Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa

Impact of the COVID-19 pandemic on care for anorexia and bulimia nervosa in US military-connected adolescents and young adults

OBJECTIVE

This study examined the impact of the COVID-19 pandemic on healthcare engagement for anorexia nervosa (AN) and bulimia nervosa (BN) in a large, geographically diverse population.

METHOD

This repeated monthly, cross-sectional study queried Military Health System records of individuals aged 10-21 before and during the pandemic (February 2019-January 2022). ICD-10 codes identified encounters for AN and BN. Monthly rates of care were modeled as the number of unique individuals with an ICD-10-identified eating disorder-related encounter per month divided by the enrolled population. Poisson regression analysis evaluated rates of care stratified by eating disorder, clinical setting, and sex.

RESULTS

In a population of 1.76 million adolescents and young adults, 1629 individuals with AN or BN received care during the pre-pandemic period; 3256 received care during the pandemic. The monthly rate of care for females with AN during the pandemic increased in inpatient settings (adjusted relative risk [aRR]: 1.31 [1.16-1.49]) and outpatient settings (aRR: 1.42 [1.37-1.47]); monthly care rates in males with AN increased in the outpatient setting (aRR: 1.46 [1.28-1.67]). Females with BN had increased engagement in outpatient settings (aRR: 1.09 [1.03-1.16]); BN care for males showed no significant monthly changes during the pandemic period in either healthcare setting.

DISCUSSION

With increased rates of AN and BN disorder-related care during the pandemic, screening for eating disorder symptomatology may allow for timely diagnosis and intervention in periods of heightened stress. Pandemic-related increases in healthcare engagement may strain limited resources, emphasizing a need to expand accessibility of clinical expertise.

PUBLIC SIGNIFICANCE

This study indicates that monthly rates of healthcare engagement during the COVID-19 pandemic for AN and BN varied based on clinical setting and sex in an adolescent and young adult population. The increased number of individuals seeking eating disorder-related care, especially outpatient care, attributed to heightened stressors necessitates accessible professionals with eating disorder clinical expertise.

Feeding and eating disorders among hospitalized children and adolescents in Thailand: A 5-year secondary national database analysis

AIMS

This study aimed to present national data for children and adolescents requiring hospitalization in Thailand.

BACKGROUND

Feeding and eating disorders can cause life-threatening and negative health impacts. In Asia, the prevalence is rising. Data from children and adolescents in Thailand are limited.

DESIGN

This study is a retrospective study of the national database.

METHODS

Data from the National Health Security Office database on Universal Health Insurance Coverage (2015-2019) of 0-17-year-olds were analysed by diagnosis (anorexia nervosa, bulimia nervosa, vomiting associated with psychological disturbances, other eating disorders and unspecified eating disorders). Descriptive statistics, chi-square test and multinomial logistic regression were used.

RESULTS

There were 163 patients, averaging 9.4 ± 5.2 years old, requiring 205 admissions. Most diagnoses showed stable trends, except for a slight decrease in anorexia and unspecified eating disorders. Most admissions were due to unspecified eating disorders and psychogenic vomiting, followed by anorexia nervosa. The overall prevalence was 3.86 per 100 000 admissions. Anorexia had the highest hospital costs and re-admission rates. Anorexia nervosa was most prevalent in early adolescence and females, while bulimia nervosa was most prominent in middle adolescence and had a male predominance.

CONCLUSION

Early recognition in clinical practice could increase early detection and improve outcomes.

Maximal Resistance Training in the Treatment of Anorexia Nervosa - A Case Report Series

Objective

Anorexia Nervosa (AN) has one of the highest mortality rates of all mental health disorders, low recovery rate and is associated with widespread endocrine dysfunction. Resistance training (RT) has been consistently shown to provide beneficial effects on health outcomes that are often negatively affected by AN, however participation in exercise is controversial for individuals with AN. The objective of this study was to assess the effects of maximal RT as an add-on to standard of care in patients with AN.

Methods

Originally, a controlled clinical trial was planned but due to COVID-19 pandemic, the study was prematurely ended and reported as a case series design. Three female inpatients with AN (Age 18-29 years, body mass index (BMI) 14.5-16.3 kg/m2, illness duration 1-7 years) underwent a supervised 6-week RT intervention as an add-on to standard of care. Primary outcome was muscular strength, as measured by a 1-repetition maximum. Secondary outcomes included BMI, eating disorder psychopathology and maladaptive exercise tendencies.

Results

No adverse events were reported. All three participants improved lower body muscle strength, ranging from 32% to 134% in the leg press. Changes of 4% to 134% in the bench press and -3% to 38% in the pulldown were also observed.

Conclusions

RT improved muscular strength in the participants. RT as part of standard of care may also provide additional benefits for individuals with AN, although further research is required to determine which subtype of patients would benefit from the addition of RT to their treatment protocol.

Qualitative study of the impact on recovery of peer relationships between female inpatients during treatment for anorexia nervosa in the United Kingdom

OBJECTIVE

Admissions to hospitals for people with anorexia nervosa (AN) often last over 2 months, during which significant time is often spent with other patients, but there is little qualitative research on the impact on recovery of the inter-patient relationships. Our aim was to conduct qualitative interviews with people with a history of inpatient treatment for AN, focusing on the impact of interactions and relationships between patients during hospital admission on recovery, including short-term and long-term effects.

METHOD

We conducted nine semi-structured, one-to-one interviews, specifically exploring the helpful and unhelpful aspects of inter-patient relationships during inpatient treatment for AN. No type of relationship was either included or excluded. Participants were recruited as volunteers in response to an online advertisement; all who met the eligibility criteria were selected. Interviews were transcribed and analyzed using thematic analysis.

RESULTS

Thematic analysis identified five themes: (1) comparison and justification, (2) learnt unhelpful behaviors, (3) dealing with distress, (4) compassion, and (5) role-modeling. All participants expressed conflicting feelings about their relationships with other patients, but generally described developing more resilience to negative effects as they got closer to recovery. Positive effects, such as compassion, appeared to hold significance long term in participants' recovered lives.

DISCUSSION

The detailed exploration of themes in this study provides a deeper understanding of inter-patient relationships during inpatient treatment for AN. This could aid clinical decision-making when choosing appropriate treatment settings for individual patients as well as informing clinical practice in hospital.

PUBLIC SIGNIFICANCE

This study closely examines the effect on recovery of relationships with other patients during hospital treatment for AN, a severe eating disorder. Findings might help hospital staff to understand the feelings of those they look after and develop ways to protect patients from the negative effects of peer relationships and enhance the positive ones, to support recovery in hospital.

Outcomes in people with eating disorders: a transdiagnostic and disorder-specific systematic review, meta-analysis and multivariable meta-regression analysis

Eating disorders (EDs) are known to be associated with high mortality and often chronic and severe course, but a recent comprehensive systematic review of their outcomes is currently missing. In the present systematic review and meta-analysis, we examined cohort studies and clinical trials published between 1980 and 2021 that reported, for DSM/ICD-defined EDs, overall ED outcomes (i.e., recovery, improvement and relapse, all-cause and ED-related hospitalization, and chronicity); the same outcomes related to purging, binge eating and body weight status; as well as mortality. We included 415 studies (N=88,372, mean age: 25.7±6.9 years, females: 72.4%, mean follow-up: 38.3±76.5 months), conducted in persons with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding and eating disorders (OSFED), and/or mixed EDs, from all continents except Africa. In all EDs pooled together, overall recovery occurred in 46% of patients (95% CI: 44-49, n=283, mean follow-up: 44.9±62.8 months, no significant ED-group difference). The recovery rate was 42% at <2 years, 43% at 2 to <4 years, 54% at 4 to <6 years, 59% at 6 to <8 years, 64% at 8 to <10 years, and 67% at ≥10 years. Overall chronicity occurred in 25% of patients (95% CI: 23-29, n=170, mean follow-up: 59.3±71.2 months, no significant ED-group difference). The chronicity rate was 33% at <2 years, 40% at 2 to <4 years, 23% at 4 to <6 years, 25% at 6 to <8 years, 12% at 8 to <10 years, and 18% at ≥10 years. Mortality occurred in 0.4% of patients (95% CI: 0.2-0.7, n=214, mean follow-up: 72.2±117.7 months, no significant ED-group difference). Considering observational studies, the mortality rate was 5.2 deaths/1,000 person-years (95% CI: 4.4-6.1, n=167, mean follow-up: 88.7±120.5 months; significant difference among EDs: p<0.01, range: from 8.2 for mixed ED to 3.4 for BN). Hospitalization occurred in 26% of patients (95% CI: 18-36, n=18, mean follow-up: 43.2±41.6 months; significant difference among EDs: p<0.001, range: from 32% for AN to 4% for BN). Regarding diagnostic migration, 8% of patients with AN migrated to BN and 16% to OSFED; 2% of patients with BN migrated to AN, 5% to BED, and 19% to OSFED; 9% of patients with BED migrated to BN and 19% to OSFED; 7% of patients with OSFED migrated to AN and 10% to BN. Children/adolescents had more favorable outcomes across and within EDs than adults. Self-injurious behaviors were associated with lower recovery rates in pooled EDs. A higher socio-demographic index moderated lower recovery and higher chronicity in AN across countries. Specific treatments associated with higher recovery rates were family-based therapy, cognitive-behavioral therapy (CBT), psychodynamic therapy, and nutritional interventions for AN; self-help, CBT, dialectical behavioral therapy (DBT), psychodynamic therapy, nutritional and pharmacological treatments for BN; CBT, nutritional and pharmacological interventions, and DBT for BED; and CBT and psychodynamic therapy for OSFED. In AN, pharmacological treatment was associated with lower recovery, and waiting list with higher mortality. These results should inform future research, clinical practice and health service organization for persons with EDs.

Recovery Trajectories in Adolescent Girls with Anorexia Nervosa

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

The Efficacy of Cognitive Remediation Therapy for Anorexia Nervosa: A Systematic Review of Systematic Reviews

BACKGROUND

Cognitive remediation therapy (CRT) for anorexia nervosa (AN) is an intervention specifically focused on addressing cognitive difficulties associated with the eating disorder. This systematic review of systematic reviews and meta-analysis aimed to provide a summary of the existing literature examining the efficacy of CRT in improving the neuropsychological, psychological, and clinical parameters of patients with AN.

METHODS

Systematic reviews and meta-analyses were sought in electronic databases, encompassing studies that explored the impact of CRT on AN. Three eligible reviews were identified based on the inclusion criteria. The Revised Assessment of Multiple SysTemAtic Reviews (R-AMSTAR) was employed to evaluate the methodological quality of the reviews, and all included reviews demonstrated satisfactory methodological quality with an R-AMSTAR score of ≥22. Relevant information was extracted from each review and qualitatively compiled.

RESULTS

Findings suggest that CRT can help people increase their awareness of cognitive styles and information processing and have a positive effect on patients' responses to treatment.

CONCLUSIONS

Further research is required to better understand its impact on other relevant outcomes, including psychological variables, to optimize the treatment's benefits.

Eating disorder hospitalizations among children and youth in Canada from 2010 to 2022: a population-based surveillance study using administrative data

BACKGROUND

Eating disorders (EDs) are severe mental illnesses associated with significant morbidity and mortality. EDs are more prevalent among females and adolescents. Limited research has investigated Canadian trends of ED hospitalizations prior to the COVID-19 pandemic, however during the pandemic, rates of ED hospitalizations have increased. This study examined rates of ED hospitalizations among children and youth in Canada from 2010 to 2022, by sex, age, province/territory, length of stay, discharge disposition and ED diagnosis.

METHODS

Cases of ED hospitalizations among children and youth, ages 5 to 17 years, were identified using available ICD-10 codes in the Discharge Abstract Database from the 2010/11 to 2022/23 fiscal years. The EDs examined in this study were anorexia nervosa (F50.0), atypical anorexia nervosa (F50.1), bulimia nervosa (F50.2), other EDs (F50.3, F50.8) and unspecified EDs (F50.9). Both cases of total and first-time ED hospitalizations were examined. Descriptive statistics and trend analyses were performed.

RESULTS

Between 2010/11 and 2022/23, 18,740 children and youth were hospitalized for an ED, 65.9% of which were first-time hospitalizations. The most frequent diagnosis was anorexia nervosa (51.3%). Females had significantly higher rates of ED hospitalization compared to males (66.7/100,000 vs. 5.9/100,000). Youth had significantly higher rates compared to children. The average age of ED hospitalization was 14.7 years. Rates of ED hospitalizations were relatively stable pre-pandemic, however during the pandemic (2020-2021), rates increased.

INTERPRETATION

Rates of pediatric ED hospitalizations in Canada increased significantly during the pandemic, suggesting that there may have been limited access to alternative care for EDs or that ED cases became more severe and required hospitalization. This emphasizes the need for continued surveillance to monitor how rates of ED hospitalizations evolve post-pandemic.

The Role of Circadian Rhythms and Sleep in Anorexia Nervosa

Importance

Observational studies have associated anorexia nervosa with circadian rhythms and sleep traits. However, the direction of causality and the extent of confounding by psychosocial comorbidities in these associations are unknown.

Objectives

To investigate the association between anorexia nervosa and circadian and sleep traits through mendelian randomization and to test the associations between a polygenic risk score (PRS) for anorexia nervosa and sleep disorders in a clinical biobank.

Design, Setting, and Participants

This genetic association study used bidirectional 2-sample mendelian randomization with summary-level genetic associations between anorexia nervosa (from the Psychiatric Genomics Consortium) and chronotype and sleep traits (primarily from the UK Biobank). The inverse-variance weighted method, in addition to other sensitivity approaches, was used. From the clinical Mass General Brigham (MGB) Biobank (n = 47 082), a PRS for anorexia nervosa was calculated for each patient and associations were tested with prevalent sleep disorders derived from electronic health records. Patients were of European ancestry. All analyses were performed between February and August 2023.

Exposures

Genetic instruments for anorexia nervosa, chronotype, daytime napping, daytime sleepiness, insomnia, and sleep duration.

Main Outcomes and Measures

Chronotype, sleep traits, risk of anorexia nervosa, and sleep disorders derived from a clinical biobank.

Results

The anorexia nervosa genome-wide association study included 16 992 cases (87.7%-97.4% female) and 55 525 controls (49.6%-63.4% female). Genetic liability for anorexia nervosa was associated with a more morning chronotype (β = 0.039; 95% CI, 0.006-0.072), and conversely, genetic liability for morning chronotype was associated with increased risk of anorexia nervosa (β = 0.178; 95% CI, 0.042-0.315). Associations were robust in sensitivity and secondary analyses. Genetic liability for insomnia was associated with increased risk of anorexia nervosa (β = 0.369; 95% CI, 0.073-0.666); however, sensitivity analyses indicated bias due to horizontal pleiotropy. The MGB Biobank analysis included 47 082 participants with a mean (SD) age of 60.4 (17.0) years and 25 318 (53.8%) were female. A PRS for anorexia nervosa was associated with organic or persistent insomnia in the MGB Biobank (odds ratio, 1.10; 95% CI, 1.03-1.17). No associations were evident for anorexia nervosa with other sleep traits.

Conclusions and Relevance

The results of this study suggest that in contrast to other metabo-psychiatric diseases, anorexia nervosa is a morningness eating disorder and further corroborate findings implicating insomnia in anorexia nervosa. Future studies in diverse populations and with subtypes of anorexia nervosa are warranted.

An overview and investigation of relapse predictors in anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

An extensive number of predictors has been examined across the literature to improve knowledge of relapse in anorexia nervosa (AN). These studies provide various recovery and relapse definitions, follow-up durations and relapse rates. The current study summarizes these values and predictors of relapse in AN in a review and meta-analysis.

METHOD

The study was executed according to PRISMA guidelines. Different databases were searched and studies in which participants did not receive an official clinical diagnosis were excluded. A quality analysis was performed using the National Institute of Health's Study Quality Assessment Tool. Random-effects meta-analyses were conducted to summarize data.

RESULTS

Definitions of relapse and recovery were diverse. During an average follow-up period of 31 months an average relapse rate of 37% was found. Predictive variables from 28 studies were grouped in six categories: age and sex, symptoms and behaviors, AN subtype and duration, weight or weight change, comorbidity, and personality. The studies were characterized by non-significant and contradictory results. Meta-analyses were performed for the predictors age, AN duration, pre-treatment BMI, post-treatment BMI and depression. These yielded significant effects for post-treatment BMI and depression: higher pre-treatment depression (SMD = .40 CI [.21-.59] and lower post-treatment BMI (SMD = -.35 CI [-.63 to -.07]) increased relapse chances in AN.

DISCUSSION

Our results emphasized a lack of sufficiently powered studies, consistent results, and robust findings. Solely post-treatment BMI and pre-treatment depression predicted relapse. Future research should use uniform definitions, larger samples and better designs, to improve our understanding of relapse in AN.

PUBLIC SIGNIFICANCE

Knowledge about predictors is important to understand high relapse rates. Our study performed a review and meta-analysis of relapse predictors in AN. Related to the heterogeneity in studies examining predictors, an overview of relapse and recovery definitions, follow-up durations and relapse rates for AN was provided. Significant effects were found for post-treatment BMI and pre-treatment depression. More studies with uniform definitions are needed to improve clinical implications.

Research on feeding and eating disorders in India: A narrative review

Despite growing evidence of their prevalence, research on feeding and eating disorders (FEDs) in India has been sporadic. This narrative review aimed to summarize the research on FED in India and set priorities for future research and translation of evidence. An electronic search was conducted in the MEDLINE, PsycINFO, and Google Scholar databases to identify relevant English peer-reviewed articles from April 1967 to July 2023. The extracted data from these studies included author names, publication year, research location, type of intervention (for interventional studies), nature of comparator treatments, and main outcomes or findings. We found a rising trend in the prevalence of EDs in India. Adolescent age group, female sex, higher socioeconomic status, family history of mental illness or disordered eating, and borderline personality pattern were risk factors for EDs. For feeding disorders (FDs), childhood age group, malnutrition, pregnancy, psychosis, intellectual disability (ID), and obsessive-compulsive disorder (OCD) were putative risk factors. Both physical and psychiatric comorbidities were common in FEDs. Culture appears to exert a pathoplastic effect on symptom presentation in FEDs; an illustrative example is the documented nonfat phobic variant of anorexia nervosa (AN) in India. Research on management has focused on using assessment tools, investigations to rule out medical comorbidities, psychosocial and family-based psychotherapies, nutritional rehabilitation, pharmacotherapy, and neuromodulation approaches. Whereas the publication output on FEDs in India has increased over the last decade, it remains an under-researched area, with a striking paucity of original research. Future research priorities in FEDs include conducting country-wide registry-based studies to offer real-world insights, longitudinal research to identify culturally relevant risk factors, and developing brief, culturally sensitive diagnostic instruments for FEDs in the Indian context. This will help generate locally relevant epidemiological data on FEDs and inform treatment and prevention strategies.

The effectiveness of interpersonal psychotherapy versus cognitive behavioural therapy for eating disorders: A systematic review and meta‐analysis

Objective

Interpersonal psychotherapy (IPT) has been proposed as a treatment strategy for eating disorders (EDs). However, cognitive behavioural therapy (CBT) is the treatment more widely used than IPT.

Method

Our study aimed to conduct a systematic review and meta‐analysis of randomized controlled trials (RCTs) in order to compare the effectiveness of IPT with CBT in treating eating disorders (EDs). To achieve this goal, we conducted a comprehensive search on PubMed, Embase, Medline, Cochrane, Web of Science, and the Clinical Trials Database for RCTs that compared the effectiveness of IPT with CBT in treating EDs.

Results

After reviewing 468 potential studies, we selected 10 suitable for our meta‐analysis, which included 833 participants. Results showed that both IPT and CBT had similar effects on the primary outcome measure (i.e., ED score) (SMD = 0.08). However, IPT had a more significant effect on the secondary outcome measure (i.e., Inventory of Interpersonal Problems) (SMD = 0.32) compared to CBT. Additionally, IPT had a better treatment effect for individuals with EDs who had a lower body mass index (SMD = 0.27) and were younger (SMD = 0.43) than those receiving CBT. Both IPT and CBT demonstrated follow‐up effects at pretest and after follow‐up periods of less than 6 months (SMD = 1.61, 1.83), between 6 and 12 months (SMD = 1.48, 1.65), and greater than 12 months (SMD = 1.29, 1.33). However, only CBT demonstrated a dose–response relationship trend (β = 0.017, p = 0.067).

Conclusions

The meta‐analysis yielded compelling evidence that IPT is an effective treatment for individuals with EDs. However, the review highlights the need for future research to further elucidate the effects of IPT on ED treatment.

Psychometric properties of self-report measures of eating disorder cognitions: a systematic review

BACKGROUND

Although eating disorder (ED) models display some differences in theory and treatment approach, cognitive-behavioural, schema-focused, and disorder-specific models all highlight the fundamental nature of cognitions as key factors in ED development and maintenance processes. As such, it is vital that ED cognitions continue to be assessed and monitored as therapeutic targets and treatment outcomes as well as being examined as constructs in empirical research. This review aimed to systematically identify and evaluate the psychometric properties of existing self-report measures of ED cognitions.

METHODS

A systematic review protocol was registered using the international prospective register of systematic reviews (PROSPERO; CRD42023440840). Included studies described the development, validation and/or the psychometric evaluation of a measure (or subscale) that was specifically developed to solely assess ED cognitions (that is thoughts, expectations, assumptions, or beliefs), in English-speaking, adult populations. The search was conducted using three electronic databases: PsycINFO, MedLine, and Embase. Two independent reviewers conducted screening, selection and evaluation of the psychometric properties of relevant measures using a standardised, well-established quality appraisal tool.

RESULTS

Of the initial search of 7581 potential studies, 59 met inclusion criteria and described the psychometric evaluation of 31 measures (or subscales) of ED cognitions. The findings from the current review indicate that of the included measures, none currently meet all nine criteria of adequate psychometric properties. The Eating Beliefs Questionnaire (EBQ; and EBQ-18), and the Eating Disorder Inventory Body Dissatisfaction subscale (EDI [BD]) currently possess the most evidence supporting their validity, reliability, and clinical utility.

CONCLUSIONS

The findings of the current systematic review provide guidance for future researchers to focus efforts on improving evidence for the validity, reliability and utility of self-report measures of ED cognitions. Overall, the present study has provided a detailed and systematic evaluation to support researchers and clinicians in future selection of measures of ED cognitions dependent on the specific aims of their research and treatment.

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Renal failure following insulin purging in atypical anorexia nervosa and type 1 diabetes mellitus

Objective

Anorexia nervosa (AN) and atypical anorexia nervosa (AAN) are severe and complex eating disorders that can be prevalent among individuals with type 1 diabetes mellitus (T1DM). Insulin purging, characterized by the intentional underuse / omission of insulin to control weight, is under-recognized in medicine and is a purging strategy of patients with AN or AAN and comorbid T1DM. Often, this can lead to renal failure, necessitating a (pancreas-) kidney transplantation. This article presents a comprehensive overview of the interplay between AN/AAN and T1DM and summarizes the evidence in literature.

Methods

A narrative review is presented on basis of a detailed case study of a 32-year-old female with end-stage renal failure seeking (pancreas-) kidney transplantation displaying etiology, diagnosis, comorbidities, complications, and treatment of AN and AAN with emphasis on those patients with T1DM.

Results

Insulin purging in patients with AN/AAN and coexisting T1DM can exacerbate T1DM complications, including accelerating the onset of end-stage renal failure. A multidisciplinary approach including nutrition treatment and psychotherapeutic techniques was considered necessary for treatment, focusing on psychosomatic in-patient care before and after organ transplantation.

Conclusion

Insulin purging in patients with AAN and T1DM poses severe health risks, including accelerated renal complications. For those considering transplantation, insulin purging has explicitly to be diagnosed and a holistic treatment addressing both the renal condition and psychosomatic symptoms/disorders is crucial for successful post-transplant outcomes.

Efficacy of pharmacotherapies for bulimia nervosa: a systematic review and meta-analysis

OBJECTIVE

The main purpose was to evaluate the efficacy and tolerability of different medications used to treat bulimia nervosa (BN).

METHODS

Randomized controlled trials (RCTs) were identified from published sources through searches in PubMed, Cochrane Library, Web of Science, and Embase from inception to November 2022. Primary outcomes were changes in the frequency of binge eating episodes and vomiting episodes from baseline to endpoint. Secondary outcomes were differences in the improvement of scores in depressive symptoms, tolerability (dropout due to adverse events) and weight change.

RESULTS

The literature search ultimately included 11 drugs, 33 studies and 6 types of drugs, 8 trials with TCAs (imipramine, desipramine), 14 with SSRIs (fluoxetine, citalopram and fluvoxamine), 6 with MAOIs (phenelzine, moclobemide and brofaromine), 3 with antiepileptic drugs (topiramate), 1 with mood stabilizers (lithium), and 1 with amphetamine-type appetite suppressant (fenfluramine). The reduction in binge eating episodes was more likely due to these drugs than the placebo, and the SMD was -0.4 (95% CI -0.61 ~ -0.19); the changes in the frequency of vomiting episodes (SMD = -0.16, 95% CI -0.3 ~ -0.03); weight (WMD = -3.05, 95% CI -5.97 ~ -0.13); and depressive symptoms (SMD = -0.32, 95% CI -0.51 ~ -0.13). However, no significant difference was found in dropout due to adverse events (RR = 1.66, 95% CI 1.14 ~ 2.41).

CONCLUSIONS

This meta-analysis indicates that most pharmacotherapies decreased the frequency of binge-eating and vomiting episodes, body weight, and depressive symptoms in BN patients, but the efficacy was not significant. In each drug the efficacy is different, treating different aspects, different symptoms to improve the clinical performance of bulimia nervosa.

Factors influencing the duration of untreated illness among patients with anorexia nervosa: A multicenter and multi-informant study

INTRODUCTION

The duration of untreated illness (DUI), that is, the interval between the onset of anorexia nervosa (AN) symptoms and start of specialized treatments, has a strong influence on the prognosis.

OBJECTIVE

To quantify modifiable predictors of the DUI and to derive recommendations for secondary prevention strategies.

METHODS

Within a multicenter, multi-informant study, DUI was assessed in interviews with patients undergoing first specialized AN treatment. Modifiable factors were assessed perspectives of AN-patients, their relatives, and primary care practitioners [PCPs]) with the FABIANA-checklist (Facilitators and barriers in anorexia nervosa treatment initiation). The effect of FABIANA-items on the DUI for each perspective was calculated using Cox Regression (control variables: age, eating disorder pathology, health care status, migration background, body mass index [BMI]).

RESULTS

We included data from N = 125 female patients with AN (72 adults, 53 adolescents, Mage  = 19.2 years, SD = 4.2, MBMI  = 15.7 kg/m2 , SD = 1.9), N = 89 relatives (81.8% female, 18.2% male, Mage  = 46.0 years, SD = 11.0) and N = 40 PCPs (Mage  = 49.7 years, SD = 9.0). Average DUI was 12.0 months. Watching or reading articles about the successful treatment of other individuals with AN (patients' perspective) and regular appointments with a PCP (PCPs' perspective) were related to a shorter DUI (HR = 0.145, p = .046/ HR = 0.395, p = .018). Patients whose relatives rated that PCPs trivialized patients' difficulties had a longer DUI (HR = -0.147, p = .037). PCPs and relatives rated PCPs' competence higher than patients did.

DISCUSSION

It is recommended (a) to incorporate treatment success stories in prevention strategies, (b) to inform PCPs about potential benefits of regular appointments during the transition to specialized care, and (c) to train PCPs in dealing with patients' complaints.

PUBLIC SIGNIFICANCE

Many individuals with AN seek treatment very late. Our study shows that a promising approach to facilitate earlier AN treatment is to inform patients about successful treatments of affected peers, to foster regular appointments with a PCP and, to motivate these PCPs to take individuals' with AN difficulties seriously. Thus, our study provides important suggestions for interventions that aim to improve early treatment in AN.

Potential applications of Schema Therapy in the treatment of adolescents with anorexia nervosa: a theoretical analysis

Purpose

The main purpose of the article is to present basic theoretical assumptions on Schema Therapy and its hypothetical application among adolescents suffering with anorexia nervosa.

Views

Anorexia nervosa is a very deadly mental disease, more frequently suffered by females than males, with the mean age of onset at approximately 14-15. Studies underline the relatively poor effectiveness of currently applied treatment methods and the need for new approaches that could be recommended for adolescent patients suffering with this disease. The results of studies conducted to date lead to the conclusion that Schema Therapy is a promising approach for this group. It is a transdiagnostic method of work that compiles elements known in other therapeutic approaches, aiming at an increase in the individual's awareness of their feelings and emotional needs, applied both in adolescent and adult groups of patients. Since the symptoms of eating disorders observed in adolescents are strongly connected with family systems it seems reasonable to use treatment techniques that rigorously address the unmet needs and rejected emotions of the individual.

Conclusions

Based on the data published so far it might be hypothesized that the techniques characteristic for Schema Therapy (e.g. imagery rescripting, chairwork, limited reparenting) could be eligible for use with adolescent patients with anorexia nervosa.They address unmet needs, rejected emotions, and early maladaptive schemas that are very frequent in patients with AN. Since the analysis presented provides only hypotheses and the discussion of theoretical aspects, empirical research in this area is needed.

Increase in incidence of anorexia nervosa among 10- to 14-year-old girls: A nationwide study in the Netherlands over four decades

OBJECTIVE

This primary care study examined time trends in the incidence of anorexia nervosa (AN) and bulimia nervosa (BN) in the Netherlands across four decades.

METHODS

A nationwide network of general practitioners, serving approximately 1% of the total Dutch population, recorded newly diagnosed patients with AN and BN in their practices from 1985 to 2019 (2,890,978 person-years). DSM-IV diagnostic criteria were consistently used and the same psychiatrist was responsible for the final diagnostic decision. Incidence rates (IRs) were calculated for: the total population (all ages), females overall, and females per 5-year age category. Time trends in IRs were analyzed using JoinPoint regression analyses.

RESULTS

In four decades, the incidence of AN among 10- to 14-year-old females increased significantly from 8.6 to 38.6 per 100,000 person-years (average period percentage change [APPC] = 56.7; 95% confidence interval [CI] = 6.5-130.6. The overall incidence of AN was stable, with IRs ranging from 6.0 (95% CI = 4.3-8.1) to 8.4 (95% CI = 6.4-10.8). The IR of BN decreased significantly from 8.7 (95% CI = 6.7-11.0) to 3.2 (95% CI = 2.0-4.9) in the 2000s, before leveling off in the 2010s (IR 3.2; 95% CI = 2.0-4.8).

DISCUSSION

The incidence of AN among 10- to 14-year-old girls increased significantly over four decades. Both biological and sociocultural factors, for example, early pubertal timing and the impact of social media, might explain this. In other age groups and overall, the incidence of AN remained stable. The significant decrease of the incidence of BN in the previous decades halted in the last decade.

PUBLIC SIGNIFICANCE

An important finding of the present study is that for 10- to 14-year-old girls, the risk for developing anorexia nervosa has increased significantly over 40 years. More healthcare facilities for younger people are needed, and prevention programs could include social media use. For bulimia nervosa, the general decrease in the occurrence of new cases has halted in the 2010s.

Understanding the impact of structural modifications at the NNAT gene's post-translational acetylation site: in silico approach for predicting its drug-interaction role in anorexia nervosa

PURPOSE

Anorexia nervosa (AN) is a neuropsychological public health concern with a socially disabling routine and affects a person's healthy relationship with food. The role of the NNAT (Neuronatin) gene in AN is well established. The impact of mutation at the protein's post-translational modification (PTM) site has been exclusively associated with the worsening of the protein's biochemical dynamics.

METHODS

To understand the relationship between genotype and phenotype, it is essential to investigate the appropriate molecular stability of protein required for proper biological functioning. In this regard, we investigated the PTM-acetylation site of the NNAT gene in terms of 19 other specific amino acid probabilities in place of wild type (WT) through various in silico algorithms. Based on the highest pathogenic impact computed through the consensus classifier tool, we generated 3 residue-specific (K59D, P, W) structurally modified 3D models of NNAT. These models were further tested through the AutoDock Vina tool to compute the molecular drug binding affinities and inhibition constant (Ki) of structural variants and WT 3D models.

RESULTS

With trained in silico machine learning algorithms and consensus classifier; the three structural modifications (K59D, P, W), which were also the most deleterious substitution at the acetylation site of the NNAT gene, showed the highest structural destabilization and decreased molecular flexibility. The validation and quality assessment of the 3D model of these structural modifications and WT were performed. They were further docked with drugs used to manage AN, it was found that the ΔGbind (kcal/mol) values and the inhibition constants (Ki) were relatively lower in structurally modified models as compared to WT.

CONCLUSION

We concluded that any future structural variation(s) at the PTM-acetylation site of the NNAT gene due to possible mutational consequences, will serve as a basis to explore its relationship with the propensity of developing AN.

LEVEL OF EVIDENCE

No level of evidence-open access bioinformatics research.

The multisensory mind: a systematic review of multisensory integration processing in Anorexia and Bulimia Nervosa

Individuals with Anorexia Nervosa and Bulimia Nervosa present alterations in the way they experience their bodies. Body experience results from a multisensory integration process in which information from different sensory domains and spatial reference frames is combined into a coherent percept. Given the critical role of the body in the onset and maintenance of both Anorexia Nervosa and Bulimia Nervosa, we conducted a systematic review to examine multisensory integration abilities of individuals affected by these two conditions and investigate whether they exhibit impairments in crossmodal integration. We searched for studies evaluating crossmodal integration in individuals with a current diagnosis of Anorexia Nervosa and Bulimia Nervosa as compared to healthy individuals from both behavioral and neurobiological perspectives. A search of PubMed, PsycINFO, and Web of Sciences databases was performed to extract relevant articles. Of the 2348 studies retrieved, 911 were unique articles. After the screening, 13 articles were included. Studies revealed multisensory integration abnormalities in patients affected by Anorexia Nervosa; only one included individuals with Bulimia Nervosa and observed less severe impairments compared to healthy controls. Overall, results seemed to support the presence of multisensory deficits in Anorexia Nervosa, especially when integrating interoceptive and exteroceptive information. We proposed the Predictive Coding framework for understanding our findings and suggested future lines of investigation.

Investigating the Link between Eating Attitudes, Taste and Odour Preferences and the Chemical Senses

OBJECTIVES

To examine if higher degrees of pathological eating attitudes in a non-clinical sample are associated with odour and taste perception and preferences based on psychophysical ratings.

PARTICIPANTS AND METHODS

A total of 80 female university students completed the eating attitudes test (EAT-26), followed by four chemosensory measures including olfactory and gustatory perception plus perceptual ratings and preferences for food odours and tastes.

RESULTS

There were no significant correlations between EAT-26 scores and measures of olfactory and gustatory perception. However, a significant interaction effect indicated higher degrees of pathological eating attitudes may be associated with differential sensitivity to sweet and fatty food odours compared to those with lower levels of pathological eating attitudes.

CONCLUSIONS

This was the first study to examine pathological eating attitudes using food stimuli with a non-clinical sample. The results remain preliminary until replication. However, the findings highlight the need for development of measures of disordered eating attitudes and behaviours that go beyond caloric restriction.

Hypercapnia in hospitalized children and adolescents with anorexia nervosa as a predictive marker for readmission: a prospective study

PURPOSE

To determine whether hypercapnia is associated with risk of hospital readmission related to anorexia nervosa (AN) in children and adolescents.

METHODS

We performed a prospective study of patients ≤ 18 years old admitted due to AN decompensation from November 2018 to October 2019. Both subtypes of AN, restricting subtype (AN-R) and binge-eating/purging subtype (AN-BP), were included. Study participants were evaluated upon admission, at discharge and six months after discharge. T-tests or Mann-Whitney U tests was used to compare means values. Pearson or Spearman correlations were used to measure the association between two variables. Logistic regression models were developed to evaluate the relationship between scoring methods and readmission.

RESULTS

Of the 154 persons admitted during the study period, 131 met the inclusion criteria. Median age was 15.1 years. At admission, 71% of participants were malnourished and 33 (25%) had been previously admitted. We observed a marked decrease in venous pH and stable pCO2 elevation during follow-up period. Hypercapnia at discharge was associated with a twofold increased likelihood of readmission and the odds of readmission increased as discharge pCO2 rose. These findings did not depend on AN subtype or participant sex. Electrolytes persisted within the normal range.

CONCLUSION

Hypercapnia and respiratory acidosis are common alterations in children and adolescents hospitalized due to AN decompensation. Hypercapnia persists for at least 6 months after discharge despite clinical improvement and is associated with higher odds of readmission. This is the first study to identify an abnormal laboratory finding as a potential predictor of readmission in AN.

LEVEL OF EVIDENCE

IV: Multiple time series without intervention.

Measuring implicit associations between food and body stimuli in anorexia nervosa: a Go/No-Go Association Task

PURPOSE

The present study aimed to explore the implicit associations between food and bodily stimuli in patients with anorexia nervosa (AN) and control subjects (HC).

METHODS

A Go/No-Go Association Task was administrated to 55 participants (28 AN and 27 HC), using food stimuli (low-calorie food vs. high-calorie food) and body stimuli (underweight vs. overweight bodies).

RESULTS

We evidenced an implicit association between food and body stimuli in the AN group, whereas the HC group only showed a tendency. AN and HC groups also exhibited different categorization strategies: the AN group tended to categorize stimuli as low-calorie foods and underweight bodies less than the HC group, and they tended to categorize stimuli as high-calorie foods and overweight bodies more than the HC group.

CONCLUSION

The present study revealed for the first time specificities of the AN population's implicit association between food and body stimuli in terms of association strength and categorization strategy. Furthermore, the results suggest that combining implicit methodologies with other methods could contribute to a better characterization of the physiopathology of AN.

LEVEL OF EVIDENCE

Level I, experimental study.

Triggers for eating disorder onset in youth with anorexia nervosa across the weight spectrum

To aid in more targeted eating disorder (ED) prevention efforts, we sought to identify sociodemographic and weight-related risk factors for identified triggers for the onset of anorexia nervosa (AN) in youth. We conducted a retrospective chart review of youth admitted for medical treatment of AN between January 2015 and February 2020. From multidisciplinary admission notes, we extracted patient-reported reasons for diet/exercise changes. We used qualitative thematic analysis to identify ED triggers, then categorized each trigger as binary variables (presence/absence) for logistic regression analysis of risks associated with each trigger. Of 150 patients, mean (SD) age was 14.1(2.3) years. A total of 129 (86%) were female and 120 (80%) were Non-Hispanic White. Triggers included environmental stressors (reported by 30%), external pressures of the thin/fit ideal (29%), internalized thin/fit ideal (29%), weight-related teasing (19%), and receiving health education (14%). Younger age was associated with higher odds of weight-related teasing (p = .04) and health education (p = .03). Males had greater odds of internalized thin/fit ideal than females (p = .04). Those with premorbid body mass indices ≥85th percentile for age and sex had greater odds of reporting positive reinforcement (p = .03) and weight-related teasing (p = .04) than those with weights <85th percentile. We use these findings to detail potential targets for advancing ED prevention efforts.

A case report of anorexia nervosa in a 23-year-old Ethiopian woman

Key Clinical Messages

Limited studies on AN in Africa, including Ethiopia. Internet and media have changed body image portrayal in developing countries. A need for a multidisciplinary approach to treatment, training on positive coaching styles, and future research.

Abstract

The Global Burden of Disease had estimated anorexia nervosa (AN) or bulimia nervosa to be 13.6 million people. The lifetime prevalence of AN ranges from 2.4 to 4.3 percent. During their lifetime, up to 4% of females and up to 0.3% of males suffer from anorexia nervosa. Studies assessing AN in Africa, including Ethiopia, are limited. This case report describes a 23-year-old female patient who presented with anorectic symptoms and signs in Ethiopia. This case report describes a 23-year-old female patient who participated in sports activities. She had a low body weight based on a BMI of 13.15 kg/m2 and lost around 10 kg within the past 6 months. She feared gaining weight or becoming fat, thus restricting food intake. The findings on psychiatric evaluation encompassing detailed history and mental state examination suggested the diagnosis of Extreme anorexia nervosa, restricting type; adult malnutrition; major depressive disorder (MDD) (in remission); low risk of aggression; low risk of suicide; severe functional impairment. The general management principles implemented in this patient included assessment of medical complications, weight restoration, psychological intervention, medication for comorbid depression, and long-term psychological and biological treatment follow-up to avoid relapse. The presented case of a 23-year-old Ethiopian female patient who is athletic shows weight-controlled sports activities and the manifestation of anorexia nervosa. Easy access to the Internet and media has changed body image portrayal in developing countries including Ethiopia. There is a need for a multidisciplinary approach involving psychiatrists, psychologists, internists, and nutritionists for the management of AN. The early screening and management of medical complications are crucial. There is a need for close monitoring of vital signs, restriction of caffeine, excess fluid, and salt, and limiting excessive exercise. Furthermore, to assess micronutrient deficiencies, vitamin supplements should be prescribed in the form of multivitamin and thiamine preparations. The need for future training about positive coaching styles for coaches is mandatory to reduce the future impacts on young athletes. There is a need for future research on eating disorders in developing countries such as Ethiopia.

The role of functional and structural properties of the nucleus accumbens subregions in eating behavior regulation of bulimia nervosa

OBJECTIVE

Although studies have demonstrated the involvement of the nucleus accumbens (NAc) in the neurobiology of eating disorders, its alterations in bulimia nervosa (BN) remain largely unknown. This study investigated the structural and functional properties of NAc in patients with BN.

METHOD

Based on the resting-state functional MRI and high-resolution anatomical T1-weighted imaging data acquired from 43 right-handed BN patients and 40 sex-, age- and education-matched right-handed healthy controls (HCs), the group differences in gray matter volume (GMV) and fractional amplitude of low-frequency fluctuation (fALFF) in slow-4 and -5 bands and functional connectivity (FC) of NAc subregions (core and shell) were compared. The relationships between MRI and clinical data were explored in the BN group.

RESULTS

Compared with HCs, BN patients showed preserved GMV, decreased fALFF in slow-5 band of the left NAc core and shell, decreased FC between left NAc core and right caudate, and increased FC between all NAc subregions and frontal regions, between all NAc subregions (except the right NAc core) and the supramarginal gyrus (SMG), and between right NAc shell and left middle temporal gyrus. FC between the NAc and SMG was correlated with emotional eating behaviors.

DISCUSSION

Our study revealed preserved GMV, local neuronal activity reduction and functional network reorganization of the NAc in BN. The functional network reorganization of the NAc mainly occurred in the frontal cortex and was correlated with emotional eating behavior. These findings may provide novel insights into the BN using NAc as an entry point.

PUBLIC SIGNIFICANCE

Although studies have demonstrated the involvement of the nucleus accumbens (NAc) in the neurobiology of eating disorders, its alterations in bulimia nervosa (BN) remain largely unknown. We used a multimodal MRI technique to systematically investigate structural and functional alterations in NAc subregions of BN patients and explored the associations between such alterations and maladaptive eating behaviors, hoping to provide novel insights into BN.

Body image and willingness to change it-A study of university students in Poland

The present study aimed to identify declared patterns of ideal appearance among students at selected higher education institutions in Poland. In the present study, we set out to identify the body image and the propensity to change it. In order to achieve the goal of the study, a nationwide survey was carried out using a voluntary diagnostic survey. A total of 810 respondents took part in the survey. The study was conducted using a custom-made self-designed survey questionnaire with an indirect interview technique via a web-based platform (CAWI). The study results indicate that women were far more eager to maintain an attractive appearance through dieting than men. Importantly, the respondents, both women and men, did not identify influencers as role models of attractive appearance. Results of the present survey reveal that attitudes towards one's physical appearance are diverse and influenced by the considered factors. The attributes that determined the perception of oneself as an attractive person included height, weight, and body build. Normal body weight is a key feature of an attractive appearance, according to the respondents; nevertheless, students show a higher tolerance for being overweight than for being underweight. Furthermore, preferences in this respect are largely conditioned by individual personal characteristics. According to young people, a person with an attractive appearance is one who eats and exercises regularly, and who does not fall into extremes in terms of their appearance. On the other hand, the fear of growing fat and losing one's attractive appearance was frequently indicated among the concerns over personal appearance. Only one in five respondents expressed complete satisfaction with how they looked, with men and those with a normal BMI significantly more likely to do so. Respondents expressed readiness to undertake a range of activities related to increased exercise regime, changes in their eating habits, or seeking assistance (e.g., of a personal trainer) to achieve the desired body shape. Our findings can be used as a basis for discussion and consideration in developing educational activities on nutrition, as well as on overweight- and obesity-related health issues.

A randomised controlled trial of clinician supported vs self-help delivery of online cognitive behaviour therapy for Bulimia Nervosa

High dropout rates and poor adherence associated with digital interventions have prompted research into modifications of these treatments to improve engagement and completion rates. This trial aimed to investigate the added benefit of clinician support when paired alongside a ten-session, online cognitive behaviour therapy (CBT) self-help intervention for bulimia nervosa (BN). As part of a three-arm, phase II randomised controlled trial, 114 participants (16 years or over) with full or subthreshold BN were randomly assigned to complete the intervention in a self-help mode (with administrative researcher contact; n = 38), with adjunct clinician support (weekly 30-minute videoconferencing sessions; n = 37), or a no-treatment waitlist control (WLC; n = 39). Baseline to post-treatment (12-weeks) decreases in objective binge episode frequency were significantly greater for clinician-supported participants as compared to WLC, but not for self-help when compared to WLC. However, due to continued improvements for self-help across follow-up (24-weeks), both arms outperformed WLC when analysed as an overall rate of change across three timepoints. Clinician-supported participants outperformed self-help in regards to laxative use and dietary restraint. Our results demonstrate that good clinical outcomes can be achieved with a relatively brief online CBT-based program even in the absence of structured clinical support, indicating a possible overreliance upon clinician support as a primary adherence-facilitating mechanism.

Prevalence of Eating Disorders and Disordered Eating Behaviours amongst Adolescents and Young Adults in Saudi Arabia: A Systematic Review

Eating disorders (EDs) and disordered eating behaviours (DEBs) are significant health problems related to body image and weight dissatisfaction among adolescents and young adults worldwide. During this stage of sensitive development, these behaviours may hinder the optimal growth process and can consequently lead to wasting, stunting, and micronutrient deficiencies. However, there is a limited amount of literature on DEB among Arab populations, particularly in Saudi Arabia. This review aims to assess the prevalence of EDs/DEB and to develop a clear understanding of the epidemiology of such conditions among adolescents and youth in Saudi Arabia. Five databases were systematically searched and 14 papers met the inclusion criteria. The Eating Attitudes Test (EAT-26) was the predominant tool used for evaluating aberrant eating behaviours, indicating a high prevalence of EDs/DEB ranging from 10.2% to 48.1%. The highest prevalence of EDs/DEB was reported in the eastern region ranging from 29.4% to 65.5%. In terms of age and sex, the prevalence was higher among older students compared to younger school students and males reported more Eds/DEB compared to female students. These disorders are found to be prevalent in Saudi Arabia, and the risk of developing such conditions is high across the whole age range.

Habits and Persistent Food Restriction in Patients with Anorexia Nervosa: A Scoping Review

The aetiology of anorexia nervosa (AN) presents a puzzle for researchers. Recent research has sought to understand the behavioural and neural mechanisms of these patients' persistent choice of calorie restriction. This scoping review aims to map the literature on the contribution of habit-based learning to food restriction in AN. PRISMA-ScR guidelines were adopted. The search strategy was applied to seven databases and to grey literature. A total of 35 studies were included in this review. The results indicate that the habit-based learning model has gained substantial attention in current research, employing neuroimaging methods, scales, and behavioural techniques. Food choices were strongly associated with dorsal striatum activity, and habitual food restriction based on the self-report restriction index was associated with clinical impairment in people chronically ill with restricting AN. High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) and Regulating Emotions and Changing Habits (REaCH) have emerged as potential treatments. Future research should employ longitudinal studies to investigate the time required for habit-based learning and analyse how developmental status, such as adolescence, influences the role of habits in the progression and severity of diet-related illnesses. Ultimately, seeking effective strategies to modify persistent dietary restrictions controlled by habits remains essential.

The Effect of Transcranial Direct Current Stimulation (tDCS) on Anorexia Nervosa: A Narrative Review

(1) Introduction: Anorexia nervosa (AN) is a severe, debilitating disease with high incidence and high mortality. The methods of treatment used so far are moderately effective. Evidence from neuroimaging studies helps to design modern methods of therapy. One of them is transcranial direct current stimulation (tDCS), a non-invasive brain neuromodulation technique. (2) Methods: The purpose of this narrative review is to bring together all studies investigating the use of tDCS in the treatment of AN and to evaluate its effect and efficiency. Searches were conducted in the Pubmed/Medline, Research Gate, and Cochrane databases. (3) Results: The literature search resulted in five articles. These studies provide preliminary evidence that tDCS has the potential to alter eating behaviour, body weight, and food intake. Additionally, tDCS reduced symptoms of depression. Throughout all trials, stimulation targeted the left dorsolateral prefrontal cortex (DLPFC). Although the number of studies included is limited, attempts were made to elucidate the potential mechanisms underlying tDCS action in individuals with AN. Recommendations for future tDCS research in AN were issued. (4) Conclusions: The included studies have shown that tDCS stimulation of the left DLPFC has a positive effect on AN clinical symptoms and may improve them, as measured by various assessment measures. It is important to conduct more in-depth research on the potential benefits of using tDCS for treating AN. This should entail well-designed studies incorporating advanced neuroimaging techniques, such as fMRI. The aim is to gain a better understanding of how tDCS works in AN.

Diet Traps during Eating Disorders among Dentate Patients at an Oral Health Glance

Persons suffering from eating disorders (ED) may often experience a recurrence/persistence symptoms despite the completion of psychiatric therapy. In most cases, their general health status is linked to current nutritional behaviors. Medical professionals, general practitioners (GPs), dieticians, and dentists may see those patients in their practices. At the same time, due to low sense of illness, some patients may delay or never seek professional medical care. The aim of this article is to analyze the main ED types according to dietary behaviors causing oral health problems and discuss oral health complications in affected dentate patients. The second objective is to update oral preventive measures and technological innovations together with active agents for oral hygiene care that might effectively support oral health maintenance during the presence of long-term symptoms. The research method involved a review of clinical reports as a synthesis of the electronic research in the Pubmed, Web of Science, and Google Scholar databases. Based on the research, ED patients were found to present related incidences of oral complications. Studies have reported that the possible course of an ED and comorbidities may be an imbalance in the oral environment. The results showed an association between biological (malnutrition, etc.), behavioral (binge eating episodes, vomiting, acidic diet, poor oral hygiene), and pharmacotherapeutic (addiction, hyposalivation) factors that may threaten oral health. Early diagnosis of the past and present symptoms is essential to eliminate and take control of destructive behaviors. Oral changes need to be tackled with medical insight, and additionally, the perception of dietary interactions is recommended.

Anorexia nervosa during COVID-19: loss of personal control and alexithymia as important contributors to symptomatology in adolescent girls

BACKGROUND

In the course of the COVID-19 pandemic, a steady increase in adolescent anorexia nervosa admissions has been observed. Contributing factors may have been uncontrollable changes in school attendance due to lockdowns and social restrictions. However, patients' reports on the impact of these factors have not been assessed in detail as of yet. Furthermore, alexithymia, the difficulty to identify and describe one's own emotions, has increased during the pandemic and is known to be heightened in eating disorders. Thus, it may have contributed to symptom severity in anorexia nervosa during the pandemic.

METHODS

The present study examined pandemic-related changes in social media use, body satisfaction, and perceived loss of control and their impact on depressive, anxious, and eating disorder symptomatology in a sample of adolescent girls with anorexia nervosa (n = 29) and healthy controls (n = 23). Additionally, the influence of current alexithymia as a cross-diagnostic risk factor was assessed. Adolescents answered questionnaires once shortly after admission to inpatient, outpatient, or daycare treatment.

RESULTS

An increase in perceived loss of control during the pandemic and heightened alexithymia explained a significant portion of variance in present depressive symptomatology, which in turn contributed to eating disorder symptomatology.

CONCLUSIONS

These relationships emphasize alexithymia and perceived loss of control as valuable constructs for early screenings and interventions.

Incidence and prevalence of eating disorders among active duty US military-dependent youth from 2016 to 2021

OBJECTIVE

The offspring of US military service members may be at increased risk for eating disorders. However, no epidemiological studies to date have evaluated eating disorder incidence rates and prevalence estimates among military-dependent youth.

METHOD

This retrospective cohort study examined eating disorder diagnoses in the military healthcare system (MHS) from 2016 through 2021. Active duty and national guard military-dependent youth, aged 10-17 years, who received care in the MHS via TRICARE Prime insurance, were identified by one or more ICD-10 codes indicative of an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, binge-eating disorder, and other-specified eating disorders).

RESULTS

During the 6-year surveillance period, 2534 dependents received incident diagnoses of eating disorders, with a crude overall incidence rate of 1.75 cases per 10,000 person-years. The most common diagnosis was other-specified eating disorder, followed by anorexia nervosa, bulimia nervosa, and binge-eating disorder. The crude annual incidence rate of all eating disorder diagnoses increased by nearly 65% from 2016 to 2021. Rates for all diagnoses were highest in 2020 and 2021. Period prevalence estimates were .08% for any eating disorder diagnosis, .01% for anorexia nervosa, .004% for bulimia nervosa, .004% for binge-eating disorder, and .06% for other-specified eating disorders.

DISCUSSION

The observed increase in eating disorder diagnoses during the surveillance period appeared to be driven by female dependents. More military dependents experienced a new-onset diagnosis during the COVID-19 pandemic compared to previous years. These findings highlight the need for eating disorder screening, identification, and treatment for dependents within the MHS.

PUBLIC SIGNIFICANCE STATEMENT

Children of US military service members may be at increased risk for eating disorders. Results indicate new-onset eating disorder cases increased 65% from 2016 to 2021, primarily among girls compared to boys. The most diagnosed and fastest growing diagnosis was other-specified eating disorder. Rates of anorexia nervosa increased following the COVID-19 pandemic. Findings highlight the need for eating disorder screening, identification, and treatment within the military healthcare system.

Early onset anorexia nervosa: Multidisciplinary hospital intervention in a 1-year follow-up study

BACKGROUND

Early onset anorexia nervosa (EOAN) is a subclassification of AN, defined by an onset before 14 years, and characterized by specific demographic, neuropsychological, and clinical features. The present study aims to provide naturalistic data on a wide sample with EOAN, focusing on psychopathological and nutritional changes occurring in the context of a multidisciplinary hospital intervention, as well as the rate of rehospitalizations during a 1-year follow-up.

METHOD

Observational, naturalistic study adopting standardized criteria for EOAN (onset before 14 years). EOAN were compared to adolescent-onset AN (AOAN) patients (onset after 14 years) by demographic, clinical, psycho and treatment variables. Psychopathology was assessed at admission (T0) and discharge (T1) with self-administered psychiatric scales for children and adolescents (SAFA) subtests for Eating Disorders, Anxiety, Depression, Somatic symptoms, and Obsessions. Then, potential differences of T0-T1 changes in psychopathological and nutritional variables were assessed. Finally, rates of re-hospitalizations at 1-year post-discharge follow-up were assessed with Kaplan-Meier analyses.

RESULTS

Two-hundred thirty-eight AN individuals (EOAN = 85) were enrolled. When compared to AOAN, EOAN participants were more frequently males (X2 = 5.360, p = .021), more frequently received nasogastric-tube feeding (X2 = 10.313, p = .001), and risperidone (X2 = 19.463, p < .001), obtained a greater T0-T1 improvement in body-mass index percentage (F[1.229] = 15.104, p < .001, η2 = 0.030), with higher 1-year freedom from re-hospitalization (hazard ratio, 0.47; Log-rank: X2 = 4.758, p = .029).

CONCLUSION

In this study, describing the broadest EOAN sample available in literature so far, EOAN patients received specific interventions and obtained better outcomes at discharge and follow-up when compared to AOAN. Longitudinal, matched studies are required.

Thyroid dysfunction in children and adolescents affected by undernourished and overnourished eating disorders

Eating disorders (ED) are one of the most prevalent chronic disorders in adolescents and young adults, with a significantly increasing prevalence in younger children, particularly in girls. Even if obesity in essence is not framed as an eating disorder and has always been considered a separate pathology, ED and obesity could be considered part of a continuum. It has become evident that one condition can lead to another, such as binge eating disorder (BED) and bulimia nervosa, and that they share the same repercussions in terms of psychosocial, metabolic, and nutritional health. This narrative review aims to investigate the hypothalamic-pituitary-thyroid axis in undernourished and overnourished patients with ED, including obesity, in order to highlight the relationship between weight control and thyroid function and its effects and to consider therapeutic and preventive strategies in children and adolescents. Literature data report that thyroid alterations occur in patients with ED, both underweight and overweight, and represent a continuum of changes depending on the severity and time course of the disease involving the endocrine system. Considering the relevant role thyroid hormones (TH) play not only in energy expenditure (EE) but also in metabolic control and cardiovascular risks related to dysmetabolism and mood regulation, continuous monitoring of thyroid homeostasis in patients with ED is mandatory to prevent severe complications and to start early treatment when necessary.

General psychiatric inpatient care for persons with anorexia nervosa-an integrative literature review protocol

INTRODUCTION

People diagnosed with anorexia nervosa are offered or compelled to undergo various treatments and therapies. In Sweden, the lack of highly specialised eating disorder services means that people with anorexia nervosa might be cared for in general psychiatric wards. However, there has been limited research attention paid to how this specific context might benefit or harm persons with anorexia nervosa. There is also limited evidence regarding which form of care is most effective in anorexia nervosa and which type of treatment is optimal in general psychiatric inpatient care. Our intention is to highlight personal and professional perspectives of care for patients with anorexia nervosa in this context, with a focus on person-centred care, gender and power. This protocol describes an integrative literature review aiming to synthesise existing knowledge on general psychiatric inpatient care for persons with anorexia nervosa.

METHODS AND ANALYSIS

The study will be an integrative literature review following Whittemore and Knafl. We will search the academic databases PubMed, CINAHL and PsycInfo in accordance with a specific search strategy determined in collaboration with a librarian with expertise on systematic reviews. Data will be analysed using a constant comparison method. Persons with their own experience of anorexia nervosa in general psychiatric inpatient care will be involved as coresearchers.

ETHICS AND DISSEMINATION

As this is a literature review, formal ethical review is not required. The findings will be disseminated through peer-reviewed publication and presented at conferences related to this field.

AMENDMENTS

If we need to amend this protocol, we will give the date of each amendment, describe the change and give the rationale in this section.

PROSPERO REGISTRATION NUMBER

CRD42023426095.

Relational attitudes in adolescent girls with and without a diagnosis of anorexia nervosa or atypical anorexia nervosa

BACKGROUND

People with eating disorders experience interpersonal difficulties, but little research explores relational attitudes in this population. We examined sense of relational entitlement towards parents, pathological concern, and psychological distress in adolescent girls with and without anorexia nervosa (AN) or atypical anorexia nervosa (AAN).

METHODS

Questionnaires assessing sense of entitlement towards parents, pathological concern, and symptoms of depression and anxiety were completed by 85 girls with and 100 girls without AN/AAN (mean age 15.06 ± 1.41). The AN/AAN group also completed a measure of ED pathology.

RESULTS

Eating pathology, pathological concern and symptoms of depression and anxiety were positively associated with both restricted and inflated sense of entitlement towards parents. AN/AAN participants scored significantly higher than controls on restricted and inflated sense of entitlement, pathological concern and symptoms of depression and anxiety. Restricted sense of entitlement and pathological concern partially mediation the association between AN/AAN and symptoms of depression and fully mediated the association between AN/AAN and anxiety. Within the AN/AAN group, pathological concern and symptoms of depression explained a large proportion of the variance in ED pathology.

CONCLUSIONS

Adolescent AN/AAN takes a heavy toll on emotional and social health, perhaps in part because crucial aspects of relational mutuality fail to develop. Teens with AN/AAN tend to over-focus on their parents' needs at the expense of their own needs. They also have impaired capacity to realistically appraise expectations from their parents, tending to feel over- and/or under-entitled to need fulfillment. These relational attitudes are associated with symptoms of depression and anxiety and should be addressed in therapy.

Acceptability, feasibility and short-term outcomes of temperament based therapy with support (TBT-S): a novel 5-day treatment for eating disorders

BACKGROUND

Temperament Based Therapy with Support (TBT-S) aims to target the mechanisms underlying the aetiology and maintenance of eating disorders, and was developed as an adjunct to treatment as usual. There is limited research investigating acceptability, feasibility and possible benefits of TBT-S. Therefore, the primary aim of the current study was to assess treatment feasibility and acceptability at a tertiary specialized eating disorders service in Norway, with a secondary aim to explore possible benefits in clinical outcome.

METHODS

Forty-one patients (mean age 25.3, range 18-43) and 58 supports were assessed pre- and post TBT-S. The majority of the patients were diagnosed with either anorexia nervosa or atypical anorexia nervosa. Participants completed an 18-item Patient and Support Satisfaction Questionnaire, in addition to a questionnaire assessing the usefulness of the different intervention components and strategies utilised in TBT-S, as well as a 4-item treatment satisfaction questionnaire. Measures of treatment efficacy were completed at both time-points, whereas treatment acceptability was only assessed post-treatment.

RESULTS

Findings reveal that TBT-S is a feasible treatment with high client satisfaction. Preliminary outcome data were also encouraging, and in line with previous studies. There were no voluntary drop-outs. All participants, both patients and supports, reported that TBT-S helped them deal more effectively with their challenges. After completing treatment, there was a significant decrease in patients' self-reported eating disorder psychopathology, psychosocial impairment and state anxiety, while trait anxiety remained unchanged. Patients also reported significantly improved social relationships, whereas supports reported a significant increase in (own) psychological health. There were no differences in family functioning.

CONCLUSIONS

TBT-S is a promising new treatment for eating disorders with high acceptability scores and low treatment attrition. Future studies should aim to explore methods which can most appropriately measure the effect of TBT-S and the usefulness of the different components of this treatment. Randomised controlled trials are needed to assess treatment efficacy of TBT-S.

Eating Disorders and Diabetes: Facing the Dual Challenge

Eating disorders and diabetes mellitus are distinct yet closely linked health conditions, presenting distinct challenges in terms of care and management. Eating disorders encompass a spectrum of mental health disorders characterized by abnormal eating behaviors and disruptions in weight regulation. Research indicates that individuals with diabetes might be at an elevated risk of developing eating disorders. The necessity to adhere to specific dietary guidelines, monitor blood sugar levels vigilantly, and manage drug administration can collectively contribute to the emergence of detrimental attitudes toward food and body image. On the other hand, incorrect eating behaviors such as binge eating and purging can disrupt blood sugar control, significantly impacting the development and management of diabetes. This intricate relationship emphasizes the crucial necessity for a comprehensive understanding and specialized care to effectively address the dual challenges faced by individuals dealing with both diabetes and eating disorders. This paper represents the inaugural comprehensive review delving into the intricate connection between eating disorders and diabetes, thereby illuminating previously under-researched areas. The insights gleaned from this review may contribute to developing integrated interventions that aim to improve the overall well-being and quality of life for individuals grappling with the complexities of eating disorders and diabetes.

TransitionED: A protocol for Co-designing and implementing Canadian practice guidelines for transitions for youth with eating disorders

OBJECTIVE

Limited guidelines inform the transition from paediatric to adult healthcare for youth and young adults (YYA) with eating disorders (EDs). This study will develop, implement, and evaluate Canadian Clinical Practice Guidelines for ED transition, including identifying the relevant measurement and evaluation tools for transition readiness and continuity of care.

METHODS

This study consists of three phases. Phase 1 involves conducting a scoping review of the evidence on transition interventions, outcomes, and measurement tools for YYA with EDs, along with guideline development using the modified Delphi method. Phase 2 identifies the contextual/cultural factors relevant to guideline implementation and co-designing an implementation protocol with governance committees and research partners. Phase 3 involves the application and evaluation of the proposed guide lines using the implementation protocol, and assessing the acceptability and feasibility of a prototype transition intervention in two Canadian paediatric ED programs.

CONCLUSIONS

Results will provide the knowledge needed to enhance the lives of YYA, improve the effectiveness of the ED care system, and support the scale of the transition guidelines across Canada. These guidelines will have international relevance by potentially informing the field on how to support young people with EDs transitioning in similar funding structures and systems of care.

Orthorexia and Orthorexia Nervosa: A Comprehensive Examination of Prevalence, Risk Factors, Diagnosis, and Treatment

Orthorexia nervosa is an emerging and controversial eating disorder characterized by an obsessive preoccupation with healthy eating and an extreme fixation on food purity. Despite growing public interest in orthorexia, its classification as a distinct eating disorder remains a subject of ongoing debate in the mental health community. This paper comprehensively reviews the current literature on orthorexia nervosa, exploring the prevalence rates, risk factors, diagnosis, and treatment options. The paper offers an overview of orthorexia and its historical context and explores the challenges and considerations in diagnosing orthorexia and orthorexia nervosa. Specifically, the distinction between "orthorexia" and "orthorexia nervosa" is a debated issue in eating disorder research due to a lack of clear diagnostic criteria, making it challenging to accurately differentiate between an obsession with healthy eating and a more severe form with potential distress and impairment. Given the absence of formal diagnostic criteria, developing valid and reliable assessment tools is crucial to accurately identify and treat individuals experiencing these disorders. The paper's final section covers the existing treatment approaches for orthorexia nervosa. Overall, the paper highlights the complex and multifaceted nature of orthorexia nervosa. This review contributes to the ongoing discourse surrounding orthorexia and provides valuable insights for clinicians, researchers, and stakeholders in the mental health and eating disorders fields.

"Getting to the Root": Ayahuasca Ceremony Leaders' Perspectives on Eating Disorders

Given the mortality, chronicity, and treatment drop-out rates observed among individuals with eating disorders (EDs), innovative approaches are needed. Ayahuasca, a psychedelic plant medicine from the Amazon, is currently being investigated. This study expands on prior exploratory research by describing the perspectives of ayahuasca ceremony leaders regarding their conceptualizations of EDs and the potential therapeutic mechanisms of action of ayahuasca for individuals with EDs. Qualitative content analysis of interviews with 15 ayahuasca ceremony leaders produced two main categories, with relevant subcategories. The first category encompassed the leaders' theories of EDs from a shamanic perspective, including that EDs are symptomatic of an underlying concern, serve a function and affect health in multiple domains. The second category described leaders' perspectives on the potential mechanisms of action of ayahuasca for EDs, including that ayahuasca facilitates "energetic healing"; helps identify, process, and integrate the "root" of the ED; promotes holistic healing; and enhances and/or reorganizes relationships. From the perspectives of ceremony leaders and consistent with previous exploratory research, ceremonial ayahuasca use may offer a potentially useful, novel and complementary intervention for EDs.

Induction of Activity-Regulated Cytoskeleton-Associated Protein and c-Fos Expression in an Animal Model of Anorexia Nervosa

Anorexia nervosa (AN) is a complex eating disorder characterized by reduced caloric intake to achieve body-weight loss. Furthermore, over-exercise is commonly reported. In recent years, animal models of AN have provided evidence for neuroplasticity changes in specific brain areas of the mesocorticolimbic circuit, which controls a multitude of functions including reward, emotion, motivation, and cognition. The activity-regulated cytoskeleton-associated protein (Arc) is an immediate early gene that modulates several forms of synaptic plasticity and has been linked to neuropsychiatric illness. Since the role of Arc in AN has never been investigated, in this study we evaluated whether the anorexic-like phenotype reproduced by the activity-based anorexia (ABA) model may impact its expression in selected brain regions that belong to the mesocorticolimbic circuit (i.e., prefrontal cortex, nucleus accumbens, and hippocampus). The marker of neuronal activation c-Fos was also assessed. We found that the expression of both markers increased in all the analyzed brain areas of ABA rats in comparison to the control groups. Moreover, a negative correlation between the density of Arc-positive cells and body-weight loss was found. Together, our findings suggest the importance of Arc and neuroplasticity changes within the brain circuits involved in dysfunctional behaviors associated with AN.

Body composition and nutritional status changes in adolescents with anorexia nervosa

INTRODUCTION

Nutritional status assessment in anorexia nervosa (AN) includes the evaluation and monitoring of body composition throughout the treatment period. The gold standard for the study of body composition is dual-energy X-ray absorptiometry (DEXA), although electrical bioimpedance (BIA) is a more accessible, cheaper and faster method that does not involve exposure to radiation.

MATERIAL AND METHODS

We recruited 33 female adolescents with AN (age, 11.7-16.3 years) by consecutive sampling. We collected data on clinical, anthropometric and laboratory variables. Patients were assessed with BIA and DEXA at inclusion in the study and at the end of the study, with a mean duration of follow-up of 1 year, during the nutritional rehabilitation phase.

RESULTS

There was significant improvement in nutritional status, reflected by the body composition obtained by anthropometric measurements and BIA. The phase angle increased significantly during the follow-up. Greater weight loss was associated with the presence of secondary amenorrhoea and decreased bone mineral density in the spine.

CONCLUSIONS

Electrical BIA is a useful tool for assessment and monitoring of nutritional status in paediatric patients with AN. Dual-energy X-ray absorptiometry continues to be essential to assess bone mineral density. The role of hormones such as leptin remains to be elucidated.

Virtually Accompanied Eating in the Outpatient Therapy of Anorexia Nervosa

BACKGROUND

Normalizing the eating pattern and weight recovery are the main objectives in treating anorexia nervosa (AN). Eating accompaniment through shared mealtimes is a common strategy in eating disorder management programs. This study aims to examine the impact on weight gain of an internet-delivered meal support group on patients with AN who were under ambulatory treatment with the Eating Disorders Unit of the UC Christus Health Network, Chile.

METHODS

An observational study of 54 female patients with AN diagnosis who participated in Online Meal Support Groups (OMSGs) three times a week was performed. Their weight, BMI and BMI%, was reviewed at the beginning of the sessions and at 45- and 90-day follow-up.

RESULTS

Patients showed significant weight gain during follow-up. At the 90-day follow-up, patients had gained 4.41 (SD ± 2.82) kg with an effect size of -1.563.

CONCLUSIONS

Statistically significant differences were found between the weight at the beginning of the intervention and at the 45- and 90-day follow-up, meaning that eating support online groups may be an effective intervention for weight gain and maintenance in patients with AN. These findings highlight the viability of developing cost-effective and more accessible interventions for AN and thus help reduce the duration of untreated disease and its consequences.

Parental Pressure on Child Body Image, BMI, Body Image Dissatisfaction Associated with Eating Disorders in School-Age Children in China: A Path Analysis

Background

Children's eating behaviors, body shape and body image cognition may be more susceptible to the influence of their parents, but these influences may be weakened with age. There may be different association pathways between parental pressure on children's body image (PPCBI), body mass index (BMI), body image dissatisfaction (BID) and eating disorders (EDs) among children and adolescents at different developmental stages.

Methods

The stratified cluster sampling method (Stratified by grade, and took the classes as clusters) was used to select 486 students aged 8-15 years in two 9-year schools. Children's body height, weight, testicular volume and breast development were measured. PPCBI, BID, and EDs were investigated using the Appearance-related Social Stress Questionnaire, Body Size Questionnaire (BID-14), and EDI-1 scale, respectively.

Results

The boys before puberty initiation had significantly higher EDs score (182.3±50.8) than girls before puberty initiation (164.1±58.1) (P<0.05). There were significant association pathways of PPCBI→BMI→BID→EDs and PPCBI→BID→EDs in boys before puberty initiation (β=0.035, P<0.01; β=0.059, P<0.01), in boys after puberty initiation (β=0.032, P<0.01; β=0.175, P<0.001), and in girls after puberty initiation (β=0.026, P<0.01; β=0.172, P<0.001). There was a positive association pathway of PPCBI→EDs in boys before puberty initiation (β=0.30, P<0.001) and PPCBI→BID→EDs in girls before puberty initiation (β=0.176, P<0.01).

Conclusion

Parental pressure on children's body image may positively associate with children's eating disorders through BMI and body image dissatisfaction in boys and girls after puberty initiation and directly associate with eating disorders in boys before puberty initiation; however, it may indirectly associate with eating disorders only through BID in girls before puberty initiation.