Medical complications in adolescents with anorexia nervosa: a review of the literature

Can bioelectrical impedance analysis be used to identify water loading in patients with anorexia nervosa?- Implications from experimental measurements in young, healthy, and normal weight women

Anorexia nervosa (AN) is a severe mental disorder, and patients with AN are characterized by a low body weight and a fear of gaining weight. Restoration of body weight to the normal range is one major treatment aim, which can be a challenging process for the patients. Hence, as a psychopathological symptom of AN, weight manipulations such as water loading before weighing are commonly observed in clinical routine. Biological impedance analysis (BIA) is a helpful tool in routinely visualizing changes in body composition during the refeeding process. Here, we targeted the question whether BIA could potentially detect water loading in healthy, young and normal weight women serving as a preclinical model for patients with AN.Sixty-one women (mean ± SD, 22.2 ± 2.2 years, 20.4 ± 1.0 kg/m2) were included in the analyses. We used a full experimental setting with a cross-over design on two consecutive days. On both days, all participants underwent a baseline BIA in the fasting state (t0). Directly thereafter, participants either consumed 1000 ml of tap water (intervention-condition) or waited for the second BIA measurement 20 min (t1) after baseline (control-condition), and vice versa the subsequent day. Two further BIA measurements took place at 40 (t2) and 60 min (t3) after baseline.After water consumption, we found increases in derived fat mass (FM) and phase angle at t1 to t3, decreases at t1 and subsequent increases at t2 and t3 in extracellular water (ECW) and total body water (TBW). In contrast, skeletal muscle mass (SMM) and ECW/TBW remained rather stable. In the control-condition, most parameters remained constant.Our study provided insight into the changes of impedance raw data and derived body compartments after water consumption among young, healthy and normal weight women. Although the considerable increase of FM in combination with a rather stable course of SMM, as found in our experiment after the consumption of water, could be a potential hint for water loading, further investigation considering the limitations of the present study as for instance the different metabolisms of patients with AN vs. healthy women is required, before transferability to the clinical setting will be given.

Delivering evidence-based treatment via telehealth for Anorexia Nervosa in rural health settings: a multi-site feasibility implementation study

BACKGROUND

Access to evidence-based treatments such as family-based therapy (FBT) is difficult for adolescents diagnosed with Anorexia Nervosa (AN) living in rural or regional areas due to a limited trained workforce, high staff turnover and inconsistent treatment fidelity. Telehealth offers a potential access solution by facilitating care irrespective of family or service location. The disruption to the health system caused by COVID-19 amplified an existing need and increased the use of telehealth to deliver FBT before its efficacy and safety was fully evaluated. This study aimed to evaluate the feasibility, acceptability and preliminary efficacy of telehealth-FBT delivered by community-based clinicians within rural services directly into the home to reduce the eating disorder symptoms of adolescents diagnosed with AN.

METHODS

A pre- and post-implementation multi-site case series delivered up to 20 sessions of telehealth-FBT to 28 adolescents (89.29% female, M = 14.68 ± 1.58 years) living in rural or regional Australia. The RE-AIM framework guided the evaluation, with Reach (treatment uptake and completion); Efficacy (change in weight, global eating disorder symptoms, and remission from baseline to end of treatment and six-month follow-up); Adoption (patient characteristics and drop out); Implementation (intervention fidelity) and Maintenance (outcomes and intervention during the follow-up period) used to assess the feasibility and preliminary efficacy of telehealth-FBT.

RESULTS

There was a high level of interest in telehealth-FBT, with two-thirds of eligible families consenting to participate. Both treatment engagement and completion rates were over 60%, and treatment was delivered with acceptable fidelity. Twenty adolescents (71.43%) met the diagnostic criteria for AN (baseline 86.03%mBMI ± 7.14), and eight (28.57%) for Atypical AN (baseline 101.34%mBMI ± 8.28), with an overall mean duration of illness of 8.53 months (SD = 5.39, range 2-24 months). There was a significant increase in %mBMI at the end of treatment compared to the baseline (p = 0.007, 95%CI: 1.04-6.65), with over 68% of adolescents weight restored and 36.8% of these achieving both weight and psychological remission criteria. Weight remained significantly improved at six-month follow-up (p = 0.005, 95%CI: 1.57-8.65). Also, there was a decrease in adolescents' global eating disorder symptoms, as rated by their parents, at the end of treatment compared to the baseline of 0.735 (p = 0.028, 95%CI: 0.079-1.385).

CONCLUSIONS

Telehealth-FBT was feasibly implemented into rural services and delivered by community clinicians with reach, adoption, preliminary efficacy, and fidelity scores comparable to those reported by specialist studies.

TRIAL REGISTRATION

The study was conducted according to the HREC-approved protocol (HREC 2020/ETH00186) and registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR # 12620001107910).

Enhanced cognitive behaviour therapy for adolescents with eating disorders: development, effectiveness, and future challenges

Eating disorders can significantly impact the psychosocial functioning and physical health of adolescents. Early and effective treatment is crucial to prevent long-lasting and potentially devastating adverse effects. The National Institute for Health and Care Excellence has recommended cognitive behaviour therapy (CBT) for eating disorders in adolescents when family therapy is unacceptable, contraindicated, or ineffective. This recommendation was primarily based on the review of promising results from the enhanced version of CBT (CBT-E) adapted for adolescents with eating disorders aged between 12 and 19 years. A non-randomized effectiveness trial has also shown that CBT-E achieved a similar outcome to family-based treatment (FBT) at 6- and 12-months. CBT-E has several advantages. It is acceptable to young people, and its collaborative nature suits ambivalent young patients who may be particularly concerned about control issues. The transdiagnostic scope of the treatment is an advantage as it can treat the full range of disorders that occur in adolescent patients. It is an individual one-on-one treatment that does not necessitate the full involvement of the family. This approach is particularly beneficial for families that can only provide limited support. Future challenges include clarifying the relative efficacy of CBT-E and family therapy for the treatment of adolescent patients with eating disorders in a randomized control trial and increasing its effectiveness, identifying the reasons for the lack of response, and modifying the treatment accordingly.

A prospective observational study comparing rates of medical instability between adolescents with typical and atypical anorexia nervosa

BACKGROUND

Recognition of atypical anorexia nervosa (AAN) has challenged underweight as a defining factor of illness severity in anorexia nervosa (AN). The present study aimed to compare rates of medical instability in adolescents with underweight (AN) and non-underweight (AAN) anorexia nervosa.

METHODS

The study examined assessment data from specialist eating disorder services in the UK between January and December 2022. Participants (n = 205) aged 11-18 years were recruited across eight eating disorder clinics and diagnosed with AN (n = 113) or AAN (n = 92) after clinical assessment. Parameters associated with risk of medical instability were compared between AN and AAN groups, using t tests and regression analysis.

RESULTS

Rates of bradycardia and hypotension did not differ significantly between AN and AAN groups (p = 0.239 and p = 0.289). Although white blood cell counts were lower in the AN group, rates of leukopaenia could not be statistically compared as a result of there being too few counts in at least one group. No incidences of hypophosphataemia were found in the sample. A significant regression equation was found for percentage median body mass index, but not rate of weight loss, as a predictor of blood pressure, serum phosphorous and magnesium.

CONCLUSIONS

Our findings indicate that medical instability occurs across a range of body weights in young people with AN and AAN. Although certain parameters of risk such as blood pressure, serum phosphorous and magnesium may be worsened at lower weight, both AN and AAN are serious mental health conditions that can lead to medical instability.

Psilocybin therapy and anorexia nervosa: a narrative review of safety considerations for researchers and clinicians

BACKGROUND

Clinical trials using psilocybin therapy to treat anorexia nervosa (AN) are currently underway. The safety and tolerability of psilocybin is of utmost importance in individuals with AN who may present unique medical vulnerabilities. The purpose of this review is to describe how the common physiologic adverse effects of psilocybin may impact medical complications experienced by individuals with AN in clinical trials of psilocybin therapy.

MAIN BODY

The physiologic underpinnings of common adverse effects following psilocybin administration are described, including tachycardia, hypertension, electrocardiogram changes, nausea, headache, and lightheadedness. These anticipated physiologic changes are described in relation to the common medical correlates seen in individuals with AN. Risk mitigation strategies for each adverse effect are proposed.

CONCLUSION

Early evidence suggests that psilocybin therapy is well-tolerated in individuals with AN. Understanding the unique medical complications of AN, and how they may be impacted by common physiologic adverse effects of psilocybin administration, leads to tailored risk mitigation strategies to enhance safety and tolerability of this novel intervention.

The Role of the Dietitian within Family Therapy for Anorexia Nervosa (FT-AN): A Reflexive Thematic Analysis of Child and Adolescent Eating Disorder Clinician Perspectives

BACKGROUND

Despite dietitians being important members of the multidisciplinary team delivering family therapy for anorexia nervosa (FT-AN), their specific responsibilities and roles are unclear and their involvement in the treatment can be a contentious issue.

METHODOLOGY

Clinicians (n = 20) experienced in the delivery of FT-AN who were working at a specialist child and adolescent eating disorder service responded to an online survey about their experience of including a dietitian in FT-AN and how they understand the role. Both categorical and open-ended questions were used. Reflexive thematic analysis was used to analyse the qualitative free-text responses of clinician perspectives on the role of the dietitian in FT-AN.

RESULTS

All clinicians agreed that dietetics had a role within FT-AN and most frequently sought dietetic involvement in the early phases of FT-AN. Reflexive thematic analysis of responses identified three main themes. These were (1) collaboration is key, (2) confidence as a core consideration and (3) case-by-case approach. These themes evidenced the role of the dietitian within FT-AN and highlighted both the benefits and concerns of this involvement.

CONCLUSIONS

This study demonstrated that dietitians can take a core role as collaborators within therapy-led teams that facilitate joint working and sharing of expertise. However, dietetic input should be considered on a case-by-case basis, given its potential for creating an over-focus on nutrition and potentially diminishing parental confidence in feeding. When indicated for selected cases, nutritional counselling should be offered in joint sessions with the therapist rather than separately. The findings of the study were limited by the small sample size of participants recruited from a single centre and heterogeneity in the professional background of respondents. Although the integration of dietetics within the multidisciplinary team and the ability of dietitians to individualise patient care can enhance FT-AN treatment, potential benefits and disbenefits should be considered for each case.

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.

A Qualitative Exploration of Prominent Factors Contributing to the Aetiology of Child and Adolescent Eating Disorder Presentations during the COVID-19 Pandemic: The Perspectives of Patients, Parents and Clinicians

AIM

The aim of this study was to explore the prominent factors that contributed to the development of child and adolescent eating disorder presentations during the COVID-19 pandemic.

METHODS

This was achieved through a qualitative analysis of interviews gathered from (1) adolescent patients diagnosed with an eating disorder (ED) during the COVID-19 pandemic (aged 13-18) (n = 4), (2) parents of patients attending an ED service (n = 7) and (3) clinicians working within a specialist child and adolescent ED support service (n = 7). Reflexive thematic analysis was used to analyse the data and establish the most prominent aetiological factors reported.

RESULTS

The most prominent aetiological factors reported were (1) the accumulation of risk factors; (2) seeking control amid increased anxiety, stress and uncertainty; (3) social isolation; (4) an increased focus on exercise and "healthy eating"; (5) increased social media use promoting unhelpful attention towards ED triggers; and (6) a lack of both awareness and support services.

CONCLUSION

During the COVID-19 pandemic, the quantity and severity of ED presentations increased. The current study uncovered six themes perceived by patients, parents and clinical staff that contributed to the aetiology of ED presentations during the COVID-19 pandemic. It is hoped that the insight gained through this research study into ED aetiology may act as a basis for further research and support ED awareness, prevention and intervention in the future.

Pediatric Patients Hospitalized With Eating Disorders in Ontario, Canada, Over Time

Importance

Understanding the evolving characteristics of pediatric patients hospitalized for eating disorders is important to ensure that services and treatments align with patient needs.

Objective

To examine temporal trends in the rates of hospitalizations for pediatric eating disorders by clinical and demographic characteristics in Ontario, Canada, over a 17-year period.

Design, Setting, and Participants

This population-based, repeated, cross-sectional study used linked health administrative and demographic databases in Ontario, Canada, to identify individuals aged 5 to 17 years hospitalized with eating disorder diagnoses from April 1, 2002, to March 31, 2020. Data analyses were performed from May 2021 to June 2023.

Exposure

Fiscal year (April 1-March 31) of eating disorder hospitalization.

Main Outcomes and Measures

Outcomes of interest were absolute and relative changes in pediatric eating disorder hospitalization rates overall and stratified by patient sex, age groups, and eating disorder diagnostic groups.

Results

Over the study period, there were 11 654 pediatric eating disorder hospitalizations, of which 5268 (45.2%) were for anorexia nervosa and 1374 (11.8%) were for bulimia nervosa. There were a total of 10 648 hospitalizations (91.4%) among female patients, and the median (IQR) age was 15.0 (14-0-16.0) years. Hospitalization rates increased 139% from 2002 to 2019, from 2.0 per 10 000 population to 4.8 per 10 000 population. The largest relative changes were observed among male patients (416%; from 0.2 per 10 000 population to 1.1 per 10 000 population), individuals aged 12 to 14 years (196%; from 2.2 per 10 000 population to 6.6 per 10 000 population), and individuals with eating disorders other than anorexia or bulimia nervosa (255%; from 0.6 per 10 000 population to 2.1 per 10 000 population). Male patients, younger adolescents, and individuals with other eating disorders also represented larger proportions of hospitalizations by fiscal 2019.

Conclusions and Relevance

In this cross-sectional study of eating disorder hospitalizations, pediatric hospitalizations increased over time, particularly among populations traditionally considered atypical. Existing eating disorder programs must adapt to accommodate changing patient presentations and increased volumes to ensure effective care delivery.

The Impact of Clinical Factors, Vitamin B12 and Total Cholesterol on Severity of Anorexia Nervosa: A Multicentric Cross-Sectional Study

Severe forms of Anorexia Nervosa (AN) are characterized by medical complications, psychiatric comorbidity, and high mortality. This study investigated potential associations between clinical/biological factors and the severity of AN, measured by the Body Mass Index (BMI). Red and white blood cells, hemoglobin, platelets, iron, vitamins D and B12, folate, and total cholesterol were measured in a mixed sample of 78 inpatients and outpatients. Linear regressions and one-way analyses of variance (ANOVAs) were carried out to evaluate the relationship between BMI and clinical/biochemical variables. BMI was significantly lower in hospitalized patients (F = 4.662; p = 0.034) and in those under pharmacological treatment (F = 5.733; p = 0.019) or poly-therapy (F = 5.635; p = 0.021). Higher vitamin B12 (β = -0.556, p < 0.001), total cholesterol (β = -0.320, p = 0.027), and later age at onset (with a trend towards significance) (β = -0.376, p = 0.058) were associated with a lower BMI. Increased total cholesterol and vitamin B12, later age at onset, current pharmacological treatment, and poly-therapy might be distinctive in patients with a lower BMI. In clinical practice, these findings may contribute to the early identification of AN patients at higher risk of developing complicated or chronic forms of the disorder. Further studies on larger samples are needed to identify potential predictive factors of AN severity in the framework of precision medicine.

Anorexia nervosa and the COVID-19 pandemic among young people: a scoping review

BACKGROUND

The extent to which the recent global COVID-19 Pandemic has impacted young people with restrictive eating disorders [i.e., anorexia nervosa (AN) and atypical anorexia nervosa (AAN)] is unclear. We conducted a scoping review of the literature to identify how the pandemic has impacted this population and to identify gaps in the current literature to inform future research efforts.

MAIN BODY

We searched PubMed, EMBASE, the Web of Science, The Cochrane Library, PsycInfo, ProQuest Dissertations and Theses Global, LitCovid, Google Scholar, and relevant agency websites from 2019 to 2022. We included studies that focused on young people with AN/AAN globally. Of the 916 unduplicated articles screened, 17 articles met the inclusion criteria, reporting on 17 unique studies including 4,379 individuals. Three key findings were identified. First, an increase in hospitalizations related to eating disorders was found during COVID-19 among young people with AN and AAN. Multiple studies cited increased medical instability, even though the overall duration of disease was shorter compared to pre-pandemic levels. Second, changes in eating disorder-related symptomology during the pandemic were reported in this population, as well as poorer overall behavioral and mental health. Suggested reasons behind changes included boredom or minimal distraction from pathological thoughts, increased social isolation, increased social media and online use (e.g., reading blogs or watching YouTube), gym and school closures, changes in routines due to lockdowns and quarantines, and worries over gaining the "Quarantine 15". Third, there was an increase in the use of telemedicine as a treatment modality for the treatment of AN. Challenges were reported by both clinicians and patients regardless of past experience using telemedicine. When compared to no treatment, telemedicine was recognized as the best option during COVID-19 lockdowns; however some individuals expressed the preference for in-person treatment and planned to return to it once it became available.

CONCLUSION

The pandemic significantly impacted young people with restrictive eating disorders as seen by increased hospitalizations and requests for outpatient care. A primary driver of the changes in eating disorder symptomatology may be lockdowns and quarantines. Further research investigating how the series of lockdowns and re-openings impacted individuals with AN/AAN is warranted.

Electrocardiographic QTc as a Surrogate Measure of Cardiac Risk in Children, Adolescents, and Young Adults With Eating Disorders

The study goal was to investigate electrocardiographic findings, including corrected QT interval (QTc), in patients aged 8 to 23 with eating disorders (EDs) at presentation, compared with an age-and sex-matched control population. We retrospectively reviewed 200 ED patients, and 200 controls. Blinded electrocardiograms (ECGs) were interpreted by an expert reader, and QT intervals corrected using the Bazett formula. Eating disorder patients were 89.5% female, with mean age 16.4 years and median percent median body mass index (BMI)-for-age (%mBMI)a of 91.1%. In ED patients, QTc was significantly shorter than controls (399.6 vs 415.0msec, P < .001). After adjusting for height, %mBMI, sex, magnesium level, and bradycardia, mean QTc duration in patients with anorexia nervosa-restricting subtype (AN-R) was significantly shorter than other ED patients (P = .010). Higher %mBMI was associated with shorter QTc duration (P = .041) after adjusting for height, magnesium, bradycardia, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis. Within the ED group, no significant association was identified between QTc and medications, electrolytes, or inpatient status.

Medical instability in typical and atypical adolescent anorexia nervosa: a systematic review and meta-analysis

This review investigates the relationship between weight and risk of medical instability (specifically bradycardia, hypotension, hypothermia, and hypophosphatemia) in adolescents with typical and atypical anorexia nervosa. Atypical anorexia nervosa, listed as an example under the DSM-5 category of Other Specified Feeding and Eating Disorders (OSFED), describes patients who are not clinically underweight but otherwise meet criteria for anorexia nervosa. There is a lack of empirical evidence exploring medical complications in adolescents presenting with atypical anorexia nervosa. The small number of studies that do exist in this area indicate that medical instability exists across a range of weights, with weight loss being associated with increased medical risk, independent of underweight. The aim of this review was to collate and analyse results from available studies and identify indicators of medical risk in these two groups of adolescents with restrictive eating disorders. Studies were identified by systematic electronic search of medical databases, including PubMed and EMBASE. All studies investigated the relationship between weight and medical instability and included adolescents diagnosed with anorexia nervosa or atypical anorexia nervosa. One randomised controlled trial, five cohort studies and three chart reviews were included, with a total sample size of 2331 participants. Between 29 and 42% of participants presented with medical instability requiring hospitalisation, in the absence of underweight. Underweight adolescents were significantly more likely to have lower blood pressures (p < 0.0001) and bradycardia was significantly associated with greater weight loss (p < 0.05). There were no statistically significant associations found between degree of underweight and heart rate, temperature, or rate of weight loss (p = 0.31, p = 0.46 and p = 0.16, respectively). Adolescents that were less than 70% median body mass index were significantly more likely to have hypophosphatemia (p < 0.05). The findings of this review support the hypothesis that medical instability can occur across a range of weights in adolescent eating disorders, with rapid weight loss being an important indicator of increasing medical risk. Results were limited by the small number of existing studies that contained data for statistical analysis. Rapid weight loss should be considered as an important indicator of medical instability in adolescents presenting with both typical and atypical anorexia nervosa.

Linear growth in young people with restrictive eating disorders: "Inching" toward consensus

Background

While the assessment of acute medical stability in patients with eating disorders should never be minimized, careful attention toward other specific age-related consequences of malnutrition can improve psychological outcomes and reduce long-term, potentially irreversible medical complications, like linear growth impairment.

Review

While the impact of malnutrition on linear growth is widely recognized, emerging data highlight consensus in several key areas: the time from onset to time of diagnosis, age at illness onset, pubertal stage at illness onset, and adequacy of weight restoration to achieve catch-up growth. This review provides concrete and actionable steps to help providers identify and explore deviations in expected growth and development while prioritizing early and aggressive weight restoration to provide the best opportunity for catch-up linear growth in patients with eating disorders.

Conclusion

The impact of restrictive eating disorders on growth and development cannot be overstated, particularly in pre- and peripubertal patients. While many consequences of malnutrition are reversible, the loss of genetic height potential may prove irreversible without early and aggressive weight restoration.

Paediatric eating disorders: Exploring virtual family therapy during a global pandemic

AIM

Explore treatment response and effectiveness of virtual treatment for a paediatric eating disorder sample.

METHODS

Twenty patients and their families who received either virtual or in-person family therapy were included in the study. Family therapy was informed by family-based treatment (FBT) principles. Patients' weight restoration at 1, 3, and 6 months after starting treatment was examined. Independent sample t tests assessed group differences and a Fisher exact test was used to evaluate the association between treatment group and weight restoration.

RESULTS

Weight restoration did not significantly differ between treatment groups (virtual vs. in-person) at any time point and there was no association between group and remission weight at 6 months.

CONCLUSIONS

Study results are considered exploratory. Future research addressing study limitations is needed. Results suggest that paediatric eating disorder patients may benefit from family therapy delivered via a virtual platform.

Rapid refeeding does not worsen anxiety in adolescents with anorexia nervosa: a pilot study

The study aimed to describe the progression of state anxiety in adolescents with anorexia nervosa (AN) hospitalized on a high calorie refeeding (HCR) protocol. Participants, 12-21 years, admitted for malnutrition due to AN were placed on a HCR protocol in which calories were advanced by 300 kcal/day. The State-Trait Anxiety Inventory for Children (STAIC) was given to participants within 24 hours of hospitalization and the state anxiety component of the STAIC was administered daily immediately before and after breakfast until discharge. Of 22 patients enrolled, 86% were female, mean age was 14.9 ± 2.0 years, and 95% had AN-restrictive type. The median state and trait anxiety scores at time of admission were 37.0 (28-55) and 35.5 (23-51), respectively. There was no significant difference in median pre-meal state anxiety from hospital day 1 to 6 (34.0(26-55) vs. 38.5(25-55), p-value = 0.079) or in median post-meal state anxiety from hospital day 1 to 6 (35.5(29-56) vs. 37(24-56), p-value = 0.484). Similarly, we found minimal correlation between change in caloric intake and change in pre-meal S-anxiety (Spearman correlation coefficient = -0.032) or post-meal S-anxiety (Spearman correlation = 0.032). While this was a small sample observing anxiety over one week, we found no evidence that state anxiety increased with advancing calories, providing additional support for the use of more rapid refeeding protocols.

Eating Disorders

Eating disorders are common behavioral disorders associated with substantial psychological and physical morbidity and mortality. Persons with eating disorders frequently present to primary care providers, who may also be responsible for their general medical management. This article reviews the diagnosis, medical assessment, and treatment of the most common eating disorders.

The use of TikTok among children and adolescents with Eating Disorders: experience in a third-level public Italian center during the SARS-CoV-2 pandemic

BACKGROUND

Recent research has documented the potential associations existing between the use of social media (SM) and the occurrence/development and treatment of Eating Disorders (ED). However, the literature directly addressing the use of SM TikTok among children and adolescents with ED is still scarce.

METHODS

In January-February 2021, during the second Italian national lockdown due to the SARS-CoV-2 pandemic, an anonymous paper survey was conducted in an Italian third-level center for ED in childhood and adolescence. Demographics, frequency of use of TikTok, frequently viewed topics and hashtags, experienced body-shaming, as well as the use of TikTok (active search, use of proposed contents) and perceived influences of this SM on eating attitudes and self-esteem were assessed. Groups of patients with different perceived SM-induced effects were compared to determine the frequency of their interaction with 3 specific contents (diet, Pro-Anorexia Nervosa (pro-Ana) and pro-ED recovery).

RESULTS

Seventy-eight patients (93.6% females, mean age 14.5 ± 2.1 years) were enrolled in the study. For 62.8%, TikTok represented the main SM, used for 1.4 ± 1.0 h/day, with diet (21.8%) as the most frequently used topic category. Pro-Ana and pro-ED recovery contents ("#foryou" and "#edrecovery" as the most frequent, respectively) were both actively searched by patients and proposed by the SM in a significant number of cases. For 59.0%, using TikTok reduced self-esteem, while 26.9% reported TikTok-related significant changes in their daily lives, and 3.8% reported experiences of body-shaming. Patients describing a negative effect of TikTok on their self-esteem more frequently searched and browsed "diet" (p = 0.007) and pro-ED recovery (p = 0.007) contents. Positive qualitative feedback on the SM was also reported.

CONCLUSIONS

This study documents the use of the SM TikTok among children and adolescents with ED. Individuals with a perceived negative effect of this SM on their self-esteem may show greater interaction with specific content. Further studies are needed to investigate the psychopathological factors influencing the relationship between ED and the use of SM.

Assessment of vitamin D among male adolescents and young adults hospitalized with eating disorders

PURPOSE

Medical complications of eating disorders in males are understudied compared to females, as is the case of vitamin D deficiency. The aim of this study was to assess vitamin D levels among male and female adolescents and young adults hospitalized for medical complications of eating disorders.

METHODS

We retrospectively reviewed electronic medical records of patients aged 9-25 years (N = 565) admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Serum vitamin D (25-hydroxy) level was assessed at admission as was history of prior calcium, vitamin D, or multivitamin supplementation. Linear regression was used to assess factors associated with vitamin D levels.

RESULTS

A total of 93 males and 472 females met eligibility criteria (age 15.5 ± 2.8, 58.8% anorexia nervosa; admission body mass index 17.6 ± 2.91). Among male participants, 44.1% had 25-hydroxyvitamin D levels < 30 ng/mL, 18.3% had 25-hydroxyvitamin D levels < 20 ng/mL, and 8.6% had 25-hydroxyvitamin D levels < 12 ng/mL. There were no significant differences in 25-hydroxyvitamin D levels in males compared to females, except that a lower proportion (1.9%) of female participants had 25-hydroxyvitamin D levels < 12 ng/mL (p = 0.001). Only 3.2% of males reported calcium or vitamin D-specific supplementation prior to hospital admission, while 8.6% reported taking multivitamins. White race, prior calcium/vitamin D supplementation, and higher calcium levels were associated with higher vitamin D levels on admission.

CONCLUSIONS

Nearly half of patients admitted to the hospital for malnutrition secondary to eating disorders presented with low 25-hydroxyvitamin D levels; males were more likely than females to have severe vitamin D deficiency. These findings support vitamin D assessment as part of the routine medical/nutritional evaluation for hospitalized eating disorder patients, with particular attention on male populations.

Increased risk of somatic diseases following anorexia nervosa in a controlled nationwide cohort study

OBJECTIVE

To assess the risk of somatic diseases in connection with anorexia nervosa (AN).

METHOD

This matched cohort study was based on Danish registries of all patients born 1961-2008 with a first-time diagnosis of AN in 1994-2018 at age 8-32 and matched controls without an eating disorder. For 13 somatic disease categories, time from inclusion date to time of first somatic diagnosis, accounting for censoring, was studied by use of time-stratified Cox models.

RESULTS

A total of 9985 AN patients born 1961-2008 and 49,351 controls were followed for a median (interquartile range) of 9.0 (4.4-15.7) years. During the first 2 years after entry there was a 60% higher hazard for any somatic disease among patients with AN than among controls, while the ratio from three to 11 years was reduced to 1.18. Regardless of age at diagnosis, the hazard among patients and controls were no different at approximately a decade after diagnosis of AN and the cumulative risk for patients for 12 of 13 disease categories was always higher or no less that for controls. For all disease categories, the hazard ratio (HR) was higher when close to entry. For most disease categories, age at diagnosis of AN did not modify the effect.

DISCUSSION

While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls. Large HRs were seen in the early years after diagnosis during which patients require extensive medical interventions.

PUBLIC SIGNIFICANCE

Based on Danish registries, a large sample of almost 10,000 patients with AN born 1961-2008 and almost 50,000 matched controls were followed for a median of 9 years. While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls.

Comparison of a low carbohydrate intake and standard carbohydrate intake on refeeding hypophosphatemia in children and adolescents with anorexia nervosa: a pilot randomised controlled trial

BACKGROUND

Nutritional rehabilitation for patients with anorexia nervosa involves balancing the need for weight gain whilst mitigating the risk of refeeding syndrome. Graded caloric increases and restriction of calories from carbohydrate have been used to minimise the risk of developing refeeding hypophosphatemia. There is little evidence to support the recommended nutrient composition, specifically the recommended carbohydrate intake that is safe in this population. The aim of this pilot study was to compare the effect of a low and a standard carbohydrate feeding protocol on serum phosphate levels in children and adolescents with anorexia nervosa.

METHODS

A pilot study of 23 children and adolescents with anorexia nervosa admitted for medical stabilisation to the adolescent ward of a tertiary hospital was undertaken. Participants were commenced on an oral feeding protocol and were randomly allocated to isocaloric meal plans that were either low carbohydrate (< 40% total energy from carbohydrate) or standard carbohydrate (50-60% total energy from carbohydrate). Serum phosphate levels were monitored daily across the first week and twice weekly thereafter. Clinical status, including weight gain, was monitored throughout admission.

RESULTS

52% (n = 12) of participants were allocated to the low carbohydrate group and 48% (n = 11) were allocated to the standard carbohydrate group. No patients in either of the diet groups developed refeeding hypophosphatemia in the first seven days of admission. Weight gain during the first week was significantly higher in the standard carbohydrate diet (1.4 kg/wk ± 0.5) compared to the low carbohydrate diet (0.6 kg/wk ± 0.9), p value 0.03. Participants from both diet groups were largely orally fed with less than 10% of the total number of meals and/or snacks across both groups provided as nutrition supplement drinks, either orally or enterally.

CONCLUSION

This pilot study supports that a standard carbohydrate intake (providing 50-60% of total energy from carbohydrate) optimises nutritional rehabilitation without increasing the risk of refeeding hypophosphatemia in adolescent inpatients with anorexia nervosa. CTN: ACTRN12621000300875. Plain English Summary: People with eating disorders who are underweight or malnourished, such as patients with anorexia nervosa, are at risk of refeeding syndrome when they receive treatment and return to regular eating. Refeeding syndrome may cause fluid and electrolyte shifts. This can occur as a result of the reintroduction of carbohydrates, and can have potentially life-threatening consequences if not managed appropriately. Refeeding hypophosphatemia is one of the early markers of refeeding syndrome. This study compared patients who were provided a low carbohydrate diet (40% total energy from carbohydrate) to those who were provided a standard carbohydrate diet (50-60% total energy from carbohydrate) to see if patients from either group were more at risk of developing refeeding syndrome. No patients in either of the diet groups developed refeeding hypophosphatemia. This pilot study may help to ensure that when patients get treated for their eating disorder in hospital, they can return to a normal diet as soon as possible with close medical monitoring.

To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

What role can accredited exercise physiologists play in the treatment of eating disorders? A descriptive study

Including exercise alongside other therapeutic approaches may help to address dysfunctional exercise use and improve eating disorder treatment outcomes. However, traditional treatment teams often lack the expertise needed to safely prescribe exercise. The aims of this study were to explore the perceptions and experiences of Accredited Exercise Physiologists (AEPs) relating to working with clients diagnosed with eating disorders to identify the role they play in the treatment of eating disorders and identify future training needs. Individual semi-structured telephone interviews were conducted with 12 (n = 9 females) AEPs working in the eating disorders field. Thematic analysis was conducted to extract major themes from the interview transcripts. Five major themes were identified: (1) The role of AEPs in the treatment of individuals with eating disorders is comprehensive; (2) Treatment is more effective when all components are addressed; (3) The absence of therapeutic exercise within standard treatment protocols reflects limitations of traditional scope of practice and knowledge about the role of AEPs; (4) Methods of acquiring further knowledge are insufficient for those in current practice; and (5) Accredited comprehensive training is currently unavailable but needed. This qualitative study showed that AEPs believe they can play a major role in the treatment of eating disorders and that treatment outcomes for individuals are likely to be greatly enhanced when dysfunctional exercise is addressed. Multidisciplinary training is needed.

Timing of Psychopharmacological and Nutritional Interventions in the Inpatient Treatment of Anorexia Nervosa: An Observational Study

This study aims to investigate possible different outcomes in the inpatient treatment of anorexia nervosa (AN) related to different timings of psychopharmacological and nutritional interventions. A retrospective observational study was conducted, involving young patients hospitalized for AN, treated with naso-gastric tube feeding (NGT). Participants were divided into five groups according to early (0–7 days) or late (8+ days) introduction of atypical antipsychotics (AAP) and NGT: early AAP-early NGT (EE), early AAP-late NGT (EL), late AAP-early NGT (LE), late AAP-late NGT (LL) and a control group treated with NGT only (NGT). Concurrent clinical and treatment variables were analyzed. AN psychopathology was measured with the Eating Disorder Inventory-3 (EDI-3) EDRC score. Outcomes were assessed as admission-discharge body-mass index (BMI) improvement and length of hospital stay (LOS). Contributions of variables related to outcomes were assessed with multifactorial-analyses of variance (MANOVA). Seventy-nine patients were enrolled in the study. LOS was different among treatment groups (F (4, 75) = 5.993, p < 0.001), and EE patients showed lower LOS than LE (p < 0.001) and LL (p = 0.025) patients. BMI improvement was not significantly different among treatment groups but correlated negatively with age (F (1, 72) = 10.130, p = 0.002), and admission BMI (F (1, 72) = 14.681, p < 0.001). In conclusion, patients treated with early AAP and early NGT showed lower LOS than those treated with late AAP. Prognostic treatment variables should be investigated in wider samples.

A qualitative study on the multi-level process of resilience development for adults recovering from eating disorders

BACKGROUND

Resilience research to date has been criticised for its consideration of resilience as a personal trait instead of a process, and for identifying individual factors related to resilience with no consideration of the ecological context. The overall aim of the current study was to explore the multi-level process through which adults recovering from EDs develop resilience, from the perspectives of clients and clinicians. The objective of this research was to outline the stages involved in the process of developing resilience, which might help to inform families and services in how best to support adults with EDs during their recovery.

METHOD

Thirty participants (15 clients; 15 clinicians) took part in semi-structured interviews, and responded to questions relating to factors associated with resilience. Using an inductive approach, data were analysed using reflexive thematic analysis.

RESULTS

The overarching theme which described the process of developing resilience was 'Bouncing back to being me', which involved three stages: 'Who am I without my ED?', 'My eating disorder does not define me', and 'I no longer need my eating disorder'. Twenty sub-themes were identified as being involved in this resilience process, thirteen of which required multi-level involvement.

CONCLUSION

This qualitative study provided a multi-level resilience framework for adults recovering from eating disorders, that is based on the experiences of adults with eating disorders and their treating clinicians. This framework provided empirical evidence that resilience is an ecological process involving an interaction between internal and external factors occurring between adults with eating disorder and their most immediate environments (i.e. family and social). Anorexia nervosa, bulimia nervosa and binge-eating disorder demonstrate high rates of symptom persistence across time and poor prognosis for a significant proportion of individuals affected by these disorders, including health complications and increased risk of mortality. Many researchers have attempted to explore how to improve recovery outcomes for this population. Eating disorder experts have emphasised the need to focus not only on the weight indicators and eating behaviours that sustain the eating disorder during recovery, but also on the psychological well-being of the person recovering. One way to achieve this is to focus on resilience, which was identified as a fundamental aspect of eating disorder recovery in previous research. This study conceptualises resilience as a dynamic process that is influenced not only at a personal level but also through the environment in which the person lives. This study gathered data from adults with eating disorders and their treating clinicians, to devise a framework for resilience development for adults recovering from eating disorders. The paper discussed ways in which these findings and the framework identified can be easily implemented in clinical practice to facilitate a better understanding of eating disorder resilience and to enhance recovery outcomes.

Health in adulthood after severe anorexia nervosa in adolescence: a study of exposed and unexposed women

OBJECTIVE

To compare the global health status, frequency of somatic and psychological problems, and alcohol use in adulthood among women hospitalized in adolescence for severe anorexia nervosa (AN), with a matched control sample from the general population.

METHOD

Women (n = 86) who had been hospitalized for AN 9.31 ± 1.82 years previously were compared with 258 controls matched for gender, age, and socio-professional category. Data were retrieved from a French survey on health and social insurance coverage, and was mainly collected by self-report, except for the assessment of current eating disorders for those previously hospitalized for AN (assessed with the MINI).

RESULTS

The women who had been hospitalized for AN reported significantly poorer current health status compared to controls (OR 2.9, 95% CI 1.5-5.79). According to the MINI, 13 women previously hospitalized with severe AN still presented an eating disorder (ED). Women with past AN reported more frequent acute throat infections (OR 4.9, 95% CI 1.81-13.51), gastralgia (OR 3.6, 95% CI 1.9-6.83), gastro-oesophageal reflux (OR 5.279, 95%CI 2.11-13.22), excess blood cholesterol or triglyceride levels (OR 2.55, 95% CI 1.03-6.33), anxiety (OR 8.7, 95% CI 3.48-21.8) and depression (OR 5.02 (2.8-9.01). These differences remained significant and of the same order of magnitude in sensitivity analyses among subjects with previous AN but without current ED, except for perceived health status and excess cholesterol and triglyceride levels.

DISCUSSION

Women who had been hospitalized for severe AN reported more symptoms 10 years after treatment, implies psychological and somatic follow-up in the long term.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Autonomic Nervous System Response to Psychosocial Stress in Anorexia Nervosa: A Cross-Sectional and Controlled Study

To foster understanding in the psychopathology of patients with anorexia nervosa (P_AN) at the psychological and physiological level, standardized experimental studies on reliable biomarkers are needed, especially due to the lack of disorder-specific samples. To this end, the autonomic nervous system (ANS) response to a psychosocial stressor was investigated in n = 19 P_AN (BMI: 18.7 ± 3.3 kg/m²), age, and gender-matched to n = 19 healthy controls (HC; BMI: 24.23 ± 3.0 kg/m²). For this purpose, heart rate (HR) and heart rate variability (HRV) parameters were assessed in a cross-sectional study design under two experimental conditions: (1) rest and (2) stress (Trier Social Stress Test). In addition, psychological indicators of stress were assessed. An 2 × 2 × 8 ANOVA demonstrated similar HR and HRV patterns (except LF-HRV) between P_AN and HC at rest. Under stress, P_AN (vs. HC) demonstrated a blunted HR [condition^*time^*group: F_{(2.91, 104.98)} = 9.326, p = 0.000, η² = 0.206] and an attenuated HRV response (reduced SNS/PNS reactivity). Significant effects of stress appraisal (SA) and BMI on HRV-reactivity were revealed. SA on SDNN = Condition^*time^*SA = F_{(4.12, 140.15)} = 2.676, p = 0.033, η² = 0.073. BMI on LF/HF-Ratio = Condition^*time^*BMI = F_{(3.53, 60.16)} = 3.339, p = 0.019, η² = 0.164. Psychological indices suggested higher levels of chronic and appraised stress in P_AN relative to HC. Additional analyses demonstrated that ED-symptoms are highly correlated with the latter constructs, as well as with psychological burden, but not with weight. Further, it was shown that abnormalities in reactivity persisted despite normalized ANS activity. Overall, we suggested that besides weight recovery, improvement in stress appraisal could be beneficial for cardiac health. In this light, a combination of therapy (e.g., development and activation of coping skills, cognitive reappraisal) and biofeedback training may improve treatment outcomes and regulate stress reactivity.

Factors related to length of stay, referral on discharge and hospital readmission for children and adolescents with anorexia nervosa

OBJECTIVE

This study examined factors related to hospital length of stay (LOS), reported referral on discharge, and hospital readmission, for children and adolescents (C&A) admitted to public hospitals for anorexia nervosa (AN), in a large health jurisdiction in Australia.

METHOD

Sociodemographic, illness, treatment, and hospital factors associated with LOS, reported referral to post-hospital treatment, and readmission within 28 days were analyzed for C&A with AN admitted to all New South Wales public hospitals in 2017, using median, multinomial logit and logit models. The sample comprised 289 admissions by 200 C&A aged 9-18 years with a primary or secondary diagnosis of AN.

RESULTS

AN as a primary diagnosis and the presence of some physical and mental co-occurring conditions (e.g., malnutrition and obsessive-compulsive disorders) conferred a longer LOS. The majority of admissions were recorded being referred to primary care physicians (59.86%) and relatively small numbers to outpatient mental health services (5.54%) or outpatient eating disorder services (8.30%), with age, area socioeconomic status, and illness factors related to referral type. Male, low socioeconomic status, the presence of some co-occurring illnesses (e.g., adjustment disorder and viral infection), and rural or remote locations increased the likelihood of readmission.

DISCUSSION

The findings have implications for service design, in particular the pathway to care from hospital into community for AN. Targeted interventions should consider recognizing and treating physical co-occurring illnesses at presentation to the health system, ensuring appropriate referral to community services, and providing services in socioeconomically disadvantaged and rural or remote areas.

Self-reported eating disorders and sleep disturbances in young adults: a prospective cohort study

PURPOSE

To evaluate the prospective association between eating disorders, disordered eating behaviors, and sleep disturbances in young adults.

METHODS

We used prospective cohort data of young adults aged 18-26 from the National Longitudinal Study of Adolescent to Adult Health (N = 12,082). Self-reported exposures of interest (at 18-26 years) included (1) an eating disorder diagnosis proxy; disordered eating behaviors such as (2) restrictive eating behaviors including fasting/skipping meals, (3) compensatory behaviors including vomiting, laxatives/diuretics, or weight loss pills; and (4) loss of control/overeating. Self-reported sleep disturbances at 7-year follow-up included trouble falling or staying asleep.

RESULTS

In negative binomial regression models, all four exposures predicted both sleep disturbance outcomes at 7-year follow-up, when adjusting for demographic covariates and baseline sleep disturbances. When additionally adjusting for baseline depressive symptoms, the associations between eating disorder diagnosis proxies and trouble falling (incidence rate ratio [IRR] 1.24; 95% CI 1.05-1.46) and staying (IRR 1.16; 95% CI 1.01-1.35) asleep remained statistically significant; however, the associations between eating behaviors and sleep disturbances were attenuated.

CONCLUSIONS

Eating disorders in young adulthood predict sleep disturbances at 7-year follow-up. Young adults with eating disorders or who engage in disordered eating behaviors may be assessed for sleep disturbances.

LEVEL III

Evidence obtained from well-designed cohort or case-control analytic studies.

Identification and Management of Eating Disorders in Children and Adolescents

Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.

Practitioners' perspectives on ethical issues within the treatment of eating disorders: Results from a concept mapping study

OBJECTIVE

Treating patients with eating disorders (EDs) is associated with an array of ethical concerns, including balancing patients' health and autonomy, access to care, and use of harm-reduction versus recovery-oriented treatment models. The primary aim of the current study is to gain a better understanding of ethical issues faced by ED practitioners by using a concept mapping, or Q-sort, approach.

METHOD

A total of 12 practitioners completed the brainstorming phase and generated statements regarding ethical issues they faced while treating patients with EDs. A subsequent 38 practitioners completed a sorting task, where they created and labeled piles, into which they grouped each statement. Of those 38 participants, 30 rated both the frequency with which they encountered each ethical issue and its impact on patient care.

RESULTS

A total of six clusters emerged: Insufficient Level of Care, Lack of Evidence-Based Practice, Insurance Barriers, Family Involvement, Patient Autonomy, and Limited Access to Expertise. Lack of Evidence-Based Practice, Insurance Barriers, and Insufficient Level of Care was the most frequent problem faced by ED practitioners, whereas Insurance Barriers and Patient Autonomy had the greatest impact.

DISCUSSION

Findings outline frequent and impactful areas of ethical concern that arise when treating patients diagnosed with EDs. Practitioners most commonly reported that patient- and insurance-driven factors limited patient access to appropriate care. Regulations supporting the provision of evidence-based care should be emphasized in public health policy and advocacy efforts, given their impact in limiting the delivery of adequate patient care.

Treatment of Eating Disorders in Adults Versus Adolescents: Similarities and Differences

FINDINGS

Although several individual psychotherapies for adults with eating disorders are empirically supported, with family-based treatment (FBT) being the leading recommended empiric treatment in adolescents, patients with eating disorders are still difficult to treat, and outcomes are often poor. In some countries, the clinical services for adolescents and adults are separate, and it is common for patients to receive treatments that differ in terms of both theory and content when they are switched from adolescent to adult services. Changes in the nature of treatment also often occur when patients move from less intensive types of care to more intensive treatment, and vice versa. These transitions may create a discontinuity in the care pathway and disorient patients and their significant others about the strategies and procedures used for addressing eating problems. However, the observation that younger and older patients essentially share the same eating-disorder psychopathology has led to evidence-based enhanced cognitive-behavioral therapy (CBT-E) being adapted for use in adolescents. Originally an evidence-based treatment for adults with eating disorders, CBT-E has yielded promising results in trials in cohorts of adolescent outpatients and inpatients, and is recommended as an alternative to FBT in adolescent patients.

IMPLICATIONS

With a unified treatment such as CBT-E, several issues that plague conventional eating-disorder services could be partially overcome, as patients can move seamlessly from adolescence to adulthood and through different levels of care, with no change in the nature of the treatment itself. Future randomized, controlled trials should compare FBT to CBT-E to better clarify the specific therapeutic needs of subgroups of adolescents and adult patients with eating disorders.

Implementing family based treatment in a child and youth eating disorder program: impact on admissions

OBJECTIVES

Anorexia Nervosa (AN) treatment is frequently associated with high costs often due to the use of hospitalization. In Family Based Treatment (FBT) a main goal is to manage recovery of AN in the home environment rather than relying on lengthy hospital admissions. This study examined whether the use of hospitalization altered following the introduction of FBT to a youth eating disorders program in 2009.

METHOD

This study compared retrospective data of 71 female adolescent patients diagnosed with AN: 10 who received treatment as usual prior to the implementation of FBT; 10 who were treated immediately after FBT implementation; and a further 51 adolescents who received FBT since 2009.

RESULTS

Results indicate that since the implementation of FBT there was a significant reduction in admissions to the medical ward and a significant reduction in cumulative length of stay on both the psychiatric and medical wards in adolescents presenting with AN.

Translating evidence-based treatment for digital health delivery: a protocol for family-based treatment for anorexia nervosa using telemedicine

BACKGROUND

Family-based treatment (FBT) is an efficacious outpatient intervention for young people diagnosed with Anorexia Nervosa (AN). To date, treatment to protocol has relied on standard face-to-face delivery. Face-to-face therapy is subject to geographic, temporal and human factors, rendering it particularly susceptible to inequities and disruption. This has resulted in poorer service provision for rural and regional families, and recently a significant challenge to providing face-to-face services during the COVID-19 global pandemic. The present study examines whether FBT for AN can be successfully translated to a digital delivery platform to address these access issues.

METHOD

Forty young people aged 12 to 18 years who meet DSM-5 diagnostic criteria for AN, and live in a rural or regional setting, will along with their family be recruited to the study. Trained therapists will provide 18 sessions of FBT over 9 months via telemedicine to the home of the young person and their family. The analysis will examine treatment effectiveness, feasibility, acceptability, and cost-effectiveness.

DISCUSSION

The study addresses the treatment needs of families not able to attend face-to-face clinical services for evidence-based treatment for eating disorders. This might be due to several barriers, including a lack of local services or long travel distances to services. There has been a recent and unprecedented demand for telemedicine to facilitate the continuity of care during COVID-19 despite geographical circumstances. If delivering treatment in this modality is clinically and economically effective and feasible, it will facilitate access to potentially lifesaving, evidence-based treatments for families formerly unable to access such care and provide evidence for the continuity of services when and where face-to-face treatment is not feasible.

Sounds unrealistic: an adolescent girl with anorexia nervosa consumes 19 L of fluid in a few hours: what happens to the physiology?

BACKGROUND

Adolescents with eating disorders (EDs) may present not only with abnormal eating behaviors but also with abnormal drinking behaviors varying widely. These behaviors include water loading to cheat on weight measurements, to feel full and suppress appetite and/or to induce vomiting; as well as restricting fluid intake in addition to food.

METHOD

We present a 16-year-old female adolescent with anorexia nervosa restrictive type and major depressive disorder who was hospitalized due to acute food refusal and developed generalized seizures due to dilutional hyponatremia in consequence of consuming excessive amount of water. Psychiatric diagnoses were made according to 'The Diagnostic and Statistical Manual of Mental Disorders' (5th ed.; DSM-5) criteria.

RESULTS

After starting nutritional rehabilitation with a low calorie meal plan to avoid refeeding syndrome, a weight gain of 2 kg was noted in the second day of hospitalization. At the bedside visit, she was observed in a disoriented manner and consecutively in seconds, lost consciousness with a generalized tonic-clonic seizure lasting 2 min. Her serum sodium level was measured as 116 mEq/L, which was normal at the time of admission. It was later learned that she secretly ingested 19 L of water in a short amount of time. She regained consciousness and no further seizures were observed after intravenous sodium deficit correction and fluid restriction therapy. Her serum sodium level was normalized (137 mEq/L) within 12 h.

CONCLUSION

A thorough clinical assessment of hydration and drinking behaviors as well as eating behaviors is essential for patients with EDs to avoid serious medical complications with high mortality and morbidity during follow-up. It is interesting that this amount of fluid consumption in such a short period of time did not present to the clinic with vomiting, gastric dilatation or bowel irrigation symptoms in a case with acute food refusal and restriction for a year, instead absorbed very quickly causing acute and severe symptomatic hyponatremia with generalized seizures.

Hospitalization following eating disorder diagnosis: The buffering effect of marriage and childbearing events

Eating Disorders (ED) are defined as abnormal eating behaviors, stemming from an obsession with food, body weight, or body shape. EDs affect 10 million men and 20 million women in the US, with an estimated 15% lifetime prevalence among women. An ED diagnosis is often accompanied with a host of adverse physical and mental health outcomes, including a heightened risk for suicidality. Given the complex comorbidities associated with EDs, treatment occurs in inpatient and outpatient settings. This study used linked administrative and health records from the Utah Population Database to create a cohort of women n = 4183 and men n = 423 who had a known diagnosis of ED between 1995 and 2015. Cox proportional hazard regression was used to model ED-related hospitalization trajectories, including subsequent risk for suicidality/self-injurious behavior-related hospitalization. To better estimate the risk profiles associated with different health care utilization patterns, models explored how family-related life course events (childbirth, marriage transitions) and sociodemographic characteristics (race, sex, and median income at census-block) modify hospitalization trajectories following initial diagnosis. Results suggested that increased outpatient treatment was associated with reduced risk of initial ED-related hospitalization, but higher risk for subsequent ED-related hospital readmission. In addition, transition to marriage (i.e., getting married) was associated with reduced risk of ED-related and suicidality/self-injurious behavior-related hospitalizations (initial hospitalization and subsequent readmission). Increased number of children was only associated with reduced risk of initial ED-hospitalization, but not readmission. When assessing individuals' risk for ED-related hospitalizations, social and health services researchers should contextualize treatment trajectories within the individual's life experiences, particularly marital transitions, while simultaneously considering sociodemographic characteristics and utilization of outpatient care. Future research should further examine whether marriage represents an important turning point in the health trajectories of individuals with EDs.

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Childbearing reduces risk of initial eating disorder hospitalization.

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Marriage reduces risk of eating disorder hospitalization and readmission.

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Marriage reduces risk of suicidality hospitalization for persons with prior eating disorder.

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Higher outpatient treatment reduces risk of initial eating disorder hospitalization.

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Higher outpatient treatment increases risk of eating disorder hospital readmission.

Effectiveness of intensive cognitive behavioral therapy in adolescents and adults with anorexia nervosa

OBJECTIVE

This study aimed to compare the effectiveness of an intensive treatment based on enhanced cognitive behavioral therapy (CBT-E) in adolescent and adult patients with anorexia nervosa.

METHODS

A total of 150 consecutive patients (74 adolescents and 81 adults) were admitted to a 20-week intensive CBT-E program (13 weeks of inpatient followed by 7 weeks of day-hospital treatment). All patients had responded poorly to previous outpatient treatments and were assessed at admission, end of treatment (EOT), and 20- and 60-week follow-ups.

RESULTS

About 70% of eligible patients began the program, and more than 85% completed it. Body mass index (BMI) in adults and BMI-for-age percentile in adolescents improved significantly from baseline to EOT, remained stable until 20-week follow-up, and slightly decreased from 20-week follow-up to 60-week follow-up, while remaining in the lower normal range. Eating disorder psychopathology, general psychopathology, and clinical impairment scores decreased significantly at EOT and showed only a slight increase from EOT to follow-ups. No difference was found between adolescent and adult patients in treatment acceptance, dropout, or any outcome measure.

DISCUSSION

These findings indicate that intensive CBT-E seems to be an effective treatment for severely ill adolescent and adult patients with anorexia nervosa.

Help-Seeking for Eating Pathology Among Collegiate Athletes: Examining Stigma and Perfectionism as Moderating and Mediating Mechanisms

Despite elevated risk of eating pathology (EP) among athletes, utilization of EP-treatment among athletes is low. Factors that may inhibit EP-help-seeking among athletes include perceived social stigma, self-stigma, and perfectionism. Heightened stigma associated with EP and sport climates may be exacerbated by negative perfectionism characteristic of athletes and decrease intentions to seek help for EP. We tested the following moderated-mediation model among a sample of collegiate athletes (N = 201) via online questionnaires: EP indirectly relates to EP help-seeking intentions through perceived and self-stigma and these relations are conditional on negative perfectionism. EP help-seeking intentions were negatively associated with EP severity, stigma, and negative perfectionism. EP was related to eating-specific help-seeking intentions through perceived social stigma, influencing self-stigma, but this was not moderated by negative perfectionism. Targeting mental-health treatment stigma among athletes may reduce risk of untreated EP among collegiate athletes.

Effects associated with the use of healthcare for eating disorders by women in the community: a longitudinal cohort study

OBJECTIVES

This study examined formal and informal healthcare use (HCU) in community women with disordered eating, and associations of HCU with mental health-related quality of life (MHRQoL), psychological distress, mental health literacy (MHL) and eating disorder (ED) symptoms over time.

HYPOTHESIS

We hypothesised that HCU would lead to improvement in ED symptom severity, MHRQoL, MHL and psychological distress.

DESIGN, SETTING, PARTICIPANTS

Data were from years 2, 4 and 9 of a longitudinal cohort of 443 community women (mean age 30.6, SE 0.4 years) with a range of ED symptoms, randomly recruited from the Australian Capital Territory electoral role or via convenience sampling from tertiary education centres. Data were collected using posted/emailed self-report questionnaires; inclusion criteria were completion of the HCU questionnaire at time point of 2 years (baseline for this study). HCU was measured using a multiple-choice question on help seeking for an eating problem. To test the effect of HCU over time on MHRQoL (Short Form-12 score), psychological distress (Kessler Psychological Distress Scale score), ED symptom severity (Eating Disorder Examination Questionnaire score) and ED-MHL, linear or logistic mixed-effects regression analyses were used.

RESULTS

20% of participants sought ED-specific help at baseline; more than half of participants sought help that was not evidence based. HCU at baseline was significantly associated with improved MHRQoL and ED symptom severity and decreased psychological distress over time (Cohen's d all >0.3, ie, small). HCU was not significantly associated with MHL over time. The predictive ability of the fitted models ranged from 32.18% to 42.42% for psychological distress and MHL treatment, respectively.

CONCLUSIONS

Formal and informal HCU were associated with small improvements in ED symptoms, MHRQoL and psychological distress but not with improved MHL. Informal services in ED management should be investigated further along with efforts to improve ED-MHL.

Risk factors for a low weight gain in the early stage of adolescent anorexia nervosa inpatient treatment: findings from a pilot study

PURPOSE

Body weight restoration is a major treatment aim in juvenile inpatients with anorexia nervosa (AN) (i.e., 500-1000 g/week according to the German guidelines). Several studies suggest the early weight gain to be crucial for remission. The identification of patients at risk of a low early weight gain could enable an adequate adaptation of treatment. Thus, we aimed at detecting risk factors of a low weight gain during inpatient treatment.

METHODS

The presented work analyzes data from a pilot study in 30 female adolescent inpatients with AN (restricting subtype; age range at admission: 12.6-17.6 years). Premorbid characteristics, history of symptomatology, anthropometric data, and eating-disorder psychopathology were compared between those who gained at least an average of 500 g/week during the first 7 weeks of treatment (high weight gainers, HWG) and those who did not (low weight gainers, LWG).

RESULTS

At admission, LWG (n = 15) had a significantly higher BMI(-SDS) and scored significantly higher in the eating-disorder examination questionnaire (EDE-Q) than HWG (n = 15). A logistic regression analysis indicated both parameters to be independently associated with a low weight gain.

CONCLUSION

Higher EDE-Q scores seem to be a major risk factor for a low weight gain at the beginning of treatment. Moreover, a higher BMI(-SDS) at admission does not necessarily indicate a less severe AN symptomatic, as it was associated with a lower weight gain in our sample during the first 7 weeks of treatment. Reassessment of our results in larger studies is required to draw firm conclusions for clinical practice.

LEVEL OF EVIDENCE

Level V.

Challenges and opportunities for enhanced cognitive behaviour therapy (CBT-E) in light of COVID-19

In the past few weeks, coronavirus disease 2019 (COVID-19) has dramatically expanded across the world. To limit the spread of COVID-19 and its negative consequences, many countries have applied strict social distancing rules. In this dramatic situation, people with eating disorders are at risk of their disorder becoming more severe or relapsing. The risk comes from multiple sources including fears of infection and the effects of social isolation, as well as the limited availability of adequate psychological and psychiatric treatments. A potential practical solution to address some of these problems is to deliver enhanced cognitive behaviour therapy (CBT-E), an evidence-based treatment for all eating disorders, remotely. In this guidance we address three main topics. First, we suggest that CBT-E is suitable for remote delivery and we consider the challenges and advantages of delivering it in this way. Second, we discuss new problems that patients with eating disorders may face in this period. We also highlight potential opportunities for adapting some aspects of CBT-E to address them. Finally, we provide guidelines about how to adapt the various stages, strategies and procedures of CBT-E for teletherapy use in the particular circumstances of COVID-19.

Bone mineral density in Anorexia Nervosa versus Avoidant Restrictive Food Intake Disorder

BACKGROUND

Avoidant Restrictive Food Intake Disorder (ARFID) and Anorexia Nervosa (AN) cause significant underweight in children and young people (CYP). The association of low bone mineral density (BMD) and underweight CYP in AN is well established, but less is known about BMD in ARFID.

METHODS

Retrospective case-note review and analysis of BMD measures by DXA on underweight patients referred to a paediatric clinic for eating disorders between 2014 and 2019. Indications for BMD measurement were age > 5 years and underweight for at least 6 months.

RESULTS

Of 134 cases where BMD was measured, 118 (88%) had AN and 16 (12%) ARFID. Age range was 6-19 years. 19% were males. ARFID cases were more likely to be male, have lower Body Mass Index (BMI), BMI z-score (BMIz), and longer underweight duration. For all cases, BMI and BMIz were positively associated with BMD z-score (BMI: coefficient 0.13,95%CI 0.04 to 0.22, p = 0.01; BMIz: coefficient 0.34, 95%CI 0.17 to 0.51, p < 0.001) and bone mineral areal density z-score (BMI: coefficient 0.12, 95% CI 0.01 to 0.23, p = 0.04 and BMIz: coefficient 0.27, 95% CI 0.05 to 0.49, p = 0.02). However, there were no associations of BMD with diagnosis (ARFID vs AN). Paired t-testing of 13 age, sex and pubertally matched pairs from AN and ARFID cases also showed no difference in standardized BMD scores.

CONCLUSION

Low BMD in our sample of underweight AN and ARFID cases was associated with BMI but not diagnosis. BMD may be as important in ARFID as AN. Further research should examine mechanisms and potential interventions.

An Inhospitable World: Exploring a Model of Objectification Theory With Trans Women

In this study, we investigated key tenets of objectification theory, a prominent model of body image disturbance, as it relates to trans women's disordered eating and intention to obtain silicone injections-a specific health risk for this population. We also incorporated appearance congruence, or the degree to which an individual personally feels that their gender expression matches their gender identity, into the objectification theory model. Results of a structural equation model using data from a sample of 173 trans women from the United States indicated that the basic objectification theory model held among this sample and that appearance congruence was associated negatively with body surveillance. However, appearance congruence did not have significant direct or indirect links (via body surveillance and body shame) with disordered eating or intention to obtain silicone injections. Thus, disordered eating and intention to obtain silicone injections are potential negative outcomes of the process of objectification among trans women, and appearance congruence does not appear to be uniquely linked to health risks associated with internalization of cultural standards of attractiveness, body surveillance, and body shame. Our findings support the application of the tenets of objectification theory with trans women as they apply to disordered eating and intention to obtain silicone injections and also indicate the need to identify other positive influences on trans women's body image to counteract internalization of cultural standards of attractiveness.

Perspectives of professionals on the treatment and service delivery of eating disorders in cyprus

This paper investigates the perspectives of care professionals on the treament of eating disorders and the capacity of the existing settings in Cyprus, to treat eating disorders. Qualitative, semi-structured interviews were conducted with seven professionals, working in settings for treating patients with eating disorders. The investigation identified two themes: The first theme concerns the necessity to fulfill the complex needs of patients with eating disorders, as well as the needs of their families. In addition, it concerns the importance of adopting a holistic and multimodal approach towards treating eating disorders, in order to achieve successful treatment outcomes. The attitudes and feelings of care professionals working with patients with eating disorders, were also identified. The second theme that emerged is an acknowledgement of the necessity for a stronger collaboration between the existing settings, for coordinated monitoring of these settings, and for upgrading specialized training. These two themes are interrelated and create barriers, which may prevent effective service delivery, affect the attitudes of professionals, and hinder the process of treatment.

Effects of vitamin D and estrogen receptor polymorphisms on bone mineral density in adolescents with anorexia nervosa

Background Anorexia nervosa (AN) is a serious eating disorder that is associated with decreased bone mineral density (BMD) and greater lifetime risk for fractures. The aim of this study was to determine the correlation between BMD and genetic polymorphisms in AN. Methods This case-control study analyzed vitamin D receptor (VDR) (VDRBsml, VDRFokl) and estrogen receptor (ESR) (ESR1Xbal, ESR1Pvull) polymorphisms in 45 adolescents diagnosed with AN and 46 age-matched healthy controls. BMD values of the AN group were classified as low or normal, and polymorphisms were compared between cases and controls. The effects of body mass index (BMI), duration of disease and amenorrhea on BMD were also evaluated. Results In girls with AN, a positive effect of the bb genotype of VDRBsmI polymorphism on femur Z-scores (p = 0.103) and of the Ff genotype of VDRFokI polymorphism on vertebra Z-scores (p = 0.097) was observed. In boys with AN, a positive effect of the Ff genotype of VDRFokI polymorphism on vertebra BMD (g/cm2) was detected (p = 0.061). No association was detected between ESR polymorphisms. An inverse relationship was observed between BMD and duration of illness and amenorrhea. A direct relationship was detected between BMD and BMI. Conclusions Specific VDR gene polymorphism genotypes may have positive effects on BMD in patients with AN. Additionally, the lack of association between ESR gene polymorphisms on BMD could be attributed to the low estrogen status of the patient.

Linking body esteem to eating disorders among adolescents: A moderated mediation model

This study explored the roles of social appearance anxiety and emotional intelligence in the relationship between body esteem and eating-disorder risk among adolescents. A total of 2509 high-school students were sampled to participate in the study. Statistical methods mainly involved descriptive statistics, Bootstrapping, and structural equation modeling analyses. The results showed that social appearance anxiety partially mediated the relationship between body esteem and eating-disorder risk among adolescents; meanwhile, emotional intelligence moderated the effects of body esteem on social appearance anxiety and eating-disorder risk among adolescents.