Examining supervised meals in patients with restrictive eating disorders

Outcomes and associated clinical features of people with eating disorders participating in residential treatment facilities: a scoping review

Residential treatment programs for eating disorders (EDs) have gained popularity in recent years, expanding beyond the United States to countries such as Canada, Italy, and the United Kingdom. These programs offer a "home-like" environment where individuals reside for several weeks or months, emphasising both physical restoration and psychological recovery. This scoping review aimed to provide an update since the most recent reviews on the literature regarding outcomes of residential treatment programs for EDs and to explore clinical features that were associated with these outcomes. Methods used followed the Joanna Briggs Institute guidelines for scoping reviews. A systematic search of electronic databases was conducted, and 12 studies met the inclusion criteria. All studies reported improvements in various outcomes from admission to discharge, including changes in eating psychopathology, weight restoration, depression, anxiety, and quality of life. Additionally, three studies reported positive outcomes at intervals after discharge and three predictive factors (self-compassion, personality organisation, and resistance to emotional vulnerability) were reported in a small number of studies. While residential treatment facilities consistently showed positive outcomes, the review highlights the need for randomised controlled studies to establish the efficacy of these programs for EDs. Future research should include controlled studies comparing residential facilities to other treatment settings and incorporate long-term follow-up outcomes and further studies of emergent predictive factors identified in this review.

Meal support intervention for eating disorders: a mixed-methods systematic review

OBJECTIVE

Mealtimes are a period of heightened distress for individuals with eating disorders. Patients frequently display maladaptive coping strategies, such as hiding food and using distraction techniques to avoid eating. The aim of this systematic review is to evaluate the evidence for meal support interventions as a first-line intervention for eating disorders.

METHOD

Six databases were systematically searched in January 2024. Papers including patients with an eating disorder, and meal support or meal supervision, were examined. Quality appraisal was conducted.

RESULTS

Ten studies met inclusion criteria. Meal support was conducted individually and in group settings. Two studies examined the practical or interpersonal processes of meal support. Carers and trained clinicians implemented meal support. Individuals across the lifespan were examined. Settings included inpatient units, community clinics, and the home. Studies were heterogeneously evaluated with retrospective chart audits, pre- and post- cohort studies, semi-structured interviews, video analysis, and surveys.

DISCUSSION

Meal support intervention is potentially suitable and beneficial for patients of various age groups and eating disorder diagnoses. Due to the lack of consistent approaches, it is apparent there is no standardised framework and manualised approach. This highlights the need for the development of a co-designed approach, adequate training, and rigorous evaluation.

Tuning in to recovery: influence of music on emotional well-being during mealtime in inpatient facilities for eating disorders

BACKGROUND

In rehabilitating eating disorders (ED), mealtimes are critical but often induce stress, both for restrictive and binge-purge disorders. Although preliminary data indicate a positive effect of music during mealtime, few studies employ an experimental approach. This study examines the influence of background music during mealtime in an inpatient ward setting, offering a real-world perspective.

METHODS

Fifty-one women diagnosed with ED participated in this within-subjects study. Over two weeks, during lunch and dinner, they were exposed to three randomized music conditions: no music, focus piano music, and pop music. The self-report questionnaires captured affective states, noise levels, and hunger, while trained dietitians recorded food consumption and eating rituals.

RESULTS

The absence of music led to an increase in uneaten food (p = 0.001) and the presence of eating rituals (p = 0.012) during mealtimes. Significantly, only silence during mealtime reduced positive emotional states, while background music maintained positive emotions (p < 0.001). No specific differences emerged between the two types of music (focus piano and pop).

CONCLUSIONS

These findings affirm the positive impact of background music during mealtime in real-world settings, enhancing the potential of inpatient eating rehabilitation programs for individuals with ED. More studies are needed to validate and extend these results, particularly in outpatient settings.

Effects of mealtime assistance in the nutritional rehabilitation of eating disorders

PURPOSE

The aim of the study was to examine the effects of meal supervision, provided by health professionals, volunteers or family members, on anthropometric, nutritional, psychological, and behavioural outcomes in patients with eating disorders (EDs).

METHODS

The present systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The last search was conducted in three databases (PubMed, Scopus, and the Cochrane library). Inclusion criteria considered paediatric and adult patients suffering from EDs, regardless of ethnicity, and treated in different therapeutic settings. The quality of the studies was evaluated using the Newcastle Ottawa Scale (NOS) adapted for cross-sectional studies and Version 2 of the Cochrane risk-of-bias assessment tool for randomised trials.

RESULTS

3282 articles were retrieved, out of which only 6 met the eligibility criteria. A marked heterogeneity in definitions and approaches to supervised mealtime was observed. This variability emerged in the methodologies used in the supervised meal, and in the reference values for the outcome measures that were used, such as the analysis of different parameters. Based on these observations, mealtime assistance provided to patients with EDs shows an overall positive effect on eating behaviour and dysfunctional attitudes. Future research should be prompted to provide a thorough definition of a structured procedure for meal assistance to be potentially and systematically included in the nutritional rehabilitation protocols for patients with EDs.

LEVEL OF EVIDENCE

Level IV systematic reviews of uncontrolled trials.

Outcomes of inpatient psychological treatments for children and adolescents with eating disorders at time of discharge: a systematic review

BACKGROUND

Recommended first line treatment for children and adolescent eating disorders is outpatient therapy. However, a significant number of children and adolescents with eating disorders continue to require inpatient treatment during the course of their illness. The effect of psychological treatments in an inpatient setting on outcomes at the time of discharge remains unclear. This paper presents the results of a review of the literature on outcomes at the time of discharge following inpatient psychological treatment for children and adolescents with eating disorders.

MAIN BODY

The majority of studies found were observational and of low quality. The most consistently reported positive outcome of inpatient treatment is weight gain. Results related to symptom change and motivation vary between studies. Within the inpatient setting, there is considerable heterogeneity in the types of treatments offered, goals of treatment, length of stay and outcomes measured.

CONCLUSION

There remains a paucity of high-quality studies examining the effect of psychological treatments provided to children and adolescents in an inpatient setting. The significant heterogeneity between studies makes it not possible to compare across studies. Future research should aim to resolve these deficiencies in order to better determine the specific factors that contribute to positive outcomes of inpatient treatment for children and adolescents with eating disorders.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Managing Eating Disorders on a General Pediatrics Unit: A Centralized Video Monitoring Pilot

Adolescents with severe eating disorders require hospitalization for medical stabilization. Supervision best practices for these patients are not established. This study sought to evaluate the cost and feasibility of centralized video monitoring (CVM) supervision on a general pediatric unit of an academic quaternary care center. This was a retrospective cohort study of nursing assistant (NA) versus CVM supervision for girls 12-18 years old admitted for medical stabilization of an eating disorder between September 2013 and March 2017. There were 37 consecutive admissions (NA = 23 and CVM = 14). NA median supervision cost was more expensive than CVM ($4,104/admission vs $1,166/admission, P < .001). Length of stay and days to weight gain were not statistically different. There were no occurances of family refusal of CVM, conversion from CVM to NA, technological failure, or unplanned discontinuation. Video monitoring was feasible and associated with lower supervision costs than one-to-one NA supervision. Larger samples in multiple centers are needed to confirm the safety, acceptability, and efficacy of CVM.

Community-based mealtime management for adolescents with anorexia nervosa: A qualitative study of clinicians' perspectives and experiences

BACKGROUND AND OBJECTIVE

Community-based mealtime management is an intensive, focused, and time-limited intervention for young people with an eating disorder which aims to support refeeding at home and thus prevent hospital admission. Little is known about clinicians' experiences of delivering this intervention. We aimed to explore mental health clinicians' perspectives on community mealtime management with children and adolescents diagnosed with an eating disorder.

METHODS

A qualitative design was used. Semistructured interviews were conducted with six mental health clinicians with experience of delivering or referral for the intervention. Interview recordings were transcribed and subjected to a thematic analysis.

RESULTS

Analysis resulted in identification of three themes: (a) technical aspects of mealtime management, (b) emotional aspects of mealtime management, and (c) a mixed zone of uncertainty around the use of dietary supplements. Overall, participants believed mealtime management to be a valuable intervention.

CONCLUSIONS

Findings highlight the perceived need for more formal training for clinicians undertaking mealtime management, and the positive impact this could potentially have on their practice. Clinicians' emotion regulation during intervention delivery was perceived to be important. There was a perceived need for greater adherence to protocols but an acceptance that flexibility was also required.

Consensus-based perspectives of pediatric inpatient eating disorder services

OBJECTIVE

There are few evidence-based guidelines for inpatient pediatric eating disorders. The aim was to gain perspectives from those providing and receiving inpatient pediatric eating disorder care on the essential components treatment.

METHOD

A modified Delphi technique was used to develop consensus-based opinions. Participants (N = 74) were recruited for three panels: clinicians (n = 24), carers (n = 31), and patients (n = 19), who endorsed three rounds of statements online.

RESULTS

A total of 167 statements were rated, 79 were accepted and reached a consensus level of at least 75% across all panels, and 87 were rejected. All agreed that families should be involved in treatment, and thatpsychological therapy be offered in specialist inpatient units. Areas of disagreement included that patients expressed a desire for autonomy in sessions being available without carers, and that weight gain should be gradual and admissions longer, in contrast to carers and clinicians. Carers endorsed that legal frameworks should be used to retain patients if required, and that inpatients are supervised at all times, in contrast to patients and clinicians. Clinicians endorsed that food access should be restricted outside meal times, in contrast to patients and carers.

DISCUSSION

The findings indicate areas of consensus in admission criteria, and that families should be involved in treatment, family involvement in treatment, while there was disagreement across groups on topics including weight goals and nutrition management. Perspectives from patients, carers, and clinicians may be useful to consider during future revisions of best practice guidelines.

Meal Supervision During Medical Hospitalization for Eating Disorders

The focus of medical hospitalization for restrictive eating disorders is weight gain; however, no guidelines exist on how to achieve successful and safe weight gain. Meal supervision may be a supportive intervention to aid in meal completion and weight gain. The aim of this study was to examine the effect of standardized meal supervision on weight gain, length of stay, vital signs, electrolytes, and use of liquid caloric supplementation in hospitalized adolescents and young adults with restrictive eating disorders. A chart review compared patients who received meal supervision from admission through discharge to an earlier cohort who received meal supervision as needed. There were no differences in weight, electrolytes, or vital signs between the two cohorts. Length of stay for those who received meal supervision from admission was 3 days shorter than earlier cohort. Nursing supervised meals beginning at admission may shorten length of stay and decrease health care costs.

Inpatient treatment for anorexia nervosa: a systematic review of randomized controlled trials

BACKGROUND

Anorexia nervosa (AN) is a serious psychiatric disease. Choice of acute inpatient care for AN is driven by the severity of symptoms and the level of risk to the patient. Inpatient hospitalization of patients with AN typically includes a behavioral weight gain protocol that is designed to address the core features of the disorder: weight, appetite, and distorted thoughts and behavior. Some add-on treatments may also be included in the inpatient treatment model and may have potential benefits, including faster or greater weight gain; such treatments include psychotherapy, psychoeducation, pharmacological treatment, and nutritional replacement.

OBJECTIVE

The goal of this study was to systematically review randomized clinical trials (RCTs) that have compared the efficacy of different forms of add-on treatment delivered during admission to a 24-hour hospital and to summarize the existing data regarding weight gain associated with such pharmacological, medical, and psychological interventions.

METHODS

Systematic electronic and manual searches were conducted to identify published RCTs concerning inpatient treatment of AN. Weight gain was used as the main outcome variable.

RESULTS

Overall, no significant increase in weight recovery was reported with atypical antipsychotics compared to placebo or therapy as usual. Only one study showed slight benefits in young patients during hospitalization (d=0.77; 95% confidence interval [CI] -0.09-1.64). No significant effects on weight recovery were found for antidepressants (d=-0.10; 95% CI=-0.63-0.42). In addition, none of the add-on psychotherapy techniques that were evaluated demonstrated superiority compared with control interventions in the inpatient setting. Cyclic enteral nutrition was studied in one RCT in which it demonstrated superiority compared to oral refeeding only (d=0.97; 95% CI=0.51-1.47). Other less common treatments such as bright light therapy and lithium carbonate were not found to produce additional significant weight improvement compared with placebo.

CONCLUSION

Most add-on treatments during the acute inpatient phase of AN treatment are not effective in increasing weight recovery. Long-term follow-up studies after the acute treatment phase are needed to make evidence-based recommendations.

Recommendations for reporting the results of studies of instrument and scale development and testing

Scales and instruments play an important role in health research and practice. It is important that studies that report on their psychometric properties do so in a way such that readers can understand what was done and what was found. This paper is a guide to writing articles about the development and assessment of these tools. It covers what should be in the abstract and how key words should be chosen. The article then discusses what should be in the main parts of the paper: the introduction, methods, results and discussion. In each of these parts, it suggests the statistical tests that should be used and how to report them. The emphasis throughout the paper is that reliability and validity are not fixed properties of a scale, but depend on an interaction among it, the population being evaluated and the circumstances under which the instrument is administered.

The canadian eating disorder program survey - exploring intensive treatment programs for youth with eating disorders

OBJECTIVE

To explore and describe philosophies and characteristics of intensive eating disorder (ED) treatment programs based in tertiary care institutions across Canada.

METHOD

A ninety-item survey examining ED services for adolescents was developed, piloted, and completed by 11 programs across Canada. Information pertaining to program characteristics and components, governance, staffing, referrals, assessments, therapeutic modalities in place, nutritional practices, and treatment protocols were collected.

RESULTS

The results highlight the diversity of programming available but also the lack of a unified approach to intensive eating disorder treatment in youth.

CONCLUSIONS

This report provides important baseline data that offers a framework that programs can use to come together to establish assessment and treatment protocols as well as a process for outcome evaluation. Continued collaboration will be essential moving forward to ensure Canadian youth, regardless of geographic location, receive the necessary treatment required to attain and sustain recovery.