# data[].attributes.body
If future pandemics arise, society should establish a system to combat them, and perhaps the trend of these cases can be reduced.

# data[].attributes.body
In this article, tuberculosis is a socially addressed health issue, and how to link social protection measures such as cash transfers and nutrition programs provided by individual clinics to social welfare systems enacted as part of national policies is reviewed. We can model multi-sectoral methods in policy, program, and research that can be used to achieve disease elimination while simultaneously improving economic and development results for the world's most disadvantaged communities by combining social protection with tuberculosis care.

# data[].attributes.attachment_link.readable_text
Tuberculosis is fundamentally a disease of poverty; being poor increases the risk of falling sick with tuberculosis. Falling sick with tuberculosis also leads to impoverishment that can trigger a downward spiral of worsening health, ongoing tuberculosis transmission, crippling medical expenses, which further entrench poverty. Because of these realities, purely biomedical or public health solutions are not enough to end the tuberculosis epidemic; countries must implement social policy strategies that can protect tuberculosis sufferers from the financial shocks of this deadly disease. In September 2018, the UN will convene a High-Level Meeting (HLM) to ensure that Heads of States and Governments commit to ending this epidemic. This meeting provides a unique opportunity to underscore the importance of social protection interventions in ending tuberculosis. Here, we present compelling evidence for why such interventions represent a critical investment for high-burden countries and global partners.

Substantial research demonstrates that tuberculosis perpetuates poverty, causes substantial losses in productivity for already poor individuals (3-4 months of work), families (30% of yearly household earnings), and countries (4-7% of GDP). National surveys in seven countries

3

demonstrate that patients who develop tuberculosis often face catastrophic costs (>20% household income) just to obtain tuberculosis services driven by high direct and opportunity costs related to accessing tuberculosis diagnostic and treatment care. In high-burden countries that have conducted patient-costing surveys, up to 83% of tuberculosis-affected households were reported to experience catastrophic costs, and up to half to have taken out loans or sold assets (so-called dissavings).

4

Significant social and economic burdens make patients with tuberculosis less likely to present for care, complete tuberculosis testing, and initiate treatment, leading to increased transmission, morbidity, and mortality.

6

With the WHO's End TB Strategy and the Sustainable Development Goals (SDG) Agenda,

8

there is a renewed policy interest in integrating social, economic, and health goals, targets, and indicators. This interest includes setting targets such as 0% of tuberculosis-affected households incurring catastrophic costs, using tuberculosis as a "tracer" disease to measure achievement of the SDGs,

8

linking socioeconomic indicators with tuberculosis indicators in standard public health platforms, and supporting universal health coverage (UHC) for all. While we acknowledge that progress towards UHC is essential to ending the epidemic, we argue that guaranteeing UHC in high-burden countries will be insufficient to address the tuberculosis epidemic. Social protection interventions that prevent or mitigate other financial risks associated with tuberculosis, such as income losses and non-medical expenditures, must also be considered.

Examples of social protection include interventions from cash transfers and nutrition programmes offered by individual clinics to social welfare systems adopted as part of national policies. They can contribute to successful tuberculosis outcomes both through indirect means, addressing social, biological, and structural determinants, or through direct means that enable access to care. The table summarises country-based social protection interventions in various stages of implementation and evaluation. Ecological and modelling studies suggest that countries that increase spending on social protection programmes have an associated decrease in tuberculosis incidence and prevalence, and a reduction in mortality.

9

, Recent models leveraging data from 192 countries to link the SDG targets to tuberculosis outcomes, suggest that expanding social protection schemes to all eligible populations could decrease tuberculosis incidence by 76%, underscoring its potential impact when used in tandem with proven biomedical interventions.

What can be done now to start implementing a social protection agenda? First, we should support additional research on social protection and tuberculosis. Data are needed to understand the burden of catastrophic costs and dissavings, and how these measures influence tuberculosis and socioeconomic outcomes. Second, we should advocate for context-specific, multi-sectoral social protection policies and programmes; poverty-alleviation is not outside of our purview but is central to our work. Additional research that incorporates implementation science, health economics, and social epidemiology is needed to identify and design feasible, scalable social protection interventions that are context-specific. Finally, policies need to be established to give national tuberculosis programmes (NTPs) the support and mandate necessary to address the socioeconomic consequences of illness for their patients.

In summary, to capitalise on the political opportunity that the HLM presents, the tuberculosis community must emphasise to Heads of States and Governments how a successful response to the epidemic needs to extend beyond biomedical solutions, and address all patient barriers to tuberculosis prevention and care. Further, by integrating social protection with tuberculosis care, we can model multisectoral approaches in policy, programme, and research that can be used to achieve disease elimination and simultaneously improve economic and development outcomes for the world's most vulnerable populations.

We declare no competing interests.

1. 1.

Lonnroth K

Glaziou P

Weil D

Floyd K

Uplekar M

Raviglione M

Beyond UHC: monitoring health and social protection coverage in the context of tuberculosis care and prevention.

: e1001693

2. 2.

Laxminarayan R

Klein E

Dye C

Floyd K

Darley S

Adeyi O

Economic benefit of tuberculosis control (English). Policy Research working paper.

World Bank, Washington, DC 2007

3. 3.

Wingfield T

WHO Taskforce on Measurement of Catastrophic Cost of Tuberculosis

Implementation of the World Health Organization's Tool for Measuring TB Patient Costs: country level results, adaptations, and future directions.

Int J Tuberc Lung Dis. 2017; 21 : S26

4. 4.

Global Tuberculosis Report 2017.

World Health Organization, Geneva 2017

5. 5.

Hargreaves JR

Boccia D

Evans CA

Adato M

Petticrew M

Porter JD

The social determinants of tuberculosis: from evidence to action.

: 654-662

6. 6.

Dye C

Lonnroth K

Jaramillo E

Williams BG

Raviglione M

Trends in tuberculosis incidence and their determinants in 134 countries.

: 683-691

7. 7.

Uplekar M

Weil D

Lonnroth K

et al.

WHO's new end TB strategy.

: 1799-1801

8. 8.

Transforming our world: the 2030 Agenda for Sustainable Development.

United Nations, New York 2015

9. 9.

Siroka A

Ponce NA

Lonnroth K

Association between spending on social protection and tuberculosis burden: a global analysis.

: 473-479

10. 10.

Carter DJ

Glaziou P

Lonnroth K

et al.

The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.

: e514-e522

Creative Commons Attribution - NonCommercial - NoDerivs (CC BY-NC-ND 4.0) |

How you can reuse

Access this article on ScienceDirect

# data[].attributes.attachment_link.title
Message to world leaders: we cannot end tuberculosis without addressing the social and economic burden of the disease

# data[].attributes.attachment_link.description
Tuberculosis is fundamentally a disease of poverty; being poor increases the risk of falling sick with tuberculosis. Falling sick with tuberculosis also leads to impoverishment that can trigger a downward spiral of worsening health, ongoing tuberculosis transmission, crippling medical expenses, which further entrench poverty.1 Because of these realities, purely biomedical or public health solutions are not enough to end the tuberculosis epidemic; countries must implement social policy strategies that can protect tuberculosis sufferers from the financial shocks of this deadly disease.

# data[].attributes.body
This infographic depicts the global impact of tuberculosis. The statistics are alarming, and they continue to rise to this day all around the world. Putting in even more effort and research can lead these tendencies to cease, notwithstanding how difficult it is to minimize the number of cases.

# data[].attributes.headline
Prevalence of Eating Disorders Worldwide from 1990 to 2017

# data[].attributes.subject
Prevalence of Eating Disorders Worldwide from 1990 to 2017

# data[].attributes.body
Over the last two decades, the global prevalence of eating disorders has risen. Eating disorders are more common among people aged 15 to 34, according to this graph. Countries all across the world may build and locate resources for people with eating disorders, as well as likely provide rehabilitative programs.

# data[].attributes.body
The disease's ongoing and significant worldwide health impact is exacerbated by a lack of research, diagnosis, and treatment. This may have an impact on the current trends in global and international health methods to the condition that aren't functioning, and a global collaboration to treat this sickness is required.

# data[].attributes.body
These diseases has touched people all around the world, with a wide range of ages, ethnic backgrounds, and other factors, making it a global health issue.

# data[].attributes.body
Diseases that are around world-wide

# data[].attributes.body
This graph shows the trends of COVID-19 cases from world-wide. As we can see here, the rest of the world has higher cases compared to the US, India, Brazil, Russia, and France. Countries working together can help reduce the amounts of cases in the rest of the world by implementing good health policies that can provide accessible aid to people.

# data[].attributes.headline
International Health + Global Health (Thesis)

# data[].attributes.subject
International Health + Global Health (Thesis)

# data[].attributes.body
I feel that taking an international health perspective to global health allows us to identify the different types of issues which every country is experiencing while also improving global health fairness by coordinating global health policies. Because international health demonstrates that health issues are interconnected, global health necessitates similar solutions that require countries to collaborate to produce more effective policies that will benefit all countries.

# data[].attributes.body
People who are or have been an eating disorder are more likely to die, have a high YLD rate, have a lower quality of life, have higher costs, and have issues with childbearing. Eating disorders also have a detrimental impact on the number of years a person spends disabled, their quality of life, the financial expenses to patients and their caregivers, and childbearing and parenting.

# data[].attributes.attachment_link.readable_text
INTRODUCTION

'Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning', as Treasure et al. [ 1] state. This makes effective treatments the more important. For bulimia nervosa [ 2, 3] and binge eating disorder (BED) [ 4], there are effective psychological treatments, especially cognitive behaviour therapy (CBT). However, for anorexia nervosa, a recent meta-analysis could not establish its efficacy over an active control condition [ 5]. For the most severe and enduring cases of anorexia nervosa, there is a paucity of evidence-based treatments [ 6].

The efficacy of treatment (or lack thereof) is reflected in illness duration and remission rates. A series of publications on very long-term (10-20 years) follow-up studies of inpatients with an eating disorder showed that, respectively 64% of persons previously diagnosed with anorexia nervosa, 53% of those previously diagnosed with bulimia nervosa, and 30% of those previously diagnosed with BED, still met diagnostic criteria for an eating disorder at follow-up; a further 6% for anorexia nervosa, 9% for bulimia nervosa and 31% for BED had remaining eating disorder symptoms [ 7, 8▪▪, 9]. Higher recovery rates of anorexia nervosa were reported in two smaller long-term (≥20 years) follow-up studies of adolescent-onset anorexia nervosa; one on an outpatient sample [ 10], the other on a community sample [ 11▪▪]. In both studies, around 65% of the cases were in complete remission at follow-up. Thus, across eating disorders, a considerable 62-70% of people who had received inpatient treatment and 35% who had received outpatient treatment, still met full diagnostic criteria or had remaining eating disorder symptoms at long-term follow-up.

Protracted eating disorder pathology means that eating disorders have a great impact on the present and future health and quality of life of affected persons, their caregivers and society. In this journal in 2016, Erskine et al.[ 12] described the inclusion of eating disorders in the Global Burden of Disease (GBD) study in 2010 as a watershed in the recognition of these disorders in the wider global health community, and presented findings on the burden of eating disorders from the GBD 2013 database. Here we review current GBD data on eating disorders. Furthermore, we widen the scope of burden to address some of the limitations of the GBD concept of burden as 'within-the-skin' health loss: as Erskine et al.[ 12] noted, the impact of eating disorders on families and other support systems is neither reflected in the GBD burden estimates nor do they represent the future adverse impact of an eating disorder on an individual's psychological and economic well being. And as only anorexia nervosa and bulimia nervosa have so far been included for burden quantification, the GBD data only pertain to a subset of eating disorders. This review addresses eating disorder-related mortality, disability, economic cost, and other individual, caregiver and family burden.

GLOBAL BURDEN OF DISEASE STUDY

A major global effort to gather, combine, and compare information on the burden associated with a large range of disorders, both somatic and mental, is the ongoing Global Burden of Disease (GBD) study, which started in 1990. Information is regularly updated and available online through the Global Health Data Exchange (GHDx) site of the Institute of Health Metrics and Evaluation (Seattle, Washington, USA): http://ghdx.healthdata.org/. Anorexia nervosa and bulimia nervosa have been included since the GBD 2010 study.

The burden of disease is defined as the gap between current health status and an ideal situation in which everyone lives into old age free of disease and disability. Causes of the gap are premature mortality, disability, and exposure to certain risk factors that contribute to illness. An important metric to express this gap is the disability-adjusted life year (DALY). One DALY expresses one lost year of 'healthy' life. The burden of a disease is the sum of DALYs for this specific disease across a population. DALYs are calculated as the sum of the years of life lost (YLL) because of premature mortality and the years lost due to disability (YLD), thus incorporating both mortality and morbidity information. Using DALYs, the burdens of various diseases can be compared, from those that cause premature death but little disability to those that cause disability but not death.

For mental health disorders, YLD are the main contributors towards DALYs. Table shows the GBD 2017 data on YLD for eating disorders, all mental disorders (substance use disorders not included), all noncommunicable diseases (of which mental disorders are part), and all causes [ 13▪, 14].

Table 1

It was estimated that in 2017, worldwide over 3.3 million healthy life years were lost to eating disorder-related disability, amounting to an age-standardized YLD rate of 9.4 for anorexia nervosa, and 33.8 for bulimia nervosa, per 100 000 population. YLD rates for eating disorders contributed 2.8% to the overall YLD load of mental disorders. Whereas from 2007 to 2017, YLD rates remained constant or decreased slightly for all causes, noncommunicable diseases, and mental disorders overall, for anorexia nervosa and bulimia nervosa these rates increased by 6 and 10%, respectively.

Challenges to the estimation of eating disorder burden were noted by Erskine et al.[ 12] in 2016, for instance that ' the representativeness of the available eating disorder prevalence data, measured as 'coverage', is poor' where 'no or limited data results in large uncertainty intervals around prevalence estimates and subsequently burden estimates', and these still hold. Thus, GBD data on eating disorders and other mental health disorders must be interpreted with caution.

In the following two sections we look into the basic parameters for burden of disease, mortality and disability, in persons with an eating disorder as compared with persons without an eating disorder.

Mortality

Studies are reviewed that have been published since the review by Smink et al.[ 15] in 2013 in this journal, and which report mortality rates for eating disorder relative to a reference population: either an age-matched and sex-matched control group (death hazard ratio), or relative to expected death rates in the age-matched and sex-matched general population as a whole (standardized mortality ratio: SMR) or in the subset of the general population that has no eating disorder (mortality rate ratio: MRR). Another commonly used measure of mortality, the crude mortality rate (CMR), represents the rate of mortality within the study population (e.g. eating disorder) over a specified period. As it does not allow for comparison across study populations like the age-matched and sex-matched controlled studies do, it is not reviewed here.

In users of secondary mental healthcare services an SMR of 5.2 (95% confidence interval (CI): 3.8-7.0) was reported for anorexia nervosa and atypical anorexia nervosa according to ICD-10 criteria [ 16]. Also using ICD-10 criteria, Suokas et al. found a hazard ratio of 6.5 (95% CI: 3.5-12.3) for people with anorexia nervosa and atypical anorexia nervosa treated in tertiary care [ 17]. These rates were comparable to the SMR for anorexia nervosa of 5.9 (95% CI 4.2-8.3) calculated in a landmark meta-analysis of worldwide eating disorder mortality rates published in 2011 [ 18], but higher than the relative risk of 2.2 (95% CI: 2.1-2.3) for mortality of mental disorders versus controls, pooled over 148 studies [ 19].

One recent study, linking data from primary and secondary care, reported mortality rates for anorexia nervosa comparable to the mortality risk pooled for various mental disorders [ 20▪▪]: the HR for anorexia nervosa and atypical anorexia nervosa (diagnosed according to ICD-10 or Read Version 2 primary care diagnostic criteria) was 2.3 (95% CI 1.9-2.8); both genders combined. Female patients had the highest hazard ratio 2.5 (95% CI 2.1-3.1). The majority of the patients had not been referred to a hospital, and thus the eating disorders may on average have been less severe than those in previous studies, which included cases identified mainly through hospital records or eating disorder treatment facilities. In the same study, a hazard ratio of 1.4 (95% CI 1.1-1.8) was reported for bulimia nervosa and atypical bulimia nervosa, diagnosed according to ICD-10 criteria [ 20▪▪]. This rate is similar to the SMR of 1.5 (95% CI 1.1-2.0) of DSM-IV defined bulimia nervosa reported by Fichter and Quadflieg [ 21] and the SMR of 1.9 (95% CI 1.4-2.6) in the meta-analysis by Arcelus et al.[ 18].

In their review, Smink et al. identified one study that reported an SMR for BED of 2.3 (95% CI 0.0-5.5) [ 9]. Since then, two follow-up studies have reported relative mortality rates for BED: in Finnish inpatients the hazard ratio was 1.8 (95% CI 0.6-5.3) [ 17], and in German inpatients, the SMR was 1.5 (0.9-2.4) [ 21]. None of the mortality rates for BED were significantly higher than in controls.

For the combined category of anorexia nervosa, bulimia nervosa, and other eating disorders (ICD-10 code F50), in a study linking data from the Danish Psychiatric Central Research Register (containing information on inpatient treatment and outpatient and emergency room visits) with the Danish Register of Causes of Death, an overall MRR of 2.9 (95% CI 2.6-3.1) was reported [ 22▪].

Finally, in one male-only, 30-year follow-up study of inpatients, SMRs were 5.9 (95% CI 3.6-9.2) for anorexia nervosa, 1.9 (95% CI 0.9-3.6) for bulimia nervosa, and 3.4 (95% CI 1.4-7.0) for EDNOS; all diagnoses according to DSM-IV [ 23]. These results are largely in line with previous studies reporting mortality in male patients with an eating disorder.

Disability and functioning

Erskine et al.[ 12] extended the GBD context for disability from time lived with loss of health to a broader concept capturing deficits in other areas and the impact on caregivers and the community. This was reflected in disability weights derived from population surveys where respondents make pairwise comparisons of health conditions as to which of the two they consider the most 'unhealthy'. On a scale of 0 (perfect health) to 1 (death), disability weights for anorexia nervosa were calculated at 0.224 and for bulimia nervosa at 0.223. These are worse (higher weights) than, for example, for chronic state kidney disease (0.104) or severe heart failure (0.179), but better than for schizophrenia (0.778), which had the highest disability weight among 301 acute and chronic diseases and injuries [ 24].

Disability and functioning are two sides of the same coin. The WHO International Classification of Functioning, Disability and Health (ICF) provides a framework for measuring functioning and disability in relation to health conditions [ 25]. The WHO Disability Assessment Schedule (WHODAS 2.0) is the associated measuring instrument and looks into psychosocial activities and participation. In DSM-5, the WHODAS 2.0 has been put forward to replace the Global Assessment of Functioning (GAF) scale used in DSM-IV [ 26]. The original version is patient-based. However, for patients with severe mental illness who lack insight into their health problems, Koopmans et al. [ 27]. advocated the use of the proxy version by a caregiver or well informed health professional.

Despite the fact that DSM-5 has been introduced in 2013, the WHODAS 2.0 has not so far been widely adopted in mental health research and practice. Although Edlund et al.[ 28] indicated that eating disorders 'might be highly disabling', in their nationally representative population surveys using the WHODAS 2.0, the authors did not include eating disorders because of their relatively low prevalence. The two studies that did assess a patient-reported version of the WHODAS in patients with an eating disorder either did not have a noneating disorder control group [ 29] or did not report separately on patients with an eating disorder [ 30]. As yet, no study has used the proxy version of the WHODAS 2.0 in people with an eating disorder. For anorexia nervosa, in particular, the proxy information may be warranted, as patients with anorexia nervosa often deny that they are ill. Furthermore, parents are an important source of information on children and adolescents, as anorexia nervosa shows a peak incidence between 12 and 19 years old [ 31].

Quality of life

A report commissioned by a UK national charity indicated that, according to both patients with an eating disorder and their caregivers, eating disorders had a significant impact on patients' participation and productivity at education and work, overall well being, and quality of life, and on social and family life for both patients and their caregivers [ 32].

Several recent studies have reported problems in quality of life for current and former patients with an eating disorder. A general population cohort study in the USA revealed that those with a lifetime history of eating disorder (anorexia nervosa, bulimia nervosa, BED, and other eating disorder diagnoses combined) had a significantly lower quality of life (as measured with the EQ-5D-5L) than noneating disorder controls [ 33]. In a review of residual eating disorder symptoms and clinical features in patients who were in remission or had recovered, Tomba et al.[ 34▪] reported that former eating disorder patients had a significantly lower quality of life and reduced capabilities in several areas of social functioning compared with noneating disorder controls, and that psychological well being did not improve up to the level of healthy controls. De Vos et al.[ 35] reported that patients with anorexia nervosa, bulimia nervosa, BED or Other Specified Feeding and Eating Disorders (OSFED) had significantly worse scores than the general population on overall, emotional and psychological well being; social well being was significantly lower only for patients with anorexia nervosa and bulimia nervosa. They also looked at 'the other side' of the spectrum of mental health states and found that some of those with an eating disorder reported they were flourishing; ranging from 9.3% (anorexia nervosa) to 24.6% (BED) compared with 36.8% in the general population.

Comorbidity is common in eating disorders and may increase the burden of disease. A 2019 review in this journal by Rijkers et al.[ 36] indicated that the prevalence of PTSS in eating disorders ranged from 9 to 24%. Patients with an eating disorder ( n = 6560) were reported to experience higher levels of personality disorders (odds ratio (OR) = 10.8; 95% CI 6.6-18.6), alcohol dependence syndrome (OR = 6.0, 95% CI 3.9-9.4), and depressive disorders (OR = 5.9; 95% CI 4.8-7.4) than a group of age-matched and sex-matched controls [ 20▪▪]. The impact of eating disorders on well being may already be visible in health service use data prior to diagnosis as indicated by increased general practitioner prescriptions for central nervous system and dietetic drugs in the 2 years before the diagnosis of an eating disorder [ 20▪▪].

Economic cost

Another way to look at illness burden is to consider the costs to the individual and to society. In 2005, Simon et al.[ 37] reviewed the health service use and cost of patients with an eating disorder. They concluded that much less was known about this topic in eating disorders than in many other mental disorders. This was still found to be the case as recently as 2019 [ 38]. Mental illnesses, in general, reduce the chances of completing school, getting and keeping a full-time job, and earning high wages [ 38]. The long-term costs of an illness may be higher when the peak age at incidence is relatively low and chronicity is high, such as in eating disorders.

Disease costs of eating disorder involve treatment costs, and direct financial burden and loss of earnings for both patients and caregivers. The BEAT report calculated direct yearly costs of eating disorders in Wales at £1500 for patients and £2800 for caregivers, and the average costs for treatment per patient at £8850 per year [ 32]. Yearly costs of time off work and education were found to be £650 for patients with an eating disorder under 20 years old, £9500 for those over the age of 20, and £5950 for caregivers. The loss of earnings was reported to extend beyond the average treatment period of 6 years. How these costs related to healthcare costs for people without an eating disorder was not assessed. A review by Agh et al.[ 39] analysed 17 studies reporting healthcare costs of eating disorders; none of these compared costs with those of noneating disorder controls. Samnaliev et al.[ 40] reported that people with an eating disorder in the USA had yearly healthcare costs that were on average 48% higher than in the general population, and that within those with an eating disorder who were employed, the presence of mental health comorbidity was associated with an almost 50% reduction of yearly earnings. Another study found that healthcare use and associated costs in the year prior to a diagnosis of BED were already higher than for controls [ 41].

Family burden

Finally, eating disorders may not only impact the person with an eating disorder, but also affect relatives, in particular caregivers (parents) and offspring as well. There are very few studies that address caregiver's burden in eating disorders, let alone compare these to other health conditions or noneating disorder controls. A comparison by Martín et al. between caregivers of patients with an eating disorder, with depression or with schizophrenia, indicated that the caregiver's burden (worrying, tension, urging) was higher for carers of patients with an eating disorder [ 42]. In a study on anorexia nervosa, negative perceptions of the consequences of anorexia nervosa for young people also negatively impacted the caregiver's burden, regardless of anorexia nervosa symptom severity [ 43].

In a small-scale longitudinal study, Martini et al.[ 44] found that at 6 months postpartum, mothers with current and past eating disorder reported higher concerns about their child being or becoming overweight, and were less aware of hunger and satiety cues in their child, compared with healthy controls. A systematic literature review of studies comparing mothers with and without an eating disorder and their children revealed a range of differences that indicate an impact of maternal eating disorder on the child's psychological, cognitive, and eating development, such as more behavioural difficulties regarding feeding and eating, more socioemotional difficulties, and possibly an increased risk for the development of eating disorder in the child [ 45]. Reports of children's difficulties by mothers with an eating disorder may be biased and need to be considered with caution.

In women from Utah, USA, with a previous eating disorder, age at first birth (anorexia nervosa: 26.4 years; bulimia nervosa: 25.7 years; EDNOS 25.6 years) was significantly higher than in matched controls from the general population (24.1 years) [ 46]. Taking marital status into consideration, fertility rates for anorexia nervosa were 18%, for bulimia nervosa 23.3%, and for EDNOS 18.6%, compared with 48.3% in age-matched general population controls. This indicates that women with an eating disorder history may experience delay or disruption of their reproduction because of their previous eating disorder. In Sweden, a large birth register study revealed increased risks for adverse pregnancy and neonatal outcomes, such as preterm birth and microcephaly, both for women with a current eating disorder as well as those with an eating disorder in remission [ 47▪].

# data[].attributes.attachment_link.title
Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden

# data[].attributes.attachment_link.description
'Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning', as Treasure et al. [ 1] state. This makes effective treatments the more important. For bulimia nervosa [ 2, 3] and binge eating disorder (BED) [ 4], there are effective psychological treatments, especially cognitive behaviour therapy (CBT).

# data[].attributes.body
The COVID-19 pandemic has been sweeping the globe since December 2019 and continues to this day. Sars-CoV-2 is a coronavirus that can cause respiratory issues and other symptoms depending on heredity, geography, and a variety of other variables. This sickness has affected everyone on the planet and continues to do so now. COVID-19 was and continues to be a big global burden, causing increased physical and mental health concerns, socioeconomic disruption, and other issues on a global scale.