Effectiveness of universal secondary school-based interventions addressing the psychological risk factors of eating disorders in adolescents: a systematic review

Abstract

To evaluate the effectiveness of universal secondary-school interventions targeting core eating disorder (ED) psychopathology and at least one additional psychological risk factor. A systematic search of databases was conducted, including Scopus, CINAHL, Embase, PsycINFO, MEDLINE and Google Scholar in March 2025. Eligible randomised controlled trials (RCTs) reported quantitative outcomes (e.g., ED psychopathology, body dissatisfaction, dieting behaviors) following universal secondary-school interventions addressing weight, shape, or eating concerns and another psychological risk factor in non-clinical adolescents aged 11–18. Results were synthesized narratively, and study quality was evaluated using the Cochrane Risk of Bias (RoB-2). Seventeen RCTs were included. Eleven studies were conducted in Europe, most participants were female and in middle adolescence. Overall, most universal school-based ED interventions produced some immediate improvement in ED symptoms or well-being but effects were generally small or rarely sustained at follow-up. There were no significant changes in BMI. However, the high risk of bias limits the confidence of findings. These improvements were short term, and their effects were mostly small. Future research would benefit from adopting active comparison groups and longer follow-ups. Whilst core ED psychopathology in addition to the risk factors of body image dissatisfaction, dieting, self-esteem, and social media appear consistent factors to include in universal interventions, further understanding of the most effective risk factors to target in this population is needed.