Prevention and Early Identification of Eating Disorders

Care pathways for longstanding eating disorders must offer paths to recovery, not managed decline

Eating disorders are historically underserved in healthcare, but are increasingly prevalent and recognised for their high costs regarding mortality, quality of life and the economy. Those with longstanding eating disorders are commonly labelled 'severe and enduring' (SEED), which has been challenged for its conceptual vagueness and potential to discourage patients. Attempts to define individuals from this cohort as having 'terminal' illness have also gained traction in recent years. This paper is grounded in lived/living experience and relevant research. It challenges the logical coherence and utility of SEED, arguing that the word 'enduring' unhelpfully situates intractability of longstanding illness within patients themselves and the nature of their illness. This risks a sense of inevitability and overlooks the important role of contextual factors such as lacking resources and insufficient evidence for withholding active treatment. Recommendations suggest approaches to dismantling unhelpful binaries between early intervention and intensive support, recovery and decline.

Measures of nutrition status and health for weight-inclusive patient care: A narrative review

In healthcare, weight is often equated to and used as a marker for health. In examining nutrition and health status, there are many more effective markers independent of weight. In this article, we review practical and emerging clinical applications of technologies and tools used to collect non-weight-related data in nutrition assessment, monitoring, and evaluation in the outpatient setting. The aim is to provide clinicians with new ideas about various types of data to evaluate and track in nutrition care.

"That's not at all what I needed" trans adults' perspectives on trans-affirming primary care and eating disorders

Transgender and gender diverse adults, referred to collectively as trans, experience eating disorders (EDs) at high rates and struggle to find primary care providers (PCPs) knowledgeable in both gender-affirming care and EDs. Most research regarding healthcare experiences of trans people with EDs focuses on specialized treatment. This qualitative study explored the experiences of trans patients with ED symptoms in trans-affirming primary care, which offers clinical support for gender affirmation in the context of interpersonally gender-affirming primary care services. Twenty-two participants were recruited via social media to participate in focus groups (n = 5). Researchers utilized thematic analysis. Participants reported gender-affirming and non-affirming experiences, experienced unwelcome comments from providers regarding bodies and gender, encountered barriers to disclosing their ED symptoms, felt transition-related medical care supported recovery but did not always resolve their ED symptoms, felt they had to self-advocate, and wanted their providers to recognize them as whole people (beyond their ED and transness) who experience joy. Importantly, despite being trans-affirming, participants critiqued trans-affirming primary care as perpetuating weight stigma and binary gender norms. Participants recommended providers receive ED training, implement universal ED screening, and explore how sociocultural norms regarding weight and gender negatively impact trans health outcomes.

Family Meals and Social Eating Behavior and Their Association with Disordered Eating among Spanish Adolescents: The EHDLA Study

PURPOSE

The aim of this study was to examine the association of family meals and social eating behavior with disordered eating behavior in Spanish adolescents.

METHODS

This was a cross-sectional study that included 706 adolescents (43.9% boys) from the Eating Habits and Daily Life Activities (EHDLA) study (aged 12 to 17) from Valle de Ricote, Region of Murcia, Spain. The frequency of family meals was assessed by asking participants to report how often their family, or most household members, had shared meals in the past week. Social eating behavior was evaluated using three statements: "I enjoy sitting down with family or friends for a meal", "Having at least one meal a day with others (family or friends) is important to me", and "I usually have dinner with others". To evaluate disordered eating, two psychologists administered the Sick, Control, One, Fat and Food (SCOFF) questionnaire.

RESULTS

After adjusting for several covariates, for each additional family meal, the likelihood of having disordered eating behavior was lower (odds ratio (OR) = 0.96; 95% confidence interval (CI) 0.93 to 0.9997, p = 0.049). On the other hand, a lower likelihood of having disordered eating behavior was observed for each additional point in the social eating behavior scale (OR = 0.85; 95% CI 0.77 to 0.93, p = 0.001). The likelihood of having disordered eating behavior was 0.7% lower for each additional family meal (95% CI 0.01% to 1.4%, p = 0.046). Furthermore, for each additional point in the social eating behavior scale, a lower probability of having disordered eating behavior was observed (3.2%; 95% CI 1.4% to 5.0%, p < 0.001).

CONCLUSIONS

While disordered eating behavior is complex and can be shaped by various factors, both family meals and social eating behavior emerge as significant factors inversely associated with this condition among adolescents. Promoting regular engagement in family meals and fostering positive social eating experiences could serve as effective strategies in public health initiatives aimed at mitigating the incidence of disordered eating behavior among the young population.

Risk factors of disordered eating in adolescent girls from a community sample: a multidimensional approach

BACKGROUND

Eating disorders (ED) are severe, chronic, and complex in nature mental illnesses that are difficult to treat. One of the ways to stave off EDs is by screening among adolescents to preempt the development of clinical forms of ED in risk groups.

AIM

1) to investigate the prevalence of ED risk among adolescent girls and compare subgroups at high and low risk of ED; 2) to investigate using a multidimensional approach those variables that can interact with temperament and character traits to predict ED symptomatology.

METHODS

The cross-sectional observational self-report study of a community sample of adolescent girls 1217 years old (n=298; M=14.771.13) was carried out in the city of Ryazan, Russia. The Russian versions of Eating Attitudes Test and Cloningers Temperament and Character Inventory-Revised were used. In addition, an original questionnaire (Risk Factors of Eating Disorders) was developed. Regression models (to test for significant moderation) and path analysis (to test for significant mediations) were used.

RESULTS

Girls at risk of developing EDs are characterized by a heightened level of concern about weight and dissatisfaction with their body, tend to suffer from low self-directedness, higher novelty seeking and tendency to higher harm avoidance, display high alexithymia, experience self-distrust, negative emotionality and are dissatisfied with family relationships. They also suffer from low self-esteem and tend to be perfectionism and engage in risk behavior. Significant moderating effects were uncovered between the following ED risk factors: (1) self-distrust/risk behavior and BMI; (2) alexithymia/negative emotionality/self-esteem and cooperativeness; and (3) negative emotionality/risk behavior and self-transcendence. Family relationship dissatisfaction mediates the association between self-directedness/cooperativeness/self-transcendence and disordered eating.

CONCLUSION

There are various mutual influences between the numerous ED risk and prevention factors, which all together determine the paths between the predictors and final outcome.

Inaccessibility of care and inequitable conceptions of suffering: a collective response to the construction of "terminal" anorexia nervosa

Informed by our lived experiences with eating disorders, our work providing direct support to communities underserved by existing healthcare structures, and our commitment to social justice, we are deeply troubled by several aspects of the proposed characteristics for "terminal" anorexia nervosa outlined by Gaudiani et al. in Journal of Eating Disorders (10:23, 2022). We have identified two substantial areas of concern in the proposed characteristics provided by Gaudiani et al. and the subsequent publication by Yager et al. (10:123, 2022). First, the original article and the subsequent publication fail to adequately address the widespread inaccessibility of eating disorder treatment, the lack of parameters for what constitutes "high quality care", and the prevalence of trauma experienced in treatment settings for those who do access treatment. Second, the characteristics proposed for "terminal" anorexia nervosa are constructed largely based on subjective and inconsistent valuations of suffering which build on and contribute to harmful and inaccurate eating disorder stereotypes. Overall, we believe these proposed characteristics in their current form stand to detract from, rather than assist, the ability of patients and providers to make informed, compassionate, and patient-centered decisions about safety and autonomy both for individuals with enduring eating disorders and for individuals with more recently diagnosed eating disorders.

Global Proportion of Disordered Eating in Children and Adolescents: A Systematic Review and Meta-analysis

Importance

The 5-item Sick, Control, One, Fat, Food (SCOFF) questionnaire is the most widely used screening measure for eating disorders. However, no previous systematic review and meta-analysis determined the proportion of disordered eating among children and adolescents.

Objective

To establish the proportion among children and adolescents of disordered eating as assessed with the SCOFF tool.

Data Sources

Four databases were systematically searched (PubMed, Scopus, Web of Science, and the Cochrane Library) with date limits from January 1999 to November 2022.

Study Selection

Studies were required to meet the following criteria: (1) participants: studies of community samples of children and adolescents aged 6 to 18 years and (2) outcome: disordered eating assessed by the SCOFF questionnaire. The exclusion criteria included (1) studies conducted with young people who had a diagnosis of physical or mental disorders; (2) studies that were published before 1999 because the SCOFF questionnaire was designed in that year; (3) studies in which data were collected during COVID-19 because they could introduce selection bias; (4) studies based on data from the same surveys/studies to avoid duplication; and (5) systematic reviews and/or meta-analyses and qualitative and case studies.

Data Extraction and Synthesis

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Proportion of disordered eating among children and adolescents assessed with the SCOFF tool.

Results

Thirty-two studies, including 63 181 participants, from 16 countries were included in this systematic review and meta-analysis. The overall proportion of children and adolescents with disordered eating was 22.36% (95% CI, 18.84%-26.09%; P < .001; n = 63 181) (I2 = 98.58%). Girls were significantly more likely to report disordered eating (30.03%; 95% CI, 25.61%-34.65%; n = 27 548) than boys (16.98%; 95% CI, 13.46%-20.81%; n = 26 170) (P < .001). Disordered eating became more elevated with increasing age (B, 0.03; 95% CI, 0-0.06; P = .049) and body mass index (B, 0.03; 95% CI, 0.01-0.05; P < .001).

Conclusions and Relevance

In this systematic review and meta-analysis, the available evidence from 32 studies comprising large samples from 16 countries showed that 22% of children and adolescents showed disordered eating according to the SCOFF tool. Proportion of disordered eating was further elevated among girls, as well as with increasing age and body mass index. These high figures are concerning from a public health perspective and highlight the need to implement strategies for preventing eating disorders.

Prevention and early intervention in eating disorders: findings from a rapid review

BACKGROUND

Eating disorders (EDs) are complex psychological disorders, with low rates of detection and early intervention. They can lead to significant mental and physical health complications, especially if intervention is delayed. Given high rates of morbidity and mortality, low treatment uptake, and significant rates of relapse, it is important to examine prevention, early intervention, and early recognition initiatives. The aim of this review is to identify and evaluate literature on preventative and early intervention programs in EDs.

METHODS

This paper is one of a series of Rapid Reviews, designed to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded, and released by the Australian Government. To provide a current and rigorous review, peer-reviewed articles between 2009 and 2021 published in English were searched across three databases: ScienceDirect, PubMed and Ovid/Medline. Priority was given to high-level evidence including meta-analyses, systematic reviews, Randomised Control Trials, and large population studies. Findings from selected studies pertaining to prevention and early intervention in EDs were evaluated and are presented in this review.

RESULTS

In total, 130 studies were identified in the current review, 72% relating to prevention and 28% to early intervention. Most programs were theory-driven and targeted one or more ED risk factors such as thin-ideal internalisation and/or body dissatisfaction. There is reasonable evidence to support prevention programs reducing risk factors, particularly as part of school or university-based programs, with established feasibility and relatively high acceptance among students. There is increasing evidence around the use of technology (to increase dissemination potential) and for use of mindfulness approaches (targeting emotional resilience). Few longitudinal studies assessing incident cases following participation in a prevention program exist.

CONCLUSIONS

Although several prevention and early intervention programs have been shown to significantly reduce risk factors, promote symptom recognition, and encourage help-seeking behaviour, most of these studies have been conducted in older adolescent and university aged students, past the age of peak ED onset. One of the most targeted risk factors, body dissatisfaction, is found in girls as young as 6 years old, indicating a need for further research implementing prevention initiatives at younger ages. Follow-up research is limited; thus, the long-term efficacy and effectiveness of studied programs is unknown. Greater attention should be paid to the implementation of prevention and early intervention programs in identified high-risk cohorts or diverse groups, where a more targeted approach may be necessary.

Emergency room presentations of people with anorexia nervosa

People with anorexia nervosa (AN) tend to shy away from engaging in typical primary care provider relationships in order to avoid detection. Therefore, they may seek care for their medical concerns through a local emergency department (ED). Inherently, AN is associated with a litany of medical complications, which become more prevalent as the severity of their eating disorder increases. Notwithstanding the typical young age at the onset of AN, no body system is immune to these medical complications. Thus, ED providers may need to pursue a medical diagnosis in order to explain presenting symptoms in people with AN. In addition to the medical issues, AN is also a serious mental illness with high mortality rates, including deaths by suicide. Therefore, ED providers also need to be familiar with relevant mental health issues for these people.

The estimated burden of bulimia nervosa in the Middle East and North Africa region, 1990-2019

OBJECTIVE

We aimed to report the burden of bulimia nervosa (BN) in the Middle East and North Africa (MENA) region by age, sex, and sociodemographic index (SDI), for the period 1990-2019.

METHODS

Estimates of the prevalence, incidence, and disability-adjusted life-years (DALYs) attributable to BN were retrieved from the Global Burden of Disease study 2019, between 1990 and 2019, for the 21 countries in the MENA region. The counts and age-standardized rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals.

RESULTS

In 2019, the estimated regional age-standardized point prevalence and incidence rates of BN were 168.3 (115.0-229.6) and 178.6 (117.0-255.6) per 100,000, which represented 22.0% (17.5-27.2) and 10.4% (7.1-14.7) increases, respectively, since 1990. Moreover, in 2019 the regional age-standardized DALY rate was 35.5 (20.6-55.5) per 100,000, which was 22.2% (16.7-28.2) higher than in 1990. In 2019, Qatar (58.6 [34.3-92.5]) and Afghanistan (18.4 [10.6-29.2]) had the highest and lowest age-standardized DALY rates, respectively. Regionally, the age-standardized point prevalence of BN peaked in the 30-34 age group and was more prevalent among women. In addition, there was a generally positive association between SDI and the burden of BN across the measurement period.

DISCUSSION

In the MENA region, the burden of BN has increased over the last three decades. Cost-effective preventive measures are needed in the region, especially in the high SDI countries.

PUBLIC SIGNIFICANCE

This study reports the estimated burden of BN in the MENA region and shows that its burden has increased over the last three decades.

Epidemiology of eating disorders among US adults

PURPOSE OF REVIEW

Public policy efforts for prevention of and intervention upon eating disorders is severely limited in the United States due to the paucity of population-based data. This review article summarizes findings regarding eating disorders based on the National Epidemiological Studies on Alcohol and Related Conditions, Third Wave. The studies reviewed provide the most recent epidemiological indicators of anorexia nervosa, bulimia nervosa, and binge-eating disorder (BED) in the United States and demonstrate the utility of population-based data for validating the generalizability of findings from clinical samples.

RECENT FINDINGS

Anorexia nervosa, bulimia nervosa, and BED are widely distributed across sociodemographic characteristics, with substantially elevated risks for a variety of serious psychiatric, medical, and functional impairments, including heighted suicidality over the lifespan. Sexual minorities and individuals with adverse childhood experiences may be particularly vulnerable. Yet, many adults with eating disorders do not seek help, particularly professional help. National Epidemiological Studies on Alcohol and Related Conditions, Third Wave studies also validated some important clinical observations (e.g., overvaluation of shape/weight and physical inactivity in BED, more severe anorexia nervosa with onset prior to 14 years old).

SUMMARY

More rigorous population-based studies are needed to further advocate for appropriate resources and policies for eating disorders in the United States.