Characteristics of seeking treatment among U.S. adolescents with eating disorders

Assessing Obstetrics and Gynecology (OBGYN) Clinicians' Knowledge, Practice, and Attitudes toward Anorexia Nervosa, Atypical Anorexia Nervosa, and Amenorrhea

STUDY OBJECTIVE

Anorexia nervosa (AN) and atypical anorexia nervosa (AAN) are eating disorders (EDs) characterized by extreme restriction of energy intake. However, in contrast to individuals with AN, those with AAN are not underweight. Although individuals with either AN or AAN can experience associated functional hypothalamic amenorrhea (FHA) that may prompt them to seek gynecologic care, little is known about obstetricians' and gynecologists' (OBGYNs') knowledge and approach to these patients; this study sought to fill this gap.

METHODS

A total of 119 OBGYNs read vignettes describing an underweight patient with AN and a normal-weight patient with AAN presenting with FHA. The OBGYNs then responded to items assessing their approaches, knowledge, and attitudes toward patients with amenorrhea and EDs more broadly.

RESULTS

The participants ranked FHA as significantly more likely in the underweight vignette than in the normal-weight vignette. The participants reported that they more frequently ask about weight, eating, exercise, and body image in underweight patients with amenorrhea relative to patients who are normal weight or overweight. Overall, the participants demonstrated low knowledge of AN and AAN and reported less familiarity with AAN.

CONCLUSION

OBGYNs may be less likely to identify FHA and assess for an ED in non-underweight patients with secondary amenorrhea. Therefore, patients with AAN having complications of malnutrition may be less likely to be properly evaluated and treated. Future research should investigate educational interventions that aim to improve OBGYN assessment and management of patients of varying weights who have EDs .

Open Pilot Trial of a Coached Digital Program for Lower-Income Adults With Eating Disorders

OBJECTIVE

This study evaluated the feasibility, acceptability, and preliminary effectiveness of the first digital intervention tailored for lower-income adults with eating disorders, who are poorly served by the public health care system.

METHOD

Adults (N = 30) with public insurance or without insurance coverage who endorsed ≥ 6 binge eating episodes, ≥ 6 vomiting episodes, and/or ≥ 6 laxative/diuretic episodes in the past three months with a body mass index ≥ 18.5 kg/m2 were enrolled in this open pilot trial. Participants received access to the coached digital CBT-based intervention, which included individualized guidance and twice-weekly SMS feedback from a program coach over three months.

RESULTS

Almost all participants (93.3%, n = 28) accessed the program after enrollment, completing about half (M = 4.15, SD = 2.68) of the 8 sessions and sending an average of 32.5 (SD = 35.2) texts to their coach over three months. From pre- to post-intervention, there were large improvements in eating disorder psychopathology (d = 0.79, p < 0.001) and moderate decreases in binge eating (d = 0.62, p = 0.003) and self-induced vomiting episodes (d = 0.43, p = 0.031). There were also large improvements in clinical impairment (d = 0.83, p < 0.001) and moderate to large reductions in anxiety (d = 0.47, p = 0.019) and depression (d = 0.84, p < 0.001). Most participants indicated that they were somewhat to very satisfied with the program (67.9%, n = 19).

DISCUSSION

The results from this pilot trial testing a brief online guided self-help intervention are promising, with relatively high treatment engagement, indicating good feasibility and acceptability and signals of preliminary effectiveness. Future research is needed to examine longer-term effectiveness relative to other active treatments or waitlist control.

Adaptations of an online cognitive-behavioral therapy intervention for binge type eating disorders in publicly-insured and uninsured adults: a pilot study

BACKGROUND

Publicly-insured and uninsured individuals-many of whom are marginalized because of race/ethnicity, ability status, and/or other social identities-experience barriers to accessing evidence-based interventions (EBIs) for eating disorders (EDs). Additionally, EBIs have not been developed with or for diverse populations, exacerbating poor treatment uptake. Mobile technology is well-positioned to bridge this gap and increase access to low-cost, culturally-sensitive EBIs.

METHODS

This study leverages a user-centered design approach to adapt an existing coached cognitive-behavioral therapy-based digital program and evaluate its usability in a sample of 11 participants with (sub)clinical binge type EDs who are publicly-insured (n = 10) or uninsured (n = 1). Participants were primarily non-Latinx White women (n = 8). Two semi-structured interviews occurred with participants: one to assess treatment needs and the other to obtain program-specific feedback. Interviews were coded using inductive thematic analysis.

RESULTS

Interview 1 feedback converged on three themes: Recovery Journey, Treatment Experiences, and Engagement with and Expectations for Online Programs. Participants endorsed facing barriers to healthcare, such as poor insurance coverage and a lack of trained providers, and interest in a coach to increase treatment accountability. Interview 2 feedback converged on three themes: Content Development, Participant Experiences with Mental Health, and Real-World Use. Participants liked the content but emphasized the need to improve diverse representation (e.g., gender, body size).

CONCLUSIONS

Overall, user feedback is critical to informing adaptations to the original EBI so that the intervention can be appropriately tailored to the needs of this underserved population, which ultimately has high potential to address critical barriers to ED treatment.

TRIAL REGISTRATION

This study was reviewed and approved by the Institutional Review Board (IRB) at the University California, San Francisco (IRB #22-35936) and the IRB at Washington University in St. Louis (IRB ID 202304167).

A call for strategy on eating disorders: the need for a comprehensive eating disorder strategy in England and specific guidance for the remote delivery of eating disorder services

There are growing calls for a comprehensive, evidence-based national eating disorder (ED) strategy for England. This is due to the rising prevalence of EDs, the lack of national guidance around different ED presentations (and potentially varying treatment needs), ad hoc data collection, and inconsistencies in both care and evaluation of service provision quality. Furthermore, the shift towards remote delivery of care during the COVID-19 pandemic underscores the need for government strategy to include specific guidance on remote delivery of ED services. The increased use of remote healthcare presents an opportunity to mitigate regional disparities in the provision of care. However, there are distinct challenges when delivering ED services remotely. In this position paper, we firstly highlight the growing need for a comprehensive national ED strategy to combat the rising prevalence and harm of EDs. Secondly, we specify the importance of ensuring that future governmental strategy incorporates evidence-based guidelines specific to remote delivery of ED services. This is crucial for promoting consistent provision of ED care. We set out the lack of comprehensive national data, and the need for further research into remote service delivery.

The Need to Increase Help-Seeking for Eating Disorders in General and Binge-Eating Disorder Specifically: Commentary on Ali et al.'s (2024) Meta-Analysis

Ali et al.'s (2025) systematic review and meta-analysis updated a previous meta-analysis on the gap between the need for eating disorder treatment and rates of seeking and receiving eating disorder treatment. They found that less than one-third of individuals with eating disorders sought help for their eating disorder, which was an improvement of only 8% over more than a decade. This updated analysis makes it apparent that we need to dedicate research and resources to meeting this treatment need. Building on this work, this commentary reviews changes in help-seeking behaviors, particularly online help-seeking. The commentary also discusses binge-eating disorder (BED) help-seeking because the addition of BED as a diagnosis occurred in the time between the original and updated meta-analysis. Barriers to seeking eating disorder treatment, including identifying behaviors as indicative of an eating disorder and problematic, appear pronounced among individuals with BED. The commentary concludes by highlighting that it is essential to direct research and policy efforts along multiple pathways to close the gap between those who need and those who seek eating disorder treatment.

The Unmet Treatment Need for Eating Disorders: What Has Changed in More Than 10 Years? An Updated Systematic Review and Meta-Analysis

OBJECTIVE

A minority of individuals with eating disorders seek help from health professionals qualified to provide eating disorder care. This review assessed the proportion of individuals with eating disorders who had sought help or received treatment, as an update to an earlier review conducted more than a decade ago.

METHOD

Three databases were searched for studies that: (1) included a community sample of help-seekers and non-help seekers, (2) used a standardized eating disorder screening instrument, and (3) assessed the percentage of participants who had sought help specifically for eating disorder concerns.

RESULTS

Of 972 articles, 21 studies met inclusion criteria, representing 37,423 participants. The pooled proportion reporting help-seeking from any source (e.g., helpline, support groups, chat rooms as well as health professionals) was 30% and the pooled proportion reporting formal treatment seeking from health professionals (e.g., psychologist) specifically for eating disorder concerns was 32%. However, there was evidence of publication bias across studies.

DISCUSSION

These rates suggest little to no improvement in the unmet need for treatment since the last review with studies continuing to focus on white adult women. Help-seeking rates among other populations remain unclear and there is an urgent need to understand reasons for overall low help-seeking rates. Clear definitions and measures of help-seeking with appropriate distinctions between sources of help are needed to improve our understanding of help-seeking pathways and identify solutions to facilitate help-seeking. Better visibility of health professionals qualified to provide safe and effective eating disorder care could help reduce the substantial treatment gap.

Meaningful Associations Between Motivation for Treatment and Interpersonal Needs Within a Residential Sample of Women With Eating Disorders

OBJECTIVE

Perceived burdensomeness (PB) and thwarted belongingness (TB), two proximal risk factors for suicide, may rise during residential eating disorder (ED) treatment when patients are separated from support and face exorbitant costs of care. In this setting, fostering motivation for treatment is challenging, and low motivation for treatment may exacerbate feelings of PB and TB. Simultaneously, PB and TB could reduce motivation for treatment, though no studies have explored this relationship longitudinally. Accordingly, this study examined associations between interpersonal needs (TB, PB) and motivation for treatment across the first 6 weeks of residential ED treatment.

METHODS

Participants (n = 98) completed the Interpersonal Needs Questionnaire (INQ) and rated treatment motivation weekly. Pearson bivariate correlations examined the relationship between motivation and interpersonal needs at each timepoint. Two autoregressive cross-lagged panel models (AR-CLPMs) tested reciprocal relationships between these constructs longitudinally across the first 6 weeks of treatment.

RESULTS

Motivation was significantly negatively correlated with PB and TB at all timepoints. In AR-CLPM 1, Week 2 Motivation predicted Weeks 3 PB, then Week 3 PB predicted Week 4 Motivation. In AR-CLPM 2, Week 2 TB predicted Week 3 Motivation, but Motivation did not predict TB at any timepoint.

DISCUSSION

This study is the first to examine longitudinal relations between interpersonal needs and treatment motivation in residential ED care. PB and TB may influence one's motivation for treatment, although motivation and PB had a stronger reciprocal relationship than motivation and TB. Interpersonal needs should be addressed early in residential treatment to mitigate negative cycling.

Socioeconomic inequity in the utilization of healthcare among people with eating disorders in Australia

BACKGROUND

Little is known about socioeconomic equity in access to healthcare among people with eating disorders in Australia. This study aims to measure the extent of inequity in eating disorder-related healthcare utilization, analyze trends, and explore the sources of inequalities using New South Wales (NSW) administrative linked health data for 2005 to 2020.

METHODS

Socioeconomic inequities were measured using concentration index approach, and decomposition analysis was conducted to explain the factors accounting for inequality. Healthcare utilization included: public inpatient admissions, private inpatient admissions, visits to public mental health outpatient clinics and emergency department visits, with three different measures (probability of visit, total and conditional number of visits) for each outcome.

RESULTS

Private hospital admissions due to eating disorders were concentrated among individuals from higher socioeconomic status (SES) from 2005 to 2020. There was no significant inequity in the probability of public hospital admissions for the same period. Public outpatient visits were utilized more by people from lower SES from 2008 to 2020. Emergency department visits were equitable, but more utilized by those from lower SES in 2020.

CONCLUSIONS

Public hospital and emergency department services were equitably used by people with eating disorders in NSW, but individuals from high SES were more likely to be admitted to private hospitals for eating disorder care. Use of public hospital outpatient services was higher for those from lower SES. These findings can assist policymakers in understanding the equity of the healthcare system and developing programs to improve fairness in eating disorder-related healthcare in NSW.

Understanding stigma in the context of help-seeking for eating disorders

BACKGROUND

Stigma is a complex construct and its association with help-seeking among those experiencing eating disorders is not well understood. Rates of help-seeking are low for those with eating disorder symptoms and, therefore, determining the role of stigma and shame in this relationship is needed to help inform effective awareness campaigns aimed at improving prognostic outcomes. The current study examined the associations between perceived stigma, self-stigma, shame, and help-seeking behaviour in a community sample of individuals with elevated eating disorder symptoms.

METHODS

Participants completed an online survey that included measures of stigma and shame as perceived barriers to help-seeking for individuals with eating disorders. Those with elevated eating disorder symptoms and high clinical impairment were included in the study (N = 333).

RESULTS

Using binary logistic regression models controlling for age and gender, results showed that perceived stigma, self-stigma, and shame predicted 64% of help-seeking behaviour (p = .005). The only significant unique predictor of formal help-seeking was "Being concerned that other people believe eating disorders are not real illnesses". No other stigma or shame items were found to significantly predict help-seeking.

CONCLUSIONS

The present findings suggest that while stigma plays an important role in help-seeking, it might not be the primary reason preventing individuals with eating disorders from accessing care. The field is encouraged to investigate these factors to promote help-seeking effectively.

Suicidal thoughts and attempts in a transdiagnostic eating disorder sample: Do diagnostic severity criteria predict risk?

OBJECTIVE

Eating disorders (EDs) are associated with elevated suicide. Low body mass index (BMI) and frequency of purging and binge eating represent severity criteria for EDs and distinguish full-threshold EDs from other specified feeding and eating disorders (OSFED). However, no work has taken a transdiagnostic approach to studying whether severity of these or other features is associated with suicidal ideation (SI) and attempts.

METHOD

We examined diagnostic status, ED features, and SI and attempts in a large, transdiagnostic, community sample of 257 women with EDs and 45 controls without a current or past ED in the United States using the EDs Examination interview and the Structured Clinical Interview for the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders).

RESULTS

SI and suicide attempts (SA) were elevated in OSFED compared to controls but did not differ between OSFED and full-threshold EDs. Higher BMI predicted increased SI. Number of purging methods, but not frequency, was related to history of SA. Binge episode frequency and size were not significant predictors.

CONCLUSIONS

OSFED presents with elevated SI and SA, and ED severity criteria that distinguish OSFED from full-threshold EDs do not predict SI or SA. Suicide risk assessments should be implemented universally across EDs in clinical practice.

Barriers and facilitators of help-seeking for eating, weight, and shape concerns among college students

Objective: Prevalence of disordered eating among college students is concerning, but professional help-seeking rates are low. This study examined barriers and facilitators of help-seeking for eating, weight, and shape concerns in this population. Participants: A non-clinical sample of undergraduates (N = 134; 64.7% females; 63.9% White; 61.7% freshman) were recruited from a research pool. Methods: Participants reported on help-seeking barriers, facilitators, intentions, and behaviors, as well as disordered eating, anxiety, and depression. Results: Commonly endorsed facilitators of help-seeking for disordered eating included desire to get better and other mental health issues. Commonly endorsed barriers highlighted themes of self-reliance. Recent and lifetime help-seeking behaviors suggested preferences for informal sources of help. Greater disordered eating predicted more endorsed facilitators of help-seeking, whereas greater depression predicted more endorsed barriers. Conclusion: Findings-highlighting self-reliance and preferences for informal sources of help-can facilitate efforts to better serve students who may be experiencing disordered eating.

What Is the Relationship between Chronotype and Disordered Eating in Adolescents? The EHDLA Study

BACKGROUND

Evidence assessing the relationship between chronotype and disordered eating in adolescents is scarce. The current study tried to evaluate the association between chronotype and disordered eating in a sample of Spanish adolescents.

METHODS

This secondary cross-sectional study analyzed data from the Eating Healthy and Daily Life Activities (EHDLA) study. The sample consisted of 703 adolescents (56.3% girls) aged between 12 and 17 years from the Valle de Ricote (Region of Murcia, Spain). Chronotype was assessed using the Morningness/Eveningness Scale in Children (MESC). Disordered eating was evaluated by two psychologists using the Sick, Control, One, Fat, and Food (SCOFF) questionnaire.

RESULTS

Adolescents with an eveningness chronotype showed a higher SCOFF score (estimated marginal mean [M] = 1.1; 95% confidence interval [CI] 0.7 to 1.5) in comparison with adolescents with a morningness chronotype (M = 0.7; 95% CI 0.5 to 0.8) (p = 0.010), as well as with those with an intermediate chronotype (M = 0.6; 95% CI 0.5 to 0.8) (p = 0.032). A higher predictive probability of having disordered eating was identified in adolescents with an eveningness chronotype (39.5%; 95% CI 22.8% to 59.1%), compared to adolescents with an intermediate chronotype (14.9%; 95% CI 10.8% to 20.1%) (p = 0.008) and with their counterparts with a morningness chronotype (16.9%; 95% CI 11.6% to 24.0%) (p = 0.021).

CONCLUSIONS

This study reveals that adolescents with an eveningness chronotype are more likely to exhibit disordered eating behaviors compared to those with morningness or intermediate chronotypes. These findings highlight the importance of considering chronotype in adolescent health, particularly in developing targeted interventions to prevent eating disorders.

Characterizing psychopharmacological prescribing practices in a large cohort of adolescents with borderline personality disorder

BACKGROUND

Psychiatric medications are not efficacious for treating borderline personality disorder (BPD), yet many patients with BPD are prescribed multiple psychiatric medications. This study aimed to (1) characterize psychiatric medication prescribing practices in adolescents with BPD and (2) assess whether demographic features are associated with prescribing practices.

METHOD

This sample was N = 2950 pediatric patients with BPD (ages 10-19) across the U.S. Data came from the NeuroBlu database, which includes data from 30 U.S. healthcare systems and hundreds of hospitals. Poisson regressions and chi-squared tests determined whether gender, race, and ethnicity were associated with (1) number of unique psychiatric medications prescribed and (2) number of unique medication classes prescribed.

RESULTS

Roughly two-thirds (64.85%) of youth were prescribed any medications. Of these youth, 79.40% were prescribed ≥ 2 unique medications and 72.66% were prescribed ≥ 2 unique medications classes. The mean number of unique medications was 3.50 (SD = 2.50). The mean number of unique medication classes was 2.35 (SD = 1.15). The most commonly prescribed medication classes were antidepressants and antipsychotics, which were often prescribed in combination. Poisson regressions showed that boys were prescribed more unique medications (M = 3.67) than girls (M = 3.47). Non-Latinx youth were prescribed significantly more unique medications (M = 44.12) than Latinx youth (M = 3.60, p = .01).

CONCLUSIONS

Results characterize psychiatric medication prescribing practices in youth with BPD. Prescribing practices vary by demographics, such that boys and non-Latinx youth are prescribed more medications than girls and Latinx youth, respectively. These demographic differences suggest that prescribers may treat BPD differently based on patient demographic characteristics.

Clinical Intervention Strategies and Family Dynamics in Adolescent Eating Disorders: A Scoping Review for Enhancing Early Detection and Outcomes

Background: This systematic review investigated the impact of familial factors on individuals aged 10-17 who have clinical signs or symptoms of eating disorders. Simultaneously, it scrutinized the involvement of the family in therapy, as well as other forms of intervention. Methods: The PsycINFO, PubMed, and Scopus databases were used to search for research material comprehensively. After applying specific criteria, 46 articles were deemed suitable and included in the systematic review. The study comprised a cohort of 4794 adolescents who received a diagnosis of either Anorexia Nervosa (AN), Bulimia Nervosa (BN), or Binge-Eating Disorder (BED). In addition, controls were utilized for 1187 adolescents, 1563 parents, 1809 siblings, and 11 other relatives. Results: The connection between family factors and eating disorders is primarily determined by the families' level of functioning, satisfaction with the family dynamic, parents' attitudes toward their children, and the role of food within the family system. Family Therapy was the most used psychotherapeutic approach in the treatment of AN. The incidence of reports in BN closely paralleled that of Cognitive-Behavioral Therapy (CBT) models. Articles about (Enhanced) CBT were exclusively associated with BED. Conclusions: Family-based approaches are crucial in comprehending, preventing, and addressing eating disorders in adolescents. Incorporating the study of family dynamics and actively engaging families in the treatment process can significantly enhance recovery rates and decrease the occurrence of relapses.

Clinical Experiences Using Cognitive-Behavioral Therapy for Eating Disorders

Data suggests that despite the availability of evidence-based psychological treatments for eating disorders (EDs), techniques from these therapies may be less frequently used within real-life clinical practice. The aim of this study was to provide the opportunity for clinicians to give feedback on their experiences treating EDs using cognitive-behavioral therapy (CBT) through reporting on use of CBT techniques and barriers to treatment implementation in naturalistic settings. Clinicians (N = 126) who self-identified as using CBT for EDs reported demographic information, frequency/usefulness of empirically supported treatment techniques, problems/limitations of CBT, and barriers faced while implementing CBT. The most frequently used technique reported by clinicians was psychoeducation, and the least frequently used technique was use of surveys to address mind reading. Patients' unwillingness to follow a meal plan/nutritional guide was rated as the most impactful barrier, alongside ED severity. Of the problems/limitations of CBT, too little guidance on treating co-occurring symptoms was rated as the most impactful. This study provided a mechanism for clinicians to share their experiences using CBT for EDs in real-world settings. Overall, results regarding frequency of use and usefulness of techniques indicate a high level of endorsement. Moreover, the most frequently endorsed barriers to/limitations of CBT related to lack of guidance on treating complex ED presentations. Future research should explore ways to treat cases that go beyond the prototypical ED case and explore ways to adapt CBT to meet the needs of naturalistic treatment settings.

Maladaptive exercise in eating disorders: lifetime and current impact on mental health and treatment seeking

BACKGROUND

Many patients with eating disorders report exercise as a central symptom of their illness-as a way to compensate for food intake, prevent weight-gain, and/or reduce negative affect. Previous findings show associations between maladaptive exercise and more severe eating disorder pathology, higher risk for relapse, other co-morbid symptoms, and worse treatment outcome.

METHODS

In this study, we included 8252 participants with eating disorders and investigated associations between maladaptive exercise (both lifetime and current) and ED pathology, illness duration, depression, anxiety, self-harm and suicidal ideation, and treatment seeking patterns in individuals with lifetime maladaptive exercise. Participants were included via the Swedish site of the large global study The Eating Disorders Genetics Initiative (EDGI) and completed measures of both lifetime and current symptomatology.

RESULTS

Results indicate that lifetime maladaptive exercise is associated with higher prevalence of lifetime depression and anxiety and with patients more often receiving treatment, although these results need to be investigated in future studies. Current maladaptive exercise was associated with more severe ED symptoms, and higher levels of depression, anxiety, obsessive-compulsive traits, and suicidal ideation.

CONCLUSIONS

Our findings point to the complexities of exercise as an eating disorder symptom and the need for clearly assessing and acknowledging this, as well as tailoring interventions to treat this symptom to achieve sustainable recovery.

Adolescents' perspectives on a novel digital treatment targeting eating disorders: a qualitative study

BACKGROUND

Eating disorders in adolescence are associated with high psychological distress, impaired function and high comorbidity. Despite the severity, eating disorders remain highly underdiagnosed and untreated. Digital technology provides promising opportunities for treatment, however studies focusing on digital treatments for adolescents with eating disorders are lacking. The main aim of this study was to explore the perspectives of adolescents with lived experience of eating disorders on factors they deemed to be relevant in the development of a novel digital treatment.

METHODS

A qualitative intervention development study using semi-structured individual interviews. Data collection, coding and analysis were conducted using the principles of reflexive thematic analysis. Participants were adolescents aged 16-19 years, with a self-reported diagnosis of anorexia nervosa, bulimia nervosa or binge eating disorder, currently in the final phase or completed psychological treatment for an eating disorder within the last five years.

RESULTS

A total of 16 adolescents participated in the study, all females. Mean age was 17 ½ years (SD = 1.01). An in-depth understanding of the adolescents' perspectives was developed into three themes: Facilitating self-awareness and readiness to change; Strengthening interpersonal relationships and decreasing social isolation; Ensuring feeling seen and motivating regular use.

CONCLUSIONS

This study provides a unique insight into the perspectives of adolescents with lived experience of eating disorders. The uptake and engagement can be optimized in a novel digital treatment for eating disorders by taking the adolescents perspectives into consideration.

Exploring Demographic and Clinical Characteristics of Racially and Ethnically Diverse Youth With Eating Disorders Using California Medicaid Claims Data

OBJECTIVE

To explore the scope of diagnosed eating disorders among Medicaid-insured youth in California, and to describe the demographic characteristics of this population in a repeated annual cross-sectional study design.

METHOD

California Medicaid claims data were extracted for youth aged 7 to 18 years between January 2014 and December 2016. Participants included all youth who received an eating disorder diagnosis at any point in the study period (N = 8,075). Additional analyses compared youth with eating disorders who were continuously enrolled across all 3 years (n = 4,500) to random subsamples of continuously enrolled youth diagnosed with a mood or anxiety disorder (n = 4,128), a disruptive behavior disorder (n = 4,599), or a psychotic disorder (n = 4,290).

RESULTS

About one-half of youth with eating disorders were Latinx (58.5%, n = 2,634) and indicated Spanish as their preferred language (48.9%, n = 2,199). About one-half (51%, n = 2,301) of eating disorder diagnoses were unspecified. Latinx ethnicity and Spanish language were significantly more frequent among youth with eating disorders than among those with other disorders (F11.97, F362.75, p values <.0005).

CONCLUSION

The first examination of publicly insured youth with eating disorders revealed a highly diverse group of individuals among whom Latinx youth were particularly prevalent. However, past-year national prevalence estimates suggest that most eating disorder cases were undiagnosed.

PLAIN LANGUAGE SUMMARY

Eating disorders affect approximately 10% of the US population and lead to serious mental health and medical problems. This study used California Medicaid claims data from 2014 to 2016 to characterize the population of youth aged 7 to 18 years with diagnosed with an eating disorder (N = 8,075). The authors found the prevalence of eating disorders among youth aged 13 to 18 years was about 0.20% across all 3 years of the study, which is far below the expected prevalence and suggests that most eating disorders in youth go undiagnosed. About half of eating disorder diagnoses provided to youth with Medicaid insurance are unspecified, which may hinder receipt of appropriate treatment. Of youth with an eating disorder, about half were Latinx and reported Spanish as their preferred language. The authors also found differences in the prevalences of eating disorder diagnoses when analyzing youth by age, sex, and ethnicity. These results suggest that more standardized screening and assessment is needed to improve eating disorders detection and diagnosis, particularly for minoritized youth.

Sex differences in electrolyte abnormalities indicating refeeding syndrome risk among hospitalized adolescents and young adults with eating disorders

BACKGROUND

Refeeding syndrome is the gravest possible medical complication in malnourished patients undergoing refeeding in the hospital. We previously reported that males with malnutrition secondary to eating disorders required more calories and had longer hospital stays than females; however, sex differences in electrolyte abnormalities indicating refeeding syndrome risk remain unknown. The objective of this study was to assess differences in electrolyte abnormalities indicating refeeding syndrome risk among male and female adolescents and young adults with eating disorders hospitalized for medical instability.

METHODS

We retrospectively reviewed the electronic medical records of 558 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability between May 2012 and August 2020. Serum was drawn per standard of care between 5 and 7 am each morning and electrolyte abnormalities indicating refeeding syndrome risk were defined as: hypophosphatemia (< 3.0 mg/dL), hypokalemia (< 3.5 mEq/L), and hypomagnesemia (< 1.8 mg/dL). Logistic regression was used to assess factors associated with electrolyte abnormalities indicating refeeding syndrome risk.

RESULTS

Participants included 86 (15.4%) males and 472 (84.6%) females, mean (SD) age 15.5 (2.8) years. Rates of refeeding hypophosphatemia (3.5%), hypokalemia (8.1%), and hypomagnesemia (11.6%) in males hospitalized with eating disorders were low, with no statistically significant differences from females. Older age was associated with higher odds of refeeding hypophosphatemia and hypomagnesemia. Lower percent median body mass index and greater weight suppression at admission were associated with higher odds of refeeding hypophosphatemia.

CONCLUSIONS

Rates of electrolyte abnormalities indicating refeeding syndrome risk were low in males hospitalized for eating disorders and rates did not significantly differ from females. Together with our finding that males have higher caloric requirements and longer hospital length of stay, the finding that electrolyte abnormalities indicating refeeding syndrome risk were not greater in males than females supports future research to evaluate the safety and efficacy of higher calorie and/or faster advancing refeeding protocols for males.

Shared genetic influences between eating disorders and gastrointestinal disease in a large, population-based sample of adult women and men

BACKGROUND

Some preliminary research suggests higher rates of gastrointestinal disease in individuals with eating disorders (EDs). However, research is limited, and it remains unknown what etiologic factors account for observed associations. This was the first study to examine how EDs and dimensional ED symptoms (e.g. body dissatisfaction, binge eating) are phenotypically and etiologically associated with gastrointestinal disease in a large, population-based twin sample.

METHODS

Adult female (N = 2980) and male (N = 2903) twins from the Michigan State University Twin Registry reported whether they had a lifetime ED (anorexia nervosa, bulimia nervosa, or binge-eating disorder) and completed a measure of dimensional ED symptoms. We coded the presence/absence of lifetime gastrointestinal disease (e.g. inflammatory bowel disease) based on responses to questions regarding chronic illnesses and medications. We first examined whether twins with gastrointestinal disease had higher rates of EDs and ED symptoms, then used correlated factors twin models to investigate genetic and environmental contributions to the overlap between disorders.

RESULTS

Twins with gastrointestinal disease had significantly greater dimensional ED symptoms (β = 0.21, p < 0.001) and odds of a lifetime ED (OR 2.90, p = 0.001), regardless of sex. Shared genetic factors fully accounted for the overlap between disorders, with no significant sex differences in etiologic associations.

CONCLUSIONS

Comorbidity between EDs and gastrointestinal disease may be explained by overlap in genetic influences, potentially including inflammatory genes implicated in both types of disorders. Screening for gastrointestinal disease in people with EDs, and EDs in those with gastrointestinal disease, is warranted.

Adaptations of an Online Cognitive-Behavioral Therapy Intervention for Binge-Purge Type Eating Disorders in Publicly-Insured and Uninsured Adults: A Pilot Study

Background Publicly-insured and uninsured individuals-many of whom are marginalized because of race/ethnicity, disability and/or sexual preferences-experience barriers to accessing evidence-based interventions for eating disorders (EDs). Additionally, EBIs have not been developed with or for diverse populations, exacerbating poor treatment uptake. Mobile technology is perfectly positioned to bridge this gap and increase access to low-cost, culturally-sensitive EBIs. Methods This study leverages a user-centered design approach to adapt an existing coached cognitive-behavioral therapy-based digital program and evaluate its usability in a sample of 11 participants with (sub)clinical binge-purge type EDs who are publicly-insured ( n  = 10) or uninsured ( n  = 1). Participants were primarily Non-Hispanic White ( n  = 8) women ( n  = 8). Two semi-structured interviews occurred with participants: one to assess treatment needs and the other to obtain app-specific feedback. Interviews were coded using inductive thematic analysis. Results Interview 1 feedback converged on three themes: Recovery Journey, Treatment Experiences, and Engagement with and Expectations for Online Programs. Participants endorsed facing barriers to healthcare, such as poor insurance coverage and a lack of trained providers, and interest in a coach to increase treatment accountability. Interview 2 feedback converged on three themes: Content Development, Participant Experiences with Mental Health, and Real-World Use. Participants liked the content but emphasized the need to improve diverse representation (e.g., gender, body size). Conclusions Overall, user feedback is critical to informing adaptations to the original EBI so that the intervention can be appropriately tailored to the needs of this underserved population, which ultimately has high potential to address critical barriers to ED treatment. Trial Registration This study was reviewed and approved by the Institutional Review Board (IRB) at the University California, San Francisco (IRB #22-35936) and the IRB at Washington University in St. Louis (IRB ID 202304167).

Binge-eating adolescent treatment (BEAT) - findings from a pilot study on effects and acceptance of a blended treatment program for youth with loss of control eating

BACKGROUND

Loss of Control Eating (LOC) is the most prevalent form of eating disorder pathology in youth, but research on evidence-based treatment in this group remains scarce. We assessed for the first time the effects and acceptance of a blended treatment program for youth between 14 and 24 years with LOC (Binge-eating Adolescent Treatment, BEAT).

METHODS

Twenty-four youths (mean age 19.1 years) participated in an active treatment of nine-weeks including three face-to-face workshops and six weekly email-guided self-help sessions, followed by four email guided follow-up sessions, one, three, six and 12 months after the active treatment. All patients completed a two-weeks waiting-time period before treatment begin (within-subject waitlist control design).

RESULTS

The number of weekly LOC episodes substantially decreased during both the waiting-time (effect size d = 0.45) and the active treatment (d = 1.01) period and remained stable during the subsequent 12-months follow-up (d = 0.20). The proportion of patients with full-threshold binge-eating disorder (BED) diagnoses decreased and transformed into LOC during the study course, while the abstainer rate of LOC increased. Values for depressive symptoms (d = 1.5), eating disorder pathology (d = 1.29) and appearance-based rejection sensitivity (d = 0.68) all improved on average from pretreatment to posttreatment and remained stable or further improved during follow-up (d between 0.11 and 0.85). Body weight in contrast remained constant within the same period. Treatment satisfaction among completers was high, but so was the dropout rate of 45.8% at the end of the 12-months follow-up.

CONCLUSIONS

This first blended treatment study BEAT might be well suited to decrease core symptoms of LOC, depressive symptoms and appearance-based rejection sensitivity. More research is needed to establish readily accessible interventions targeted more profoundly at age-salient maintaining factors such as appearance-based rejection sensitivity, while at the same time keeping dropout rates at a low level.

TRIAL REGISTRATION

The trial was registered at the German Clinical Trials Register (ID: DRKS00014580; registration date: 21/06/2018).

Barriers and facilitators affecting treatment uptake behaviours for patients with eating disorders: A systematic review synthesising patient, caregiver and clinician perspectives

OBJECTIVE

A significant treatment gap exists between persons affected by eating disorders (ED), and those engaging with treatment services. This systematic review aims to provide a thorough understanding of the barriers and facilitators affecting eating disorder treatment engagement, including a synthesis of the perspectives of patients, caregivers and healthcare professionals.

METHOD

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were retrieved from three databases (PubMed, PsycInfo, Web of Science) and were screened and assessed independently by two raters. A thematic analysis was completed to determine the key barriers and facilitators reported by the included studies.

RESULTS

A total of 73 studies were included. From these studies, 12 barriers and 13 facilitators were identified. Patients reported stigma, shame and guilt as the most prominent barrier affecting their engagement with treatment services. Meanwhile, caregivers and healthcare professionals reported a lack of eating disorder knowledge of clinicians as the most important barrier. Positive social support was cited as the most prominent facilitator to promote help-seeking.

DISCUSSION

Patients, caregivers and healthcare professionals experience a variety of barriers and facilitators to treatment uptake for ED. Interventions addressing barriers and facilitators could increase treatment engagement, including anti-stigma campaigns and positive peer-support interventions.

Food insecurity among youth seeking eating disorder treatment

Food Insecurity (FI) is associated with a myriad of mental health concerns in children and adolescents. Eating disorder (ED) risk is higher in youth experiencing FI, and FI in childhood is associated with ED diagnoses later in life. Although a growing body of research has shown that FI is associated with a heightened risk for ED-related symptoms, little is known about how experiencing FI may impact ED treatment, particularly in youth. In this study, we characterize the treatment characteristics of youth aged 6-24 (N = 729) with FI receiving family-based treatment for an ED. FI was defined as self-reported experience of FI (family-level FI) at treatment admission, and living in a low income, low access area according to USDA census tract data. Seventeen patients (2.3 % of sample) self-reported family-level FI at intake and 24 (3.3 % of sample) were designated as living in a low income/low access location. Descriptive analyses only were used to characterize the sample due to sample sizes. Group means on measures of weight, ED symptomatology, depression, anxiety, and caregiver burden were evaluated at admission and after four, eight, 12, 16, and 20 weeks of treatment. Results characterize how FI may impact ED treatment and showcase variation in changes. ED treatment must be responsive to needs related to FI as access to and consumption of food is the very foundation of ED treatment.

Exploring the eating disorder curricula of accredited university dietetic programs in Australia and New Zealand

BACKGROUND

Dietitians are viewed as integral members of the multidisciplinary treatment team for people with eating disorders (EDs). However, low levels of perceived confidence, competence, and willingness to practice in this clinical area, have been reported by dietitians and student dietitians. As the extent of ED-specific knowledge and skills-based training within tertiary accredited dietetic programs is currently unknown, this research aimed to: (1) obtain insights into the current ED-specific knowledge base and training content of dietetic curricula in both Australian and New Zealand universities; (2) understand the perspectives of course convenors regarding the role of dietitians in ED treatment and their employment opportunities; and (3) identify gaps and opportunities for improving university programs and the dietetic workforce.

METHODS

Course convenors (or their nominated representative) of Australian and New Zealand accredited dietetic programs were invited to participate in a semi-structured virtual interview. A purpose-built question guide was developed to explore the inclusion and/or integration of ED-specific content into the curricula, and the perspectives of course convenors toward the role of dietitians in the treatment of EDs, and their employment opportunities. The interviews were audio recorded, transcribed verbatim, and analysed qualitatively using inductive thematic analysis.

RESULTS

Thirteen participants who represented 14 universities and 19 individual accredited dietetic programs, were interviewed, with some participants representing more than one university. Three dominant themes emerged: (1) varying ED-specific content and training in dietetic programs; (2) unclear dietitian's role in the treatment of EDs, and (3) contrasting views regarding ED clinical practice and employment.

CONCLUSIONS

ED-specific content was embedded within all the dietetic programs investigated in this study. However, this content was generally limited to an introductory level, with notable variations found between the depth of content and the type of training provided. Risk-mitigation skill development, such as screening for EDs, and early identification of symptoms, also varied between programs. Therefore, it is recommended that ED-specific skill development and knowledge is enhanced within Australian and New Zealand university programs, to support effective, safe, and timely care for people with EDs. This research has implications for current and future university dietetic program development and the broader dietetic workforce.

Modified cue exposure for adolescents with binge eating behaviour: study protocol of a randomised pilot trial called EXI(ea)T

INTRODUCTION

Binge eating (BE) behaviour is highly prevalent in adolescents, and can result in serious metabolic derangements and overweight in the long term. Weakened functioning of the behavioural inhibition system is one potential pathway leading to BE. Food cue exposure focusing on expectancy violation (CE_EV) is a short intervention for BE that has proven effective in adults but has never been tested in adolescents. Thus, the current randomised pilot trial evaluates the feasibility of CE_EV for adolescents and its efficacy in reducing eating in the absence of hunger (EAH) of binge food items.

METHODS AND ANALYSIS

The trial will include N=76 female adolescents aged between 13 and 20 years with a diagnosis of bulimia nervosa, binge eating disorder (BED) or their subthreshold forms based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Participants will be randomly assigned to two sessions of CE_EV or behavioural analysis (BA), a classical cognitive-behavioural therapy-based intervention. The primary endpoint is the change in EAH measured according to ad libitum consumption of personally preferred binge food in a bogus taste test at post-test based on the intention-to-treat population. Key secondary endpoints are changes in EAH of standardised binge food at post-test, in EAH at 3-month follow-up (FU) and in food craving after induction of food cue reactivity at post-test and FU. To identify further valid outcome parameters, we will assess effects of CE_EV compared with BA on global ED psychopathology, BE frequency within the last 28 days, body weight, response inhibition and emotion regulation abilities. Treatment groups will be compared using analysis of covariance with intervention as fixed factor and body mass index at baseline as covariate.

ETHICS AND DISSEMINATION

This clinical trial has been approved by the Ethics Review Committee of the Medical Association of Rhineland-Palatinate and the Medical Faculty of the Ruhr-University Bochum. The collected data will be disseminated locally and internationally through publications in relevant peer-reviewed journals and will be presented at scientific and clinical conferences. Participants data will only be published in an anonymised form.

TRIAL REGISTRATION NUMBER

DRKS00024009.

Interpersonal attribution bias and social evaluation in adolescent eating disorders

OBJECTIVE

Improved understanding of adolescent eating disorders (EDs), including identification and refinement of treatment and recovery targets, may help improve clinical outcomes. Interpersonal function is a proposed risk and maintenance factor that may be particularly relevant given the significance of adolescence for both psychosocial development and ED onset. This study examined self-referential thinking in adolescents with EDs compared to healthy adolescents.

METHOD

Twenty-nine adolescents with EDs and 31 healthy controls completed a self-report measure of interpersonal attributions as well as a verbal appraisal task that required conducting direct and indirect evaluations about oneself and direct evaluations about others.

RESULTS

The ED group had a more negative self-attribution bias than the control group (p = 0.006) even when controlling for depression severity. Additionally, the ED group exhibited less positive direct self (p < 0.001), direct social (p = 0.015), and social reflected self-appraisals (p = 0.011) than the healthy cohort. After including depression as a covariate in the verbal appraisal model, the model was no longer significant, suggesting group differences related to social appraisals may be mediated by depression.

CONCLUSIONS

Adolescents with EDs have more negative interpersonal beliefs than comparison adolescents. Future studies are needed to determine how the constructs identified here relate to clinical course.

Self-injury, suicidality and eating disorder symptoms in young adults following COVID-19 lockdowns in Denmark

An aggravation in mental health during the COVID-19 lockdown has been suggested but the impact on self-injury, suicidality and eating disorders (EDs) are less elucidated. Using linear regression in different data set-ups that is longitudinal (n = 7,579) and repeated cross-sectional data (n = 24,625) from the Danish National Birth Cohort, we compared self-reported self-injury, suicidality and symptoms of EDs from before through different pandemic periods until spring 2021. The longitudinal data indicate a reduction in the proportion of self-injury in men (-3.2% points, 95% confidence interval (CI) = -4.3%; -2.2%, P < 0.001, d.f. = 2) and women (5.7% points, 95% CI = -6.6%; -4.8%, P < 0.001, d.f. = 2) and of suicide ideation in men (-3.0% points, 95% CI = -4.6%; -1.4%, P = 0.002, d.f. = 2) and women (-7.4% points, 95% CI = -8.7%; -6.0%, P < 0.001, d.f. = 2), as well as symptoms of EDs in women (-2.3% points, 95% CI = -3.2%; -1.4%, P < 0.001, d.f. = 2). For suicide attempt, indication of an increase was observed in men only (0.4% points, 95% CI = 0.1%; 0.7%, P = 0.019, d.f. = 2). In the repeated cross-sectional data, we observed no changes in any of the outcomes. Our findings provide no support for the increase in self-injury, suicidality and symptoms of EDs after the lockdowns. Key limitations are differential attrition and varying age in pre- and post-lockdown measures in the longitudinal data.

Pathways to improve early intervention for eating disorders: Findings from a systematic review and meta-analysis

OBJECTIVE

Treatment-seeking rates among eating disorder (ED) populations are relatively low, with only one in four individuals seeking help. Previous research has identified many factors that might be associated with help-seeking in EDs, but to date no review has investigated the quantitative association between these factors and actual help-seeking behavior. The aim of the current review was to synthesize the relevant quantitative literature on factors (i.e., perceived barriers, characteristics associated with treatment seeking, demographic variables) associated with help-seeking using meta-analytic strategies, as well as provide recommendations on future early intervention research strategies to promote early help-seeking.

METHOD

Overall, 19 studies were included, identifying 141 perceived barriers (e.g., stigma) or individual characteristics (e.g., BMI, duration of illness) and 56 demographic variables (e.g., ethnicity), which were synthesized into 24 unique variables.

RESULTS

Less help-seeking was predicted by higher levels of denial and less perceived ability of others to provide help.

DISCUSSION

Given the small number of studies these results should be considered preliminary. Future studies should consider barriers to help-seeking when creating early intervention approaches. To improve help-seeking rates we suggest the use of targeted psychoeducational materials and co-design with people with lived experience when developing new strategies.

PUBLIC SIGNIFICANCE

The present study addresses a significant gap in the literature by synthesizing factors associated with help-seeking, with the aim of informing early intervention strategies to promote early help-seeking in eating disorder populations. Denial of illness and perceived inability of others to provide help were associated with lower help-seeking. Future studies should consider barriers to help-seeking and co-design with people with lived experience when creating new early intervention strategies.

Understanding outcomes in family-based treatment for adolescent anorexia nervosa: a network approach

BACKGROUND

Family-based treatment (FBT) is the first-line treatment for adolescent anorexia nervosa (AN). Yet, remission is not achieved for about half of adolescents with AN receiving FBT. Understanding patient- and parent-level factors that predict FBT response may inform treatment development and improve outcomes.

METHODS

Network analysis was used to identify the most central symptoms of AN in adolescents who completed the Eating Disorder Examination (EDE) prior to FBT (N = 409). Bridge pathways between adolescent AN and parental self-efficacy in facilitating their child's recovery from AN were identified in a subset of participants (n = 184). Central and bridge symptoms were tested as predictors of early response (⩾2.4 kg weight gain by the fourth session of FBT) and end-of-treatment weight restoration [⩾95% expected body weight (EBW)] and full remission (⩾95% EBW and EDE score within 1 standard deviation of norms).

RESULTS

The most central symptoms of adolescent AN included desiring weight loss, dietary restraint, and feeling fat. These symptoms predicted early response, but not end-of-treatment outcomes. Bridge symptoms were parental beliefs about their responsibility to renourish their child, adolescent discomfort eating in front of others, and adolescent dietary restraint. Bridge symptoms predicted end-of-treatment weight restoration, but not early response nor full remission.

CONCLUSIONS

Findings highlight the prognostic utility of core symptoms of adolescent AN. Parent beliefs about their responsibility to renourish their child may maintain associations between parental self-efficacy and AN psychopathology. These findings could inform strategies to adapt FBT and improve outcomes.

Influence of eating disorder psychopathology and general psychopathology on the risk of involuntary treatment in anorexia nervosa

PURPOSE

We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment.

METHODS

This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)).

RESULTS

Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment.

CONCLUSIONS

Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment.

LEVEL OF EVIDENCE

Level III, cohort study.

The use of technology in the treatment of youth with eating disorders: A scoping review

BACKGROUND

Adolescence and young adulthood is a high-risk period for the development of eating disorders. In recent years, there has been an increase in use of technology-based interventions (TBIs) for the treatment of eating disorders. The objective of this study was to determine the types of technology used for eating disorder treatment in youth and their effectiveness.

METHODS

A scoping review was conducted according to PRISMA-ScR guidelines. Four databases were searched. Eligible articles included: (1) a TBI (2) participants with a mean age between 10- and 25-years and meeting DSM-IV or DSM-5 criteria for any eating disorder and (3) qualitative or quantitative designs. Quantitative and qualitative studies were assessed for quality.

RESULTS

The search identified 1621 articles. After screening of titles and abstracts, 130 articles were read in full and assessed for eligibility by two raters. Forty-nine (29 quantitative and 20 qualitative, observational, or mixed methods studies) met inclusion criteria. Quality ratings indicated that 78% of quantitative studies had a low risk of bias and 22% had a moderate risk. Technologies reviewed in our study included videoconference therapy, mobile applications, and online self-help. We considered interventions used both within sessions with clinicians as well as those used in between sessions by patients alone. Fifteen of 18 (83%) quantitative studies found that TBIs reduce eating disorder symptomatology, with nine of those reporting medium-to-large effect sizes. Qualitative data was of high quality and suggested that virtual interventions are acceptable in this population.

CONCLUSIONS

Although identified studies are of high quality, they are limited in number. More research is needed, particularly regarding videoconferencing and mobile applications. Nonetheless, TBIs show promise for the treatment of eating disorders in youth.

TRIAL REGISTRATION

Not applicable.

Implementation and outcomes of home-based treatments for adolescents with anorexia nervosa: Study protocol for a pilot effectiveness-implementation trial

OBJECTIVE

Although family-based treatment (FBT) is considered a first-line treatment for adolescent anorexia nervosa (AN), it is underutilized in community settings and is unavailable to many families for a multitude of practical reasons (e.g., costs of treatment, transportation constraints). Adapting FBT interventions for delivery in home-based and community-based settings may reduce pragmatic barriers to treatment uptake and engagement.

METHODS

This pilot effectiveness-implementation trial will assess outcomes, implementation, and mechanisms of FBT adapted for the home setting (FBT-HB), delivered in the context of community-based behavioral health agencies. Adolescents with AN-spectrum disorders (n = 50) and their caregivers will be randomly assigned to either FBT-HB or home-based treatment as usual (TAU; integrated family therapy approach). Caregivers and adolescents will provide data on weight, eating, and putative treatment mechanisms, including caregiver self-efficacy and adolescent eating-related and weight-related distress. Implementation constructs of feasibility, acceptability, and appropriateness will be measured among providers and participating families.

HYPOTHESES

We expect that FBT-HB will be feasible, acceptable, and appropriate, and will outperform TAU in terms of improvements in adolescent weight and eating-related psychopathology. We further expect that caregiver self-efficacy and adolescent eating-related and weight-related distress, but not general distress, will show greater improvements in FBT-HB relative to TAU and will be associated with better adolescent weight and eating outcomes in FBT-HB.

POTENTIAL IMPLICATIONS

The proposed study has clear potential to advance scientific and clinical understanding of the real-world effectiveness of FBT for AN, including whether adapting it for the home setting improves its accessibility and effects on treatment outcome.

Predictors of treatment seeking and uptake among respondents to a widely disseminated online eating disorders screen in the United States

OBJECTIVE

To explore predictors of treatment seeking and uptake among individuals following an online eating disorders (EDs) screen in the U.S. disseminated by the National Eating Disorders Association.

METHOD

Respondents who screened at risk or positive for a probable ED from 04/2019 to 05/2021 (N = 263,530) were eligible to complete a 2-month follow-up survey that assessed treatment seeking and uptake after being offered referral options following screening. Analyses were conducted using chi-square tests or logistic regressions.

RESULTS

Sixty thousand thirty-four respondents (22.8%) opted-in to the follow-up survey, of whom 2276 (3.8%) completed it. Of the final analytic sample (n = 1922), 35.7% of respondents reported seeking and 22.4% reported receiving treatment. Treatment seeking and uptake were more common among respondents who were female, White, or >24 years of age; uptake was more common among respondents who were non-Hispanic or higher income. Elevated shape/weight concerns were significantly, albeit modestly, associated with reduced likelihood to receive treatment.

DISCUSSION

Demographic differences in treatment seeking and uptake highlight the need to optimize ED screening tools/feedback to meet the needs of underserved groups and to address stereotypes and structural barriers that may interfere. Research is also needed to identify barriers to uptake among those with elevated shape/weight concerns.

PUBLIC SIGNIFICANCE

Relatively low rates of treatment seeking and uptake were observed, particularly among underserved groups, 2 months following a widely disseminated online eating disorders screen. Optimization of online eating disorder screening tools and delivery of feedback and referral information may be needed to increase health care utilization.

Mapping the landscape and structure of global research on binge eating disorder: Visualization and bibliometric analysis

BACKGROUND

Binge-eating disorder (BED) is a clinical syndrome and is considered the most common type of eating disorder. However, our understanding of the global performance and progress of BED research is limited.

AIM

To describe and perform a bibliometric analysis of the state of BED research.

METHODS

The term 'Binge eating' was searched in the title throughout the previous year's up to December 31, 2020. We searched the Scopus and Reference Citation Analysis for publications on Binge eating. The VOSviewer software version 1.6.17 was used to produce the network visualization map of the most frequent author, collaborative relationships between countries/regions, and to determine the hotspots related to binge eating research. In addition, conventional bibliometric indicators were generated.

RESULTS

The search strategy found 2713 total articles and an average of 62 articles per year. Among them, 'Article' represented 82.49% of the publications (n = 2238 articles) and was the most frequent type, followed by reviews (n = 243; 8.96%). The number of publications increased steadily during the last decade of the study period. One hundred and thirty-two countries contributed to binge eating research, with 1495 (55.11%) articles published in the United States, followed by Italy with 256 (9.44%), the United Kingdom with 183 (6.75%), and Germany with 182 (6.71%). Currently, the main hot topics related to BED are 'type of treatment and management and treatment provided to BED"; "processes and pathways to binge eating"; and 'diagnosis, signs and symptoms, comorbidities and prevalence and associated factors with BED'.

CONCLUSION

The number of publications has increased noticeably during the previous decade. There are indeed relatively few publications on BED from low-and middle-income nations, so much is to be learned from the experience of all countries. Studies on this topic are critical in all countries to discover risk factors and effective intervention measures. Although our findings are preliminary, they imply that the future prospects for interventions aimed at BED management are bright, focusing on complex models of care and long-term maintenance of therapeutic gains.

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.

Knowledge and Myths about Eating Disorders in a German Adolescent Sample: A Preliminary Investigation

Eating disorder mental health literacy (ED-MHL) refers to knowledge about the symptoms, causes, and treatment of eating disorders (EDs) and is an important factor in people’s attitudes towards individuals with EDs and help-seeking for EDs. Associations between ED-MHL, stigma, ED symptomatology, and gender were investigated in a sample of N = 194 German high school students. Knowledge and myths about EDs were assessed with 18 factual statements about EDs and agreement/disagreement with common myths about ED. Students also completed the Universal Stigma Scale (USS), the Weight Concerns Scale (WCS), and demographic items. Students judged M = 8.39 (SD = 3.40) statements correctly, while the average agreement with all ED myths was low (M = 0.19, SD = 0.14). Greater ED-MHL was associated with lower stigmatization of EDs. Male participants were less knowledgeable and more likely to agree with the ED myths. Participants displayed moderate ED-MHL; however, certain aspects such as ED risk factors or symptoms of specific disorders such as anorexia nervosa and bulimia nervosa were less well known. These results can inform the design of future MHL interventions for adolescents.

First onset of treatment of patients with eating disorders and treatment course: Results of data from a German health insurance company

OBJECTIVE

This study examines, inpatient treatment costs, and typical treatment courses of patients with an eating disorder using secondary data.

METHOD

The data were provided by a German health insurance company (data from 4.2 million members from 2004 to 2010; corresponds to a market share of 6% of all statutorily insured persons in Germany). An age and gender matched control group without an eating disorder diagnosis was assessed for comparisons from the same dataset.

RESULTS

Two thousand seven hundred and thirty four cases with an eating disorder diagnosis (anorexia nervosa [AN], bulimia nervosa [BN] or combination [ANBN]) were identified. The inpatient costs of treatment were €5471.15 for BN, €9080.26 for AN, €10,809.16 for ANBN and €339.37 for the control group. Interestingly, there are numerous mild episodes of eating disorders that could be successfully treated solely on an outpatient basis with a short treatment duration.

CONCLUSION

Our findings suggest that course and severity of eating disorders can vary from mild to very severe. Data from health insurance companies depict rather different disease and treatment courses than studies on primary data derived from treatment institutions.

Gender-based clinical differences in evidence-based treatment for adolescent anorexia nervosa: analysis of aggregated randomized controlled trials

PURPOSE

Boys represent a small proportion of samples in randomized clinical trials (RCT) investigating evidence-based treatment for adolescents with anorexia nervosa (AN). Consequently, knowledge of potential gender differences in clinical characteristics and treatment response in adolescents is considerably limited.

METHODS

Secondary analyses of aggregated data from two RCTs were used to characterize baseline and end-of-treatment clinical features in male and female adolescents with AN (n = 228, 10.53% male). Mixed analyses of variance were used to investigate potential gender differences in treatment response relative to weight outcomes (% median BMI) and eating disorder cognitions (Eating Disorder Examination Global scores; EDE).

RESULTS

There were no significant gender differences in prior inpatient care, illness duration, psychiatric comorbidity, or psychotropic medication use at baseline. Nor were there significant gender differences in binge eating, purging, or driven exercise at baseline or end-of-treatment. Girls reported elevated weight and shape concern compared to boys at baseline but overall reduction in EDE Global scores over the course of treatment did not differ according to gender. Boys gained more relative weight during treatment than girls, but this difference was statistically non-significant.

CONCLUSION

Overall findings do not suggest significant differences in treatment outcome relative to weight or ED cognitions, by gender. Current evidence suggests that, with the exception of shape and weight concerns, boys present with cognitive and behavioral symptoms as severe as their female counterparts which underscores the need for increased accuracy in assessment of these disorders in boys and young men.

LEVEL OF EVIDENCE

Level 1, secondary data analysis of randomized controlled trials.

Exploring perceived training and professional development needs of Australian dietetic students and practising dietitians in the area of eating disorders: a focus group study

BACKGROUND

Timely diagnosis and treatment of eating disorders (EDs) are essential for achieving the best possible outcomes, and dietitians have an important role in the multidisciplinary team. ED-specific training has been shown to enhance the knowledge, mental health literacy and confidence of health professionals in providing patient treatment. However, the ED-specific training needs of dietitians have yet to be determined. This study aimed to explore the perceived readiness of dietitians and student dietitians to treat patients with EDs; to identify the key training components that would enhance their confidence in delivering ED-specific treatment; and to examine any barriers associated with engagement in ED-specific professional development.

METHODS

A semi-structured question guide was developed by researchers to elicit information from six virtual focus groups consisting of a purposive sample of practising dietitians and student dietitians enrolled in their final year of an Australian tertiary accredited dietetic program. Members of professional organisations were approached to participate via email; and a recruitment flyer was promoted on various social media platforms. Discussions were recorded, transcribed verbatim and analysed qualitatively using inductive thematic analysis.

RESULTS

Thirty-eight participants (26 dietitians, 12 student dietitians) were recruited, mean age of 32.5 years ± 11 SD. Three major themes emerged: (1) reluctance to practice in EDs, which was associated with limited ED-specific training at university, lack of clinical guidelines, mental health complexities of patients with an ED, ambiguity regarding the dietitian's role, systemic complexities with ED care, and beliefs of health professionals; (2) the need for additional ED-specific training and clinical supervision both during and after university, with the focus on identification, assessment, management and treatment, mental health literacy, and counselling skills, identified as an essential component to improving professional confidence and competence; (3) limited awareness and access/supply of ED-specific training opportunities were found, which included the financial cost of training/clinical supervision, and limited access to suitable clinical supervision.

CONCLUSION

Dietitians currently practising in the workplace and dietetic students perceive that enhanced ED-specific training during university and after graduation is essential to work with patients confidently and competently with EDs. This research has implications for Australian university dietetic programs and workforce development. This study aimed to explore the perceptions and readiness of dietitians and student dietitians to treat patients with eating disorders (EDs); to identify the key training components that would enhance their confidence and competence in delivering treatment; and to examine any barriers associated with engaging in ED-specific professional development. Twenty-six dietitians and twelve dietetic students participated in six virtual focus group discussions, which identified three main themes: (1) reluctance to practice which was associated with limited ED-specific training at university, lack of clinical guidelines, mental health complexities of patients with an ED, ambiguity regarding the dietitian's role, systemic complexities with ED care, and beliefs of health professionals; (2) the importance of engaging in ED-specific training, beyond an introductory level, during university and after graduation to confidently and competently work with patients with EDs; (3) barriers to accessing further ED-specific training and clinical supervision were found, including poor awareness of training opportunities, high financial cost of training/clinical supervision, and limited access to obtaining suitable clinical supervision. Results from this study provide insight into the ED-specific training needs of practising and student dietitians. This research has value for university programs and workforce development.

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders

OBJECTIVE

Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group - anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder.

METHOD

Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13-60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis).

RESULTS

Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group.

CONCLUSION

Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.

Help-seeking attitudes and behaviours among youth with eating disorders: a scoping review

BACKGROUND

Although early intervention is crucial in interrupting the development of eating disorders, little is currently known about help-seeking behaviours among individuals experiencing eating disorder symptoms. Given that eating disorders typically begin early in life, it is necessary to investigate the processes employed by children, adolescents, and emerging adults when seeking services for troubling symptoms. This is a growing concern as the COVID-19 pandemic has resulted in an increase in the number of individuals engaging in disordered eating behaviours. This scoping review explores the current state of the literature for evidence on how youth with eating disorder symptoms seek help, with the aim of better understanding how to identify and treat more individuals earlier.

METHODS

Using scoping review methodology, we searched seven databases for studies published from January 2000 to April 2021 that reported on help-seeking attitudes, behaviours, and healthcare utilization patterns for children and adolescents (< 18 years), emerging adults (18-25 years), and a mixture of these groups (< 25 years). Seven thousand, two hundred, and eighteen articles were identified for review. After duplicates were removed, three reviewers independently screened titles and abstracts and reviewed full-text articles. Findings related to help-seeking activity were extracted from the 62 articles that were ultimately included in this scoping review.

RESULTS

Study findings were summarized into help-seeking patterns (i.e., rates, types) as well as factors ranging from the individual level to society that influenced help-seeking behaviour. Many youth meeting eating disorder criteria were not seeking help. Notable barriers to help-seeking included poor mental health literacy, experiences with healthcare providers who failed to detect and lacked knowledge about eating disorders, minimal support from family and friends, and stigma surrounding eating disorders and help-seeking for mental health concerns.

CONCLUSIONS

The results of this scoping review can be used to inform early intervention and health promotion program development. Future research should focus on the help-seeking attitudes and activities among underrepresented groups with eating disorders (e.g., men, ethnic and gender minorities), the perspectives of family and other supporters in the help-seeking process for youth, and retrospective accounts from adults with lived experience of an eating disorder. Plain English summary Addressing and interrupting eating disorder-related thoughts and behaviours as soon as possible, with the help of a mental health professional, leads to better outcomes for youth struggling with an eating disorder. However, little is known about what prompts youth to talk about their weight, body, or eating concerns with someone-like their parent, friend, teacher, guidance counsellor, or primary care practitioner. This review explores the available published research on help-seeking patterns and preferences among youth with eating disorder concerns. Our team followed a standardized process to find 62 relevant articles for this paper. Of note, many young people who reported eating disorder concerns were not seeking help for themselves. Feeling supported by family and their primary care provider, understanding the signs of an eating disorder, and not feeling shame for reaching out for help reportedly led youth to speak up about their concerns. The findings have clinical implications for learning effective ways to help youth feel safe to speak freely about their eating disorder-related concerns, which enhances the chances of intervening early and catching symptoms before they worsen.

Sex differences in refeeding among hospitalized adolescents and young adults with eating disorders

OBJECTIVE

To determine sex differences in refeeding (i.e., short-term nutritional rehabilitation) outcomes among hospitalized adolescents and young adults with eating disorders.

METHODS

We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical and nutritional management between May 2012 and August 2020. Descriptive statistics, crude, and adjusted linear regression models were used to assess the association between sex and nutritional outcomes and predictors of length of stay.

RESULTS

A total of 588 adolescents and young adults met eligibility criteria (16% male, mean [SD] age 15.96  [2.75], 71.6% anorexia nervosa, admission percent median body mass index [%mBMI] 87.1 ± 14.1). In unadjusted comparisons, there were no significant sex differences in prescribed kilocalories (kcal) per day at admission (2013 vs. 1980, p = .188); however, males had higher estimated energy requirements (EER, kcal) (3,694 vs. 2,925, p < .001). In linear regression models adjusting for potential confounders, male sex was associated with higher prescribed kcals at discharge (B = 835 kcal, p < .001), greater weight change (B = 0.47 kg, p = .021), and longer length of stay (B = 1.94 days, p = .001) than females. Older age, lower admission weight, lower prescribed kcal at admission, higher EER, and lower heart rate at admission were factors associated with longer length of stay in a linear regression model.

DISCUSSION

These findings support the development of individualized approaches for males with eating disorders to improve quality of care and health care efficiency among an underserved population.

The development and psychometric evaluation of FABIANA-checklist: a scale to assess factors influencing treatment initiation in anorexia nervosa

BACKGROUND

A long duration of untreated illness (DUI) is an unfavorable prognostic factor in anorexia nervosa (AN) and is associated with chronic illness progression. Although previous preventive measures aimed at reducing DUI and thus improving short- and long-term treatment outcomes have been partially successful, a better understanding of the factors involved in the sensitive phase prior to treatment initiation is needed. To date, there is no validated instrument available to assess these factors specifically for patients with AN. The FABIANA-project (Facilitators and barriers in anorexia nervosa treatment initiation) aims at identifying predictors of the DUI in order to target preventive measures better in the future. As part of this project, the FABIANA-checklist was developed, based on a multi-informant perspective and a multimodal bottom-up approach. The present study focusses on the process of item generation, item selection and psychometric validation of the checklist.

METHODS

Based upon a previous qualitative study, an initial set of 73 items was generated for the most frequently mentioned facilitators and barriers of treatment initiation in AN. After a process of consensual rating and cognitive pre-testing, the resulting 25-item version of the FABIANA-checklist was provided to a sample of female patients (N = 75), aged ≥ 14 years with AN that underwent their first psychotherapeutic treatment in the last 12 months. After item analysis, dimensionality of the final version of the FABIANA-checklist was tested by Principal Component Analysis (PCA). We evaluated construct validity assuming correlations with related constructs, such as perceived social support (F-SozU), support in the health care system (PACIC-5A), illness perception and coping (BIPQ).

RESULTS

We included 54 adult and 21 adolescent patients with AN, aged on average 21.4 years. Average BMI was 15.5 kg/m², age of onset was 19.2 years and average DUI was 2.25 years. After item analysis, 7 items were excluded. The PCA of the 18-item-FABIANA-checklist yielded six components explaining 62.64% of the total variance. Overall internal consistency was acceptable (Cronbach's α = .76) and construct validity was satisfactory for 14 out of 18 items. Two consistent components emerged: "primary care perceived as supportive and competent" (23.33%) and "emotional and practical support from relatives" (9.98%). With regard to the other components, the heterogeneity of the items led to unsatisfactory internal consistency, single item loading and in part ambiguous interpretability.

CONCLUSIONS

The FABIANA-checklist is a valid instrument to assess factors involved in the process of treatment initiation of patients with AN. Psychometrics and dimensionality testing suggests that experienced emotional and practical support from the primary health care system and close relatives are main components. The results indicate that a differentiated assessment at item level is appropriate. In order to quantify the relative importance of the factors and to derive recommendations on early-intervention approaches, the predictive effect of the FABIANA-items on the DUI will be determined in a subsequent study which will further include the perspective of relatives and primary caregivers. Trial registration Clinical Trials.gov Identifier: NCT03713541: https://clinicaltrials.gov/ct2/show/NCT03713541 .

Anxiety and depression in a sample of UK college students: a study of prevalence, comorbidity, and quality of life

ObjectiveThis study sought to estimate the prevalence of depression and anxiety in UK college students and examine associations between mental health symptoms and quality of life (QoL). Associations between psychiatric comorbidity and degree of QoL impairment were also investigated. Participants: Participants (N = 286) were recruited from a UK university (76.1% ≤20 years-old; 86.8% female; 71.1% White). Methods: Self-report measures of depression, anxiety, and QoL were completed online. Group differences and within-group associations were examined with Chi-square analyses, linear regressions, and ANOVAs. Results: Prevalence rates were in line with global estimates and suggest female students are at elevated risk of mental health problems. Symptom severity and comorbidity were associated with greater QoL impairment. Conclusions: Presence of depression, anxiety, or both was associated with QoL impairment. Findings develop understanding of the impact of mental health problems on QoL and could inform appropriate screening and effective interventions for student mental health.

Exploring the experience of being viewed as "not sick enough": a qualitative study of women recovered from anorexia nervosa or atypical anorexia nervosa

BACKGROUND

Despite common misconceptions, an individual may be seriously ill with a restrictive eating disorder without an outwardly recognizable physical sign of the illness. The aim of this qualitative study was to investigate the perspectives of individuals who have previously battled a restrictive eating disorder who were considered "not sick enough" by others (e.g., peers, families, healthcare professionals) at some point during their illness, and to understand the perceived impact on the illness and recovery. Such misconceptions are potentially damaging, and have been previously linked with delayed help-seeking and poorer clinical outcomes.

METHODS

Seven women who had recovered from anorexia nervosa or atypical anorexia nervosa participated in semi-structured interviews. Interviews were transcribed and interpretive phenomenological analysis was used.

RESULTS

Three main themes emerged: (1) dealing with the focus upon one's physical appearance while battling a mental illness, (2) "project perfect": feeling pressure to prove oneself, and (3) the importance of being seen and understood. Participants reported that their symptoms were occasionally met with trivialization or disbelief, leading to shame, confusion, despair, and for some, deterioration in eating disorder symptoms which drove further weight loss. In contrast, social support and being understood were viewed as essential for recovery.

CONCLUSION

To facilitate treatment seeking and engagement, and to optimize chances of recovery, greater awareness of diverse, non-stereotypical presentations of restrictive eating disorders is needed which challenge the myth that weight is the sole indicator of the presence or severity of illness.

Evaluating evidence-based interventions in low socio-economic-status populations

OBJECTIVE

Socio-economic-status (SES) has rarely been reported or investigated in eating disorders (EDs) research. This Research Forum considers, from various perspectives, how SES may impact on evaluating evidence-based treatments for EDs.

METHOD

We first reviewed previous literature that informs how SES impacts prevalence of EDs, help-seeking, and treatment outcome. We then present findings from a case series effectiveness study of an early intervention program in low SES areas for EDs and discuss implications about the impact of SES on the effectiveness of evidence-based interventions. Finally, we examine barriers to conducting rigorous evaluations in this population and discuss directions for future treatment outcome research.

RESULTS

Evidence suggests a higher level of disordered eating but less help seeking in lower SES groups. In our case series, 96 participants started treatment and completed a mean of 13.85 sessions, 84 (87.5%) completed a mean of 6.40 sessional measures on ED cognitions and behaviors, but only 31% completed more extensive pre-treatment and post-treatment measures. The completer effect size decrease for the global Eating Disorder Examination-Questionnaire score was 2.05 (95% CI: 1.43, 2.68) commensurate with other effectiveness studies in mixed SES groups. The high rates of missing data related to more extensive assessment present a barrier to evaluating evidence-based treatments in this population.

DISCUSSION

Evidence from the present study revealed individuals from low SES can achieve similar treatment outcomes to other populations when receiving evidence-based ED treatment. Future studies should investigate a range of approaches to maximizing data collection, including use of shorter sessional measures.

Dissociation and Suicidality in Eating Disorders: The Mediating Function of Body Image Disturbances, and the Moderating Role of Depression and Anxiety

In patients with eating disorders (EDs), elevated dissociation may increase the risk of suicide. Bodily related disturbances, depression, and anxiety may intervene in the association between dissociation and suicidality. In this study we aimed to examine the influence of bodily related disturbances, depression, anxiety, severity of ED symptoms, body mass index (BMI), and type and duration of the ED on the relationship between elevated dissociation and elevated suicidality. The study included 172 inpatients: 65 with anorexia nervosa restricting type, 60 with anorexia nervosa binge/purge type, and 37 with bulimia nervosa. Participants were assessed using self-rating questionnaires for dissociation, suicidality, bodily related parameters, and severity of ED symptomatology, depression, and anxiety. We found that dissociation and suicidality were directly associated. In addition, depression and anxiety moderated the mediating role of body image parameters in the association between increased dissociation and increased suicidality. Thus, only in inpatients with high depression and anxiety, i.e., above the median range, body image disturbances were found to mediate the association between dissociation and suicidality. ED-related parameters did not moderate these relationships. Our study demonstrates that in inpatients with EDs, increased dissociation may be significantly associated with increased suicidality, both directly and via the intervening influence of body image, depression, and anxiety.