricter public health measures for most of the study duration so a comparison of impact was made to the rest of Australia. Current ED illness level as indexed by EDE Global score (MD=0.01; t(1221)=0.15, p=0.88) was not signi cantly different for Victorian residents (Table 3), and the only signi cant ED symptom increase was for food restrictions/dieting behaviour (RR 1.2; 95%CI, 1.07 to 1.38) ( Table 4). While there was no signi cant difference in stress, anxiety or loneliness, Victorian participants reported signi cant difference from the rest of Australia for depression (MD=1.93; t(1194)=2.72 p=0.007) to a large effect size (Table 3).

Discussion
This work represents one of the only national studies to have captured the impact of the pandemic on this pervasive and sometimes life-threatening psychiatric disorder during the height of a unique global experience. This was a well-advertised online community observational survey inviting anyone with a lived experience of an eating disorder to participate with a large response rate of over 1700 participants compared to other published studied to date. As might be expected for this population, 91% of the cohort identi ed as female. The cohort was overall skewed younger (mode 24.9 years) than other community studies (Hay et al., 2008), potentially due to the online nature and social media promotion of the study. Forty percent had never sought formal assessment for an eating disorder and 27% had never sought treatment, highlighting the importance of broad community-based recruitment for research to access those not engaged in the health system (Hart et al., 2011). The community cohort reported a high level of ED symptomatology with mean EDE global score comparable to clinical norms (Aardoom et al., 2012), with Anorexia Nervosa (17.1% current diagnosis, 19.4% previous diagnosis) being the most prevalent diagnostic group and body image concerns (90.8%) and food restriction (75.5%) the most pervasive symptoms.
As with emerging research (Castellini et al., 2020, Phillipou et al., 2020, Branley-Bell & Talbot, 2020), the hypothesis of the detrimental impact of the pandemic on the symptomatology of people with a lived experience of an eating disorder was well supported here, with 88.0% of the total cohort reporting increase in body image concern, 74.1% an increase in food restriction/dieting, 66.2% in binge/over-eating, 48.6% in driven/over-exercise and 25.4% in self-induced vomiting. For those reporting an ED symptom present at pandemic onset, a stronger impact of the pandemic was found across all ED symptoms, with 90.5% of participants who reported body image concern prior to the pandemic reporting an increase during the pandemic through to 54.6% for laxative and/or pill misuse. For the subset of participants who reported resolved ED symptoms pre-pandemic, nearly half reported symptoms re-emerging during the pandemic, namely body image concern (for 59.3% of the subset), food restriction/dieting (47.7%), binge/over-eating (47.2%), and driven/over exercise (40.5%), similar to reports of 41.9% of patients being treated for an ED experiencing a reactivation of symptoms (Graell et al., 2020). There was a subset of people in every ED behaviour category that reported rst-time emergence of that symptom during the pandemic, such as body image concern (62 out of 95 participants), food restriction/dieting (65/120), and binge/over-eating (96/358) ( Table 2), although these subsets were small compared to the proportion of the sample reporting a current experience of each symptom.
Overall, ndings of global increase across all ED symptoms, whether present prior to the onset of the pandemic or not, are of clinical concern, particularly noting that over half of the cohort were not engaged in any form of treatment during the pandemic. The pandemic impacted those with more severe illness more signi cantly than those with less severe illness (Table 3), with increase in all ED symptoms associated with higher EDE scores and/or formal diagnosis, except for binge/over-eating. Current treatment engagement related to less likely reporting of increased binge/over-eating but an increase in self-induced vomiting, driven/over exercise and laxative misuse, however those engaged in treatment did report more severe illness and likely more impact on symptoms due to the pandemic. Ongoing data collection to 6 months follow up, including analysis of the relationship of type and intensity of treatment during the pandemic, particularly the role of telehealth, is ongoing and will provide insights into the effect of treatment on symptoms during the pandemic.
Co-occurring mental health conditions are prevalent in ED cohorts and evidence suggests can increase the risk of severe eating disorder psychopathology (Herzog & Eddy, 2007). The cohort reported 79% having at least one co-occurring mental health condition and the presence of at least one co-occurring condition was associated with increased body image concern and food restriction during the pandemic, with higher mental health states of depression, anxiety and stress signi cantly associated with an increase in most ED symptoms. Social isolation and loneliness are risk factors common to EDs (Levine, 2012) and have been predictive of general psychiatric disorders during the pandemic especially in young women (Li & Wang, 2020), a group in which EDs are common; in this study, higher reported loneliness was found to be signi cantly associated with all ED symptoms except for driven/over-exercise. Other indicators of declining mental health were reported, such as reduced sleep quality (69.3%) and increased alcohol use (50.3%). Sixty ve percent of participants reported a history of selfharm and/or suicidal ideation or attempt, including a quarter in the 12 months prior to the pandemic. Given the association between EDs and self-harming behaviours (Franko & Keel, 2006) and escalating suicide risk due to the profound psychological and social effects of the pandemic in general (Gunnell et al., 2020), people with a lived experience of an eating disorder need to be particularly aware of the risk of declining mental health during such times of stress and uncertainty.
Even though only 10% of the sample reported a direct impact of the COVID-19 virus, namely themselves or an immediate family member becoming unwell, most reported high levels of worry and fear, and low levels of con dence and hopefulness associated with the pandemic. To curb viral spread, Australia's public health response was profound, and the impact of public health measures and general pandemic experiences had a negative impact for most participants, more signi cantly for those with more acute ED illness, such as the impact of changes in daily routine, social media and news coverage of the pandemic, and reduced access to social supports and health professionals and treatments. Negative impact of the intensity of public health measures (measured by the comparison of the participants residing in the state of Victoria to the rest of Australia) was only found for an increase in food restriction/dieting and a higher level of state depression. The overall public health response in Australia was timely, consistent and comprehensive, so increased restrictions for Victorian residents 5 months into the pandemic may have had minimal negative impact for study participants at this baseline analysis but will be reassessed during follow-up. In Australia, the pandemic itself has had a comparably mild impact compared to international standards yet a profound one for people with a lived experience of EDs, so it stands to reason that this population may be more at risk in those countries where the pandemic has more devastating repercussions.
Due to the rapid need for data collection within a critical timeframe, this study required a prerequisite of written and computer literacy in the English language which may have limited demographic diversity. Given the necessity for social distancing, online data collection was essential and therefore the self-report nature of observations without clinical validation of ED diagnosis or symptom severity is noted. However, high quality validated instruments with demonstrated good concordance with clinical presentation were used and the elevated ED index indicates this sample as indicative of a clinical population consistent with previous studies reporting high levels of body shape and weight concerns and eating disorder symptomatology in the community (Hay et al., 2008).

Conclusions
The Coronavirus pandemic has had a profound impact on the global community, with varied but concerted efforts to protect those most vulnerable from the infectious disease. Comprehensive public health response has attened the viral spread curve; however, the World Health Organisation warn of an accompanying mental health pandemic for generations to come requiring concerted action from Governments, communities and at risk individuals (Mohsen, 2020). The current study presents the impact of COVID-19 pandemic on people with a lived experience of an eating disorder within the Australian population to highlight the risk, especially for those with higher severity of illness, those with co-occurring mental health conditions, and those not currently engaged in clinical care, which was over half of our sample. Only 25% of people actively seek treatment for an ED (Shah et al., 2020) with up to 70% never accessing any care (Dearden & Mulgrew, 2013), and, as in other mental illness, lack of contact with the health care system is a risk factor for deterioration, the development of chronic illness, and death (Demmler et al., 2020). Previous research has suggested eating disorder assessment and management is challenged within primary health care settings (Ivancic et al., 2020), so these ndings highlight the importance of regular comprehensive mental health assessment and treatment across the health care system, especially for eating disorders, across the community presenting for care during this critical time. Increased awareness, screening, assessment, and an increase in the available options for treatment may well be needed to deal with the effects of the pandemic on this illness group and mental health more broadly.

Declarations Ethics approval and consent to participate
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. This study was approved by the Human Ethics Review Committee (Royal Prince Alfred Hospital Zone) of the Sydney Local Health District, Australia, protocol number X20-0181. Participants gave informed consent to participate and could cease or withdraw at any time.

Consent for publication
Not applicable

Availability of data and materials
The data that support the ndings of this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.

Competing interests
The study was conducted by the team at the InsideOut Institute, University of Sydney, of which Stephen Touyz (Editor-in-Chief of Journal of Eating Disorders) is a co-Director.

Funding
This study did not receive external funding, rather it was conducted by the research team from the InsideOut Institute, University of Sydney, due to the unprecedented opportunity and recognised need.

Author's contributions
The study was conceived by JMW, EK, RS and SM and HREC approval was managed by JMW and EK. The survey was designed by JMW, EK and RS and was approved by SM, JMW managed promotion and recruitment and EK managed online data collection. MK and EK conduced statistical analysis and the manuscript was prepared by JMW, EK, MK and SM. All authors read and approved the nal manuscript.  Denotes number of participants who reported this experience as applicable Figure 1 shows the proportion of the sample by diagnostic group, the largest proportion reporting a lifetime experience of Anorexia Nervosa (AN) (42.3%). To note, participants could identify more than one diagnosis, with 33.1% identifying multiple.

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