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The role of complementary and alternative medicine in the treatment of eating disorders: A systematic review
The role of complementary and alternative medicine in the treatment of Eating Disorders: A systematic review Sarah Fogarty, Caroline A. Smith, Phillipa Hay PII: DOI: Reference:
S1471-0153(16)30026-5 doi: 10.1016/j.eatbeh.2016.03.002 EATBEH 1024
To appear in:
Eating Behaviors
Received date: Revised date: Accepted date:
29 August 2015 23 February 2016 1 March 2016
Please cite this article as: Fogarty, S., Smith, C.A. & Hay, P., The role of complementary and alternative medicine in the treatment of Eating Disorders: A systematic review, Eating Behaviors (2016), doi: 10.1016/j.eatbeh.2016.03.002
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CAM and Eating Disorder Systematic Review
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Caroline A Smith Phillipa Hay
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National Institute of Complementary Medicine, Western Sydney University, Sydney
[email protected]
School of Medicine, University of Western Sydney, [email protected]
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Sarah Fogarty*
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The role of Complementary and Alternative Medicine in the treatment of Eating Disorders: A Systematic Review
* Corresponding Author: Sarah Fogarty, Western Sydney University, Locked Bag 1797, Penrith, NSW
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2751, Australia. Email: [email protected] or [email protected]
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Key words: Eating disorders, Complementary and Alternative Medicine, Systematic Review
ABSTRACT
This systematic review critically appraises the role of complementary and alternative medicine in the treatment of those with an eating disorder. Sixteen studies were included in the review. The results of this review show that the role of complementary and alternative medicine in the treatment of those with an eating disorder is unclear and further studies should be conducted. A potential role was found for massage and bright light therapy for depression in those with bulimia nervosa and a potential role for acupuncture and relaxation therapy, in the treatment of State Anxiety, for those with an eating disorder. The role of these complementary therapies in treating eating disorders should only be provided as an adjunctive treatment only.
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BACKGROUND
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Complementary and alternative medicine (CAM) refers to a broad range of health
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practices (1-3) and thus a definition of what constitutes a CAM therapy has at times been unclear. The National Centre for Complementary and Integrative Health separate
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complementary and alternative medicine with complementary being “a non-mainstream practice used together with conventional medicine” and alternative being a non-
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mainstream practice used in place of conventional medicine” (4). An operational definition of CAM proposed by Wiedland and colleagues defines CAM based on (i) therapies that rely
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upon non-allopathic models of health, (ii) exclusion from standard treatment within the dominant medical system, and (iii) self-care or care delivered by alternative practitioners
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(5). This review uses this definition of CAM as there are therapies that are used, both in combination with conventional medicine, and as the primary treatment. A list of the CAM
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modalities can be seen in See Appendix 1.
Eating disorders according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), include Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), PICA, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder (ARFID) or Other Specified or Unspecified Feeding or Eating Disorder (OSFED or UFED) (6). OSFED/UFED replaces the Eating Disorder Not Otherwise Specified (EDNOS) category.
In the developed world the lifetime prevalence of eating disorders is 1.01% and they appear to be increasing (7, 8). Eating disorder morbidity is also high, and mortality is 2
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amongst the highest of psychiatric disorders (9). Eating disorders are chronic illnesses with frequent relapses occurring for many individuals (10). Greater than 20% of individuals
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continue to have an eating disorder on long term follow up, and many may develop mental
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illness such as depression (15-60%), anxiety disorders (20-60%), or personality disorders
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(11).
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A multidimensional treatment approach to the treatment of eating disorders is most commonly adopted. Multidimensional treatment addresses the physical, psychological,
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psychosocial and family needs of the individual, and can include psychiatrists, psychologists, primary care physicians, social workers, nurses and dieticians. Treatment aims to restore the
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individual’s weight within normal range for their height and age, to reduce abnormal eating
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behaviours, and weight and shape cognitions, and manage co-morbidities (both mental and
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physical). There is evidence for the use of cognitive behavioural therapy for BN and BED and family based therapy for adolescents with AN (12) and a small base of evidence for
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pharmacological management of AN (13), however the evidence base underlying these current therapeutic approaches has limitations.
Some of these limitations include
addressing personal recovery needs such as a personally satisfying quality of life (14) and personal concepts of recovery (10). Recovery from an eating disorder varies between individuals but generally involves restoration of healthy eating habits and “a healthier physical and psychological state of being” (15).
Reported use of CAM is increasing and especially for acupuncture, deep breathing exercises, massage therapy, meditation and yoga (16). CAM use is high among individuals diagnosed with mental health conditions especially anxiety and depression where 56.7% of
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those with anxiety attacks, and 53.6% of those with severe depression reported using CAM as an adjunct to treat their conditions (17). There is an increasing evidence base identifying
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the adjunctive use of complementary therapies to assist with the management of eating
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disorders however the prevalence of CAM use among people with and eating disorder is
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unknown (18-20). Previous reviews on the use of CAM therapies and eating disorders have not been systematic, are dated and were inconclusive (18, 19). Qualitative research findings
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indicate that eating disorder sufferers’ find CAM therapies acceptable and beneficial as adjuncts to their eating disorder treatment (18, 19, 21, 22). Complementary and alternative
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therapies that improve patient outcomes, reduce the burden of poor health and help facilitate personal recovery needs are highly desirable. The aim of this review is to examine
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the role of CAM therapies in the treatment of eating disorders.
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METHODS
Inclusion and exclusion criteria
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Studies were included if they involved CAM treatment of an Eating Disorder (ED). An eating disorder was defined as meeting DSM diagnostic criteria (Editions 1-5) (6) or equivalent diagnostic criteria e.g., International Classification of Diseases (23), or clinical assessment by a specialist e.g. psychologist, psychiatrist. Eating disorders included in this criterion are: Anorexia Nervosa, Bulimia Nervosa, Eating Disorder not Otherwise Specified, Binge Eating Disorder, PICA, Avoidant/Restrictive Food Intake Disorder and Other Specified or Unspecified Feeding or Eating Disorders. Studies also had to involve one of the CAM modalities defined by Wiedland and colleagues (5). Dietary supplements and diet therapy have been excluded as these are
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frequently used as standard Western medicine treatments for eating disorders (24) See
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Appendix 1 for a list of all the CAM modalities.
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All published and unpublished randomised controlled trials were eligible for
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inclusion. Studies were excluded if they were not a randomised controlled trial, if they were not investigating a CAM therapy or they did not include an eating disorder population or
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sample.
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Search strategy
The electronic databases The Cochrane Collaboration Depression, Anxiety and
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Neurosis Controlled Trials Registers, Medline (years 1946-2013), EMBASE (1974-2013),
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CINHL (1950-2015), PsycINFO (1786-2015) and PubMed (1950-2015) were searched for
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Randomised Controlled Trials (RCT’s) investigating CAM therapies and the treatment of eating disorders in September 2013 and again in January 2015. The search strategy can be seen in Appendix 2 and was applied for each CAM therapy excluding dietary supplements
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and therapy, and for each database. One author (SF) independently selected articles that met the criteria for the systematic review through scrutiny of all the abstracts of papers identified from the searches after duplicates were removed. The data extraction procedure was performed according to the guidelines outlined by the PRISMA statement (25). Where it was unclear if a paper was to be included, a second reviewer was consulted (PH or CS). Reasons for excluding trials have been stated in Figure 1. One author (SF) independently reviewed all the studies and two authors (CS and PH) both independently reviewed half of the studies, using the standardised data extraction form. Data was entered into the Review Manager
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Software by author SF.
Any discrepancies were discussed by the three reviewers.
Additional searching of conference proceedings, the International Clinical Trial Registry and
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the Australian, New Zealand Clinical Trial Registry (ANZCTR) and the reference lists of all
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papers selected was undertaken to identify further relevant studies.
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Outcome measures
The outcomes that were included within the review were improvements in eating
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psychopathology (e.g. binge eating, restriction, drive for thinness, shape and eating
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concerns) or improvements in general psychopathology (weight, anxiety, depression, quality of life). Side-effects or negative effects (where provided) and patient satisfaction (where
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assessed) were also included.
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Data analysis
A meta-analysis of the data, although initially planned, was not undertaken due to
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the small number of studies within each CAM modality. All included articles were reviewed in detail and analysed thematically according to diagnostic classification and effect. Risk of bias (investigating random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data and selective reporting) for each study was assessed using the Cochrane tool for assessing bias (26). Findings and limitations in the literature as well as areas of further research are addressed below.
RESULTS
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Sixteen articles that involved CAM therapies and eating disorders were identified and reviewed; see Table 1. Nine different CAM therapies were investigated in the RCT’s;
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acupuncture, bright light therapy, eye movement desensitization and reprocessing,
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hypnosis, massage, relaxation, repetitive transcranial magnetic stimulation, spirituality and
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yoga. See Appendix 3 for a description of the nine CAM therapies. It is of note that the authors of the included papers used varied outcome tools covering a wide range of eating
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disorder symptomology to assess treatment efficacy such as binging, purging, depression, anxiety and the like. Comparison interventions or control groups for the included studies
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involved wait lists, placebo/attention controls, active controls e.g. other CAM therapies, pharmacotherapy or Treatment as usual (TAU). The majority of therapies were used as an
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adjunct to treatment as usual, and treatment always involved psychological care. One study
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using repetitive transcranial magnetic stimulation for the treatment of Bulimia Nervosa
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appears to be the primary treatment (27). One study using yoga for the treatment of binge eating disorder was the primary therapy for participants (28). Treatment for each included
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study was administered at different settings with an even mixture of outpatient, inpatient and eating disorder clinic settings. Participants were in different stages of their eating disorder and no study looked at the specific timing of the CAM intervention.
Studies involving information on CAM therapies, evidence of treatments and expected outcomes are categorised below according to eating disorder diagnostic classification i.e. Anorexia Nervosa, Bulimia Nervosa and mixed eating disorders.
Anorexia Nervosa
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The literature search yielded four studies investigating CAM therapy use for the treatment of Anorexia Nervosa. The CAM modalities for the four studies were acupuncture,
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bright light therapy, massage and relaxation. Of these studies two were conducted on
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patients over 18 years of age and two included those 15 years of age or greater. Only one
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study included both genders (29).
There was no common outcome measure that was investigated in each of the four
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studies however all studies looked at either weight or Body Mass Index (BMI). None of the studies reported a significant effect from their respective CAM treatment on weight/BMI
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(29-32).
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Two studies investigated eating psychopathology via the Eating Disorder Inventory
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(29, 31). One of these studies found less eating psychopathology for participants following
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their first and their last massage (a one month time period) however no between group comparisons were undertaken (31). No significant effect was found for the use of
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acupuncture for eating psychopathology (29). Two studies investigated anxiety (one via the State Trait Inventory and the other via the Depression, Anxiety and Stress scale) (29, 31). One of these studies found less anxiety for participants following their first and their last massage (a one month time period), however no between group comparison was undertaken (31). No significant effect was found for the use of acupuncture for anxiety (29). Two studies investigated depression (one via the Hamilton Depression Rating Scale and the other via the Depression, Anxiety and Stress scale) (29, 30). One of these studies
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found significantly less depression for participants following bright light therapy (30), the other found no changes (29).
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All the other outcome measures used in these four studies were individual to the study and effects included improved mood (31) and greater self-esteem and less fear of fat
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(32).
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Bulimia Nervosa
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The literature search yielded six studies investigating CAM therapy use for the treatment of Bulimia Nervosa. The CAM modalities for the six studies were bright light
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therapy, hypnosis, massage, relaxation and repetitive transcranial magnetic stimulation. All
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of the studies involved women as participants in their trials. The majority of these studies
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were conducted on patients over 17 years of age. There was no common outcome measure that was investigated in each of the six
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studies. Binge-purge outcomes were investigated in five of the studies usually through record keeping of binge and or purge episodes (27, 33-36). The bright light therapy studies had mixed results with one study finding significantly less binging and purging for participants (34) however the other study found no significant effect (33). The three other studies found no significant effects for the use of hypnosis (35), relaxation (36) or repetitive transcranial magnetic stimulation (27) for decreasing or abstaining from binging and or purging. Four studies investigated eating psychopathology (three via the Eating Disorder Inventory and two via the Eating Attitudes Test*) (33-37). One study found significantly less
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eating psychopathology for participants in the domains of the EAT-dieting subscale, EATbulimia and food preoccupation, the EDI-bulimia subscale for hypnosis and EDI-drive for
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thinness and EDI-bulimia subscale for relaxation (35). No significant effect was found for the
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use of bright light therapy, relaxation or massage for eating psychopathology (34, 36, 37).
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Five studies investigated depression (three using the Hamilton Depression Rating Scale, one utilised the Hamilton Depression Rating Scale- Seasonal Affective Disorder, four
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using the Becks Depression Index, and one study used the Profile of Mood StateDepression*) (27, 33, 34, 36, 37). Three of these studies found significantly less depression
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for participants however the massage study (Field et at 1998) did not undertake a between group comparison (33, 34, 37). No significant effect was found for the use of repetitive
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transcranial magnetic stimulation or relaxation for depression (27, 36).
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All the other outcome measures used in these six studies were individual to the
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study and effects included less clinical rated body dissatisfaction and food restriction (36).
* Outcome measures included multiple measures that investigated the same outcome e.g. in some studies both the Hamilton Depression Rating Scale and the Becks Depression Inventory or the Eating Disorder Inventory and the Eating Attitudes Test were used.
Side effects Some side effects in both groups of the Bright Light Therapy 1994 study were recorded, these were headache, eye fatigue and feeling ‘speedy’ (34).
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Mixed Eating Disorders The literature search yielded five studies investigating CAM therapy use for the
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treatment of a mixture of eating disorders (Anorexia Nervosa, Bulimia Nervosa or Eating Disorder Not Otherwise Specified).
The CAM modalities for the five studies were
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acupuncture, eye movement desensitization and reprocessing, relaxation, spirituality and yoga. The majority of the studies involved women as participants in their trials with only the
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yoga study including any males. The majority of these studies were conducted on patients
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over 15 years of age.
All five studies investigated eating psychopathology (three using the Eating Disorder
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Inventory, two utilised the Eating Attitudes Test and one using the Eating Disorder
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Examination) (38-42). One study found a significant improvement for eating disorder
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symptoms with yoga (42). The authors of the eye movement desensitization and reprocessing study mention a finding of lower body dissatisfaction (BD) post treatment in the abstract but the main paper results do not report any significant differences for Eating
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Disorder Inventory-Body Dissatisfaction (39). No significant effect was found for the use of acupuncture, eye movement desensitization and reprocessing, relaxation or spirituality for eating psychopathology (38-41). Three studies investigated anxiety (all using the State Trait Inventory) (38, 40, 42). Two of these studies found significantly less State anxiety, one with acupuncture (38) and one with relaxation (40). The relaxation treatment also found significantly less Trait anxiety (40). No significant effect was found for the use of yoga for anxiety (42).
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Three studies investigated depression (all via the Becks Depression Inventory (38, 39, 42). No significant effect was found for the use of yoga (42), acupuncture (38) or eye
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movement desensitization and reprocessing (39) for depression. All the other outcome measures used in these five studies were individual to the
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study and effects included significantly lower social role conflict with spirituality (41) and significantly improved quality of life with acupuncture (38).
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Side effects
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The acupuncture study reported side effects; one patient felt faint and nauseous,
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Binge eating disorder
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needles were removed and participant recovered and continued with the treatment (38).
One study investigated Binge Eating Disorder. The McIver et al 2009 trial of yoga
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and Binge Eating Disorder involved ninety overweight or obese women (28). A benefit was found for yoga with a significant reduction in binge eating, BMI and hip and waist measurements and an increase in physical activity (28).
Quality Assessment An assessment for quality of the included studies was undertaken using the Cochrane Review questions for assessing bias (26), see Table 2. For the majority of studies the risk of bias was unclear. Two studies, which investigated the use of acupuncture, were assessed to have an overall low risk of bias (29, 38). The majority of the studies had issues
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with the reporting thus leading to the unclear findings. Blinding of participants and personnel in the included CAM studies was limited due to the inherent difficulties in finding
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an appropriate control that ensures blinding can occur. Only three studies involving bright
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light therapy and repetitive transcranial magnetic stimulation were able to administer
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blinded controls. Blinding of the outcome assessors and incomplete reporting of the outcome data was reasonably well reported in just under half of the included studies
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however the reporting of how the randomised sequence was generated and allocation concealment was poor, also many authors not provide data on participant loss.
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Subgroup Analysis
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Participant numbers
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In a traditional meta-analysis the results are weighted due to participant numbers,
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thus a subgroup analysis based on participant numbers in each study was undertaken. This involved weighting the study results (significant or not significant) based on the proportion
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of the total number of participants in each subgroup i.e. (sum of the total number of participants in the included studies with significant results/sum total number of study participants in that category) x 100 = %. Where the participant numbers were within 20% of each other the studies were viewed as equal weighting. The results when the studies were weighted were as above excepting for two outcomes: the benefits for depression in those with Bulimia Nervosa using massage and bright light therapy became less beneficial, and second the benefits for anxiety in those with a mixed eating disorder using acupuncture and relaxation became less beneficial.
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Quality Assessment A statement about the quality of the included studies based on bias is given above.
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A subgroup analysis is undertaken based on the quality of the included studies. Only two studies, which investigated the use of acupuncture, were assessed to have an overall low
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risk of bias (29, 38). Weighting was given by level of bias; low bias was given a third more weight, unclear the same weight and high bias given a third less weight. Weighting the AN
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and acupuncture study more than the other AN and CAM studies does not change the results. Weighting the results of the acupuncture and mixed eating disorder study more
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than the CAM and mixed eating disorder results gives more strength to the findings of
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significantly less state anxiety for those with a mixed eating disorder.
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The subgroup analysis results indicate that study bias is not unduly influencing the
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DISCUSSION
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review findings however participant numbers may be influencing the review findings.
The aim of the review was to evaluate the literature and to clarify the role that CAM plays in the treatment of eating disorders.
The review found a potential role for
complementary and alternative medicine (CAM) therapies in the treatment of depression with massage and bright light therapy, for those with bulimia nervosa. There was also a potential role for CAM therapies in the treatment of State Anxiety, with acupuncture and relaxation for those with an eating disorder (Anorexia Nervosa, Bulimia Nervosa or Eating Disorder Not Otherwise Specified). Whilst a number of studies reported beneficial findings for anxiety and depression a sub group analysis based on study participant numbers
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indicates that these findings are not conclusive. There was mixed evidence for the role of the CAM treatments hypnosis, relaxation, massage or bright light therapy on the Eating
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Disorder Inventory domain of Bulimia. The review found little evidence that CAM therapies
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had a specific benefit on eating disorder symptomology/psychopathology for any eating
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disorder diagnostic category (AN, BN, or mixed diagnostic group (AN, BN and EDNOS). These results build extensively on the work of two now dated non-systematic reviews into CAM
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and eating disorder adjunctive treatments (18, 19) that provided inconclusive evidence of the role of CAM in the treatment of eating disorders. While improving and identifying areas
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for future research is important, so is providing evidence-based information for consumers, caregivers and medical providers. Research has identified a need for access to eating
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disorder services and CAM therapies have the potential to play an adjunctive role in the
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steeped care approach for the above-mentioned conditions (43).
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The reporting of safety and adverse effects in these studies was limited, however there were similar frequency of events to those in the current literature, with most evidence
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finding that CAM therapies are relatively safe (44-46). There was no evidence of any CAM therapy having a detrimental effect on the eating disorder, but the poor reporting of adverse events limits this finding. A role of CAM therapies in the recovery of eating disorders (as opposed to treatment) might be addressing the need for a unique and personal recovery and a personally satisfying quality of life for eating disorder sufferers (10, 14, 47). For recovery, much more than clinical treatment is required (47-49). There are benefits from the experience of receiving CAM therapies, which might be able to assist in recovery from an eating disorder such as making connections, motivation and interests beyond the illness (10,
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47-50). Receiving touch can give eating disorder suffers hope, comfort and feelings of being connected (51).
Massage and acupuncture were viewed positively as a welcome
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supplementary activity from usual care and something to look forward to (29) and yoga has
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been shown to provide relaxation, stillness and peace (52). Being able to choose a CAM
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therapy as part of the process of recovery may engage and motivate sufferers to continue with the recovery journey, foster new interests and meet the individual needs of the
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sufferer. A sense of connection may arise from the therapeutic relationship. The therapeutic relationship has been shown to be important in eating disorder treatments (10, 53-56). The
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experience of the CAM treatment commonly includes the therapeutic relationship (57, 58). The role of CAM therapies in recovery has not been the focus of research and more
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evidence is needed before the role CAM plays in recovery is determined. The findings from this review show no substantial beneficial effect from CAM
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therapies on the eating disorder itself. The majority of included studies were using the CAM therapy as an adjunctive treatment and thus it is probable that the researchers were not
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expecting global changes in the participant’s eating disorder. The use of CAM treatment research as an adjunct mirrors CAM clinical practice (20). A survey of acupuncturists in the United Kingdom found that acupuncturist’s commonly treated eating disorder related sideeffects/symptoms such as mental and emotional issues, menstrual irregularities and stress or depression and provided emotional support, rather than primarily treating patients for their eating disorder (20). It is recommended that CAM treatments should be provided as adjunctive treatments only. Future research could focus on the therapies and eating disorders that are the most promising, such as massage, bright light therapy and acupuncture. Future CAM and eating
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disorder studies might consider investigating experiential benefits such as increased hope, feeling ‘normal’, making connections, being motivated and so forth and more global
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outcome measures of health such as quality of life, emotional well-being and so forth to
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capture both the experience/effect of the treatment and the effect of the CAM therapy on
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recovery. Limitations of this review include that a meta-analysis could not be undertaken due to the small number of studies available. Also the reporting of the methodology was
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poor in many of the included studies, which lead to an overall unclear risk of bias for the majority of studies. This was taken into account when reporting the review findings and
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recommendations and information about methodological issues have been included
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throughout the review text where relevant.
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CONCLUSION
This systematic review summarises and critically appraises the literature on complementary and alternative medicine as an adjunct therapy for people with an eating
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disorder. Sixteen studies were included in the review. Due to the small study numbers a meta-analysis was unable to be undertaken. This review found the role of complementary and alternative medicine in the treatment of those with an eating disorder is unclear and further studies should be conducted. There may be a potential role for the CAM treatments relaxation, massage and bright light therapy, in the treatment of depression for those with bulimia nervosa and a potential role for the CAM treatments acupuncture and relaxation, in the treatment of State Anxiety, for those with an eating disorder. The review found no evidence that CAM treatment has a substantial beneficial effect on the eating disorder itself and thus CAM treatments should be provided as adjunctive treatments. CAM treatments
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may have a role in the recovery from an eating disorder through making connections,
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motivation and developing interests.
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Role of Funding Sources
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The authors of this paper received no funding to conduct the research and or preparation of the manuscript.
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Contributors
All authors designed the study and wrote the protocol. Author SF conducted the literature
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searches and eliminated papers based on study criteria. All authors were involved in the final papers to be included and in the extraction of data for review. Author SF conducted
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the analysis. Author SF wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript. Conflict of Interest All authors declare that they have no conflicts of interest.
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Appendix 1 List of CAM modalities
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Acupressure Acupuncture (e.g. needle acupuncture, electro-acupuncture) Alexander technique Aromatherapy Arts therapy (e.g. dance therapy, drama therapy, music therapy) Ayurvedic traditional medicine (Ayurveda) Balneotherapy Bee Products (e.g. honey, pollen, propolis, royal jelly, venom) Biofeedback Chelation therapy Chinese traditional medicine Chiropractic (e.g. spinal manipulation) Colour therapy (i.e chromotherapy) Craniosacral manipulation Dietary supplements * Diet therapy* Distant healing Electric stimulation therapy (e.g. transcutaneous electrical nerve stimulation) Electromagnetic therapy Eye movement desensitization and reprocessing (EMDR) Feldenkrais method Herbal supplements Homeopathy Hydrotherapy Hyperbaric oxygenation
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Hypnosis Imagery (i.e. visualization techniques) Light therapy (phototherapy) Magnetic field therapy (e.g. transcranial magnetic stimulation) Massage Meditation Morita therapy Moxibustion Naturopathy Osteopathic manipulation Ozone therapy Play therapy Prolotherapy Qi gong Reflexology Reiki therapy Relaxation techniques Snoezelen Spelcotherapy Spiritual healing (e.g. prayer) Tai chi Therapeutic touch Traditional healers and healing practices (other than Chinese) (e.g. Kampo, Shamanism) Tui na Ultrasonic therapy Yoga
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* These therapies are not included in the review as these are part of the standardised Western Medicine treatment for Eating Disorders
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Appendix 2
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Search Outline
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1. Anorexia Nervosa or anorexia 2. Bulimia Nervosa or Bulimia
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3. EDNOS or Eating Disorder not otherwise specified 4. OSFED or Other Specified Eating Disorders 5. Binge Eating Disorder or BED
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6. Eating disorder
7. 1 or 2 or 3 or 4 or 5 or 6 8. Acupressure 9. 7 AND 8 This search was then repeated for the other CAM modalities listed in Table 1 (excluding dietary supplements and dietary therapy) and by replacing the CAM therapy in Step 8. Where the CAM therapy had additional search term e.g. colour therapy and chromotherapy, this term was also searched e.g., 8. Colour therapy or chromotherapy All terms listed in Appendix 1 in brackets were searched along with the CAM therapy.
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Appendix 3
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Definition of CAM modalities in this review
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Acupuncture: a system of complementary medicine in which fine needles are inserted in the skin at specific points along what are considered to be lines of energy (meridians), used in
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the treatment of various physical and mental conditions.
Bright light therapy: Light therapy or phototherapy (classically referred to as heliotherapy) consists of exposure to daylight or to specific wavelengths of light using polychromatic
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polarised light, lasers, light-emitting diodes, fluorescent lamps, dichroic lamps or very bright, full-spectrum light.
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Eye movement desensitization and reprocessing: is a psychotherapy developed by Francine
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Shapiro that emphasizes disturbing memories as the cause of psychopathology. It is
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commonly used to help with the symptoms of post traumatic stress disorder (PTSD). Hypnosis: the induction of a state of consciousness in which a person apparently loses the power of voluntary action and is highly responsive to suggestion or direction. Its use in
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therapy, typically to recover suppressed memories or to allow modification of behaviour, has been revived.
Massage: is the use of touch to manually manipulate the soft body tissues (muscle, and connective tissue) to enhance a person's health and well-being. Relaxation: The teaching of relaxation techniques via a method, process, procedure, or activity, that helps a person to relax; to attain a state of increased calmness; or otherwise reduce levels of pain, anxiety, stress or anger. Repetitive transcranial magnetic stimulation: is a form of brain stimulation therapy. It uses magnetic pulses instead of electricity to activate parts of the brain. Developed in 1985 it has been commonly used as a possible therapy for depression
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Spirituality: Spiritual therapy is using a spiritual approach within the treatment framework. Spirituality is a broad concept with room for many perspectives. In general, it includes a sense of connection to something bigger than ourselves, and it typically involves a search for
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meaning in life.
Yoga: a Hindu spiritual and ascetic discipline, a part of which, including breath control,
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simple meditation, and the adoption of specific bodily postures, is widely practiced for
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health and relaxation.
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1. Weir M. What is complementary and alternative medicine. Faculity of Law at ePublications@bond: Bond University; 2005. p. 14-40. 2. NICM. Highlighting Complementary Medicine Research- Choosing Complementary Medicine. In: Medicine) NNIoC, editor. Fact Sheet2011. p. 3. 3. National Centre for Complementary and Alternative Medicine N. What is Complementary and Alternative Medicine? : NCCAM; 2012 [updated May 2012; cited 2013 4th April]. NCCAM Pub No.: D347]. Available from: http://nccam.nih.gov/health/whatiscam. 4. National Center for Complementary and Integrative Health. Complementary, Alternative, or Integrative Health: What's In a Name? : National Institutes of Health; 2008 [updated March 2015; cited 2016 16th February]. NCCIH Pub No: D347:[Available from: https://nccih.nih.gov/health/integrative-health. 5. Wieland SL, Manheimer E, Berman BM. Development and classification of an operational definition of complementary and alternatvie medicine for the Cochrane Collaboration. Altern Ther Health Med. 2011;17(2):50-9. 6. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Feeding and Eating Disoders): The American Psychiatric Association (APA); 2013 [cited 2013 6th September]. Available from: http://www.dsm5.org/Documents/Eating Disorders Fact Sheet.pdf. 7. Mitchison D, Hay P, Slewa-Younan S, Mond J. Time trends in population prevalence of eating disorder behaviors and their relationship to quality of life. PLoS ONE. 2012;7(11):1-7.
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8. Qian J, Hu Q, Wan Y, Li T, Wu M, Ren Z, et al. Prevalence of eating disorders in the general population: a systematic review. Shanghai Arch Psychiatry. 2013;25(4):212-23. 9. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. . Arch Gen Psychiatry. 2011;68(7):724-31. 10. Dawson L, Rhodes P, Touyz S. “Doing the Impossible”: The Process of Recovery From Chronic Anorexia Nervosa. Qual Health Res. 2014;24(4):494-505. 11. Lowe B, Zipfel S, Buchholz C, Dupont Y, Reas D, Herzog W. Long-term outcome of anorexia nervosa in a prospective 21-year follow up study. Psychol Med. 2001;31:881-90. 12. Hay P. A systematic review of evidence for psychological treatments in eating disorders: 2005–2012. International Journal of Eating Disorders. 2013;46(5):462-9. 13. Treasure J, Claudino A, Zucker N. Eating Disorders. Lancet. 2010;375(9714):583-93. 14. Mitchison D, Morin A, Mond J, Slewa-Younan S, Hay P. The bidirectional relationship between quality of life and eating disorder symptoms: a 9-year community-based study of Australian women. PLoS One. 2015;Mar 26;10(3). 15. National Eating Disorders Collaboration. Understanding Recovery 2015 [updated 5th May 2015; cited 2015 25th May]. Available from: http://www.nedc.com.au/recovery. 16. Barnes P, Bloom B, Nahin R. Complementary and Alternative Medicine Use Among Adults and Children. United States: National Center for Health Statistics, 2008. 17. Kessler R, Soukup J, Davis R, al e. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry. 2001;158:289-94. 18. Madden S, Fogarty S, Smith C. Alternative and Complementary Therapies in the Treatment of Eating Disorders, Addictions, and Substance Use Disorders. In: Brewerton TD, Dennis AB, editors. Eating Disorders, Addictions and Substance Use Disorders. New York: Springer; 2014. p. 625-47. 19. Fogarty S, Madden S. A review of the use of acupuncture in the treatment of Anorexia Nervosa. In: Gramagila C, Zeppegno P, editors. New Developments in Anorexia Nervosa Research. New York: Nova Science Publishers Inc; 2014. p. 141-50. 20. Clarke L. Exploring the basis for Acupuncture Treatment of Eating Disorders; A Mixed Methods Study: Northern College of Acupuncture (NCA); 2009. 21. Vancampfort D, Vanderlinden J, De Hert M, Soundy A, Adámkova M, Skjaerven LH, et al. A systematic review of physical therapy interventions for patients with anorexia and bulemia nervosa. Disabil Rehabil. 2014;36(8):628-34. 22. Katterman SN, Kleinman BM, Hood MM, Nackers LM, Corsica JA. Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: A systematic review. Eat Behav. 2014;15(2):197-204. 23. World Health Organization. International Classification of Diseases,. 1992. 24. Birmingham CL, Beumont P. Medical Management of Eating Disorders. Cambridge: Cambridge University Press; 2004. 289 p. 25. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement2009 2009-07-21 10:46:49. 26. Higgins J, Green S. Cochrane Handbook of Systematic Reviews of Interventions: The Cochrane Collaboration; 2008. Available from: http://www.cochrane-handbook.org. 27. Walpoth M, Hoertnagl C, Mangweth-Matzek B, Kemmler G, Hinterholzl J, Conca A, et al. Repetitive transcranial magnetic stimulation in bulimia nervosa: preliminary results of a singlecentre, randomised, double-blind, sham-controlled trial in female outpatients. Psychotherapy & Psychosomatics. 2008;77(1):57-60. 28. McIver S, O’Halloran P, McGartland M. Yoga as a treatment for binge eating disorder: A preliminary study. Complement Ther Med. 2009;17(4):196-202. 29. Smith C, Fogarty S, Touyz S, Madden S, Buckett G, Hay P. Acupuncture and acupressure health outcomes for patients with anorexia nervosa: findings from a pilot randomised controlled trial and patient interviews J Altern Complement Med. 2014;Feb; 20(2,):103-12.
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30. Janas-Kozik M, Krzystaneck M, Stachowicz M, Krupka-Matuszczyk I, Janas A, Rybakowski JK. Bright light treatment of depressive symptoms in patients with restrictive type of anorexia nervosa. J Affect Disord. 2011;130:462-5. 31. Hart S, Field T, Hernandez-Reif M, Nearing G, Shaw S, Schanberg S, et al. Anorexia Nervosa Symptoms are Reduced by Massage Therapy. Eating Disorders. 2001;9(4):289-99. 32. Goldfarb LA, Fuhr R, Tsujimoto RN, Fischman SE. Systematic desensitization and relaxation as adjuncts in the treatment of anorexia nervosa: a preliminary study. Psychological Reports. 1987;60(2):511-8. 33. Blouin AG, Blouin JH, Iversen H, Carter J, Goldstein C, Goldfield G, et al. Light Therapy in Bulimia nervosa: a double-blind, placebo controlled study. Psychiatry Res. 1996;60:1-9. 34. Lam RW, Goldner EM, Solyom L, Remick R. A Controlled Study of Light Theray for Bulimia Nervosa. Am J Psychiatry. 1994;151(5):744-50. 35. Griffiths RA, Hadzi-Pavlovic D, Channon-Little L. A controlled evaluation of hypnobehavioural treatment for bulimia nervosa: Immediate pre-post treatment effects. Eur Eat Disord Rev. 1994;2(4):202-20. 36. Bulik CM, Sullivan PF, Carter FA, McIntosh VV, Joyce PR. The role of exposure with response prevention in the cognitive-behavioural therapy for bulimia nervosa. Psychological Medicine. 1998;28(3):611-23. 37. Field T, Schanberg S, Kuhn C, Fierro K, Henteleff T, Mueller C, et al. Bulimic adolescents benefit from massage therapy. Adolescence. 1998;33(131):555-63. 38. Fogarty S, Harris D, Zaslawski C, McAinch AJ, Stojanovska L. Acupuncture as an Adjunct Therapy in the Treatment of Eating Disorders: A Pilot Study. Complement Ther Med. 2010;18(6):22776. 39. Bloomgarden A, Calogero RM. A randomized experimental test of the efficacy of EMDR treatment on negative body image in eating disorder inpatients. J Eat Disord. 2008;16(5):418-27. 40. McComb JJR, Clopton JR. The effects of movement, relaxation, and education on the stress levels of women with subclinical levels of bulimia. Eat Behav. 2003;4(1, March ):79-88. 41. Richards SP, Berrett ME, Hardman RK, Eggett DL. Comparative Efficacy of Spirituality, Cognitive, and Emotional Support Groups for Treating Eating Disorder Inpatients. J Eat Disord. 2006;14(5):401-15. 42. Carei RT, Fyfe-Johnson AL, Breuner CC, Brown MA. Randomized Controlled Clinical Trial of Yoga in the Treatment of Eating Disorders. Journal of Adolescent Health. 2010;46:346–51. 43. Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, et al. Royal Austalian and New Zealand College of Psychaitrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014;48(11):977-1008. 44. Zhang J, Shang H, Gao X, Ernst E. Acupucnture-related adverse events: a systematic review of the Chinese literature. Bulletin of the World Health Organisation: The World Health Organisation, 2010. 45. Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, et al. Safety of Acupuncture: Results of a Prospective Observational Study with 229,230 Patients and Introduction of a Medical Information and Consent Form. Forsch Komplementmed. 2009;16(2):91-7. 46. Harris T, Grace S, Eddey S. Adverse Events from Complemetary Therapies: An Update from the Natural Therapies Workforce Survey Part 1. Journal of the Australian Traditional Medicine Society. 2015;21(2):86-91. 47. Espíndola C, Blay S. Long term remission of anorexia nervosa: factors involved in the outcome of female patients. PLoS One. 2013;8((2):e56275). 48. Hay PJ, Cho K. A Qualitative Exploration of Influences on the Process of Recovery from Personal Written Accounts of People with Anorexia Nervosa. Women & Health. 2013;53(7):730-40. 49. Espindola C, Blay S. Anorexia Nervosa treatment from the patient perspective: a metasynthesis of qualitative studies. Ann Clin Psychiatry. 2009;21:38 - 48.
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50. Federici A, Kaplan AS. The patient's account of relapse and recovery in anorexia nervosa: a qualitative study. Eur Eat Disord Rev. 2008;16(1):1-10. 51. Henricsona M, Segestena K, Berglundb A-L, Määttäa S. Enjoying tactile touch and gaining hope when being cared for in intensive care. A phenomenological hermeneutical study. Intensive Crit Care Nurs. 2009;25:323-31. 52. Douglass L. Yoga as an Intervention in the Treatment of Eating Disorders: Does it Help? J Eat Disord. 2009;17(2):126-39. 53. Fogarty S, Smih C, Touyz S, Madden S, Buckett G, Hay P. Patients with anorexia nervosa receiving acupuncture or acupressure; their view of the therapeutic encounter. Complement Ther Med. 2013. 54. Wright KM. Theraputic relationship: Developing a new understanding for nurses and care workers within an eating disorder unil. J Psychiatr Ment Health Nurs. 2010;19:154-61. 55. Wright KM. An Interpretive Phenomenological Study of the Therapeutic Relationship between Women Admitted to Eating Disorder Services and Their Care Workers. Lancashire: University of Central Lancashire; 2014. 56. Wright KM, Hacking S. An angel on my shoulder: a study of relationships between women with anorexia and healthcare professionals. Journal of Psychiatric and Mental Health Nusing. 2012;19:107-15. 57. Paterson C, Zheng Z, Xue C, Wang Y. Playing Their Parts”: The Experiences of Participants in a Randomized Sham-Controlled Acupuncture Trial J Altern Complement Med. 2008;March, 14(2). 58. Anderson KT. Holistic Medicine Not “Torture”: Performing Acupuncture in Galway, Ireland. Medical Anthropology. 2010;29(3):253-77.
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Table 1. Summary of included studies and the significant findings by CAM therapy Results at end of the treatment Mean (M), Mean Deviation (MD,) odds ratio (OR) or F statistic for ratio of variances (F) Confidence interval (CI) / Standard Deviation (SD)/Standard Error/r /df/ f
TCM style acupuncture + TAU n = 9 v TAU n=9
AN or BN Patients > 17 years of age at a private outpatient eating disorder clinic AN Inpatients at a private hospital > 15 years of age
EDI-3, BDI, STAI & EDQoL
The acupuncture group has a mean STAI score of 37.6, 3.3 (SE) which was significantly less than the control group which had a mean STAI score of 46.3, 5.8 (SE). The acupuncture group has a mean Physical/Cognitive domainEDQoL score of 8.0, 1.8 (SE) which was significantly less than the control group which had a Physical/Cognitive domain-EDQoL score of 9.7, 3.3 (SE) .
BN. Females, 17 years or over
BDI, HDRSSAD, Bulimia symptom checklist, Daily Binge record, POMS. HDRS & BMI
Bright Light Therapy (BLT) Bloudin 1996 BLT n = 9 v Placebo BLT n = 9
BLT n= 17 v placebo BLT n= 17
AN. Female patients at an impatient hospital, aged 15-20 years & > 17 points on the HDRS
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The control group had significantly lower EDE-Q eating concerns score than the acupuncture group 1.0 (MD), 95% CI 0.05-1.9
BN. Binges/purges Active per week, illness HDRS, BDI, determined Weight, Visual by at least Analog Bulimia 3 episodes Scale, Visual of Binge Analog eating or carbohydrate purging per craving scale, week EAT Eye Movement Desensitization & Reprocessing (EMDR) Bloomgarden EMDR + TAU n= AN, BN or BIM, BIS, ASI, 2008 43 or TAU only EDNOS. EDI-BD, n= 43 Females at SATAQ-R, EATa 26, BDI, DES residential eating disorder setting Hypnosis Griffiths HypnoBN EDE, EDI-3, 1994 behavioural Female EAT-40, EATTherapy n = 21 v patients at 26 (Dieting, Cognitive a teaching Food Behaviours hospital, preoccupation, therapy (CBT) n = aged 17-50 Oral Control),
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BLT + CBT n= 12 v CBT alone n= 12
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BMI, EDI-3, EDE-Q, DASS, EDQoL
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Acupuncture + TAU n = 13 v acupressure/light massage + TAU n = 13
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Outcome Measures
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Intervention and participant numbers (n)
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The BLT group had a significantly lower depression score than the placebo group 4.14 (F), 2.15 (df)
The BLT group has a mean depression score of 10.67, 1.61 (SD) which was significantly less than the control group which had a mean depression score of 13.58, 3.09 (SD).
The BLT group has a mean BDI depression score of 9.0, 7.4 (SD) which was significantly less than the control group which had a mean depression score of 17.8 11.1 (SD). The BLT group has a mean total binging score of 4.4, 5.3 (SD) which was significantly less than the control group which had a mean total binge score of 6.5, 6.0 (SD). The BLT group has a mean total purging score of 4.5, 5.6 (SD) which was significantly less than the control group which had a mean total purging score of 6.7, 6.5 (SD).
The EMDR group had a significantly lower distress about negative body image memories score (earliest memory) than the placebo group 3,252 (F) = 7.27, 0.17 (r) The EMDR group had a significantly lower distress about negative body image memories score (worst memory) than the placebo group 3,252 (F) =6.78, 0.16 (r)
The hypnosis and CBT groups (together) had a significantly lower Eating Attitudes Test (EAT) total score, EAT-dieting subscale, EATbulimia and food preoccupation subscale and EDI-3 Bulimia subscale scores than the control. Eating Attitudes Test F (1,59) = 25.03 EAT-dieting subscale F (1,59) = 15.96
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BN. Women at an inpatient residential treatment centre
POMSDepression, BOS, Salivary cortisol, EDI, CES-D
No statistics were given on between group comparisons. The massage group has a mean STAI pre first massage score of 50.1, 3.3 which was significantly less than the post last massage score of 37.4. The massage group has a mean depression pre first massage score of 36.2 which was significantly less than the post last massage score of 27.2.
Massage therapy n = 10 v TAU n= 9
AN. Women at an inpatient and outpatient centre
STAI, POMS, salivary cortisol, weight, CES-D, EDI
Relaxation & CBT n = 39 v Binge Exposure therapy & CBT n = 39 v Purge exposure therapy & CBT n =38
BN. Women aged 17-45 years with a diagnosis of BN and a BMI of < 30.
Frequency of Binging, frequency of purging. EDI-2 BD, EDI-2 DT, EDI-2 B, food restriction, HDRS, Global Assessment of Functioning Scale
The relaxation intervention compared to the binge exposure group or the purge exposure groups showed no significant effects.
Weight, Roseenburg self esteem scale, Goldfarb Fear of Fat Scale.
At the 6 month follow up the relaxation therapy group had significantly greater self esteem than the control group At the 6 month follow up the relaxation therapy group had significantly less fear for fat than the control group F (1,4) = 49.48
Relaxation n = 3 v desensitization n = 4 v non equivalent control group n= 11
Mc Comb 2003
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Massage therapy n = 12 v TAU n= 12
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Goldfarb 1987
EAT-bulimia and food preoccupation subscale F = (1,59) = 30.99 EDI-3 Bulimia subscale F (1.59) = 30.69 There were no significant changes between the two treatment groups.
No statistics were given on between group comparisons. The massage group has a significantly lower STAI pre first massage score compared to the post last massage score F (1, 17) = 17.3. The massage group has a significantly lower moode pre first massage score compared to the post last massage score F (1, 17) = 5.0.
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Relaxation Bulik 1998
Harvard Group Scale of Hypnotic Susceptibility & occurrence's of binging and purging.
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years with a BMI 1826 & no more than two previous inpatient admissions for treatment of an eating disorder.
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Massage Field 1998
19 v a wait-list group n = 22
AN. Females aged 18 years and over
An 8 week group EDNOS. STAI, program for 1.5 Female and Coopersmith hours each week not Self-Esteem discussing anorexic Inventory, movement BUILT-R, EDI-2 improvisation & DT, EDI-2 BD relaxation n = 6 v no treatment n = 6 Repetitive Transcranial Magnetic Stimulation (RTMS) Walpoth RTMS n = 7 v a BN. Binge-Purge 2008 sham RTMS with Females status, HDRS, a magnetic field aged 18-35 BDI, YBOCS absorbing metal years with plate n = 7 a BMI of > 17.5 & a HAMD score of < 18 Spirituality Richards Spirituality group AN, BN or EAT, BSQ, OQ-
There was significantly less STAI state for the relaxation group compared to the control group F (1, 10) = 5.10, f = 0.71 There was significantly less STAI trait anxiety for the relaxation group compared to the control group F (1, 10) = 7.44, f = 0.86
No statistical difference between groups for any outcome measures
There was significantly less eating disorder symptoms for the
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n = 45 v a cognitive group n = 35 v an emotional support group n = 44
EDNOS Private inpatient facility for women with from 13 -52 years
45, MSEI, SWBS, EDSMS, TSOS
8 one hour a week yoga sessions plus TAU n = 26 v TAU n = 27
AN, BN or EDNOS.
EDE, BMI, BDI & STAI
spirituality group compared to the cognitive group F (2, 111) = 4.56 There was significantly less Social role conflict for the spirituality group compared to the cognitive F (2, 113) = 5.91 There was significantly less symptom distress for the spirituality group compared to the cognitive and emotional groups F (2, 113) = 3.78 There was significantly less relationship distress for the spirituality group compared to the cognitive and emotional groups F (2, 113) = 5.37 There was significantly more religious well being for the spirituality group compared to the cognitive and emotional groups F (2, 108) = 3.74 There was significantly more existential well being for the spirituality group compared to the cognitive and emotional groups F (2, 109) = 3.07
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There was significantly less binge eating for the yoga group compared to the control group F (1,48) = 38.3 There was significantly more physical activity for the yoga group compared to the control group F (1,48) = 12.8 There was significantly less BMI scores for the yoga group compared to the control group F (1,48) = 7.5 There was significantly less hip measurement scores for the yoga group compared to the control group There was significantly less binge eating for the yoga group compared to the control group F (1,48) = 38.1 There was significantly less waist measurement scores for the yoga group compared to the control group F (1,48) = 61.2
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Binge eating Disorder. Women from a community based sample of overweight or obese women (BMI of> 25) BED defined by a score of > 20 on the BES, aged between 25 -65 years
BES, Short form of IPAQ
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60 min weekly yoga group for 12 weeks plus a home yoga program n = 25 v wait list n - 25
There was significantly less eating disorder symptoms for the yoga group compared to the control group F (2,35) = 3.26
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McIver 2009
Patients at a Children's hospital outpatient department between ages 10-21 years.
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AN = Anorexia Nervosa, BN = Bulimia Nervosa, EDNOS = Eating Disorder Not Otherwise Specified, BED= Binge Eating Disorder, EDI = Eating Disorder Inventory, BDI = Becks Depression Inventory, STAI = State Trait Anxiety Intervention, EDQoL = Eating Disorder Quality of Life Scale, BMI = Body Mass Index, EDE-Q = Eating Disorder Examination Questionnaire, DASS = Depression, Anxiety and Stress Scale, HDRS = Hamilton Depression Rating Scale, HDRS-SAD= Hamilton Depression Rating Scale-Seasonal Affective Disorder, POMS= Profile of Mood States, EAT= Eating Attitudes test, BIM= Body Image memory questionnaire, BIS= Body Investment Scale, ASI= Appearance Schemas Inventory, SATAQ-R= Sociocultural Attitudes towards Appearance Questionnaire Revised, DES= Dissociative Experiences Scale, BOS = Behaviour Observation Scale, CES-D = Centre for epidemiology studies depression scale, DT= Drive for Thinness, B= Bulimia, BD= Body Dissatisfaction, YBOCS= Yale Brown Obsessive Compulsive Scale
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Table 2: Risk of bias in included studies Incomplete outcome data
Selective reporting
Yes
Unclear
Unclear
None
Unclear Unclear Unclear Unclear Yes Unclear
Unclear Unclear Unclear Unclear Unclear Unclear
Yes No No No No Unclear
Yes Unclear Unclear Unclear Yes Unclear
Unclear Unclear Yes Unclear Yes Yes
Unclear Unclear Yes Unclear Yes Unclear
Yes None Unclear Unclear None None
Unclear Unclear Unclear
Unclear Unclear Unclear
No No No
Yes Unclear Yes
No Yes Unclear
No Unclear Unclear
Unclear None Unclear
Unclear Unclear
Unclear Unclear
Yes No
Unclear Unclear
Unclear Yes
No No
Unclear None
Yes Unclear
Unclear Unclear
No No
Unclear Unclear
No Yes
Unclear Yes
Unclear Unclear
Yes Unclear
Yes Unclear
No Yes
Yes Yes
Yes Unclear
Unclear No
None Unclear
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Yes
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Blinding of outcome assessment
Unclear
Blinding of participants and personnel No
Other bias
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Allocation Concealment
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Bloomgarden 2008 Blouin 1996 Bulik 1998 Carei 2010 Field 1998 Fogarty 2010 Goldfarb 1987 Griffiths 1994 Hart 2001 Janas-Kozik 2010 Lam 1994 McComb 2003 McIVer 2009 Richards 2006 Smith 2013 Walpoth 2008
Random sequence generation
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Figure 1. Flow Diagram of literature search
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S1471-0153(16)30026-5 doi: 10.1016/j.eatbeh.2016.03.002 EATBEH 1024
To appear in:
Eating Behaviors
Received date: Revised date: Accepted date:
29 August 2015 23 February 2016 1 March 2016
Please cite this article as: Fogarty, S., Smith, C.A. & Hay, P., The role of complementary and alternative medicine in the treatment of Eating Disorders: A systematic review, Eating Behaviors (2016), doi: 10.1016/j.eatbeh.2016.03.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Caroline A Smith Phillipa Hay
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National Institute of Complementary Medicine, Western Sydney University, Sydney
[email protected]
School of Medicine, University of Western Sydney, [email protected]
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Sarah Fogarty*
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The role of Complementary and Alternative Medicine in the treatment of Eating Disorders: A Systematic Review
* Corresponding Author: Sarah Fogarty, Western Sydney University, Locked Bag 1797, Penrith, NSW
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2751, Australia. Email: [email protected] or [email protected]
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Key words: Eating disorders, Complementary and Alternative Medicine, Systematic Review
ABSTRACT
This systematic review critically appraises the role of complementary and alternative medicine in the treatment of those with an eating disorder. Sixteen studies were included in the review. The results of this review show that the role of complementary and alternative medicine in the treatment of those with an eating disorder is unclear and further studies should be conducted. A potential role was found for massage and bright light therapy for depression in those with bulimia nervosa and a potential role for acupuncture and relaxation therapy, in the treatment of State Anxiety, for those with an eating disorder. The role of these complementary therapies in treating eating disorders should only be provided as an adjunctive treatment only.
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BACKGROUND
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Complementary and alternative medicine (CAM) refers to a broad range of health
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practices (1-3) and thus a definition of what constitutes a CAM therapy has at times been unclear. The National Centre for Complementary and Integrative Health separate
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complementary and alternative medicine with complementary being “a non-mainstream practice used together with conventional medicine” and alternative being a non-
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mainstream practice used in place of conventional medicine” (4). An operational definition of CAM proposed by Wiedland and colleagues defines CAM based on (i) therapies that rely
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upon non-allopathic models of health, (ii) exclusion from standard treatment within the dominant medical system, and (iii) self-care or care delivered by alternative practitioners
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(5). This review uses this definition of CAM as there are therapies that are used, both in combination with conventional medicine, and as the primary treatment. A list of the CAM
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modalities can be seen in See Appendix 1.
Eating disorders according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), include Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), PICA, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder (ARFID) or Other Specified or Unspecified Feeding or Eating Disorder (OSFED or UFED) (6). OSFED/UFED replaces the Eating Disorder Not Otherwise Specified (EDNOS) category.
In the developed world the lifetime prevalence of eating disorders is 1.01% and they appear to be increasing (7, 8). Eating disorder morbidity is also high, and mortality is 2
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amongst the highest of psychiatric disorders (9). Eating disorders are chronic illnesses with frequent relapses occurring for many individuals (10). Greater than 20% of individuals
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continue to have an eating disorder on long term follow up, and many may develop mental
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illness such as depression (15-60%), anxiety disorders (20-60%), or personality disorders
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(11).
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A multidimensional treatment approach to the treatment of eating disorders is most commonly adopted. Multidimensional treatment addresses the physical, psychological,
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psychosocial and family needs of the individual, and can include psychiatrists, psychologists, primary care physicians, social workers, nurses and dieticians. Treatment aims to restore the
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individual’s weight within normal range for their height and age, to reduce abnormal eating
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behaviours, and weight and shape cognitions, and manage co-morbidities (both mental and
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physical). There is evidence for the use of cognitive behavioural therapy for BN and BED and family based therapy for adolescents with AN (12) and a small base of evidence for
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pharmacological management of AN (13), however the evidence base underlying these current therapeutic approaches has limitations.
Some of these limitations include
addressing personal recovery needs such as a personally satisfying quality of life (14) and personal concepts of recovery (10). Recovery from an eating disorder varies between individuals but generally involves restoration of healthy eating habits and “a healthier physical and psychological state of being” (15).
Reported use of CAM is increasing and especially for acupuncture, deep breathing exercises, massage therapy, meditation and yoga (16). CAM use is high among individuals diagnosed with mental health conditions especially anxiety and depression where 56.7% of
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those with anxiety attacks, and 53.6% of those with severe depression reported using CAM as an adjunct to treat their conditions (17). There is an increasing evidence base identifying
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the adjunctive use of complementary therapies to assist with the management of eating
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disorders however the prevalence of CAM use among people with and eating disorder is
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unknown (18-20). Previous reviews on the use of CAM therapies and eating disorders have not been systematic, are dated and were inconclusive (18, 19). Qualitative research findings
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indicate that eating disorder sufferers’ find CAM therapies acceptable and beneficial as adjuncts to their eating disorder treatment (18, 19, 21, 22). Complementary and alternative
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therapies that improve patient outcomes, reduce the burden of poor health and help facilitate personal recovery needs are highly desirable. The aim of this review is to examine
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the role of CAM therapies in the treatment of eating disorders.
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METHODS
Inclusion and exclusion criteria
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Studies were included if they involved CAM treatment of an Eating Disorder (ED). An eating disorder was defined as meeting DSM diagnostic criteria (Editions 1-5) (6) or equivalent diagnostic criteria e.g., International Classification of Diseases (23), or clinical assessment by a specialist e.g. psychologist, psychiatrist. Eating disorders included in this criterion are: Anorexia Nervosa, Bulimia Nervosa, Eating Disorder not Otherwise Specified, Binge Eating Disorder, PICA, Avoidant/Restrictive Food Intake Disorder and Other Specified or Unspecified Feeding or Eating Disorders. Studies also had to involve one of the CAM modalities defined by Wiedland and colleagues (5). Dietary supplements and diet therapy have been excluded as these are
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frequently used as standard Western medicine treatments for eating disorders (24) See
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Appendix 1 for a list of all the CAM modalities.
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All published and unpublished randomised controlled trials were eligible for
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inclusion. Studies were excluded if they were not a randomised controlled trial, if they were not investigating a CAM therapy or they did not include an eating disorder population or
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sample.
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Search strategy
The electronic databases The Cochrane Collaboration Depression, Anxiety and
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Neurosis Controlled Trials Registers, Medline (years 1946-2013), EMBASE (1974-2013),
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CINHL (1950-2015), PsycINFO (1786-2015) and PubMed (1950-2015) were searched for
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Randomised Controlled Trials (RCT’s) investigating CAM therapies and the treatment of eating disorders in September 2013 and again in January 2015. The search strategy can be seen in Appendix 2 and was applied for each CAM therapy excluding dietary supplements
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and therapy, and for each database. One author (SF) independently selected articles that met the criteria for the systematic review through scrutiny of all the abstracts of papers identified from the searches after duplicates were removed. The data extraction procedure was performed according to the guidelines outlined by the PRISMA statement (25). Where it was unclear if a paper was to be included, a second reviewer was consulted (PH or CS). Reasons for excluding trials have been stated in Figure 1. One author (SF) independently reviewed all the studies and two authors (CS and PH) both independently reviewed half of the studies, using the standardised data extraction form. Data was entered into the Review Manager
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Software by author SF.
Any discrepancies were discussed by the three reviewers.
Additional searching of conference proceedings, the International Clinical Trial Registry and
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the Australian, New Zealand Clinical Trial Registry (ANZCTR) and the reference lists of all
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papers selected was undertaken to identify further relevant studies.
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Outcome measures
The outcomes that were included within the review were improvements in eating
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psychopathology (e.g. binge eating, restriction, drive for thinness, shape and eating
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concerns) or improvements in general psychopathology (weight, anxiety, depression, quality of life). Side-effects or negative effects (where provided) and patient satisfaction (where
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assessed) were also included.
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Data analysis
A meta-analysis of the data, although initially planned, was not undertaken due to
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the small number of studies within each CAM modality. All included articles were reviewed in detail and analysed thematically according to diagnostic classification and effect. Risk of bias (investigating random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data and selective reporting) for each study was assessed using the Cochrane tool for assessing bias (26). Findings and limitations in the literature as well as areas of further research are addressed below.
RESULTS
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Sixteen articles that involved CAM therapies and eating disorders were identified and reviewed; see Table 1. Nine different CAM therapies were investigated in the RCT’s;
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acupuncture, bright light therapy, eye movement desensitization and reprocessing,
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hypnosis, massage, relaxation, repetitive transcranial magnetic stimulation, spirituality and
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yoga. See Appendix 3 for a description of the nine CAM therapies. It is of note that the authors of the included papers used varied outcome tools covering a wide range of eating
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disorder symptomology to assess treatment efficacy such as binging, purging, depression, anxiety and the like. Comparison interventions or control groups for the included studies
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involved wait lists, placebo/attention controls, active controls e.g. other CAM therapies, pharmacotherapy or Treatment as usual (TAU). The majority of therapies were used as an
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adjunct to treatment as usual, and treatment always involved psychological care. One study
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using repetitive transcranial magnetic stimulation for the treatment of Bulimia Nervosa
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appears to be the primary treatment (27). One study using yoga for the treatment of binge eating disorder was the primary therapy for participants (28). Treatment for each included
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study was administered at different settings with an even mixture of outpatient, inpatient and eating disorder clinic settings. Participants were in different stages of their eating disorder and no study looked at the specific timing of the CAM intervention.
Studies involving information on CAM therapies, evidence of treatments and expected outcomes are categorised below according to eating disorder diagnostic classification i.e. Anorexia Nervosa, Bulimia Nervosa and mixed eating disorders.
Anorexia Nervosa
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The literature search yielded four studies investigating CAM therapy use for the treatment of Anorexia Nervosa. The CAM modalities for the four studies were acupuncture,
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bright light therapy, massage and relaxation. Of these studies two were conducted on
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patients over 18 years of age and two included those 15 years of age or greater. Only one
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study included both genders (29).
There was no common outcome measure that was investigated in each of the four
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studies however all studies looked at either weight or Body Mass Index (BMI). None of the studies reported a significant effect from their respective CAM treatment on weight/BMI
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(29-32).
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Two studies investigated eating psychopathology via the Eating Disorder Inventory
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(29, 31). One of these studies found less eating psychopathology for participants following
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their first and their last massage (a one month time period) however no between group comparisons were undertaken (31). No significant effect was found for the use of
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acupuncture for eating psychopathology (29). Two studies investigated anxiety (one via the State Trait Inventory and the other via the Depression, Anxiety and Stress scale) (29, 31). One of these studies found less anxiety for participants following their first and their last massage (a one month time period), however no between group comparison was undertaken (31). No significant effect was found for the use of acupuncture for anxiety (29). Two studies investigated depression (one via the Hamilton Depression Rating Scale and the other via the Depression, Anxiety and Stress scale) (29, 30). One of these studies
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found significantly less depression for participants following bright light therapy (30), the other found no changes (29).
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All the other outcome measures used in these four studies were individual to the study and effects included improved mood (31) and greater self-esteem and less fear of fat
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(32).
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Bulimia Nervosa
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The literature search yielded six studies investigating CAM therapy use for the treatment of Bulimia Nervosa. The CAM modalities for the six studies were bright light
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therapy, hypnosis, massage, relaxation and repetitive transcranial magnetic stimulation. All
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of the studies involved women as participants in their trials. The majority of these studies
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were conducted on patients over 17 years of age. There was no common outcome measure that was investigated in each of the six
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studies. Binge-purge outcomes were investigated in five of the studies usually through record keeping of binge and or purge episodes (27, 33-36). The bright light therapy studies had mixed results with one study finding significantly less binging and purging for participants (34) however the other study found no significant effect (33). The three other studies found no significant effects for the use of hypnosis (35), relaxation (36) or repetitive transcranial magnetic stimulation (27) for decreasing or abstaining from binging and or purging. Four studies investigated eating psychopathology (three via the Eating Disorder Inventory and two via the Eating Attitudes Test*) (33-37). One study found significantly less
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eating psychopathology for participants in the domains of the EAT-dieting subscale, EATbulimia and food preoccupation, the EDI-bulimia subscale for hypnosis and EDI-drive for
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thinness and EDI-bulimia subscale for relaxation (35). No significant effect was found for the
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use of bright light therapy, relaxation or massage for eating psychopathology (34, 36, 37).
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Five studies investigated depression (three using the Hamilton Depression Rating Scale, one utilised the Hamilton Depression Rating Scale- Seasonal Affective Disorder, four
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using the Becks Depression Index, and one study used the Profile of Mood StateDepression*) (27, 33, 34, 36, 37). Three of these studies found significantly less depression
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for participants however the massage study (Field et at 1998) did not undertake a between group comparison (33, 34, 37). No significant effect was found for the use of repetitive
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transcranial magnetic stimulation or relaxation for depression (27, 36).
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All the other outcome measures used in these six studies were individual to the
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study and effects included less clinical rated body dissatisfaction and food restriction (36).
* Outcome measures included multiple measures that investigated the same outcome e.g. in some studies both the Hamilton Depression Rating Scale and the Becks Depression Inventory or the Eating Disorder Inventory and the Eating Attitudes Test were used.
Side effects Some side effects in both groups of the Bright Light Therapy 1994 study were recorded, these were headache, eye fatigue and feeling ‘speedy’ (34).
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Mixed Eating Disorders The literature search yielded five studies investigating CAM therapy use for the
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treatment of a mixture of eating disorders (Anorexia Nervosa, Bulimia Nervosa or Eating Disorder Not Otherwise Specified).
The CAM modalities for the five studies were
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acupuncture, eye movement desensitization and reprocessing, relaxation, spirituality and yoga. The majority of the studies involved women as participants in their trials with only the
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yoga study including any males. The majority of these studies were conducted on patients
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over 15 years of age.
All five studies investigated eating psychopathology (three using the Eating Disorder
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Inventory, two utilised the Eating Attitudes Test and one using the Eating Disorder
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Examination) (38-42). One study found a significant improvement for eating disorder
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symptoms with yoga (42). The authors of the eye movement desensitization and reprocessing study mention a finding of lower body dissatisfaction (BD) post treatment in the abstract but the main paper results do not report any significant differences for Eating
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Disorder Inventory-Body Dissatisfaction (39). No significant effect was found for the use of acupuncture, eye movement desensitization and reprocessing, relaxation or spirituality for eating psychopathology (38-41). Three studies investigated anxiety (all using the State Trait Inventory) (38, 40, 42). Two of these studies found significantly less State anxiety, one with acupuncture (38) and one with relaxation (40). The relaxation treatment also found significantly less Trait anxiety (40). No significant effect was found for the use of yoga for anxiety (42).
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Three studies investigated depression (all via the Becks Depression Inventory (38, 39, 42). No significant effect was found for the use of yoga (42), acupuncture (38) or eye
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movement desensitization and reprocessing (39) for depression. All the other outcome measures used in these five studies were individual to the
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study and effects included significantly lower social role conflict with spirituality (41) and significantly improved quality of life with acupuncture (38).
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Side effects
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The acupuncture study reported side effects; one patient felt faint and nauseous,
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Binge eating disorder
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needles were removed and participant recovered and continued with the treatment (38).
One study investigated Binge Eating Disorder. The McIver et al 2009 trial of yoga
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and Binge Eating Disorder involved ninety overweight or obese women (28). A benefit was found for yoga with a significant reduction in binge eating, BMI and hip and waist measurements and an increase in physical activity (28).
Quality Assessment An assessment for quality of the included studies was undertaken using the Cochrane Review questions for assessing bias (26), see Table 2. For the majority of studies the risk of bias was unclear. Two studies, which investigated the use of acupuncture, were assessed to have an overall low risk of bias (29, 38). The majority of the studies had issues
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with the reporting thus leading to the unclear findings. Blinding of participants and personnel in the included CAM studies was limited due to the inherent difficulties in finding
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an appropriate control that ensures blinding can occur. Only three studies involving bright
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light therapy and repetitive transcranial magnetic stimulation were able to administer
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blinded controls. Blinding of the outcome assessors and incomplete reporting of the outcome data was reasonably well reported in just under half of the included studies
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however the reporting of how the randomised sequence was generated and allocation concealment was poor, also many authors not provide data on participant loss.
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Subgroup Analysis
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Participant numbers
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In a traditional meta-analysis the results are weighted due to participant numbers,
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thus a subgroup analysis based on participant numbers in each study was undertaken. This involved weighting the study results (significant or not significant) based on the proportion
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of the total number of participants in each subgroup i.e. (sum of the total number of participants in the included studies with significant results/sum total number of study participants in that category) x 100 = %. Where the participant numbers were within 20% of each other the studies were viewed as equal weighting. The results when the studies were weighted were as above excepting for two outcomes: the benefits for depression in those with Bulimia Nervosa using massage and bright light therapy became less beneficial, and second the benefits for anxiety in those with a mixed eating disorder using acupuncture and relaxation became less beneficial.
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Quality Assessment A statement about the quality of the included studies based on bias is given above.
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A subgroup analysis is undertaken based on the quality of the included studies. Only two studies, which investigated the use of acupuncture, were assessed to have an overall low
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risk of bias (29, 38). Weighting was given by level of bias; low bias was given a third more weight, unclear the same weight and high bias given a third less weight. Weighting the AN
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and acupuncture study more than the other AN and CAM studies does not change the results. Weighting the results of the acupuncture and mixed eating disorder study more
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than the CAM and mixed eating disorder results gives more strength to the findings of
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significantly less state anxiety for those with a mixed eating disorder.
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The subgroup analysis results indicate that study bias is not unduly influencing the
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DISCUSSION
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review findings however participant numbers may be influencing the review findings.
The aim of the review was to evaluate the literature and to clarify the role that CAM plays in the treatment of eating disorders.
The review found a potential role for
complementary and alternative medicine (CAM) therapies in the treatment of depression with massage and bright light therapy, for those with bulimia nervosa. There was also a potential role for CAM therapies in the treatment of State Anxiety, with acupuncture and relaxation for those with an eating disorder (Anorexia Nervosa, Bulimia Nervosa or Eating Disorder Not Otherwise Specified). Whilst a number of studies reported beneficial findings for anxiety and depression a sub group analysis based on study participant numbers
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indicates that these findings are not conclusive. There was mixed evidence for the role of the CAM treatments hypnosis, relaxation, massage or bright light therapy on the Eating
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Disorder Inventory domain of Bulimia. The review found little evidence that CAM therapies
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had a specific benefit on eating disorder symptomology/psychopathology for any eating
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disorder diagnostic category (AN, BN, or mixed diagnostic group (AN, BN and EDNOS). These results build extensively on the work of two now dated non-systematic reviews into CAM
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and eating disorder adjunctive treatments (18, 19) that provided inconclusive evidence of the role of CAM in the treatment of eating disorders. While improving and identifying areas
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for future research is important, so is providing evidence-based information for consumers, caregivers and medical providers. Research has identified a need for access to eating
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disorder services and CAM therapies have the potential to play an adjunctive role in the
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steeped care approach for the above-mentioned conditions (43).
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The reporting of safety and adverse effects in these studies was limited, however there were similar frequency of events to those in the current literature, with most evidence
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finding that CAM therapies are relatively safe (44-46). There was no evidence of any CAM therapy having a detrimental effect on the eating disorder, but the poor reporting of adverse events limits this finding. A role of CAM therapies in the recovery of eating disorders (as opposed to treatment) might be addressing the need for a unique and personal recovery and a personally satisfying quality of life for eating disorder sufferers (10, 14, 47). For recovery, much more than clinical treatment is required (47-49). There are benefits from the experience of receiving CAM therapies, which might be able to assist in recovery from an eating disorder such as making connections, motivation and interests beyond the illness (10,
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47-50). Receiving touch can give eating disorder suffers hope, comfort and feelings of being connected (51).
Massage and acupuncture were viewed positively as a welcome
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supplementary activity from usual care and something to look forward to (29) and yoga has
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been shown to provide relaxation, stillness and peace (52). Being able to choose a CAM
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therapy as part of the process of recovery may engage and motivate sufferers to continue with the recovery journey, foster new interests and meet the individual needs of the
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sufferer. A sense of connection may arise from the therapeutic relationship. The therapeutic relationship has been shown to be important in eating disorder treatments (10, 53-56). The
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experience of the CAM treatment commonly includes the therapeutic relationship (57, 58). The role of CAM therapies in recovery has not been the focus of research and more
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evidence is needed before the role CAM plays in recovery is determined. The findings from this review show no substantial beneficial effect from CAM
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therapies on the eating disorder itself. The majority of included studies were using the CAM therapy as an adjunctive treatment and thus it is probable that the researchers were not
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expecting global changes in the participant’s eating disorder. The use of CAM treatment research as an adjunct mirrors CAM clinical practice (20). A survey of acupuncturists in the United Kingdom found that acupuncturist’s commonly treated eating disorder related sideeffects/symptoms such as mental and emotional issues, menstrual irregularities and stress or depression and provided emotional support, rather than primarily treating patients for their eating disorder (20). It is recommended that CAM treatments should be provided as adjunctive treatments only. Future research could focus on the therapies and eating disorders that are the most promising, such as massage, bright light therapy and acupuncture. Future CAM and eating
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disorder studies might consider investigating experiential benefits such as increased hope, feeling ‘normal’, making connections, being motivated and so forth and more global
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outcome measures of health such as quality of life, emotional well-being and so forth to
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capture both the experience/effect of the treatment and the effect of the CAM therapy on
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recovery. Limitations of this review include that a meta-analysis could not be undertaken due to the small number of studies available. Also the reporting of the methodology was
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poor in many of the included studies, which lead to an overall unclear risk of bias for the majority of studies. This was taken into account when reporting the review findings and
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recommendations and information about methodological issues have been included
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throughout the review text where relevant.
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CONCLUSION
This systematic review summarises and critically appraises the literature on complementary and alternative medicine as an adjunct therapy for people with an eating
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disorder. Sixteen studies were included in the review. Due to the small study numbers a meta-analysis was unable to be undertaken. This review found the role of complementary and alternative medicine in the treatment of those with an eating disorder is unclear and further studies should be conducted. There may be a potential role for the CAM treatments relaxation, massage and bright light therapy, in the treatment of depression for those with bulimia nervosa and a potential role for the CAM treatments acupuncture and relaxation, in the treatment of State Anxiety, for those with an eating disorder. The review found no evidence that CAM treatment has a substantial beneficial effect on the eating disorder itself and thus CAM treatments should be provided as adjunctive treatments. CAM treatments
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may have a role in the recovery from an eating disorder through making connections,
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motivation and developing interests.
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Role of Funding Sources
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The authors of this paper received no funding to conduct the research and or preparation of the manuscript.
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Contributors
All authors designed the study and wrote the protocol. Author SF conducted the literature
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searches and eliminated papers based on study criteria. All authors were involved in the final papers to be included and in the extraction of data for review. Author SF conducted
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the analysis. Author SF wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript. Conflict of Interest All authors declare that they have no conflicts of interest.
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Appendix 1 List of CAM modalities
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Acupressure Acupuncture (e.g. needle acupuncture, electro-acupuncture) Alexander technique Aromatherapy Arts therapy (e.g. dance therapy, drama therapy, music therapy) Ayurvedic traditional medicine (Ayurveda) Balneotherapy Bee Products (e.g. honey, pollen, propolis, royal jelly, venom) Biofeedback Chelation therapy Chinese traditional medicine Chiropractic (e.g. spinal manipulation) Colour therapy (i.e chromotherapy) Craniosacral manipulation Dietary supplements * Diet therapy* Distant healing Electric stimulation therapy (e.g. transcutaneous electrical nerve stimulation) Electromagnetic therapy Eye movement desensitization and reprocessing (EMDR) Feldenkrais method Herbal supplements Homeopathy Hydrotherapy Hyperbaric oxygenation
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Hypnosis Imagery (i.e. visualization techniques) Light therapy (phototherapy) Magnetic field therapy (e.g. transcranial magnetic stimulation) Massage Meditation Morita therapy Moxibustion Naturopathy Osteopathic manipulation Ozone therapy Play therapy Prolotherapy Qi gong Reflexology Reiki therapy Relaxation techniques Snoezelen Spelcotherapy Spiritual healing (e.g. prayer) Tai chi Therapeutic touch Traditional healers and healing practices (other than Chinese) (e.g. Kampo, Shamanism) Tui na Ultrasonic therapy Yoga
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* These therapies are not included in the review as these are part of the standardised Western Medicine treatment for Eating Disorders
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Appendix 2
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Search Outline
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1. Anorexia Nervosa or anorexia 2. Bulimia Nervosa or Bulimia
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3. EDNOS or Eating Disorder not otherwise specified 4. OSFED or Other Specified Eating Disorders 5. Binge Eating Disorder or BED
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6. Eating disorder
7. 1 or 2 or 3 or 4 or 5 or 6 8. Acupressure 9. 7 AND 8 This search was then repeated for the other CAM modalities listed in Table 1 (excluding dietary supplements and dietary therapy) and by replacing the CAM therapy in Step 8. Where the CAM therapy had additional search term e.g. colour therapy and chromotherapy, this term was also searched e.g., 8. Colour therapy or chromotherapy All terms listed in Appendix 1 in brackets were searched along with the CAM therapy.
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Appendix 3
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Definition of CAM modalities in this review
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Acupuncture: a system of complementary medicine in which fine needles are inserted in the skin at specific points along what are considered to be lines of energy (meridians), used in
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the treatment of various physical and mental conditions.
Bright light therapy: Light therapy or phototherapy (classically referred to as heliotherapy) consists of exposure to daylight or to specific wavelengths of light using polychromatic
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polarised light, lasers, light-emitting diodes, fluorescent lamps, dichroic lamps or very bright, full-spectrum light.
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Eye movement desensitization and reprocessing: is a psychotherapy developed by Francine
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Shapiro that emphasizes disturbing memories as the cause of psychopathology. It is
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commonly used to help with the symptoms of post traumatic stress disorder (PTSD). Hypnosis: the induction of a state of consciousness in which a person apparently loses the power of voluntary action and is highly responsive to suggestion or direction. Its use in
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therapy, typically to recover suppressed memories or to allow modification of behaviour, has been revived.
Massage: is the use of touch to manually manipulate the soft body tissues (muscle, and connective tissue) to enhance a person's health and well-being. Relaxation: The teaching of relaxation techniques via a method, process, procedure, or activity, that helps a person to relax; to attain a state of increased calmness; or otherwise reduce levels of pain, anxiety, stress or anger. Repetitive transcranial magnetic stimulation: is a form of brain stimulation therapy. It uses magnetic pulses instead of electricity to activate parts of the brain. Developed in 1985 it has been commonly used as a possible therapy for depression
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Spirituality: Spiritual therapy is using a spiritual approach within the treatment framework. Spirituality is a broad concept with room for many perspectives. In general, it includes a sense of connection to something bigger than ourselves, and it typically involves a search for
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meaning in life.
Yoga: a Hindu spiritual and ascetic discipline, a part of which, including breath control,
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simple meditation, and the adoption of specific bodily postures, is widely practiced for
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8. Qian J, Hu Q, Wan Y, Li T, Wu M, Ren Z, et al. Prevalence of eating disorders in the general population: a systematic review. Shanghai Arch Psychiatry. 2013;25(4):212-23. 9. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. . Arch Gen Psychiatry. 2011;68(7):724-31. 10. Dawson L, Rhodes P, Touyz S. “Doing the Impossible”: The Process of Recovery From Chronic Anorexia Nervosa. Qual Health Res. 2014;24(4):494-505. 11. Lowe B, Zipfel S, Buchholz C, Dupont Y, Reas D, Herzog W. Long-term outcome of anorexia nervosa in a prospective 21-year follow up study. Psychol Med. 2001;31:881-90. 12. Hay P. A systematic review of evidence for psychological treatments in eating disorders: 2005–2012. International Journal of Eating Disorders. 2013;46(5):462-9. 13. Treasure J, Claudino A, Zucker N. Eating Disorders. Lancet. 2010;375(9714):583-93. 14. Mitchison D, Morin A, Mond J, Slewa-Younan S, Hay P. The bidirectional relationship between quality of life and eating disorder symptoms: a 9-year community-based study of Australian women. PLoS One. 2015;Mar 26;10(3). 15. National Eating Disorders Collaboration. Understanding Recovery 2015 [updated 5th May 2015; cited 2015 25th May]. Available from: http://www.nedc.com.au/recovery. 16. Barnes P, Bloom B, Nahin R. Complementary and Alternative Medicine Use Among Adults and Children. United States: National Center for Health Statistics, 2008. 17. Kessler R, Soukup J, Davis R, al e. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry. 2001;158:289-94. 18. Madden S, Fogarty S, Smith C. Alternative and Complementary Therapies in the Treatment of Eating Disorders, Addictions, and Substance Use Disorders. In: Brewerton TD, Dennis AB, editors. Eating Disorders, Addictions and Substance Use Disorders. New York: Springer; 2014. p. 625-47. 19. Fogarty S, Madden S. A review of the use of acupuncture in the treatment of Anorexia Nervosa. In: Gramagila C, Zeppegno P, editors. New Developments in Anorexia Nervosa Research. New York: Nova Science Publishers Inc; 2014. p. 141-50. 20. Clarke L. Exploring the basis for Acupuncture Treatment of Eating Disorders; A Mixed Methods Study: Northern College of Acupuncture (NCA); 2009. 21. Vancampfort D, Vanderlinden J, De Hert M, Soundy A, Adámkova M, Skjaerven LH, et al. A systematic review of physical therapy interventions for patients with anorexia and bulemia nervosa. Disabil Rehabil. 2014;36(8):628-34. 22. Katterman SN, Kleinman BM, Hood MM, Nackers LM, Corsica JA. Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: A systematic review. Eat Behav. 2014;15(2):197-204. 23. World Health Organization. International Classification of Diseases,. 1992. 24. Birmingham CL, Beumont P. Medical Management of Eating Disorders. Cambridge: Cambridge University Press; 2004. 289 p. 25. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement2009 2009-07-21 10:46:49. 26. Higgins J, Green S. Cochrane Handbook of Systematic Reviews of Interventions: The Cochrane Collaboration; 2008. Available from: http://www.cochrane-handbook.org. 27. Walpoth M, Hoertnagl C, Mangweth-Matzek B, Kemmler G, Hinterholzl J, Conca A, et al. Repetitive transcranial magnetic stimulation in bulimia nervosa: preliminary results of a singlecentre, randomised, double-blind, sham-controlled trial in female outpatients. Psychotherapy & Psychosomatics. 2008;77(1):57-60. 28. McIver S, O’Halloran P, McGartland M. Yoga as a treatment for binge eating disorder: A preliminary study. Complement Ther Med. 2009;17(4):196-202. 29. Smith C, Fogarty S, Touyz S, Madden S, Buckett G, Hay P. Acupuncture and acupressure health outcomes for patients with anorexia nervosa: findings from a pilot randomised controlled trial and patient interviews J Altern Complement Med. 2014;Feb; 20(2,):103-12.
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30. Janas-Kozik M, Krzystaneck M, Stachowicz M, Krupka-Matuszczyk I, Janas A, Rybakowski JK. Bright light treatment of depressive symptoms in patients with restrictive type of anorexia nervosa. J Affect Disord. 2011;130:462-5. 31. Hart S, Field T, Hernandez-Reif M, Nearing G, Shaw S, Schanberg S, et al. Anorexia Nervosa Symptoms are Reduced by Massage Therapy. Eating Disorders. 2001;9(4):289-99. 32. Goldfarb LA, Fuhr R, Tsujimoto RN, Fischman SE. Systematic desensitization and relaxation as adjuncts in the treatment of anorexia nervosa: a preliminary study. Psychological Reports. 1987;60(2):511-8. 33. Blouin AG, Blouin JH, Iversen H, Carter J, Goldstein C, Goldfield G, et al. Light Therapy in Bulimia nervosa: a double-blind, placebo controlled study. Psychiatry Res. 1996;60:1-9. 34. Lam RW, Goldner EM, Solyom L, Remick R. A Controlled Study of Light Theray for Bulimia Nervosa. Am J Psychiatry. 1994;151(5):744-50. 35. Griffiths RA, Hadzi-Pavlovic D, Channon-Little L. A controlled evaluation of hypnobehavioural treatment for bulimia nervosa: Immediate pre-post treatment effects. Eur Eat Disord Rev. 1994;2(4):202-20. 36. Bulik CM, Sullivan PF, Carter FA, McIntosh VV, Joyce PR. The role of exposure with response prevention in the cognitive-behavioural therapy for bulimia nervosa. Psychological Medicine. 1998;28(3):611-23. 37. Field T, Schanberg S, Kuhn C, Fierro K, Henteleff T, Mueller C, et al. Bulimic adolescents benefit from massage therapy. Adolescence. 1998;33(131):555-63. 38. Fogarty S, Harris D, Zaslawski C, McAinch AJ, Stojanovska L. Acupuncture as an Adjunct Therapy in the Treatment of Eating Disorders: A Pilot Study. Complement Ther Med. 2010;18(6):22776. 39. Bloomgarden A, Calogero RM. A randomized experimental test of the efficacy of EMDR treatment on negative body image in eating disorder inpatients. J Eat Disord. 2008;16(5):418-27. 40. McComb JJR, Clopton JR. The effects of movement, relaxation, and education on the stress levels of women with subclinical levels of bulimia. Eat Behav. 2003;4(1, March ):79-88. 41. Richards SP, Berrett ME, Hardman RK, Eggett DL. Comparative Efficacy of Spirituality, Cognitive, and Emotional Support Groups for Treating Eating Disorder Inpatients. J Eat Disord. 2006;14(5):401-15. 42. Carei RT, Fyfe-Johnson AL, Breuner CC, Brown MA. Randomized Controlled Clinical Trial of Yoga in the Treatment of Eating Disorders. Journal of Adolescent Health. 2010;46:346–51. 43. Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, et al. Royal Austalian and New Zealand College of Psychaitrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014;48(11):977-1008. 44. Zhang J, Shang H, Gao X, Ernst E. Acupucnture-related adverse events: a systematic review of the Chinese literature. Bulletin of the World Health Organisation: The World Health Organisation, 2010. 45. Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, et al. Safety of Acupuncture: Results of a Prospective Observational Study with 229,230 Patients and Introduction of a Medical Information and Consent Form. Forsch Komplementmed. 2009;16(2):91-7. 46. Harris T, Grace S, Eddey S. Adverse Events from Complemetary Therapies: An Update from the Natural Therapies Workforce Survey Part 1. Journal of the Australian Traditional Medicine Society. 2015;21(2):86-91. 47. Espíndola C, Blay S. Long term remission of anorexia nervosa: factors involved in the outcome of female patients. PLoS One. 2013;8((2):e56275). 48. Hay PJ, Cho K. A Qualitative Exploration of Influences on the Process of Recovery from Personal Written Accounts of People with Anorexia Nervosa. Women & Health. 2013;53(7):730-40. 49. Espindola C, Blay S. Anorexia Nervosa treatment from the patient perspective: a metasynthesis of qualitative studies. Ann Clin Psychiatry. 2009;21:38 - 48.
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50. Federici A, Kaplan AS. The patient's account of relapse and recovery in anorexia nervosa: a qualitative study. Eur Eat Disord Rev. 2008;16(1):1-10. 51. Henricsona M, Segestena K, Berglundb A-L, Määttäa S. Enjoying tactile touch and gaining hope when being cared for in intensive care. A phenomenological hermeneutical study. Intensive Crit Care Nurs. 2009;25:323-31. 52. Douglass L. Yoga as an Intervention in the Treatment of Eating Disorders: Does it Help? J Eat Disord. 2009;17(2):126-39. 53. Fogarty S, Smih C, Touyz S, Madden S, Buckett G, Hay P. Patients with anorexia nervosa receiving acupuncture or acupressure; their view of the therapeutic encounter. Complement Ther Med. 2013. 54. Wright KM. Theraputic relationship: Developing a new understanding for nurses and care workers within an eating disorder unil. J Psychiatr Ment Health Nurs. 2010;19:154-61. 55. Wright KM. An Interpretive Phenomenological Study of the Therapeutic Relationship between Women Admitted to Eating Disorder Services and Their Care Workers. Lancashire: University of Central Lancashire; 2014. 56. Wright KM, Hacking S. An angel on my shoulder: a study of relationships between women with anorexia and healthcare professionals. Journal of Psychiatric and Mental Health Nusing. 2012;19:107-15. 57. Paterson C, Zheng Z, Xue C, Wang Y. Playing Their Parts”: The Experiences of Participants in a Randomized Sham-Controlled Acupuncture Trial J Altern Complement Med. 2008;March, 14(2). 58. Anderson KT. Holistic Medicine Not “Torture”: Performing Acupuncture in Galway, Ireland. Medical Anthropology. 2010;29(3):253-77.
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Table 1. Summary of included studies and the significant findings by CAM therapy Results at end of the treatment Mean (M), Mean Deviation (MD,) odds ratio (OR) or F statistic for ratio of variances (F) Confidence interval (CI) / Standard Deviation (SD)/Standard Error/r /df/ f
TCM style acupuncture + TAU n = 9 v TAU n=9
AN or BN Patients > 17 years of age at a private outpatient eating disorder clinic AN Inpatients at a private hospital > 15 years of age
EDI-3, BDI, STAI & EDQoL
The acupuncture group has a mean STAI score of 37.6, 3.3 (SE) which was significantly less than the control group which had a mean STAI score of 46.3, 5.8 (SE). The acupuncture group has a mean Physical/Cognitive domainEDQoL score of 8.0, 1.8 (SE) which was significantly less than the control group which had a Physical/Cognitive domain-EDQoL score of 9.7, 3.3 (SE) .
BN. Females, 17 years or over
BDI, HDRSSAD, Bulimia symptom checklist, Daily Binge record, POMS. HDRS & BMI
Bright Light Therapy (BLT) Bloudin 1996 BLT n = 9 v Placebo BLT n = 9
BLT n= 17 v placebo BLT n= 17
AN. Female patients at an impatient hospital, aged 15-20 years & > 17 points on the HDRS
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The control group had significantly lower EDE-Q eating concerns score than the acupuncture group 1.0 (MD), 95% CI 0.05-1.9
BN. Binges/purges Active per week, illness HDRS, BDI, determined Weight, Visual by at least Analog Bulimia 3 episodes Scale, Visual of Binge Analog eating or carbohydrate purging per craving scale, week EAT Eye Movement Desensitization & Reprocessing (EMDR) Bloomgarden EMDR + TAU n= AN, BN or BIM, BIS, ASI, 2008 43 or TAU only EDNOS. EDI-BD, n= 43 Females at SATAQ-R, EATa 26, BDI, DES residential eating disorder setting Hypnosis Griffiths HypnoBN EDE, EDI-3, 1994 behavioural Female EAT-40, EATTherapy n = 21 v patients at 26 (Dieting, Cognitive a teaching Food Behaviours hospital, preoccupation, therapy (CBT) n = aged 17-50 Oral Control),
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BLT + CBT n= 12 v CBT alone n= 12
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BMI, EDI-3, EDE-Q, DASS, EDQoL
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Acupuncture + TAU n = 13 v acupressure/light massage + TAU n = 13
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Outcome Measures
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Smith 2013
Eating Disorder type and setting
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Acupuncture Fogarty 2010
Intervention and participant numbers (n)
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CAM Therapy
The BLT group had a significantly lower depression score than the placebo group 4.14 (F), 2.15 (df)
The BLT group has a mean depression score of 10.67, 1.61 (SD) which was significantly less than the control group which had a mean depression score of 13.58, 3.09 (SD).
The BLT group has a mean BDI depression score of 9.0, 7.4 (SD) which was significantly less than the control group which had a mean depression score of 17.8 11.1 (SD). The BLT group has a mean total binging score of 4.4, 5.3 (SD) which was significantly less than the control group which had a mean total binge score of 6.5, 6.0 (SD). The BLT group has a mean total purging score of 4.5, 5.6 (SD) which was significantly less than the control group which had a mean total purging score of 6.7, 6.5 (SD).
The EMDR group had a significantly lower distress about negative body image memories score (earliest memory) than the placebo group 3,252 (F) = 7.27, 0.17 (r) The EMDR group had a significantly lower distress about negative body image memories score (worst memory) than the placebo group 3,252 (F) =6.78, 0.16 (r)
The hypnosis and CBT groups (together) had a significantly lower Eating Attitudes Test (EAT) total score, EAT-dieting subscale, EATbulimia and food preoccupation subscale and EDI-3 Bulimia subscale scores than the control. Eating Attitudes Test F (1,59) = 25.03 EAT-dieting subscale F (1,59) = 15.96
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BN. Women at an inpatient residential treatment centre
POMSDepression, BOS, Salivary cortisol, EDI, CES-D
No statistics were given on between group comparisons. The massage group has a mean STAI pre first massage score of 50.1, 3.3 which was significantly less than the post last massage score of 37.4. The massage group has a mean depression pre first massage score of 36.2 which was significantly less than the post last massage score of 27.2.
Massage therapy n = 10 v TAU n= 9
AN. Women at an inpatient and outpatient centre
STAI, POMS, salivary cortisol, weight, CES-D, EDI
Relaxation & CBT n = 39 v Binge Exposure therapy & CBT n = 39 v Purge exposure therapy & CBT n =38
BN. Women aged 17-45 years with a diagnosis of BN and a BMI of < 30.
Frequency of Binging, frequency of purging. EDI-2 BD, EDI-2 DT, EDI-2 B, food restriction, HDRS, Global Assessment of Functioning Scale
The relaxation intervention compared to the binge exposure group or the purge exposure groups showed no significant effects.
Weight, Roseenburg self esteem scale, Goldfarb Fear of Fat Scale.
At the 6 month follow up the relaxation therapy group had significantly greater self esteem than the control group At the 6 month follow up the relaxation therapy group had significantly less fear for fat than the control group F (1,4) = 49.48
Relaxation n = 3 v desensitization n = 4 v non equivalent control group n= 11
Mc Comb 2003
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Massage therapy n = 12 v TAU n= 12
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EAT-bulimia and food preoccupation subscale F = (1,59) = 30.99 EDI-3 Bulimia subscale F (1.59) = 30.69 There were no significant changes between the two treatment groups.
No statistics were given on between group comparisons. The massage group has a significantly lower STAI pre first massage score compared to the post last massage score F (1, 17) = 17.3. The massage group has a significantly lower moode pre first massage score compared to the post last massage score F (1, 17) = 5.0.
MA
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Relaxation Bulik 1998
Harvard Group Scale of Hypnotic Susceptibility & occurrence's of binging and purging.
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Hart 2001
years with a BMI 1826 & no more than two previous inpatient admissions for treatment of an eating disorder.
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Massage Field 1998
19 v a wait-list group n = 22
AN. Females aged 18 years and over
An 8 week group EDNOS. STAI, program for 1.5 Female and Coopersmith hours each week not Self-Esteem discussing anorexic Inventory, movement BUILT-R, EDI-2 improvisation & DT, EDI-2 BD relaxation n = 6 v no treatment n = 6 Repetitive Transcranial Magnetic Stimulation (RTMS) Walpoth RTMS n = 7 v a BN. Binge-Purge 2008 sham RTMS with Females status, HDRS, a magnetic field aged 18-35 BDI, YBOCS absorbing metal years with plate n = 7 a BMI of > 17.5 & a HAMD score of < 18 Spirituality Richards Spirituality group AN, BN or EAT, BSQ, OQ-
There was significantly less STAI state for the relaxation group compared to the control group F (1, 10) = 5.10, f = 0.71 There was significantly less STAI trait anxiety for the relaxation group compared to the control group F (1, 10) = 7.44, f = 0.86
No statistical difference between groups for any outcome measures
There was significantly less eating disorder symptoms for the
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n = 45 v a cognitive group n = 35 v an emotional support group n = 44
EDNOS Private inpatient facility for women with from 13 -52 years
45, MSEI, SWBS, EDSMS, TSOS
8 one hour a week yoga sessions plus TAU n = 26 v TAU n = 27
AN, BN or EDNOS.
EDE, BMI, BDI & STAI
spirituality group compared to the cognitive group F (2, 111) = 4.56 There was significantly less Social role conflict for the spirituality group compared to the cognitive F (2, 113) = 5.91 There was significantly less symptom distress for the spirituality group compared to the cognitive and emotional groups F (2, 113) = 3.78 There was significantly less relationship distress for the spirituality group compared to the cognitive and emotional groups F (2, 113) = 5.37 There was significantly more religious well being for the spirituality group compared to the cognitive and emotional groups F (2, 108) = 3.74 There was significantly more existential well being for the spirituality group compared to the cognitive and emotional groups F (2, 109) = 3.07
NU
There was significantly less binge eating for the yoga group compared to the control group F (1,48) = 38.3 There was significantly more physical activity for the yoga group compared to the control group F (1,48) = 12.8 There was significantly less BMI scores for the yoga group compared to the control group F (1,48) = 7.5 There was significantly less hip measurement scores for the yoga group compared to the control group There was significantly less binge eating for the yoga group compared to the control group F (1,48) = 38.1 There was significantly less waist measurement scores for the yoga group compared to the control group F (1,48) = 61.2
MA
Binge eating Disorder. Women from a community based sample of overweight or obese women (BMI of> 25) BED defined by a score of > 20 on the BES, aged between 25 -65 years
BES, Short form of IPAQ
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60 min weekly yoga group for 12 weeks plus a home yoga program n = 25 v wait list n - 25
There was significantly less eating disorder symptoms for the yoga group compared to the control group F (2,35) = 3.26
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Patients at a Children's hospital outpatient department between ages 10-21 years.
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AN = Anorexia Nervosa, BN = Bulimia Nervosa, EDNOS = Eating Disorder Not Otherwise Specified, BED= Binge Eating Disorder, EDI = Eating Disorder Inventory, BDI = Becks Depression Inventory, STAI = State Trait Anxiety Intervention, EDQoL = Eating Disorder Quality of Life Scale, BMI = Body Mass Index, EDE-Q = Eating Disorder Examination Questionnaire, DASS = Depression, Anxiety and Stress Scale, HDRS = Hamilton Depression Rating Scale, HDRS-SAD= Hamilton Depression Rating Scale-Seasonal Affective Disorder, POMS= Profile of Mood States, EAT= Eating Attitudes test, BIM= Body Image memory questionnaire, BIS= Body Investment Scale, ASI= Appearance Schemas Inventory, SATAQ-R= Sociocultural Attitudes towards Appearance Questionnaire Revised, DES= Dissociative Experiences Scale, BOS = Behaviour Observation Scale, CES-D = Centre for epidemiology studies depression scale, DT= Drive for Thinness, B= Bulimia, BD= Body Dissatisfaction, YBOCS= Yale Brown Obsessive Compulsive Scale
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Table 2: Risk of bias in included studies Incomplete outcome data
Selective reporting
Yes
Unclear
Unclear
None
Unclear Unclear Unclear Unclear Yes Unclear
Unclear Unclear Unclear Unclear Unclear Unclear
Yes No No No No Unclear
Yes Unclear Unclear Unclear Yes Unclear
Unclear Unclear Yes Unclear Yes Yes
Unclear Unclear Yes Unclear Yes Unclear
Yes None Unclear Unclear None None
Unclear Unclear Unclear
Unclear Unclear Unclear
No No No
Yes Unclear Yes
No Yes Unclear
No Unclear Unclear
Unclear None Unclear
Unclear Unclear
Unclear Unclear
Yes No
Unclear Unclear
Unclear Yes
No No
Unclear None
Yes Unclear
Unclear Unclear
No No
Unclear Unclear
No Yes
Unclear Yes
Unclear Unclear
Yes Unclear
Yes Unclear
No Yes
Yes Yes
Yes Unclear
Unclear No
None Unclear
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Yes
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Blinding of outcome assessment
Unclear
Blinding of participants and personnel No
Other bias
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Allocation Concealment
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Bloomgarden 2008 Blouin 1996 Bulik 1998 Carei 2010 Field 1998 Fogarty 2010 Goldfarb 1987 Griffiths 1994 Hart 2001 Janas-Kozik 2010 Lam 1994 McComb 2003 McIVer 2009 Richards 2006 Smith 2013 Walpoth 2008
Random sequence generation
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Figure 1. Flow Diagram of literature search
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