METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines, with the protocol registered in PROSPERO. Four electronic databases, which are PubMed, Scopus, ProQuest and Science Direct, were systematically searched for studies published between 2000 and 2025. Twenty-two studies met the inclusion criteria and were assessed for quality using the Joanna Briggs Institute tool. Meta-analysis using a random-effects model was performed in RStudio to estimate pooled prevalence rates of XDR-TB, as well as resistance to key anti-tuberculosis drugs. Given the evolution of the XDR-TB definition in 2021, studies were evaluated for definitional consistency. Where necessary, differences between pre-2021 and post-2021 definitions were acknowledged and addressed through subgroup interpretation.
RESULTS: The pooled prevalence of XDR-TB was estimated at 16.5% (95% CI: 5.8-27.1), with substantial regional variation. Higher prevalence was observed in Asia (12.3%) compared to Africa (0.4%), although the low estimate in Africa likely reflects limited diagnostic capacity and incomplete drug susceptibility testing. Resistance to XDR-defining drugs was uniformly high, with isoniazid and rifampicin resistance observed in 100% of cases, consistent with the definition of XDR-TB. Among fluoroquinolones, high resistance rates were observed, particularly for ofloxacin (88.4%) and levofloxacin (90.4%), while ciprofloxacin showed complete resistance in the limited studies available. Resistance to last-resort Group A drugs was variable, with bedaquiline (31.7%) and linezolid (60.0%) resistance reported based on single-study estimates. High resistance was also observed among second-line and legacy drugs, including amikacin (88.8%), capreomycin (83.7%), kanamycin (76.7%), and streptomycin (97.4%), reflecting widespread resistance across both historical and current treatment regimens. However, interpretation of these estimates should consider variability in diagnostic capacity and differences in XDR-TB definitions across study periods.
CONCLUSION: The findings highlight the substantial burden and underreported nature of XDR-TB, particularly in Africa, where diagnostic limitations may obscure true prevalence. While newer anti-TB drugs remain largely effective, increasing resistance trends threaten their future utility. The high resistance rates to both first-line and Group C drugs underscore the urgent need for strengthened diagnostic infrastructure, robust antimicrobial stewardship, and accelerated development of new anti-tuberculosis therapies. Effective policy implementation and international collaboration are essential to curb the escalation of drug resistance and improve treatment outcomes. These findings underscore the urgency of evidence-based drug policy reforms that strengthen antimicrobial stewardship, ensure equitable access to effective XDR-TB diagnostics and medicines, and integrate surveillance of resistance trends into national and global TB control strategies.
OBJECTIVE: To estimate the global, regional, and national prevalence and disability burden of anorexia nervosa and bulimia nervosa-and mortality attributable to anorexia nervosa-from 1990 to 2023, and to forecast prevalence to 2050.
DESIGN, SETTING, AND PARTICIPANTS: Using Global Burden of Disease (GBD) 2023 methods, data were synthesized from systematic literature reviews, population surveys, and vital registration systems. Estimates were produced for 204 countries and territories from 1990 to 2023, with forecasts through 2050. These data were analyzed from October 2025 to August 2026.
EXPOSURE: Anorexia nervosa or bulimia nervosa diagnosis.
MAIN OUTCOMES AND MEASURES: Counts and age-standardized rates with 95% uncertainty intervals (UIs) for anorexia nervosa and bulimia nervosa prevalence, years lived with disability (YLDs), and disability-adjusted life-years (DALYs), and anorexia nervosa mortality, reported by age, sex, and location.
RESULTS: In 2023, an estimated 18.1 million people (95% UI, 13.9-24.0) globally were living with anorexia nervosa or bulimia nervosa, of whom 12.6 million (69.4%) were female, 5.5 million were male (30.6%), and 41.2% were aged 10 to 24 years. These cases accounted for 3.83 million DALYs (95% UI, 2.23-5.69). Since 1990, the global number of prevalent cases increased by 71.0%, while age-standardized prevalence and DALY rates rose by about 21%. Females experienced substantially higher prevalence and DALY rates than males. The highest age-standardized prevalence rates were observed in high-income regions, particularly Australasia and Western Europe, whereas the largest relative increases in age-standardized prevalence occurred in East Asia, South Asia, and Southeast Asia. Forecasts indicate continued increases in prevalent cases through 2050.
CONCLUSIONS AND RELEVANCE: This GBD 2023 analysis found that anorexia nervosa and bulimia nervosa contribute substantially to global nonfatal health loss. These findings support the integration of eating disorders into mental health surveillance, prevention, and service planning worldwide.