Social support networks and eating disorders: an integrative review of the literature

Figures & data

Figure 1 Flowchart of bibliographic search results based on the PRISMA statement guidelines.

Table 1 Characteristics of the studies that addressed “family as a source of social support” according to the authors, year of publication, participants, study design, objectives, and instruments (n=14)

Authors (year)	Participants	Study design	Objectives	Instruments
Dimitropoulos et al^Citation39 (2013)	26 patients paired with their siblings, recruited from an ED program	Nonexperimental, descriptive, correlational	1) To identify perceptions of patients with AN and their siblings regarding differential experiences within and external to the family including sibling interactions, parental treatment, relationships with peers and events that are unique to each sibling; 2) to compare how patients and their siblings perceive ED symptoms, parental affection/control, social support, and stigma; 3) to test the difference between the perception of patients with AN and their siblings about the association between family functioning and symptoms of AN.	Eating Disorder Examination Questionnaire, Sibling Inventory of Differential Experience, Devaluation of Consumers and Consumer Families Scales, SPS, Eating Disorders Symptom Impact Scale, and McMaster FAD-GFS.
Linville et al^Citation36 (2012)	22 women between the ages of 23–55 years who were recovered from ED	Exploratory, descriptive	To examine how social supports were helpful and hurtful during the ED recovery process and to learn about varying experiences with social supports from the perspectives of recovered women.	Semistructured interviews that lasted between 60 minutes and 90 minutes; ten were conducted in person, and 12 were conducted over Skype (Skype Technologies S.A., Luxembourg, Luxembourg) via computer.
Campos et al^Citation37 (2012)	Groups of family members of patients with ED	Exploratory, descriptive	To expand upon knowledge about the mother–daughter relationship in AN, with a focus on developing a conceptual framework that is able to improve the treatment of the disorder, reduce factors that perpetuate it, and improve prognosis.	A clinical method, anchored with psychodynamic references, was employed in a group of family members of patients with ED. The group met weekly, and the sessions were led by psychologists from the ED outpatient clinic of a university hospital.
Fitzsimmons and Bardone-Cone^Citation28 (2011)	96 females seen at one point for an ED, including 53 with a current ED diagnosis and 43 who were at varying levels of recovery	Nonexperimental, descriptive, correlational	To examine two possible moderating factors that have the ability to potentially attenuate anxiety’s effect on an ED: coping skills and social support.	Structured clinical interview for the DSM-IV, Patient Edition, Spielberger State–Trait Anxiety Inventory, Trait Anxiety Scale, Coping Inventory for Stressful Situations, Multidimensional Scale of Perceived Social Support, and Eating Attitudes Test-26.
Rothschild-Yakar et al^Citation26 (2010)	Female adolescents with AN (n=34) and non-ED controls (n=35)	Experimental	To compare the mental abilities of women with AN and women without ED; to compare the perception of women with and without AN about the quality of their relationship with their parents; to assess whether the mental capacity and quality of relationships with parents may serve as potential predictors for the development of ED.	The Reflective Function Scale, Social Cognition and Object Relation Scale, Quality of Present Interpersonal Relationships, and two subscales of the EDI: Drive for Thinness and Bulimia.
Limbert^Citation6 (2010)	Women aged between 18–35 years old (n=132)	Nonexperimental, descriptive, correlational	To investigate the relationship between social support and ED symptomatology among a female, nonclinical population.	Sociodemographic questionnaire and a scale of 36 questions to assess social support, based on the Student Social Support Scale. The scale also included 64 questions taken from the EDI.
Gillet et al^Citation34 (2009)	102 families (51 families with a member with ED and 51 control families)	Experimental	To compare implicit family process rules (specifically rules pertaining to kindness; expressiveness and connection; constraining thoughts, feelings, and self; inappropriate caretaking; and monitoring) in families with a young adult female diagnosed with ED and families with a young adult female without an ED diagnosis.	Sociodemographic questionnaire, Family Implicit Rules Profile, Family Substance Abuse Profile, Children of Alcoholics Screening Test, Adolescent Substance Abuse Subtle Screening Inventory-2, Substance Abuse Subtle Screening Inventory-3, and six questions about ED.
Marcos and Cantero^Citation3	98 female ED patients, with ages between 12–34 years old	Nonexperimental, descriptive	To assess social support dimensions (providers, satisfaction and different support actions) in patients with ED, while looking at diagnosis, sociodemographic and clinical characteristics, and self-concepts.	Sociodemographic and clinical questionnaire, perceived social support scale and self concept questionnaire.
Cunha et al^Citation32 (2009)	34 women with an ED diagnosis and 34 controls	Nonexperimental, descriptive, correlational	To explore the differences in perceived family characteristics between a group of female patients with AN and females without an eating pathology.	Family Adaptability and Cohesion Scale, Family Crisis Oriented Personal Evaluation Scale, Inventory of Parent and Peer Attachment, and Family Beliefs Questionnaire.
Cooley et al^Citation25 (2008)	91 pairs of mothers and their college-aged daughters	Nonexperimental, descriptive, correlational	To examine the effects of maternal eating behaviors and attitudes, maternal feedback to daughters about the daughters’ weight issues, mother–daughter relationship closeness, media influences, and mothers’ perceptions of their daughters’ shape on the daughters’ body image and eating pathology.	Two subscales of the EDI were used: the Composite Eating Pathology Scale and the Weight Concerns Scale. In addition, Body Image Silhouettes, Sociocultural Attitudes Toward Appearance Questionnaire-Revised: Female Version.
Dimitropoulos et al^Citation38 (2008)	63 caregivers (parents, partners, and/or siblings) of patients with AN	Experimental	To determine influences on caregiver distress and family functioning in AN using the stress process model.	The Burden Assessment Scale, Family Conflict Scales, the Devaluation of Consumers and the Devaluation of Consumer Families Scales, the SPS, the Professional Support Instrument, the FAD-GFS, and the GHQ.
Dallos and Denford^Citation20 (2008)	n=16, four of which were the members of four families (a daughter with AN, parents, and a sibling).	Multiple case study	To explore the experiences of four families, each of which contained a young person who had suffered with AN. The focus of the study included an exploration of the current relationships in the family, transgenerational patterns of relating within the family, and the role of food with respect to comfort.	Semistructured interviews were conducted, which drew upon aspects of the Adult Attachment Interview, including questions regarding early family experiences, family relationships, the provision of comfort, as well as losses, traumas, and integrative questions.
Winn et al^Citation33 (2007)	112 caregivers and 68 adolescents with BN or ED not otherwise specified	Nonexperimental, descriptive	To explore levels of mental health problems in caregivers, to assess whether a negative experience of caregiving predicts a caregiver’s mental health status, and to determine which factors predict a negative experience of caregiving.	GHQ-12, Experience of Caregiving Inventory, Level of Expressed Emotion, Self-report Family Inventory, and Inventory of Interpersonal Problems.
Hillege et al^Citation35 (2006)	19 mothers and three fathers of adolescents with ED	Exploratory, descriptive	To consider the impact that an ED had on the family, particularly on the parents, as well as to give parents a voice to develop new understandings of their experiences, leading to more appropriate clinical decision making.	Semistructured interviews. Themes were identified through an in-depth analysis.

Abbreviations: n, number; AN, anorexia nervosa; ED, eating disorder; SPS, Social Provision Scale; FAD, Family Assessment Device; GFS, General Functioning Scale; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition; EDI, Eating Disorders Inventory; GHQ, General Health Questionnaire; BN, bulimia nervosa.

Table 2 Characteristics of the studies that addressed “peer relations” according to the authors, year of publication, participants, study design, objectives, and instruments (n=3)

Authors (year)	Participants	Study design	Objectives	Instruments
Shomaker and Furman^Citation31 (2009)	199 adolescents (49.75% females), their mothers, and friends	Nonexperimental, descriptive, correlational	To investigate interpersonal influences on changes in late adolescent boys’ and girls’ symptoms of disordered eating over 1 year.	Sociodemographic questionnaire, Pressure to be Physically Attractive Questionnaire, Perceived Sociocultural Pressure Scale, Satisfaction and Dissatisfaction with Body Parts Scale, and Eating Attitudes Test-26.
Hutchinson and Rapee^Citation24 (2007)	1,094 female students with a mean age of 12.3 years old	Nonexperimental, descriptive, correlational	To examine the role of friendship networks and peer influences on body image concerns, dietary restraints, extreme weight loss behaviors, and binge eating in a large community sample of young adolescent females.	Sociodemographic questionnaire, Body Attitudes Questionnaire, Dutch Eating Behavior Questionnaire – Revised, and the Bulimia subscale of the Eating Disorders Inventory. Data collected from friends’ networks were analyzed by a statistical program (UCINET VI).
Campos et al^Citation37 (2012)	Groups of family members of patients with ED	Exploratory, descriptive	To expand upon the knowledge about the mother–daughter relationship in AN, with a focus on developing a conceptual framework that is able to improve the treatment of the disorder, reduce factors that perpetuate it, and improve the patient’s prognosis.	Clinical method based on psychodynamic references, was employed in a group of family members of patients with ED. The group met weekly, and sessions were led by psychologists from the ED outpatient clinic of a university hospital.

Abbreviations: n, number; ED, eating disorder.

Table 3 Characteristics of the studies that addressed “websites and online forums” according to the authors, year of publication, participants, study design, objectives, and instruments (n=6)

Authors (year)	Participants	Study design	Objectives	Instruments
Rodgers et al^Citation41 (2012)	30 female members of online pro-ana communities; mean age was 17.4 years	Exploratory, descriptive	To explore individuals’ motivations to become a member of a French-language “pro-AN” online community, their perceptions of support provided by other members of the site, and the nature of the information provided.	EAT-40 and a Pro-ED online community questionnaire developed by the authors.
Borzekowski et al^Citation21 (2010)	180 websites pro-ED	Nonexperimental, descriptive	To examine the features of pro-ED websites that describe, endorse, and support these disorders, and the messages to which users may be exposed.	Systematic content analysis of 180 active websites noting site logistics, site accessories, ‘‘thinspiration’’ material (images and prose intended to inspire weight loss), tips and tricks, recovery, themes, and perceived harm.
Ransom et al^Citation29 (2010)	A survey of 60 forum members and 64 age-matched university controls	Experimental	To explore the positive and negative behaviors encouraged on online forums about ED by comparing forum members’ perceptions of support received from online and offline relationships to the support received by age-matched controls in their relationships.	Assessment of body mass index and ED symptoms by the EAT-26. Then, information was collected about the clinical diagnosis, history of treatment, the specific behaviors of ED, the use of online forums, and the social support received by the online forums, and the support received from people with whom participants interact personally.
Csipke and Horne^Citation27 (2007)	78 users of pro-ED websites	Nonexperimental, descriptive	To investigate characteristics of users of pro-ED websites and the perceived impact of the visits.	A 24-item questionnaire supplemented with the EAT-26 was developed and posted on the website of the UK mental health charity institution to which the authors are linked. The questionnaire was also posted on the ED website and on two pro-ED websites.
Brotsky and Giles^Citation22 (2007)	12 websites pro-AN	Exploratory, descriptive	To investigate the kind of psychological support offered by pro-AN websites. Also, to comprehend website member’s beliefs towards ED, treatment and recovery.	Covert participation and thematic analysis of the topics, concerns, beliefs, and contributions of website users.
Mulveen and Hepworth^Citation23 (2006)	15 websites pro-AN	Exploratory, descriptive	To examine the meaning of participation in a pro-AN website and its relationship with disordered eating.	Interpretative phenomenological analysis of 15 separate message “threads” were observed over a 6-week period.

Abbreviations: n, number; EAT, Eating Attitudes Test; ED, eating disorder; AN, anorexia nervosa.

Table 4 Characteristics of the study that addressed “spiritual support” according to the authors, year of publication, participants, study design, objectives, and instruments (n=1)

Authors (year)	Participants	Study design	Objectives	Instruments
Richards et al^Citation30 (2006)	122 women receiving inpatient ED treatment	Experimental	To evaluate the effectiveness of a spiritual group intervention for ED inpatients.	Eating Attitudes Test-26, Body Shape Questionnaire, Outcome Questionnaire-45, Multidimensional Self-Esteem Inventory, and Spiritual Well-Being Scale.

Abbreviations: n, number; ED, eating disorder.

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