Decreasing the duration of untreated illness for individuals with anorexia nervosa: study protocol of the evaluation of a systemic public health intervention at community level

Low levels of proinflammatory cytokines in a transdiagnostic sample of young male and female early onset eating disorders without any previous treatment: A case control study

Growing interest exists in the association of the immune system and its role in the development and maintenance of eating disorders (ED). Current evidence suggests that serum cytokine levels seem to be elevated in females with anorexia nervosa (AN). However, less is known in bulimia nervosa (BN) and other specified feeding and eating disorders (OSFED), specially in males. We aimed to perform a case-control study in a sample of forty eight young patients (38 females and 10 males) with early diagnosis of AN, BN or OSFED and without any previous treatment, compared with twenty nine healthy controls (19 females and 10 males) matched by age, sex and socioeconomic status. We evaluated eating-related psychopathology and depressive symptoms and measured serum concentration of proinflammatory cytokines IL-1β, IL-6, and TNF-α and anti-inflammatory cytokine IL-10. Contrary to expectations, levels of IL-1β and IL-6 were significantly lower in ED patients, compared with healthy controls. Comparing the different groups of females, we found elevated levels of IL-10 among ED patients therefore supporting the idea of an immunosuppressive status in the early stages. This could indicate that early onset patients without any previous treatment could remain in a reward-dependent state with a lower immune response.

A retrospective investigation of the prodromal stages of eating disorders and use of health services in young patients the year prior to the diagnosis

AIM

The aim of this study was to analyse the characteristics and the frequency of medical consultations in the year prior to the diagnosis and the intervention onset of the Eating Disorder, as well as the different prodromal symptoms. The final aim was to understand the origin of all referrals and their possible influence on the duration of untreated illness.

METHODS

We selected 99 young patients (15-25 years) and 61 healthy controls. Their primary and specialized care medical records were both studied retrospectively.

RESULTS

87.6% of patients attended different consultations (primary care, specialized care and emergency department) the year prior compared to 67.2% of the controls (p = .002). The average number of consultations was 3.59 in the case group and 1.57 in the control group (p < .001). These consultations were related to prodromal symptoms in 57.4% compared to 16.4% for the controls (p < .001). They ranged from 29.8% of unspecific digestive symptoms, 22.8% of psychological symptoms, 19.3% of gynaecologic symptoms, 11.9% of weight variation, 8.8% of analytical changes, to 5.3% of malnutrition symptoms. Patients were mainly referred by Primary Care (42.7%). Overall, the mean of the Duration of Untreated Illness was of 7.45 months.

CONCLUSIONS

The majority of reasons for consultation were related to symptoms that could be prodromal symptoms, but the patients were not diagnosed with an eating disorder. These findings highlight the importance of professionals understanding how to identify the warning signs of an eating disorder, so they can refer patients to a specialized unit to establish an early treatment.

The First Episode Rapid Early Intervention for Eating Disorders - Upscaled study: Clinical outcomes

BACKGROUND

First Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway for emerging adults aged 16 to 25-years with a recent onset eating disorder (ED) of <3 years. A previous single-site study suggests that FREED significantly improves clinical outcomes compared to treatment-as-usual (TAU). The present study (FREED-Up) assessed the scalability of FREED. A multi-centre quasi-experimental pre-post design was used, comparing patient outcomes before and after implementation of FREED in participating services.

METHODS

FREED patients (n = 278) were consecutive, prospectively ascertained referrals to four specialist ED services in England, assessed at four time points over 12 months on ED symptoms, mood, service utilization and cost. FREED patients were compared to a TAU cohort (n = 224) of similar patients, identified retrospectively from electronic patient records in participating services. All were emerging adults aged 16-25 experiencing a first episode ED of <3 years duration.

RESULTS

Overall, FREED patients made significant and rapid clinical improvements over time. 53.2% of FREED patients with anorexia nervosa reached a healthy weight at the 12-month timepoint, compared to only 17.9% of TAU patients (X2 [1, N = 107] = 10.46, p < .001). Significantly fewer FREED patients required intensive (i.e., in-patient or day-patient) treatment (6.6%) compared to TAU patients (12.4%) across the follow-up period (X2 [1, N = 40] = 4.36, p = .037). This contributed to a trend in cost savings in FREED compared to TAU (-£4472, p = .06, CI -£9168, £233).

DISCUSSION

FREED is robust and scalable and is associated with substantial improvements in clinical outcomes, reduction in inpatient or day-patient admissions, and cost-savings.

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 .

Clinical and Cognitive Functioning Changes After Partial Hospitalization in Patients With Anorexia Nervosa

Introduction: Anorexia nervosa is usually associated with emotional and cognitive difficulties. Little knowledge is available about the changes in cognitive functioning in patients undergoing treatments. The aim of the present study was to longitudinally assess the impact of partial hospitalization on clinical and cognitive functioning in anorexia nervosa. Materials and Methods: 56 women with anorexia nervosa according to DSM-5 criteria and 58 healthy women were enrolled in the study. At baseline, all participants underwent clinical, diagnostic and neuropsychological assessment (T0). Patients were also assessed at the end of the treatment program (T1; n = 56). Results: BMI improved significantly throughout treatment. At baseline, patients showed significantly poorer executive abilities and less specific autobiographical memory. After the day-hospital program, decision-making abilities improved significantly. Response to treatment was predicted by BMI at admission and duration of illness, but neuropsychological performance did not contribute to the prediction model. Discussion: Cognitive difficulties, mostly regarding executive functions, resulted differently affected by clinical improvement. In particular, while cognitive monitoring and cognitive inhibition appear to be mostly stable trait-like characteristics, decision-making is both more state-dependent and sensitive to clinical status. None of the cognitive variables added information about the response to day hospital treatment; patients with short duration of illness and a rapidly decreasing BMI would benefit more from intensive interventions than less "acute" patients. These observations, if confirmed by future studies, have important clinical implications in order to understand the impact of malnutrition on cognitive functioning and to provide individualized effective treatment for patients with anorexia nervosa.

Psychological Impact of Pro-Anorexia and Pro-Eating Disorder Websites on Adolescent Females: A Systematic Review

(1) Background: Teenagers (in particular, females) suffering from eating disorders report being not satisfied with their physical aspect and they often perceive their body image in a wrong way; they report an excessive use of websites, defined as PRO-ANA and PRO-MIA, that promote an ideal of thinness, providing advice and suggestions about how to obtain super slim bodies. (2) Aim: The aim of this review is to explore the psychological impact of pro-ana and pro-mia websites on female teenagers. (3) Methods: We have carried out a systematic review of the literature on PubMed. The search terms that have been used are: "Pro" AND "Ana" OR "Blogging" AND "Mia". Initially, 161 publications were identified, but in total, in compliance with inclusion and exclusion criteria, 12 studies have been analyzed. (4) Results: The recent scientific literature has identified a growing number of Pro Ana and Pro Mia blogs which play an important role in the etiology of anorexia and bulimia, above all in female teenagers. The feelings of discomfort and dissatisfaction with their physical aspect, therefore, reduce their self-esteem. (5) Conclusion: These websites encourage anorexic and bulimic behaviors, in particular in female teenagers. Attention to healthy eating guidelines and policies during adolescence, focused on correcting eating behavioral aspects, is very important to prevent severe forms of psychopathology with more vulnerability in the perception of body image, social desirability, and negative emotional feedback.

The psychenet public health intervention for anorexia nervosa: a pre-post-evaluation study in a female patient sample

Aim This non-randomized pre-post-intervention study investigated the effect of a systemic public health intervention on the length of time between anorexia nervosa symptom onset and contact with the health care system as well as the initiation of treatment.

BACKGROUND

Although systemic public health interventions have successfully been implemented in physical and mental health fields, their effect on the early treatment of patients with anorexia nervosa remains unclear.

METHODS

In total, 59 anorexia nervosa patients (mean age=21.5 years, SD=7.2) were recruited before a systemic public health intervention, and 18 patients (mean age=22.2 years, SD=8.9) were recruited afterwards. Using validated self-report measures and a semi-structured interview, the duration of untreated anorexia nervosa and the duration until first contact with the health care system were investigated. Findings At the beginning of the individual treatment initiation process, participants in both samples most frequently consulted their general practitioner or paediatrician about their eating disorder-related symptoms. Neither the mean duration of untreated anorexia nervosa, that is, the time between illness onset and the initiation of a recommended treatment, nor the duration until first contact with the health care system significantly decreased after the implementation of the systemic public health intervention. The mean duration of untreated anorexia nervosa was 36.5 months (SD=68.2) before the systemic public health intervention and 40.1 months (SD=89.4) after the implementation of the systemic public health intervention. The mean duration until first contact with the health care system was 25.0 months (SD=53.0) before the intervention and 32.8 months (SD=86.5) after the intervention.

CONCLUSION

Primary care providers are crucial to the treatment initiation process and should be involved in future interventions to improve early detection and treatment commencement amongst patients with anorexia nervosa.

Proeating disorder websites and subjective well-being: A four-country study on young people

OBJECTIVE

Proeating disorder (pro-ED) communities online encourage harmful weight-loss and weight-control practices. This study examined the association between exposure to pro-ED content online and subjective well-being (SWB) among adolescents and young adults in four countries.

METHOD

Cross-national data were collected in the US, Germany, the UK and Finland from Internet users aged 15-30 years (N = 3,557; 50.15% male). The questionnaire assessed SWB, exposure to harm-advocating websites, online activity, prior victimization, and social belonging. Ordinary least squares (OLS) regression models assessed the relationship between SWB and pro-ED exposure and adjusted for a number of confounding factors.

RESULTS

Of the participants, 17% had been exposed to pro-ED content (US 20%, Germany 7%, UK 21%, Finland 22%). Exposure to pro-ED content online was negatively associated with SWB in the US, Germany, and Finland, also after adjusting for the confounding factors. Offline social belonging moderated the association between pro-ED and SWB.

DISCUSSION

Participants who visited pro-ED websites reported lower SWB than others did. The potentially harmful impact of visiting these sites was buffered by the strong offline social belonging. Given the observed similarities across the countries, it is important for families, health professionals, and educators to stay abreast of online communities that have possible contra recovery influences and to be able to discuss such Internet contents in a way that increases treatment motivation. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2017; 50:50-57).

Non-traditional biomarkers of eating disorder symptoms among female college students

Background: Eating disorders (ED) are often diagnosed at an advanced stage because traditional symptoms related to unhealthy eating habits are poorly recognized. ED may be also associated with non-traditional and objective biomarkers, which could prove an important screening tool to support health care professionals in diagnosing, treating, and ultimately preventing ED. Aim: To investigate the association between non-traditional physiological ED biomarkers and symptoms of ED among female college students. Methods: This study included 113 female college students, aged 18 to 23 years, enrolled in their first semester as a Bachelor of Health Sciences undergrad at public universities in the urban zone of Recife, Brazil. Symptoms of ED were measured by self-report questionnaires. Circulating levels of IL-6, IL-10, leptin, insulin, ghrelin, PYY and adiponectin were assessed using commercial immunoassays. Results: Students with symptoms of an ED exhibited higher values of IL-6 (p = 0.03) and leptin (p < 0.001) compared to those without symptoms. A positive correlation was found between leptin levels and bulimia nervosa (r = 0.42; p = 0.00), between leptin levels and binge eating (r = 0.38; p = 0.00), and between IL-6 concentrations and binge eating (r = 0.25; p = 0.04). Multiple linear regression analysis with anorexia nervosa, bulimia nervosa and binge eating as dependent variables showed that IL-6 and leptin best explained ED symptoms, even when adjusted for body mass index (BMI). Conclusions: These findings suggest that peripheral peptides, namely leptin and IL-6, are associated with symptoms of ED in female college students. Future studies are needed to determine if there is a causal relationship between these biomarkers and the onset of ED. Relevance for patients: If future longitudinal studies demonstrate causality between the biomarkers assessed here and ED symptoms, these serum makers could be used as screening tool for inappropriate eating behavior. This may in turn improve the early diagnosis, treatment, and, ultimately, the prognosis of patients with ED.

Children's Eating Attitudes Test: Reliability and validation in Japanese adolescents

Eating disorders (ED) are serious psychosomatic disorders that commonly occur in girls during adolescence. An increase in earlier onset ED has recently been suggested. Therefore, accurate assessment of eating attitudes in children is a necessary part of school mental health. The 26-item Children's Eating Attitudes Test (ChEAT-26) is widely used internationally to assess abnormal eating attitudes. The present study aimed to validate the Japanese version of the ChEAT-26. Participants were 7076 school children (aged 10-15years) from large, medium-sized, and small cities, and 44 children with anorexia nervosa. We examined the average ChEAT-26 score by participant attributes, including sex, age, geographical region, and school style. Factor analysis of the ChEAT-26 content was performed with varimax rotation. The optimal cut-off point was evaluated using receiver operating characteristic (ROC) analysis. The mean ChEAT-26 score was 7.94 for girls and 5.86 for boys. The mean score was significantly higher in children from larger cities than small cities, and was higher with increasing age, and private schools. Five factors explained 31.4% of the variance. The Cronbach's alpha was 0.81 for the scale. The area under the ROC curve was 0.83; sensitivity was 0.69 and specificity was 0.93 for a cut-off score of 18. The Japanese version of the ChEAT-26 is a reliable and valid psychometric tool that may be useful in the triage and assessment of children with anorexia nervosa.

Correlates of health related quality of life in anorexia nervosa

OBJECTIVE

We examined the association between disorder specific factors, comorbidity and health related quality of life (HRQoL) in anorexia nervosa (AN).

METHOD

HRQoL was assessed using the EuroQol-5D visual analog scale (EQ-VAS) in this cross-sectional study. Three regression models were estimated to determine the association between AN subtype (restrictive vs. binge/purge), duration of the eating disorder (ED), age (adolescents vs. adults), ED pathology (EDE-Q), Body Mass Index (BMI), depressive symptoms (PHQ-9), somatic complaints (PHQ-15), anxiety (GAD-7) and EQ-VAS.

RESULTS

The sample comprised 218 female AN patients (mean age = 23.3 years [SD = 8.2]; mean EQ-VAS score = 53.4 [SD = 21.4]). A lower BMI, higher levels of depressive symptoms, and somatic complaints were significantly associated with lower EQ-VAS scores.

DISCUSSION

Findings of the present study suggest that BMI and comorbidity might be more relevant to HRQoL impairments in AN than age, diagnostic subtype, duration of the ED or current psychopathology. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:630-634).

Preventing eating disorders with an interactive gender-adapted intervention program in schools: study protocol of a randomized controlled trial

BACKGROUND

There are a high number of adolescents who are at risk of developing an eating disorder. There is, therefore, a strong need to implement prevention programs aimed at reducing the incidence of eating disorders at this critical age. Among other factors, successful prevention programs have been shown to be interactive, carried out by professionals, focused on educational as well as psychosocial elements and have taken risk factors as well as resources into account. The objective of this study protocol is to present the design of a new prevention program for eating disorders in schools.

METHODS/DESIGN

The gender-adapted prevention program extends over six school hours. It contains interactive and educational elements about eating disorders and their treatment. Participants pass through different exercises and reflect on the influences of the media, self-esteem, body perception and individual resources. A cluster-randomized controlled trial is chosen to evaluate the program. Based on an estimated effect size of d = 0.3 a total of 1848 participants are enrolled in the study. Eating disorder risk, internalization of Western beauty ideals, body dissatisfaction, self-concept as well as anxiety and symptoms of depression are measured before and immediately after the intervention as well as at a six-month follow-up. In addition, the intervention group evaluates the different components of the program.

DISCUSSION

The study intends to test the practicability and efficacy of an interactive, gender-adapted ED prevention program in schools. Moreover, it will provide valuable information about the occurrence of eating disorder risk factors in school-aged children.

TRIAL REGISTRATION

ISRCTN97989348; Registered 19 December 2012.