Management of eating disorders for people with higher weight: clinical practice guideline

Glucagon-like Peptide-1 Receptor Agonists in the Context of Eating Disorders: A Promising Therapeutic Option or a Double-Edged Sword?

Glucagon-like peptide-1 Receptor Agonists (GLP-1 RAs) have been one of the most discussed issues in medicine for the past few years. Initially dedicated to patients with type 2 diabetes mellitus (T2DM), the medicine turned out to be an effective weight-loss treatment for people beyond this population. Whereas their beneficial somatic and metabolic effect are beyond doubt, their possible psychiatric adverse reactions have raised concerns. Eating disorders (EDs) are among the mental illnesses whose number is increasing worldwide. Thus, this review aims to summarize the status of knowledge on the correlation between the popularity of GLP-1 RAs and EDs. The conclusions are not unequivocal, pointing out that GLP-1 ARs have the potential to be an effective therapeutic option in some cases of Eds, but if used inappropriately, may increase morbidity of eating disorders.

New Approaches to the Treatment of Severe Obesity-Prehabilitation as the Key to Success

PURPOSE OF REVIEW

Bariatric surgery (BS) has emerged as a crucial and effective treatment for severe obesity (SO), providing significant and sustained weight loss and improving comorbidities. Optimizing perioperative careparticularly through structured prehabilitation is crucial for improving surgical outcomes and long-term weight management. This review examines the role of prehabilitation, nutrition, psychological support, physical activity, and pharmacologic treatment in improving the effectiveness of BS.

RECENT FINDINGS

Despite the benefits of prehabilitation, there are significant differences in the way it is implemented in different healthcare centers. Protocols vary widely in terms of duration, components and intensity, leading to inconsistencies in patient preparation and postoperative recovery. Many patients still do not receive multidisciplinary support from dietitians, psychologists or physiotherapists prior to surgery, which can affect long-term outcomes. Barriers to effective prehabilitation include a lack of standardized guidelines, insufficient healthcare resources and limited patient adherence due to lack of awareness, low motivation or logistical constraints. Despite its proven benefits, structured prehabilitation lasting at least 3-6 months is not available to all patients, as access remains unequal and suboptimal in many healthcare settings. Prehabilitation is an important but underutilized component of BS preparation. Standardizing protocols and ensuring multidisciplinary, patient-centered support are essential to maximizing surgical benefit. Overcoming barriers such as healthcare system limitations, patient motivation and knowledge gaps is critical to integrating prehabilitation into routine bariatric care. This review emphasizes the need for evidence-based, multimodal prehabilitation strategies to improve perioperative care and long-term outcomes for BS patients.

Development of a Trauma-Informed, Culturally Sensitive Eating-Disorder-Specific Nutrition-Focused Physical Examination Tool: A Modified Delphi Study

Objective: This study aimed to identify components of a trauma-informed, culturally sensitive eating-disorder-specific nutrition-focused physical examination (ED-NFPE) tool. Method: The modified Delphi methodology was used to develop a consensus on the clinical relevance of nine evidence-informed ED-specific nutrition examination domains and 46 components within those domains. Purposive sampling was used to recruit a panel of registered dietitian nutritionist (RDN) experts in the ED field. The panelists responded to survey statements on a five-point Likert scale. The panelists also provided qualitative feedback on domain and component additions, exclusions, modifications, and trauma-informed culturally sensitive examination practice techniques. Results: Twenty-two RDN expert panelists completed Round One of the study, and eighteen panelists completed Round Two (82% retention). Twenty-one were female. Fifteen panelists had ten or more years of experience in ED dietetics. Fifty percent held an advanced practice credential from the International Association of Eating Disorders Professionals (IAEDP). After the two survey rounds, the nine ED-NFPE domains and 46 of the 48 components achieved a consensus for clinical relevance. The panelists proposed two new examination components and provided qualitative feedback for trauma-informed culturally sensitive practice techniques in all nine domains. Conclusions: This modified Delphi study design was chosen to reach a consensus on developing an ED-NFPE tool, as there are few current evidence-based guidelines for nutrition examinations in ED care. An NFPE tool specifically designed to detect the nutrition-related findings of individuals with EDs would strengthen the overall nutrition assessment. RDNs at every level of care and with all degrees of experience could use an ED-NFPE to inform patient treatment goals.

Incorporating Weight-Inclusive Approaches in Higher Education Curriculum for Future Nutrition and Dietetics Professionals

While weight-inclusive approaches are becoming more widely accepted and used in nutrition and dietetics, educators and professionals often lack adequate training. The purpose of this paper is to provide faculty and preceptors with strategies to incorporate weight-inclusive approaches into nutrition and dietetics curricula. We present a framework for demonstrating how students can meet knowledge and competency requirements embedded in courses in nationally accredited nutrition and dietetics programs using a variety of weight-inclusive concepts and learning activities. Providing weight-inclusive approaches is essential for equipping nutrition professionals to offer patient-centered care that minimizes weight stigma and disordered eating.

'Do no harm' - the impact of an intervention for addictive eating on disordered eating behaviours in Australian adults: secondary analysis of the TRACE randomised controlled trial

BACKGROUND

Designing interventions to change addictive eating behaviours is a complex process and understanding the treatment effect on co-occurring disordered eating behaviours is of importance. This study aimed to explore treatment effects of the TRACE (Targeted Research for Addictive and Compulsive Eating) intervention for addictive eating on eating disorder psychopathology, binge eating, reward driven eating and grazing behaviours.

METHODS

This study involved secondary analysis of data from a randomised control trial among 175 participants (18-85 yrs) endorsing ≥ 3 Yale Food Addiction Scale (YFAS) symptoms who were randomly allocated to (1) active intervention, (2) passive intervention, or (3) control group. Change in YFAS, EDE-Q 6.0, Binge Eating Scale, RED-X5 and Short Inventory of Grazing scores were assessed at 3-months (immediate post-intervention) and 6-months (3-months post-intervention) follow-up.

RESULTS

Using Linear Mixed Models, from baseline to 3-months there was a significant reduction in eating disorder global scores in the active intervention [mean decrease - 0.6 (95% CI: -0.8, -0.4)], but not in the passive intervention [-0.2 (95% CI: -0.5, 0.1)] or control groups [-0.1 (95% CI: -0.3, 0.1)]. In the active and passive intervention groups there were significant reductions in reward driven eating [-3.8 (95% CI: -4.9, -2.7; -2.5 (95% CI: -3.9, -1.1), respectively], compulsive grazing (-1.8 (95% CI: -2.4, -1.3); -1.1 (95% CI: -1.7, -0.5), respectively] and non-compulsive grazing scores (-1.4 (95% CI: -1.9, -1.0); -1.1 (95% CI: -1.7, -0.4), respectively], but not in the control group. The reduction in binge eating scores over time was similar for all groups. The reduction in addictive eating symptoms from baseline to 3-months was positively associated with the reduction in eating disorder global scores, binge eating, reward driven eating and grazing behaviours (rs ranged from 0.23 to 0.69).

CONCLUSION

The dietitian-led TRACE intervention which adopted a weight-neutral, harm reduction approach for the management of addictive eating in adults demonstrated positive effects on some co-occurring disordered eating behaviours. Importantly the intervention did not cause any adverse changes in the eating disorder pathologies measured.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12621001079831.

Clinical Experiences Using Family Based Treatment for Eating Disorders

OBJECTIVE

Despite the availability of several evidence-based treatments for eating disorders (EDs), including Family-Based Treatment (FBT), therapist drift from evidence-based treatments in real-life clinical settings is common. This study explores clinicians' use of FBT techniques and identifies clinician-reported barriers to their use in real-world settings.

METHODS

Clinicians (N = 54) who self-identified as using FBT for EDs were recruited through social media, professional listservs, and mental health provider databases. Participants completed an online survey comprised of questions developed alongside ED researchers (n = 5). Questions included quantitative self-rating of frequency of FBT technique use and usefulness, limitations of the treatment, and barriers to effective implementation of FBT.

RESULTS

Descriptive statistics indicated frequent use of most FBT techniques (i.e., Ms > 75 on scales ranging from 0 [never use] to 100 [always use]). On a scale from 0 (not at all a barrier) to 100 (a major barrier), ratings of FBT barriers ranged from 25.07 (i.e., caregiver motivation decreases when learning reasons for ED) to 80.70 (i.e., low time resources). Regarding limitations of FBT, between 37% and 42.6% of participants indicated challenges in establishing an alliance with youth and validating their experiences as barriers to treatment success.

DISCUSSION

Overall, clinicians reported frequent use of FBT techniques. Barriers that received higher mean ratings included items related to emotional processes experienced by caregivers, caregiver/patient beliefs related to weight stigma/diet culture, resource and time-related constraints, and challenges with caregiver buy-in/beliefs about treatment. Future research should explore ways to adapt FBT to address these barriers within naturalistic settings.

Intersectionality in help-seeking for eating disorders: a systematic scoping review

BACKGROUND

Individuals with marginalised social characteristics (e.g. by race/ethnicity, gender, body weight) report experiencing eating disorder (ED) symptoms but do not proportionally access treatment. There may be unique factors experienced by individuals with multiple marginalised social characteristics which are not included in our current understanding of help-seeking for EDs. The present review sought to examine the extent of evidence exploring help-seeking and service utilisation for (EDs) by people with more than one marginalised social characteristic or identity. MAIN: A systematic scoping review was conducted in accordance with the Joanna Briggs Institute guidelines for scoping reviews. Four databases (PsycINFO, PubMED, Embase, Medline) were searched for papers explicitly examining help-seeking or service utilisation for people with more than one marginalised social characteristic or identity (e.g. race/ethnicity, sexual orientation, weight status). Included studies underwent qualitative synthesis employing an existing model of help-seeking adapted for this review. The most common ED investigated was binge eating disorder (BED) and the most frequently reported marginalised characteristics were overweight/obesity and race/ethnicity. Other intersectional characteristics identified included socioeconomic status (SES), gender, and sexual orientation. People with marginalised social identities such as race/ethnicity or gender were more likely to seek help for BED when they also experienced a higher BMI. There was consensus across studies included in this review that help-seeking rates are low for people with an ED.

CONCLUSION

Mental health literacy and cultural beliefs about help-seeking are important factors affecting the experiences of people with intersectional identities and this may impact their likelihood to seek help. Results suggest that future studies should consider the interaction between social characteristics and identities in their analyses of outcomes in EDs as this is an emerging area of research, extension of our findings is also needed. The protocol for this review is registered via PROSPERO number CRD42024525849.

Establishing a psychiatry clinic within an Australian publicly funded specialist obesity service

OBJECTIVE

In January 2023, the Canberra Health Services Department of Bariatric Medicine introduced a psychiatry clinic into its model of care to optimise the management of patients with comorbid obesity and mental illness. This paper describes the scope of the psychiatry clinic and reviews patient characteristics and management during the first year of operation.

METHODS

This study is an outline of the clinic and a retrospective review of patient demographics, body mass index, psychiatric diagnoses and initial management. Descriptive statistics were performed (2024.LRE.00027).

RESULTS

Clinic scope, staffing and patient eligibility were presented. Of the 22 patients referred, 20 attended initial assessment and at least one review (102 encounters). Females outnumbered males (82%). Mean age was 44 years (18-73 years). Mean body mass index was 51.74 kg/m2 (29.36-74.23 kg/m2). Depressive and anxiety disorders were the most prevalent existing diagnoses. Trauma and stressor-related disorders and feeding and eating disorders were common new diagnoses. 75% of patients had two or more psychiatric disorders. Management comprised medications, supportive psychotherapy and referral recommendations.

CONCLUSIONS

This is the first time the Department of Bariatric Medicine has embedded a psychiatry clinic into its model of care. The clinic provides specialist-level psychiatric care within a multi-disciplinary team which may have benefits in managing comorbid obesity and mental illness.

A Narrative Review on the Neurocognitive Profiles in Eating Disorders and Higher Weight Individuals: Insights for Targeted Interventions

Background/Objectives: Recent research has increasingly explored the cognitive processes underlying eating disorders (EDs), including anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding or eating disorders (OSFEDs), and individuals with higher weight (HW). This critical narrative review focuses on neurocognitive findings derived from mainly experimental tasks to provide a detailed understanding of cognitive functioning across these groups. Where experimental data are lacking, we draw on self-report measures and neuroimaging findings to offer supplementary insights. Method: A search of major databases that prioritized meta-analyses and recent publications (last 10 years) was conducted. Using comprehensive search terms related to EDs, HW, and neurocognition, eligible studies focused on human neurocognitive outcomes (e.g., cognitive flexibility, attentional bias, etc.) published in English were selected. Results: We found that some neurocognitive characteristics, such as cognitive rigidity, impulsivity, emotion processing difficulties, and dysregulated reward processing, appear transdiagnostic, spanning multiple ED subtypes and HW populations. We also revealed neurocognitive features specific to ED subtypes and HW. For instance, individuals with AN demonstrate an enhanced focus on detail, and BN and BED are characterized by a pronounced attentional bias toward food-related stimuli. In individuals with HW, cognitive processes underpin behaviours associated with overeating and weight gain. Conclusions: These findings highlight the critical importance of understanding both the unique and shared neurocognitive patterns across ED subtypes and HW populations. By identifying transdiagnostic factors, such as cognitive rigidity and reward processing, alongside ED subtype/HW-specific vulnerabilities, researchers and clinicians can develop more nuanced, evidence-based interventions that address the core mechanisms driving disordered eating behaviours.

Long-Term Follow-Up After Bariatric Surgery: Key to Successful Outcomes in Obesity Management

Background/Objectives: Bariatric surgery (BS) is considered one of the most effective interventions for the treatment of obesity. To achieve optimal long-term results, continuous follow-up (FU) within a multidisciplinary treatment team is essential to ensure patient compliance and maximize the benefits of BS. However, many patients find it difficult to maintain regular FU, which can affect the quality of care and lead to postoperative complications. This review aims to highlight factors that may hinder compliance with FU after BS, examine potential causes and consequences of inadequate FU, and identify strategies to improve patient participation in long-term FU. Methods: The literature search was conducted between October 2023 and June 2024 in Medline (PubMed) and the Cochrane Library datasets. Studies were selected for their relevance to adherence to FU, multidisciplinary approaches, and long-term bariatric outcomes. Results: The pre- and postoperative period is critical for educating patients and healthcare team members about the importance of FU, addressing potential barriers (e.g., logistical, psychological, and social challenges), and highlighting the risk of relapse to obesity after surgery. The lack of a standardized FU protocol leads to differences between medical centers, further impacting patient adherence. Conclusions: Tailored and regularly updated strategies are essential to address individual patient needs and improve adherence to FU. Further research is needed to identify the specific factors that influence variability in long-term BS outcomes, highlighting the need for a patient-centered approach to obesity treatment.

Assessing nutritional adequacy ratios in women with and without binge eating disorder: a comprehensive evaluation

BACKGROUNDS

Bing eating disorder (BED) has been associated with a number of health problems. Remarkably little research has been done to measure dietary intake in people who suffer from binge eating disorder. This study aimed to compare the dietary intake and nutrient adequacy ratio (NAR) between BED individuals and those without BED and also to investigate the association between BED and NAR.

METHODS

In this cross- sectional study, 180 overweight and obese females who aged between 19 and 50 years old and with BMI between 25 and 40 kg/m2 were interviewed. The women were categorized into BED and non- BED groups based on their earned score in Binge Eating Scale (BES) questionnaire. Nutritional adequacy ratio was assessed as Micronutrient adequacy ratio, Macronutrient adequacy ratio and total adequacy ratio (the sum of the previous two) based on last year's dietary intakes collected using a semi-quantitative food frequency questionnaire (FFQ). The odds of binge eating disorder across the nutritional adequacy scores were assessed using multiple logistic regression models. Data were analyzed using SPSS software.

RESULTS

About 41.6% (n = 75) of the subjects were diagnosed with BED. Carbohydrate, saturated fats, sugar levels were significantly higher in women with BED compared to non-BED women (P < 0.05). All vitamins, with the exception of Retinol, and all minerals' levels were significantly lower in BED participants (P < 0.05). Micronutrient adequacy score and total adequacy score differed significantly between individuals with and without BED (P < 0.001) and non- BED group were significantly more nutritional adequate. The odds of having BED were lower in micronutrient, macronutrient adequate individuals (OR = 0.87, 95% CI = 0.78-0.98, P = 0.02), (OR = 0.81, 95% CI = 0.66-0.99, P = 0.049) respectively.

CONCLUSION

Overall, the results demonstrate low intake of key micronutrients and high intake of saturated fatty acids and carbohydrates among binge sufferers. Also, the findings indicate that individuals with BED experience a notably lower nutrient adequacy ratio compared to their peers without the disorder, suggesting that the eating behaviors associated with BED such as high consumption of processed foods and diet with low quality may lead to inadequate intake of vital nutrients.

Navigating the food environment: Experiences of reduced calorie interventions to manage Type 2 Diabetes Mellitus

Research into achieving Type 2 Diabetes Mellitus remission through weight loss efforts has grown steadily in the past decade. Most of this research has focused on the effectiveness of weight loss as a method to achieve remission, rather than considering individuals experiences of engaging with such change. This paper aims to review the qualitative research on individuals' experience of proposed dietary modifications with a weight loss focus. Six databases were searched for qualitative and mixed-methods research studies, and studies were subject to analysis following Thomas and Hardin's guidelines. The search yielded 2945 results, of which 47 were reviewed in full, and nine were included for analysis. Four analytical themes were identified; variability in support; choosing dietary change; re-negotiating the food relationship; and looking beyond weight loss. Providing tailored nutritional information that is comprehensible and culturally appropriate must be the premise of the interventions offered. Supporting patients to understand their relationship with food and identify meaningful goals beyond weight loss is an important starting point.

Predictors of treatment outcome in higher levels of care among a large sample of adolescents with heterogeneous eating disorders

BACKGROUND

Despite widespread use of higher levels of care in treating eating disorders in adolescents, research supporting the use of these treatments remains limited by small sample sizes and a predominant focus on anorexia nervosa. Further, existing data regarding predictors of outcome have yielded mixed findings. In the current study, we evaluated treatment outcomes and predictors of outcome among a large sample of adolescents with eating disorders presenting to inpatient, residential, partial hospitalization programs, and intensive outpatient programs across the United States.

METHODS

Adolescents (N = 1,971) completed self-report measures of eating disorder symptoms, depression, and anxiety at treatment admission, stepdown, and discharge. Using linear mixed effect models, we evaluated changes in symptoms over treatment separately among youth admitted to inpatient/residential treatment and those admitted to partial hospitalization/intensive outpatient programs, and used established metrics to gauge frequency of reliable (i.e., statistically reliable) and clinically significant change.

RESULTS

Results suggested decreases in eating disorder symptoms, depression, and anxiety from intake to discharge. Around 50% of the sample reported reliable decreases in eating disorder symptoms at stepdown and discharge, with 30% of the sample reporting reliable reductions in depression and anxiety. Psychiatric comorbidity, primary diagnosis, age, and eating disorder symptoms at admission consistently predicted treatment-related change, although patterns in findings varied across symptoms.

CONCLUSIONS

Data from our sample are consistent with past work suggesting that adolescents enrolled in higher levels of care report clinical benefit; however, these effects are heterogenous, and a significant portion of individuals may not report reliable change in symptoms. Ultimately, ongoing work is required to better understand how and for whom higher levels of care may achieve their benefit and to identify the optimal approach for improving outcomes for adolescents with eating disorders.

Summary of the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome: an Australian perspective

INTRODUCTION

The Australian-led 2023 International evidence-based guideline for the assessment and management of polycystic ovary syndrome was based on best available evidence, clinical expertise and consumer preference. It followed best practice, involved extensive evidence synthesis and applied relevant frameworks across evidence quality, feasibility, acceptability, cost and implementation. Thirty-nine societies and organisations covering 71 countries were engaged. The evidence in the assessment and management of polycystic ovary syndrome (PCOS) has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report, 52 systematic reviews and analyses (approximately 6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points.

MAIN RECOMMENDATIONS

Changes include: refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only, and differentiation of adolescent and adult criteria; strengthening the recognition of broad features of PCOS including metabolic effects, cardiovascular disease, dermatological symptoms, sleep apnoea, a high prevalence of psychological features and a high risk of adverse pregnancy outcomes; emphasising the poorly recognised, diverse burden of disease, the vital need for greater health professional education, evidence-based patient information, improved models of care, shared decision making and research efforts to improve patient experience; maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and emphasising evidence-based medical therapy and cheaper and safer fertility management.

CHANGES IN MANAGEMENT AS A RESULT OF THIS GUIDELINE

The 2023 guideline is approved by the National Health and Medical Research Council and provides clinicians and patients with clear advice on best practice in a common and neglected condition, based on the best available evidence, expert multidisciplinary input and consumer preferences. It provides vital, extensive patient and provider resources to enhance evidence-based care. The full guideline is available at www.monash.edu/medicine/mchri/pcos/guideline.

US Military Veteran Perspectives on Eating Disorder Screening, Diagnosis, and Treatment: A Qualitative Study

OBJECTIVE

We aimed to explore US veteran perspectives on eating disorder screening, diagnosis, patient-provider conversations, and care in the Veterans Health Administration (VHA).

METHOD

Rapid qualitative analysis of 30-45 min phone interviews with 16 (N = 16) veterans with an electronic health record ICD-10 eating disorder diagnosis, who received care at one of two VHA healthcare systems in Connecticut or California. Topics covered included: conversations with providers about eating disorder symptoms, diagnosis, and referral to treatment; feedback about an eating disorder screener, and; reflections on eating disorders among veterans and VHA's effort to address them.

RESULTS

Most veterans reported difficulty understanding and defining the problems they were experiencing and self-diagnosed their eating disorder before discussing it with a provider. Treatment referrals were almost universally for being overweight rather than for an eating disorder, often leading veterans to feel misunderstood or marginalized. Overall, veterans were enthusiastic about the screener, preferred screening to be conducted by primary care providers, and noted that conversations needed to be non-stigmatizing. There was consensus that VHA is not doing enough to address this issue, that group support and therapy could be beneficial, and that resources needed to be centralized and accessible.

DISCUSSION

For the most part, veterans felt that, at best, eating disorders and disordered eating are overlooked, and at worst, conflated with overweight. The majority of veterans got referred for weight loss or weight management services but would welcome the opportunity to be screened for, and referred to, eating disorder treatment.

Managing patients with eating disorders: a qualitative study in primary care

BACKGROUND

GPs play a key role in the diagnosis and management of eating disorders (EDs).

AIM

To explore GPs' experiences of managing patients with EDs.

DESIGN & SETTING

A qualitative study utilising remote semi-structured interviews in the UK.

METHOD

Fourteen GPs were interviewed about their experiences of supporting patients with EDs. The interviews were recorded, transcribed, and analysed using thematic analysis.

RESULTS

The analysis described the following four themes: (i) 'Continuity of care', addressing the GP's relationship with patients and family, patient transitions across life stages and geographical areas, and patient non-attendance; (ii) 'The role of guidance', focusing on guidelines and protocols, referrals and specialist professionals as points of contact; (iii) 'Structural barriers', including waiting times, lack of resources, referral criteria, and relationships between services; (iv) 'Confidence and skills', reflecting professional and personal experience in EDs, previous training and training needs. Transcending these themes was the notion of the 'Limits to the care' GPs can provide owing to professional boundaries and the emotional impact of managing patients with EDs.

CONCLUSION

This study found that while GPs want to help patients with EDs many limits remain to the care they can provide owing to both internal and external factors. Funding is required for training and accessible specialist ED support, and greater clarity is needed regarding referral processes if ED management in primary care is to be optimised.

Adaptation of mental health first aid guidelines for eating disorders for Iran

BACKGROUND

This study aimed to adapt mental health first aid guidelines to support individuals with or at risk of developing eating disorders in Iran. This adaptation seeks to enhance the support available for the Iranian population dealing with these disorders.

METHODS

We employed the Delphi expert consensus method, utilizing two panels: health professionals (n = 37 in the first round; n = 29 in the second) and individuals with lived experience (n = 20 in the first round; n = 18 in the second). The health professionals panel was selected from the graduates of various eating disorders associated scientific fields who had a history of providing services to or conducting research on people with eating disorders, and the lived experience panel had a history of eating disorders themselves or in their family. The panel of individuals with lived experience included those who had personal or familial histories of eating disorders. Efforts were made to ensure cultural, gender, and age diversity in the selection of panel members. Panellists rated the importance of each item for inclusion in the guidelines for Iran based on the English-language Mental Health First Aid guidelines for eating disorders. Items deemed essential by at least 80% of both panels were included in the final guideline. Additionally, panel members were invited to suggest any missing items.

RESULTS

A total of 57 participants took part in the first round of the survey, and 47 participated in the second round. In the first round, 204 items across 11 categories were assessed, with 174 items endorsed by the panels. Thirteen items were re-scored in the second round, and 17 items were rejected. Participants suggested 11 new items in the first round. In the second round, 18 out of 24 items were endorsed, while six were rejected. Ultimately, 192 items were incorporated into the Iranian guidelines.

CONCLUSIONS

The adaptation process considered Iran's social and cultural characteristics, including the stigma associated with mental health disorders, religious beliefs and rituals such as fasting, linguistic differences between English and Farsi, distrust of strangers, the influence of friends and family, differences in food access, and low mental health literacy. We recommend piloting the adapted guidelines in high schools, universities, and non-governmental organizations to evaluate their feasibility and effectiveness in real-world settings. Furthermore, it is essential to establish mechanisms for feedback, update content based on the latest evidence, and collaborate with the media to promote educational programs and public participation.

Two identical twin pairs discordant for longstanding anorexia nervosa and OSFED: lived experience accounts of eating disorder and recovery processes

Research into the risk of anorexia nervosa (AN) has examined twin pairs to further the understanding of the contributions of genetics, trait inheritance, and environmental factors to eating disorder (ED) development. Investigations of twin experiences of EDs have been biologically-based and have not considered the qualitative, phenomenological aspects of twin experiences. A gap in the literature exists regarding understanding of discordant twins with EDs. This research was developed in response, with the aim to deepen understanding of AN in discordant twins and to create novel ideas for further research and testing. The case studies presented in this article provide lived experience insights of two identical discordant twin pairs: one twin pair discordant for longstanding AN and one twin pair discordant for 'atypical' AN (the twin with AN has recovered). The perspectives and experiences of each co-twin (one with AN and one without) explore a number of factors that may have contributed to twin discordance in these cases, and how each twin has responded to the impact of AN in their lives. Through use of first-person accounts in case study presentation, this article centres social justice values of lived experience leadership and involvement in research. This article aims to extend current knowledge and understanding of EDs in discordant twins, particularly regarding risk for ED development, ED duration, diagnosis and treatment, and recovery processes.

Behavioral weight loss treatment for adults with binge-eating disorder: A qualitative analysis of patients' perspectives and experiences

OBJECTIVE

Understanding the perspectives of behavioral weight loss (BWL) participants could inform whether, how, and for whom BWL should be offered.

METHOD

All 126 participants in a clinical trial of BWL for adults with binge-eating disorder (BED) and overweight/obesity were contacted about a qualitative study. 45 participants, 11 of whom had dropped out of the parent study, completed qualitative interviews. The interview guide was developed using data from a survey of providers who offer Health at Every Size and other weight-neutral lifestyle interventions. Questions were phrased to invite even the most negative responses. Questions focused on participants' experiences of weight stigma during treatment, perceptions of BWL's calorie and WL goals, and opinions of BWL and weight-neutral interventions.

RESULTS

We identified four themes using thematic analysis: (1) BWL did not perpetuate weight stigma. (2) Calorie and WL goals did not exacerbate participants' binge eating. (3) Patients should have the right to pursue any treatment that aligns with their personal goals. (4) BWL can improve participants' overall health.

DISCUSSION

BWL participants with BED and overweight/obesity want others to have access to a program that can reduce both weight and binge eating. Participants emphasized that no treatment works for everyone, and they all agreed that BWL had not perpetuated weight stigma. Fewer than 20% of participants considered the program's calorie and WL goals to be harmful; most participants viewed those goals as achievable and helpful, and many asserted that their participation in BWL had improved their overall health.

PUBLIC SIGNIFICANCE

We interviewed adults with binge-eating disorder and overweight/obesity who had participated in a behavioral weight loss (BWL) program. Our participants wanted others in their position to have access to BWL because it aims to reduce both weight and binge-eating frequency. Efforts should be made to provide patients, clinicians, and policymakers with the knowledge that supervised, evidence-based BWL is an effective and desired treatment choice for this population.

Gender differences in body composition, dietary patterns, and physical activity: insights from a cross-sectional study

Introduction

This study investigates the interplay between body composition, dietary patterns, and physical activity across genders, focusing on gender-specific differences in food preferences and eating behaviors. Understanding these interactions is crucial for developing targeted nutritional and lifestyle interventions.

Methods

A cross-sectional study was conducted with 1,333 participants (58.7% female, 41.3% male), aged 18-65 years. Participants were categorized into tertiles based on their fat mass to fat-free mass (FM-to-FFM) ratio. Data on dietary choices, eating behaviors, and physical activity were collected and analyzed to identify gender-specific trends.

Results

Significant gender-specific differences were observed in food preferences and eating behaviors. Males experienced greater hunger in the late afternoon, while females felt more hunger in the morning. Males showed a preference for processed and red meats, whereas females preferred cooked vegetables. Eating behaviors such as meal skipping, uncontrolled eating, nocturnal eating, and taste preferences (sweet or salty) varied distinctly between FM-to-FFM tertiles and genders. Higher FM-to-FFM ratios correlated with lower physical activity levels, particularly in strength training and general sports engagement.

Discussion

These findings highlight the complex interactions between body composition, dietary habits, and lifestyle factors, emphasizing gender-specific differences. The results suggest that body composition and BMI significantly impact health-related behaviors, necessitating tailored interventions to address these differences and promote healthier lifestyles.

'Beyond the Scale': A Qualitative Exploration of the Impact of Weight Stigma Experienced by Patients With Obesity in General Practice

OBJECTIVE

Obesity is a complex, chronic, relapsing disease that requires an individualised approach to treatment. However, weight stigma (WS) experienced in healthcare settings poses a significant barrier to achieving person-centred care for obesity. Understanding the experiences of people living with obesity (PwO) can inform interventions to reduce WS and optimise patient outcomes. This study explores how patients with obesity perceive WS in general practice settings; its impact on their psychological well-being and health behaviours, and the patients suggestions for mitigating it.

METHODS

In-depth semistructured interviews were conducted with 11 PwO who had experienced WS in general practice settings in Ireland. The interviews were conducted online via Zoom between May and August 2023; interviews lasted between 31 and 63 min (M = 34.36 min). Interviews were audio-recorded, transcribed verbatim and analysed using inductive reflexive thematic analysis.

RESULTS

Three overarching themes specific to participants' experience of WS in general practice were generated: (1) shame, blame and 'failure'; (2) eat less, move more-the go-to treatment; (3) worthiness tied to compliance. A fourth theme: (4) the desire for a considered approach, outlines the participants' suggestions for reducing WS by improving the quality of patient-provider interactions in general practice.

CONCLUSION

The findings call for a paradigm shift in the management of obesity in general practice: emphasising training for GPs in weight-sensitive communication and promoting respectful, collaborative, and individualised care to reduce WS and improve outcomes for people with obesity.

PATIENT OR PUBLIC CONTRIBUTION

PPI collaborators played an active and equal role in shaping the research, contributing to the development of the research questions, refining the interview schedule, identifying key themes in the data, and granting final approval to the submitted and published version of the study.

Medical Nutrition Education for Health, Not Harm: BMI, Weight Stigma, Eating Disorders, and Social Determinants of Health

Effective nutrition training is fundamental to medical education. Current training is inadequate and can cause harm to students and patients alike; it leaves physicians unprepared to counsel on nutrition, places undue focus on weight and body mass index (BMI), can exacerbate anti-obesity bias, and increase risk for development of eating disorders, while neglecting social determinants of health and communication skills. Physicians and educators hold positions of influence in society; what we say and how we say it matters. We propose actionable approaches to improve nutrition education to minimize harm and pursue evidence-based, effective, and equitable healthcare.

Dismantling the myth of "all foods fit" in eating disorder treatment

We call for a reevaluation of the long-standing dogmatic nutritional principle that "all foods fit" for all cases of eating disorders (EDs) and its corollary, "there are no bad foods" (for anyone ever) during ED treatment. Based on accumulated scientific research, we challenge these ideologies as outdated, confusing, and potentially harmful to many patients. We review the evidence that indicates the folly of these assumptions and show there are a variety of exceptions to these rules, including (1) food allergies, sensitivities, and intolerances, (2) religious and spiritual preferences or doctrines, and (3) the ubiquitous emergence and widespread availability of ultra-processed foods leading to the potential development of addiction-like eating and a higher prevalence of various medical and psychiatric comorbidities, as well as higher mortality. This evidence supports a nutritional psychiatry approach that should be integrated into (rather than dissociated from) ED treatment research and practice.

A prospective observational study examining weight and psychosocial change in adolescent and adult eating disorder inpatients admitted for nutritional rehabilitation using a high-energy re-feeding protocol

BACKGROUND

High-energy re-feeding protocols are increasingly utilised for nutritional rehabilitation in adolescents with anorexia nervosa (AN), however, concern persists that adults with AN may be at greater risk of developing complications. In addition, research on psychological outcomes of eating disorder (ED) inpatient treatment programs, and outcomes of high-energy protocols in avoidant restrictive food intake disorder (ARFID) and bulimia nervosa (BN), is limited. This study of an ED inpatient program using a high-energy protocol, compared changes in weight and psychosocial outcomes between adolescents and adults, and identified medical risk factors associated with deviation from the protocol.

METHOD

This prospective observational study took place in a voluntary ED treatment program in a private hospital. Weight, height, and psychosocial questionnaires (ED Examination-Questionnaire, Depression Anxiety Stress Score, Clinical Impairment Assessment and AN/BN Stage of Change) were collected from consenting adolescents (16-20 years) and adults (> 20 years) on admission and discharge. Medical tolerance to the high-energy protocol was assessed daily. Independent samples t-tests and paired samples t-tests were applied to normally distributed data, and Mann-Whitney U tests and Wilcoxon signed-rank tests to skewed data. P-values < 0.05 were considered significant statistically.

RESULTS

Ninety-seven participants were recruited. The majority (n = 91, 94%) were female and most (n = 80, 83%) had AN. Forty-two (43%) were adolescents and 55 (57%) were adults. In participants with AN, weight change (Δ) was significant [median Δ 8.0 (interquartile range (IQR) 4.3) kg]. There was no difference in rate of weight change between adolescents and adults with AN [mean Δ 1.8 (standard deviation (SD) 0.5) kg/week vs. Δ 1.8 (SD 0.6) kg/week; p = 0.841, respectively]. One (1%) participant with AN did not tolerate the high-energy protocol due to oedema. Participants achieved positive change in psychosocial questionnaire scores (p < 0.001) after the the specialist ED program, with no difference between adolescents and adults (p > 0.05).

CONCLUSIONS

This voluntary ED treatment program using a high energy re-feeding protocol was effective in achieving positive weight and psychological change for adolescents and adults with minimal adverse events. This indicates that the specialist ED program has both nutritional and psychological benefits.

Course and outcome in individuals with atypical anorexia nervosa: Findings from the Study of Refeeding to Optimize iNpatient Gains (StRONG)

OBJECTIVE

We previously reported that participants with atypical anorexia nervosa (atypical AN) had higher historical and admission weights, greater eating disorder psychopathology, but similar rates of amenorrhea and weight suppression at baseline as compared to anorexia nervosa (AN); here, we compare 1-year outcomes.

METHOD

Weight, % median body mass index (%mBMI), Eating Disorder Examination Questionnaire (EDE-Q) scores, resumption of menses, and rehospitalizations were examined at 3, 6, and 12 months post-discharge. Analyses (N = 111) compared changes in %mBMI, weight suppression, and EDE-Q scores over time between atypical AN and AN.

RESULTS

Among the participants (48 atypical AN, 63 AN), both groups gained weight but those with atypical AN had lower gains than those with AN in %mBMI (p = .02) and greater weight suppression (p = .002) over time. EDE-Q scores improved over time, independent of weight suppression, with no significant difference between atypical AN and AN. Groups did not differ by rates of resumption of menses (80% atypical AN, 76.9% AN) or rehospitalization (29.2% atypical AN, 37.9% AN). Greater weight suppression predicted longer time to restore menses and more days of rehospitalization.

DISCUSSION

Individuals with atypical AN regained a smaller proportion of body mass and were more weight suppressed over time. Change in eating disorder cognitions, resumption of menses, and rehospitalization rates at 1-year follow-up did not differ between groups. There was no significant difference in weight suppression between groups for those who were psychologically improved at 12 months. Findings highlight limitations in our understanding of weight recovery in atypical AN. New metrics for recovery are urgently needed.

PUBLIC SIGNIFICANCE

Little is known about outcome in atypical anorexia nervosa (atypical AN). We examined recovery metrics in young people with atypical AN and anorexia nervosa (AN) 1 year after medical hospitalization. Individuals with atypical AN showed slower weight gain and remained further from their pre-illness weight. There were no differences in the rates of psychological recovery, resumption of menses, or rehospitalization. New metrics are needed to assess recovery in atypical AN.

Time to revisit the definition of atypical anorexia nervosa

In this special issue, international researchers investigate how atypical anorexia nervosa (atypical AN) differs from anorexia nervosa (AN) and other eating disorders with respect to demographics, psychological and physiological morbidity, as well as treatment course and outcome. Manuscripts in this special issue report that atypical AN is associated with substantial medical and psychological morbidity, and the majority of studies find few differences between atypical AN and AN. While much remains to be learned about the long-term course and treatment response of individuals with atypical AN to psychological and pharmacological interventions, the evidence supports conceptualization of atypical AN as part of a spectrum-based restrictive eating disorder. These findings together with the potentially stigmatizing use of the term "atypical" suggest it may be time to revise the existing definition of atypical AN.

The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study

OBJECTIVE

Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED.

METHOD

This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change.

RESULTS

Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21-30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1-17.3) kg/m2 . The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930-1500) kcal/day. Seventy-three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93-1.00], p = .035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission.

DISCUSSION

The incidence of severe RFS was low in this cohort and was associated with lower admission weight.

PUBLIC SIGNIFICANCE

This study is one of the largest studies to utilize consensus-defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced.

The Role of the Pediatrician in the Promotion of Healthy, Active Living

Few children and adolescents meet federal nutrition or physical activity recommendations, and many experience poor or inadequate sleep and negative health effects from screen use and social media. These lifestyle factors exacerbate physical and mental health risks for children and adolescents. This clinical report provides guidance to help pediatricians address the nutritional, physical activity, sleep, media and screen use, and social-emotional factors that affect child and adolescent health and wellness. The recommendations in this clinical report aim to promote health and wellness practices for infants, children, and adolescents across several domains of influence, including the individual, interpersonal, institutional, community, and public policy levels.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

The treatment of dissociative identity disorder in an eating disorder residential treatment setting

OBJECTIVE

Child maltreatment, dissociation and dissociative disorders have been noted in relationship to eating disorders (EDs) for decades, and their co-occurrence generally is associated with greater morbidity, self-harm and mortality. The concomitant presentation of dissociative identity disorder (DID) with an ED (ED + DID) is especially challenging, and there is limited information on approaches to and the effects of integrated treatment for this serious comorbidity, especially in higher levels of care. There are also limited treatment resources for such patients, since they are often turned away from specialty units due to lack of expertise with or bias toward one or the other disorder.

METHOD

We report our experience with a case series of 18 patients with DSM-5 defined ED + DID (mean age (SD) = 32.6 (11.8) years) admitted to residential treatment (RT) and assessed using validated measures for symptoms of ED, major depression (MD), PTSD, state-trait anxiety, quality of life (QOL), age of ED onset, and family involvement during treatment. All patients received integrated, multimodal, trauma-focused approaches including those based on DID practice guidelines, principles of cognitive processing therapy (CPT), and other evidence-based approaches. Fifteen of 18 patients also completed discharge reassessments, which were compared to admission values using paired t-tests.

RESULTS

Following integrated, trauma-focused RT, patients with ED + DID demonstrated statistically significant improvements in all measures, with medium (anxiety) to high (ED, PTSD, MD, QOL) effect sizes.

DISCUSSION

These results provide positive proof of concept that patients with ED + DID can be effectively treated in a specialty, trauma-focused ED program at higher levels of care.

PUBLIC SIGNIFICANCE

EDs and dissociative identity disorder (DID) are related conditions, but little is known about treating patients with both conditions. We describe the clinical features and integrated treatment of 18 such patients, 15 of whom completed discharge assessments. Significant clinical improvements were found in multiple domains (ED, PTSD, mood, anxiety, quality of life), which demonstrate positive proof of concept that ED + DID can be effectively treated in a specialty, trauma-focused ED program.

What medical providers need to elevate outpatient care for adolescents and young adults with binge-eating disorder: A novel protocol

PURPOSE

Binge-eating disorder (BED) in adolescents and young adults is underrecognized and understudied and no standardized guidelines exist for medical providers caring for this population. To highlight the lack of extant evidence, we examine the demographic characteristics of youth with BED in an academic eating disorders (EDs) program and primary care clinic and describe the needs of their medical care providers.

METHOD

A retrospective chart review was conducted for patients who met criteria for BED from July 2021 to June 2022. We surveyed their medical providers to understand their needs in caring for this population. A multidisciplinary team with expertise in the care of youth with EDs amalgamated current evidence in caring for youth with BED into a protocolized care schema designed for implementation in the outpatient medical setting.

RESULTS

Eighteen youth with BED were reviewed, 14 identified as female, 3 as male, and 1 as "Other." Average age was 15.4 (2.7) years old, and mean body mass index was 35.90 (8.25). 33.3% (6) patients identified as White/Caucasian, followed by 22.2% (4) Hispanic/Latinx. Eleven of 18 were privately insured. The most common medical recommendations were for regular meals and snacks and for individual psychotherapy. Medical providers desired more education about identification and management of youth with BED.

CONCLUSIONS

To address the lack of medical care guidelines for youth with BED, recommendations in this Forum include: increased education for medical providers, standardized medical monitoring, an emphasis on psychotherapy, and a weight-inclusive orientation.

PUBLIC SIGNIFICANCE

Adolescents and young adults with BED are underrecognized and undertreated. Little is known about the characteristics of these patients and the medical care these patients receive within academic EDs program. For the first time, preliminary recommendations for medical care are provided.

Body appearance values modulate risk aversion in eating restriction

The understanding of eating disorders is hindered by the lack of integration between existing psychosocial and neurobiological approaches. We address this problem by developing a novel transdiagnostic and computational approach to eating restriction decisions. We first validated a novel paradigm which extends an established monetary risk task to involve body stimuli with psychosocial values. We used advanced behavioral data analysis of a large (total N = 539) sample of women from across the eating restraint spectrum, including those with anorexia nervosa (AN; n = 31), recovered from AN (n = 23), and subclinical women with varying levels of eating restraint (n = 485), obtained from an online experiment, public event, and laboratory-based study. We found that social and motivational values regarding body appearance have a significant effect on value-based, decision making in eating restriction. Subsequently, validated descriptive and predictive advanced computational modeling indicated that these behaviors are driven by an aversion to risk rather than loss, with desirable body outcomes being associated with less risk aversion, and undesirable body outcomes linked to greater risk aversion. These findings indicate that cognitive and social factors influence eating decisions by distinct mechanisms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

"I Need Someone to Help Me Build Up My Strength": A Meta-Synthesis of Lived Experience Perspectives on the Role and Value of a Dietitian in Eating Disorder Treatment

Dietitians are included in eating disorder (ED) treatment teams for their expertise in nutrition. However, little is known about an individual's experience of dietetic intervention as part of their ED treatment and what they value as part of dietetic care. Therefore, the aim of this review was to synthesise the available qualitative literature to understand the role and value of a dietitian in ED treatment from the perspective of individuals with lived experience. Six databases and Google Scholar were searched and a thematic synthesis and meta-synthesis of fifteen studies were conducted. Four themes were constructed from the data: (1) "guidance and structure"-Provision of nutrition knowledge and skills; (2) "having all my bases covered"-Dietitians as part of a multidisciplinary team; (3) Challenges in nutritional treatment; and (4) "it was my treatment and my recovery"-Person-centred dietetic treatment. Across all identified themes was the cross-cutting theme of a shared treatment journey between the dietitian and the individual receiving treatment. These findings support dietitians having a role that is not limited only to the provision of nutrition treatment in ED care and illustrates the importance of dietitians engaging with clients by centring on the individual's needs and preferences. Further understanding helpful dietetic treatment components and identifying gaps in training is needed to develop these broader roles for dietetic care.

Avoidant/restrictive food intake disorder (ARFID) in New Zealand and Australia: a scoping review

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder that involves restrictive or avoidant eating behaviour not related to weight or body image concerns. It was first included in the Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) in 2013. ARFID frequently begins in childhood and can have serious psychosocial impacts and detrimental health consequences when nutritional and energy needs are persistently unmet. This systematic scoping review focuses on Australasia, synthesizing the current literature landscape on ARFID, and offering recommendations for targeted, actionable research directions for both funders and researchers.

METHODS

Online databases and university thesis repositories were systematically searched for studies examining ARFID in the New Zealand or Australian population since 2013. Database search results were exported to Rayyan software, and two independent reviewers screened all identified sources, prior to extraction of key data.

RESULTS

Twenty-nine studies and one thesis from 138 screened sources were eligible for inclusion. Frequent study types were treatment interventions and cross-sectional studies, with populations including individuals with ARFID, ED service populations, parents/caregivers, health professionals, and non-clinical populations. ARFID presents in a range of settings and is associated with poorer quality of life and significant functional impairment. Assessment of ARFID was varied, and no specific treatment guidelines for ARFID have been written as yet.

CONCLUSION

This review calls for more accurate prevalence estimates of ARFID in children and larger-scale studies in all ages using validated measures. It emphasizes the need for education and training of healthcare professionals, and interdisciplinary collaboration. Established interventions like behaviour analytics should be considered, and more comprehensive research is needed on interventions for ARFID, including controlled trials and longitudinal studies. Urgent research is needed to improve outcomes for those affected by ARFID.

Is binge eating associated with poor weight loss outcomes in people with a high body weight? A systematic review with meta-analyses

OBJECTIVES

This systematic review aimed to compare the weight change in people with or without binge eating who underwent various weight loss treatments.

METHODS

We searched for studies in PubMed, American Psychological Association, and Embase from inception to January 2022. The studies selected included assessment of binge eating and body weight before and after weight loss treatment in people of any age. The meta-analyses were conducted using Comprehensive Meta-Analysis (CMA). We used Egger's regression test, the funnel plot, and the Trim and Fill test to assess the risk of publication bias.

RESULTS

Thirty-four studies were included in the systematic review, with a total of 10.184 participants. The included studies were divided into three categories according to types of weight loss treatments, namely, (1) bariatric surgery; (2) pharmacotherapy isolated or combined with behavioral interventions; and (3) behavioral and/or nutritional interventions. The meta-analyses showed no significant difference in weight loss between people with or without binge eating engaged in weight loss treatments, with an overall effect size of - 0.117 (95% CI - 0.405 to 0.171; P = 0.426).

CONCLUSIONS

Our findings showed no difference in weight loss in people with or without pre-treatment binge eating who received various weight loss treatments. Weight loss treatments should not be withheld on the basis that they will not be effective in people with pre-treatment binge eating, albeit their safety and longer term impacts are unclear.

LEVEL OF EVIDENCE

Level I, at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies.

Current approaches in the recognition and management of eating disorders

Eating disorders are now well acknowledged mental health problems that are common and present in people from diverse sociodemographic backgrounds. The past decade has seen a rapid expansion in research into eating disorder interventions. In response to the increasing burden of eating disorders, the Australian Government Department of Health and Aged Care has implemented significant policy changes to improve patient access to Medicare and inpatient treatment facilities. There are several international clinical practice guidelines and a robust evidence base particularly for first line care with specific psychological therapies, including guidelines for the management of eating disorders in individuals with a high weight. Medications play an important adjunct role in care, and novel neuromodulating treatments, such as psychostimulants, are under study. There is emerging evidence for increased person-centred care, with more choice in the form of alternatives to hospital inpatient programs and more respectful consideration of care for all who experience an eating disorder, including people with high weight.

Obtaining long-term recovery: advances in optimizing treatment outcomes in patients with binge-eating disorder

INTRODUCTION

Binge-eating disorder (BED) is a complex and disabling eating disorder (ED) associated with considerable burden and impairments in quality of life and physical/mental health. It has been recognized as a formal ED category since 2013, however BED is still underdetected and undertreated.

AREAS COVERED

This review summarizes the advances in the understanding of the pathophysiology of BED as well as the evidence on the efficacy of the existing treatments. The authors searched Scopus, PubMed, ClinicalTrials.Gov, and ANZCTR with terms including 'assessment' OR 'treatment' OR 'diagnosis' OR 'mechanisms' AND 'binge eating' OR 'binge-eating disorder' for manuscripts published between January 2013 and April 2023.

EXPERT OPINION

Most of the trials on treatments of BED have been in people of high weight with weight loss as an outcome. Nevertheless, less is known about the treatment of this condition in people with body mass index (BMI) within the normal range where weight stabilization may be a more appropriate goal. Moreover, there is a need for an enhanced appreciation of the role of combination treatment to improve overall outcomes. Also, there are important opportunities for future research in understanding the mechanisms of action and effectiveness of BED treatments.

Behavioral approaches to nutrition and eating patterns for managing type 2 diabetes: A review

Nutritional interventions are a key component of type 2 diabetes management; making health-supporting changes in eating patterns can improve postprandial glycemic excursions and lower HbA1c to reduce diabetes-related morbidity and mortality. Research around implementing calorie-restricted and/or low-carbohydrate diets is plentiful, though the ability to sustain physiologic and behavioral changes for longer than 12 months is a concern. An understanding of intervention goals and adherence is needed to apply this research to patient care and translate expectations to real-world living contexts. Diverse dietary patterns including a Mediterranean eating pattern, vegetarian or plant-based eating pattern, or others that emphasize high-quality carbohydrates (e.g., whole grains), vegetables, whole fruits, legumes, and fish can support achievement of glycemic targets. Counseling strategies like motivational interviewing can be used to build eating competence. These approaches prioritize collaborative decision-making with the goal of increasing patient empowerment and self-efficacy. Strategies for incorporating these tools and frameworks in a clinical setting are highlighted. Providing ongoing diabetes and nutrition education, paired with appropriate support to address the challenges in implementing and sustaining behavior changes, is warranted. Further, social determinants of health including environmental context, education, socioeconomic status, access to healthcare, and experiences of systemic stigma (e.g., racism or weight bias) can interfere with individuals' diabetes self-care and nutrition behaviors. Providing medical nutrition therapy and tailoring nutrition interventions to individual needs and circumstances can be an important way physicians, dietitians, and diabetes providers can support individuals with type 2 diabetes.

Outcomes for binge eating disorder in a remote weight-inclusive treatment program: a case report

BACKGROUND

There are no known published reports on outcomes for medically and psychiatrically compromised patients with binge eating disorder (BED) treated remotely in higher level of care settings. This case report presents outcomes of an intentionally remote weight-inclusive partial hospitalization and intensive outpatient program based on Health at Every Size® and intuitive eating principles.

CASE PRESENTATION

The patient presented with an extensive trauma background and long history of disturbed eating and body image. She was diagnosed with BED along with several comorbidities, most notably major depressive disorder with suicidality and non-insulin dependent diabetes mellitus. She completed a total of 186 days in the comprehensive, multidisciplinary treatment program encompassing individual and group therapy, as well as other supportive services such as meal support and in vivo exposure sessions. Upon discharge, her BED was in remission, her major depressive disorder was in partial remission, and she no longer exhibited signs of suicidality. Overall, she showed decreases in eating disorder, depressive, and anxiety symptoms as well as increases in quality of life and intuitive eating throughout treatment, which were largely maintained after one year.

CONCLUSIONS

This case highlights the potential of remote treatment as an option for individuals with BED, especially in cases where access to higher levels of care might be limited. These findings exemplify how a weight-inclusive approach can be effectively applied when working with this population.

The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines

Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.

The need for future research into the assessment and monitoring of eating disorder risk in the context of obesity treatment

In adolescents and adults, the co-occurrence of eating disorders and overweight or obesity is continuing to increase, and the prevalence of eating disorders is higher in people with higher weight compared to those with lower weight. People with an eating disorder with higher weight are more likely to present for weight loss than for eating disorder treatment. However, there are no clinical practice guidelines on how to screen, assess, and monitor eating disorder risk in the context of obesity treatment. In this article, we first summarize current challenges and knowledge gaps related to the identification and assessment of eating disorder risk and symptoms in people with higher weight seeking obesity treatment. Specifically, we discuss considerations relating to the validation of current self-report measures, dietary restraint, body dissatisfaction, binge eating, and how change in eating disorder risk can be measured in this setting. Second, we propose avenues for further research to guide the development and implementation of clinical and research protocols for the identification and assessment of eating disorders in people with higher weight in the context of obesity treatment. PUBLIC SIGNIFICANCE: The number of people with both eating disorders and higher weight is increasing. Currently, there is little guidance for clinicians and researchers about how to identify and monitor risk of eating disorders in people with higher weight. We present limitations of current research and suggest future avenues for research to enhance care for people living with higher weight with eating disorders.

Mediating effects of a weight-inclusive health promotion program on maladaptive eating in women with high body mass index

Research shows that individuals with a body mass index (BMI) over 30 have experienced an 11-fold increase in restrictive eating and a 7-fold increase in binge eating since the 1990s. Most health promotion programs for higher-weight individuals have not been developed with the high eating disorder risk for this population in mind. The purpose of current study was to test two hypothesized mechanisms underlying improvement in maladaptive eating patterns shown in a weight-inclusive health promotion program designed for women with BMIs at or above 30. Participants (N = 40) were primarily White (93 %), 30-45 years old (M = 39.83, SD = 4.34) with BMIs ranging from 30 to 45 kg/m² (M = 37.42, SD = 3.58). Using the MEMORE macro, we tested a parallel mediation model hypothesizing that internalized weight stigma and intuitive eating would explain improvements on two subscales from the Three-Factor Eating Questionnaire-R18 after a 6-month program. Total effects of the program on uncontrolled (b = -3.76, SE = 0.64, p < .0001) and emotional eating (b = -1.79, SE = 0.34, p < .0001) were significant. The indirect effects (IE) of internalized weight stigma on uncontrolled eating (IE = 1.59, SE = 0.79, 95 % CI = 0.46, 3.49) and emotional eating (IE = 0.67, SE = 0.40, 95 % CI = 0.11, 1.68) were also significant. Likewise, the IEs of intuitive eating on uncontrolled eating (IE = 2.09, SE = 0.70, 95 % CI = 0.60, 3.38) and emotional eating (IE = 1.03, SE = 0.43, 95 % CI = 0.08, 1.82) were significant. These findings indicate that weight-inclusive health promotion programs that directly address weight bias and eating according to cues from the body may help higher-weight individuals improve maladaptive eating patterns via reductions in internalized weight stigma and increases in intuitive eating.

Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results

INTRODUCTION

We studied whether provisional posttraumatic stress disorder (PTSD) moderated discharge (DC) and 6-month follow-up (FU) outcomes of multi-modal, integrated eating disorder (ED) residential treatment (RT) based upon principles of cognitive processing therapy (CPT).

METHODS

ED patients [N = 609; 96% female; mean age (± SD) = 26.0 ± 8.8 years; 22% LGBTQ +] with and without PTSD completed validated assessments at admission (ADM), DC and 6-month FU to measure severity of ED, PTSD, major depressive disorder (MDD), state-trait anxiety (STA) symptoms, and eating disorder quality of life (EDQOL). We tested whether PTSD moderated the course of symptom change using mixed models analyses and if ED diagnosis, ADM BMI, age of ED onset and LGBTQ + orientation were significant covariates of change. Number of days between ADM and FU was used as a weighting measure.

RESULTS

Despite sustained improvements with RT in the total group, the PTSD group had significantly higher scores on all measures at all time points (p ≤ .001). Patients with (n = 261) and without PTSD (n = 348) showed similar symptom improvements from ADM to DC and outcomes remained statistically improved at 6-month FU compared to ADM. The only significant worsening observed between DC and FU was with MDD symptoms, yet all measures remained significantly lower than ADM at FU (p ≤ .001). There were no significant PTSD by time interactions for any of the measures. Age of ED onset was a significant covariate in the EDI-2, PHQ-9, STAI-T, and EDQOL models such that an earlier age of ED onset was associated with a worse outcome. ADM BMI was also a significant covariate in the EDE-Q, EDI-2, and EDQOL models, such that higher ADM BMI was associated with a worse ED and quality of life outcome.

CONCLUSIONS

Integrated treatment approaches that address PTSD comorbidity can be successfully delivered in RT and are associated with sustained improvements at FU. Improving strategies to prevent post-DC recurrence of MDD symptoms is an important and challenging area of future work.

Considerations of eating disorder risk during obesity treatment in Australia: Current practice, attitudes and barriers

INTRODUCTION

People with obesity are vulnerable to eating disorders. It has been suggested that screening for eating disorder risk be part of obesity care. However, it is unclear what current practice entails.

OBJECTIVE

To explore considerations of eating disorder risk during treatment of obesity, including assessment and intervention strategies used in clinical practice.

MATERIALS AND METHODS

An online (REDCap) cross-sectional survey was distributed to health professionals working with individuals with obesity in Australia through professional societies and social media. The survey had three sections: 1. Characteristics of Clinician/Practice, 2. Current Practice, 3. Attitudes. Data were summarised using descriptive statistics and free-text comments were independently coded in duplicate to identify themes.

RESULTS

59 health professionals completed the survey. Most were dietitians (n = 29), identified as women (n = 45) and worked within a public hospital (n = 30) and/or private practice (n = 29). Overall, 50 respondents reported assessing for eating disorder risk. Most reported that having a history of, or risk factors of eating disorders should not preclude obesity care but emphasised the importance of treatment modification including using a patient-centred approach involving a multidisciplinary team and promoting healthy eating behaviours, with less emphasis on calorie restriction or bariatric surgery. Management approaches did not differ for those with eating disorder risk factors or a diagnosed eating disorder. Clinicians identified the need for additional training and clear referral pathways.

CONCLUSION

Individualised care, balancing models of care for eating disorders and obesity and further access to training and services will be important in improving care of patients with obesity.

Reimagining eating disorder spaces: a qualitative study exploring Māori experiences of accessing treatment for eating disorders in Aotearoa New Zealand

BACKGROUND

Health, illness, and the body are conceptualized within the cultural context of a society. The values and belief systems of a society, including media portrayals, shape how health and illness present. Traditionally, Western portrayals of eating disorders have been prioritized over and above Indigenous realities. This paper explores the lived experiences of Māori with eating disorders and their whānau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand.

METHOD

Kaupapa Māori research methodology was used to ensure the research supported Māori health advancement. Fifteen semi-structured interviews were completed with Māori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whānau. Structural, descriptive, and pattern coding was undertaken within the thematic analysis. Low's spatializing culture framework was used to interpret the findings.

RESULTS

Two overarching themes identified systemic and social barriers to accessing treatment for Māori with eating disorders. The first theme, was space, that described the material culture within eating disorder settings. This theme critiqued eating disorder services, including idiosyncratic use of assessment methods, inaccessible service locations, and the limited number of beds available in specialist mental health services. The second theme, place, referred to the meaning given to social interactions created within space. Participants critiqued the privileging of non-Māori experiences, and how this makes a place and space of exclusion for Māori and their whānau in eating disorder services in New Zealand. Other barriers included shame and stigma, while enablers included family support and self-advocacy.

CONCLUSION

More education is needed for those working in the space of primary health settings about the diversity of those with eating disorders to enable them to look beyond the stereotype of what an eating disorder looks like, and to take seriously the concerns of whaiora and whānau who present with disordered eating concerns. There is also a need for thorough assessment and early referral for eating disorder treatment to ensure the benefits of early intervention are enabled for Māori. Attention given to these findings will ensure a place for Māori in specialist eating disorder services in New Zealand.

Women's perceptions of weight stigma and experiences of weight-neutral treatment for binge eating disorder: A qualitative study

BACKGROUND

The detrimental effects of weight stigma are a growing concern as a contributor to negative physical and mental health outcomes, disparities in care, and healthcare avoidance. Research exploring the impact of weight-neutral healthcare is limited but suggests weight-neutral interventions are associated with positive psychological and behavioral outcomes. Little is known about patients' lived experiences receiving weight-neutral healthcare.

METHODS

We conducted semi-structured interviews between Feb 5, 2019 and Feb 25, 2020 with 21 women (90% non-Hispanic white, mean age 49 ± 14.8 years) who had type 2 diabetes or prediabetes and high body weight (mean body mass index 43.8 ± 8.4, range: 30.2-63.9) and previously attended a specialized treatment program for binge eating disorder. We recruited individuals with type 2 diabetes or prediabetes who completed of >2 weeks of a specialized binge eating disorder treatment program with the ability to participate in an English-spoken interview and did not have cognitive impairment or severe psychopathology that would limit recall or engagement in the interview. Interviews were analysed using thematic analysis and Nvivo software. The main outcome we studied was patients' lived experience in healthcare settings and in a weight-neutral eating disorder treatment program.

FINDINGS

Participants reported experiencing weight stigma in healthcare encounters and believed this decreased the quality of care they received. While participants frequently attempted to lose weight, they experienced embarrassment, internalized a sense of failure, and felt blamed for their weight and health conditions. In describing experiences within a weight-neutral paradigm, participants reported that helpful elements included consistency in the eating pattern (emphasizing adequate, varied, and nourishing intake), sufficient and specific education, and comprehensive support. Reported impacts included decreased binge episodes, experiencing less shame, and increased resiliency following treatment. Some participants experienced the weight-neutral treatment recommendations and the absence of the pursuit of weight loss as challenging.

INTERPRETATION

Weight-neutral treatment may improve psychological and behavioral outcomes regarding binge eating, and longitudinal, quantitative research is warranted. These findings are useful to decrease weight stigma in provider-patient interactions.

FUNDING

The Dudley Allen Sargent Research Fund, Boston University.

Weighing in: qualitative explorations of weight restoration as recovery in anorexia nervosa

BACKGROUND

Anorexia Nervosa (AN) continues to capture the public's imagination, centered around physical appearance, particularly weight. Clinical conceptions of AN also emphasize weight. The objective of this study was to explore how individuals with lived AN experience thought about the role of weight in illness and recovery.

METHODS

The current study employed a grounded theory approach through qualitative inductive inquiry and analysis of 150 anonymous narratives, exploring firsthand experience of AN and recovery of adult individuals, based in the United States of America.

RESULTS

Individuals with AN histories contested intersecting popular cultural and medical presumptions of their health and illness positioned in weight. Respondents indicated that while weight does not measure recovery, it matters to recovery in unanticipated ways. Others' expectations for a low weight served as a gatekeeper to various forms of social and institutional support. Respondents felt that the weight obsessions of other people made it difficult to earn the illness legitimacy to access sufficient care.

CONCLUSIONS

Research findings bear implications for future AN research, advocacy, and clinical practice, as respondents pivot research emphasis from weight as a sociocultural motivation for AN, to weight as a sociocultural obstacle to AN recovery.

Disentangling eating disorder diagnostic schemes. Commentary on Walsh et al., "A systematic review comparing atypical anorexia nervosa and anorexia nervosa"

This commentary discusses the systematic review by Walsh et al. that has found that people with atypical anorexia nervosa have similar symptoms and severity as have people with anorexia nervosa. In this paper, the discussion is broadened to other eating disorders diagnoses and the problem of overlap and crossover between syndromes that impacts adversely on the need for diagnoses to be distinct both at assessment but also over time. It is argued that the derivation of eating disorder diagnostic criteria has also been vulnerable to erroneous assumptions and biased observations. Whether atypical anorexia nervosa becomes a standalone diagnosis or is joined with an expanded anorexia nervosa, future delineations should be based on empirical research including neuroscience.

Dismantling weight stigma in eating disorder treatment: Next steps for the field

The authors posit current guidelines and treatment for eating disorders (EDs) fail to adequately address, and often perpetuate, weight stigma. The social devaluation and denigration of higher-weight individuals cuts across nearly every life domain and is associated with negative physiological and psychosocial outcomes, mirroring the harms attributed to weight itself. Maintaining focus on weight in ED treatment can intensify weight stigma among patients and providers, leading to increased internalization, shame, and poorer health outcomes. Stigma has been recognized as a fundamental cause of health inequities. With no clear evidence that the proposed mechanisms of ED treatment effectively address internalized weight bias and its association with disordered eating behavior, it is not hard to imagine that providers' perpetuation of weight bias, however unintentional, may be a key contributor to the suboptimal response to ED treatment. Several reported examples of weight stigma in ED treatment are discussed to illustrate the pervasiveness and insidiousness of this problem. The authors contend weight management inherently perpetuates weight stigma and outline steps for researchers and providers to promote weight-inclusive care (targeting health behavior change rather than weight itself) as an alternative approach capable of addressing some of the many social injustices in the history of this field.