Research and clinical assessment of eating and exercise behaviour

Loss of control as a transdiagnostic feature in obesity-related eating behaviours: A systematic review

OBJECTIVE

Emerging evidence suggests that loss of control (LOC) may present as a common feature across disordered eating behaviours. However, there has been limited research on the transdiagnostic nature of LOC in this area. The primary aim of this study was to systematically review disordered eating behaviours and measures of LOC in clinical and non-clinical populations.

METHOD

Electronic searches of the relevant databases were conducted. Selected articles were screened for eligibility and assessed for methodological quality.

RESULTS

Thirty-four studies met inclusion criteria. Findings demonstrated that LOC was associated with disordered eating behaviours across bariatric populations, eating disorder populations, and community populations. Specifically, LOC was associated with binge eating (subjective and objective episodes), grazing, night eating, and emotional or stress eating. Findings also revealed that LOC was inconsistently operationalised across studies, with varied approaches to measuring the construct.

CONCLUSION

Overall, the findings from this review provide support for LOC as a transdiagnostic feature of disordered eating behaviours. Future studies should utilise robust multi-method assessments to measure the severity of LOC, which may provide greater insight into how LOC manifests across different eating disorder presentations.

Relationships between compulsive exercise, quality of life, psychological distress and motivation to change in adults with anorexia nervosa

BACKGROUND

For people with anorexia nervosa (AN), compulsive exercise is characterized by extreme concerns about the perceived negative consequences of stopping/reducing exercise, dysregulation of affect, and inflexible exercise routines. It is associated with increased eating disorder psychopathology and poor clinical outcome. However, its relationships with two important clinical issues, quality of life (QoL) and motivation to change, are currently unknown. This study aimed to assess the cross-sectional relationships between compulsive exercise, QoL, psychological distress (anxiety and depressive symptoms, and obsessive-compulsive traits) and motivation to change in patients with AN.

METHOD

A total of 78 adults with AN participated in this study, which was nested within a randomized controlled trial of psychological treatments for AN. At baseline (pre-treatment), participants completed questionnaires assessing compulsive exercise, eating disorder (ED) psychopathology, QoL, psychological distress and motivation to change.

RESULTS

Baseline correlational analyses demonstrated a moderate positive relationship between compulsive exercise and ED psychopathology, and a weak positive relationship between compulsive exercise and psychological distress. There was a moderate negative relationship between compulsive exercise and eating disorder QoL.

CONCLUSIONS

These results indicate compulsive exercise is moderately associated with poorer QoL and weakly associated with higher distress. Targeting compulsive exercise in the treatment of anorexia nervosa may help reduce the burden of illness and improve patients' engagement in treatment.

TRIAL REGISTRATION

ACTRN12610000585022. Taking a LEAP forward in the treatment of anorexia nervosa: a randomized controlled trial. NHMRC grant: 634922.

Transitioning from DSM-IV to DSM-5: A systematic review of eating disorder prevalence assessment

OBJECTIVE

The objective of this study was to systematically review the literature on assessment of eating disorder prevalence during the DSM-IV era (1994-2015).

METHOD

A PubMed search was conducted targeting articles on prevalence, incidence and epidemiology of eating disorders. The review was performed in accordance with PRISMA guidelines, and was limited to DSM-IV based eating disorder diagnoses published between 1994 and 2015.

RESULTS

A total of 74 studies fulfilled inclusion criteria and were included in the study. Results yielded evidence of over 40 different assessment instruments used to assess eating disorder prevalence, with the EAT-40 being the most commonly used screening instrument, and the SCID being the most frequently used interview. The vast majority of studies employed two-stage designs, closely followed by clinical interviews. Observations of higher prevalence rates were found in studies employing self-reports compared to two-stage designs and interviews.

DISCUSSION

Eating disorder prevalence rates have varied significantly during the DSM-IV era, and are dependent on assessment methods used and samples investigated. Following the transition to the DSM-5, eating disorder prevalence will change, warranting novel approaches to assessment and treatment planning. © 2016 Wiley Periodicals, Inc.

Functional gastrointestinal disorders in eating disorder patients: Altered distribution and predictors using ROME III compared to ROME II criteria

AIM: To compare the prevalence of Functional gastrointestinal disorders (FGIDs) using ROME III and ROME II and to describe predictors of FGIDs among eating disorder (ED) patients.

METHODS: Two similar cohorts of female ED inpatients, aged 17-50 years, with no organic gastrointestinal or systemic disorders, completed either the ROME III (n = 100) or the ROME II (n = 160) questionnaire on admission for ED treatment. The two ROME cohorts were compared on continuous demographic variables (e.g., age, BMI) using Student’s t-tests, and on categorical variables (e.g., ED diagnosis) using χ²-tests. The relationship between ED diagnostic subtypes and FGID categories was explored using χ²-tests. Age, BMI, and psychological and behavioural predictors of the common (prevalence greater than 20%) ROME III FGIDs were tested using logistic regression analyses.

RESULTS: The criteria for at least one FGID were fulfilled by 83% of the ROME III cohort, and 94% of the ROME II cohort. There were no significant differences in age, BMI, lowest ever BMI, ED diagnostic subtypes or ED-related quality of life (QOL) scores between ROME II and ROME III cohorts. The most prevalent FGIDs using ROME III were postprandial distress syndrome (PDS) (45%) and irritable bowel syndrome (IBS) (41%), followed by unspecified functional bowel disorders (U-FBD) (24%), and functional heartburn (FH) (22%). There was a 29% or 46% increase (depending on presence or absence of cyclic vomiting) in functional gastroduodenal disorders because of the introduction of PDS in ROME III compared to ROME II. There was a 35% decrease in functional bowel disorders (FBD) in Rome III (excluding U-FBD) compared to ROME II. The most significant predictor of PDS was starvation (P = 0.008). The predictor of FH (P = 0.021) and U-FBD (P = 0.007) was somatisation, and of IBS laxative use (P = 0.025). Age and BMI were not significant predictors. The addition of the 6-mo duration of symptoms requirement for a diagnosis in ROME III added precision to many FGIDs.

CONCLUSION: ROME III confers higher precision in diagnosing FGIDs but self-induced vomiting should be excluded from the diagnosis of cyclic vomiting. Psychological factors appear to be more influential in ROME II than ROME III.

Body weight dissatisfaction: a comparison of women with and without eating disorders

OBJECTIVE

Body dissatisfaction is present in a majority of women without eating disorders (EDs), and almost all women with EDs. We compared body dissatisfaction in women with and without EDs to determine at which BMI women are content with their weight, and to determine if body dissatisfaction is affected by the presence of purging behaviours.

METHODS

We assessed women, age 18 to 55 with an ED (N=431) and without an ED (N=719) using the discrepancy between their current and desired BMI. This measure of body weight dissatisfaction (BWD) has been validated as being representative of overall body dissatisfaction. We also measured perceptions of (i) Body Appearance and (ii) Body Image to confirm our results.

RESULTS

Women with and without EDs wished to lose weight until very low weights were achieved (BMI 15-16 kg/m(2) and BMI 18-19 kg/m(2) respectively). BWD is higher in women with EDs (median 1.77, IQR 0-4.61) than women without EDs (median 0.85, IQR 0-1.80, p<0.001). Purging behaviours in women with EDs were associated with lower BMIs to achieve body satisfaction (BMI 15-16 kg/m(2)) than women who did not purge (16-17 kg/m(2)).

CONCLUSIONS

Body weight dissatisfaction is highly prevalent amongst women with and without EDs. Understanding body weight dissatisfaction in women with EDs and its association with purging may assist in the prevention, detection and treatment of these disorders. Women with EDs should be informed that body weight dissatisfaction will not resolve with the cessation of their disorder, as it is prevalent within the general population.

Personality factors and eating disorders: self-uncertainty

The International Personality Disorder Examination interview (IPDE) was used to examine common features of personality amongst eating disorder (ED) patients. Female inpatients (N=155), aged 18 to 45, BMI<30 kg/m(2), were interviewed. Items present in ≥ 25% of patients were analysed by factor analysis. Five factors emerged - 'interpersonal anxiety', 'instability', 'self-uncertainty', 'obsessionality' and 'perfectionism' accounting for 62% of the variance. Patients with BMI, <18.5 kg/m(2) had significantly greater 'interpersonal anxiety' factor scores. Patients who purged had higher 'interpersonal anxiety', 'instability', and 'perfectionism' factor scores. Differences between ED diagnostic groups were accounted for by body weight and purging. Increasing age was weakly associated with improvement in 'self-uncertainty' and 'instability' scores. This study separates obsessionality and perfectionism, possibly reflecting ED patients' 'need for control', and introduces a new factor 'self-uncertainty' which reflects their poor self-concept. The contribution of this factor structure to development and duration of illness should be studied.

Vitamin D, bone mineral density and body mass index in eating disorder patients

AIM

To investigate associations of vitamin D with BMD and BMI in ED patients.

METHODS

Vitamin D, BMD and BMI for 50 patients admitted to a specialised ED inpatient unit were measured. Patients were aged 15-54 years with BMI 8-25 kg/m(2).

RESULTS

Of the patients, 18% were vitamin D deficient. There was a significant linear relationship between vitamin D and BMD T-score at the lumbar spine (p=0.029), femoral neck (p<0.001) and total hip (p=0.001). There was no relationship between vitamin D and BMI. There was a significant linear relationship between BMI and BMD T-score at the lumbar spine (p<0.001), femoral neck (p=0.008) and total hip (p=0.001).

CONCLUSIONS

Low vitamin D and low BMI are associated with low BMD in ED patients. Despite widespread belief that it is not necessary, our findings suggest it is appropriate to measure vitamin D in ED patients. It should not be assumed ED patients take supplements.

Do the digestive tract symptoms in eating disorder patients represent functional gastrointestinal disorders?

Background

Gastrointestinal (GI) symptoms are common in patients with eating disorders. The aim of this study was to determine, using factor analysis, whether these GI symptom factors (clusters) in eating disorder patients hold true to the Rome II classification of functional gastrointestinal disorders (FGIDs).

Methods

Inpatients in a specialised eating disorder unit completed the Rome II questionnaire. Data from 185 patients were analysed using factor analysis of 17 questions cited as present in 30% to 70% of the patients.

Results

Five factors emerged accounting for 68% of the variance and these were termed: ‘oesophageal discomfort’, ‘bowel dysfunction’, ‘abdominal discomfort’, ‘pelvic floor dysfunction’, and ‘self-induced vomiting’. These factors are significantly related to the Rome II FGID categories of functional oesophageal, bowel and anorectal disorders, and to the specific FGIDs of IBS, functional abdominal bloating, functional constipation and pelvic floor dyssynergia. Both heartburn and chest pain were included in the oesophageal discomfort factor. The ‘pelvic floor dysfunction’ factor was distinct from functional constipation.

Conclusions

The GI symptoms common in eating disorder patients very likely represent the same FGIDs that occur in non-ED patients. Symptoms of pelvic floor dysfunction in the absence of functional constipation, however, are prominent in eating disorder patients. Further investigation of the items comprising the ‘pelvic floor dysfunction’ factor in other patient populations may yield useful results.

Perceived body weight, eating and exercise problems of different groups of women

OBJECTIVE

To compare prevalence of problems with body weight, eating and exercise (past or present) of female psychiatric inpatients with routine care, gynaecological and obstetric female outpatients, and eating disorder inpatients.

METHOD

One thousand and thirty-eight females aged 18-55 years from routine care (n=99), gynaecological (n=263) and obstetric (n=271) outpatient clinics, and eating disorder (n=223) and general psychiatric units (n=182) participated. Participants self-reported past or current problems with weight, eating and exercise using a short survey. A sub-sample of women completed the Eating and Exercise Examination (EEE) which includes the Quality of Life for Eating Disorders (QOL ED).

RESULTS

The prevalence of self-reported problems controlling weight (52%), disordered eating and eating disorders (43%) for the psychiatric patients was significantly greater than for the routine care and gynaecological and obstetrics outpatients. The psychiatric group had a significantly higher mean body mass index (BMI) of 27.3 kg/m(2) (standard deviation (SD)=6.7) and prevalence of self-reported obesity (28%) than the other groups.

CONCLUSION

Treatment of women with psychiatric problems should include assessment and concurrent attention to body weight, eating disorder and exercise problems in association with appropriate medical, psychiatric, psychological and medication treatment of their presenting disorder.

Exploring eating disorder quality of life and functional gastrointestinal disorders among eating disorder patients

BACKGROUND

Functional gastrointestinal-like disorders (FGIDs) are prevalent among eating disorder (ED) patients. The aims are to explore the relationship between quality of life related to eating disorders (QOL ED) and FGIDs.

METHODS

Consecutive ED patients, 18-45 years old, completed the Rome II, QOL ED, Irritable Bowel Syndrome QOL (IBS-QOL) and Bowel Symptom Severity Index (BSSI) questionnaires on admission to hospital for treatment of their ED.

RESULTS

Despite the high prevalence of FGIDs (93%), only IBS is clearly correlated with QOL ED scores. The QOL ED subscores significantly related are ED feelings, psychological feelings and effect on daily living. These subscores contain items such as fearing loss of control over your body and feelings, being preoccupied with thoughts of body weight and shape, feeling confused and that eating and exercise have a negative effect on work/study. There were no relationships between QOL ED behavior and individual FGIDs or categories of FGIDs. The QOL ED and IBS-QOL are highly correlated, and there is a positive linear relationship between the QOL ED global and IBS-QOL total and BSSI scores.

CONCLUSION

The presence of IBS (but not other FGIDs) in ED patients is strongly related to eating disordered and psychological feelings. The poorer the QOL ED is, the poorer the IBS-QOL is and the more severe the IBS symptoms are.

Weight changes during inpatient refeeding of underweight eating disorder patients

AIM

To describe patterns of weight change in patients admitted to a specialised eating disorder program with established protocols for inpatient refeeding.

METHODS

Weight records between January 2000 and December 2006 were categorised using Body Mass Index (BMI) at first admission (BMI ranges < 14.0, 14.1-17.49, 17.5-18.9 kg/m(2)). Total weight gained, number of days of inpatient treatment and rate of weekly weight gain were examined.

RESULTS

In total there were 247 patients representing 414 admissions. The rate of weight gain was 0.77, 0.63 and 0.53 kg/week, respectively, for each BMI group. Twenty patients (8.1%) in the refeeding program did not gain weight.

CONCLUSION

Weight gain in underweight patients is highly variable. A greater understanding of the processes that contribute to weight gain, and establishment of best practice in achieving weight gain in patients needs to be determined. This data provide detailed information about expectations for refeeding without artificial feeding.

Appearance and disappearance of functional gastrointestinal disorders in patients with eating disorders

BACKGROUND

Functional gastrointestinal disorders or 'functional gastrointestinal disorder-like' symptoms (FGIDs) occur commonly in eating disorders (ED), but it is not known if these disorders are stable over time. The aims were to evaluate the turnover of FGIDs in patients with ED, and to relate this turnover to changes in body mass index (BMI), ED behaviors, and psychological variables.

METHODS

Patterns and repeated measures analysis of presence of individual FGIDs and regional FGID categories (esophageal, gastroduodenal, bowel, and anorectal) in ED patients (n = 73) at admission to hospital and at 12-month follow-up, using change in BMI and ED behaviors as between patient variables.

KEY RESULTS

Functional gastrointestinal disorders prevalence was 97% at admission and 77% at follow-up. The only individual FGIDs to decrease over time were functional heartburn (admission 53%, follow-up 23%) and functional dysphagia (21%, 7%). There was significant patient variation in the disappearance, persistence, and appearance of both individual FGIDs and FGID regional categories. Twenty-five (34%) of patients acquired at least one new FGID regional category at follow-up. There was no relationship between changes in BMI, self-induced vomiting, laxative use, binge eating, anxiety, depression, somatization, and the turnover of individual or regional FGIDs.

CONCLUSIONS & INFERENCES

Functional gastrointestinal disorders remain common after 12 months in patients with an ED. Considerable turnover of the FGIDs occurs, however, and the appearance of new FGIDs is not restricted to the original FGID regional category. There is no apparent relationship between the turnover of the FGIDs and ED behaviors, psychological variables or body weight change. These findings have implications for the clinical evaluation and management of FGIDs in ED patients.

A controlled intervention to promote a healthy body image, reduce eating disorder risk and prevent excessive exercise among trainee health education and physical education teachers

This study examined the impact of two interventions on body image, eating disorder risk and excessive exercise among 170 (65% female) trainee health education and physical education (HE&PE) teachers of mean (standard deviation) age 21.6 (2.3) who were considered an 'at-risk' population for poor body image and eating disorders. In the first year of the study, the control group cohort (n = 49 females, 20 males) received the regular didactic health education curriculum; in the second year of the study, the Intervention 1 cohort (n = 31 females, 21 males) received a self-esteem and media literacy health education program and in the third year of the study, the Intervention 2 cohort (n = 30 females, 19 males) received a combined self-esteem, media literacy and dissonance program using online and computer-based activities. Intervention 2 produced the best results, with males improving significantly in self-esteem, body image and drive for muscularity. Intervention 2 females improved significantly on Eating Disorders Inventory Drive for Thinness, Eating Disorder Examination and excessive exercise. The improvements were consistent at 6-month follow-up for females. It is feasible to promote body image, reduce body dissatisfaction and reduce excessive exercise among trainee HE&PE teachers via a health education curriculum.

Health-related quality of life and eating disorders: a review and update

OBJECTIVE

The aim of this article is to provide a narrative review of empirical studies related to health-related quality of life (HRQOL) and eating disorders and to report recent changes in the measurement of HRQOL in eating disorders.

METHOD

Twenty-five articles of central importance to the topic were identified in a systematic search of six databases. All articles were selected based on a consensus relevancy rating process. Key themes were extracted from the articles and validated by all authors.

RESULTS

We identify six themes in the extant empirical literature.

DISCUSSION

We discuss these six themes and review them in light of the fact that they are identified in studies using only generic measures of HRQOL. Four recently developed disease-specific HRQOL measures specific to patients with eating disorder are discussed.

Feelings: what questions best discriminate women with and without eating disorders?

This study explored feelings that discriminate between eating disorder and community groups of women. Responses to 25 questions about body image (9), eating (8) self-esteem (3) general psychology (5) were collected in 2002-2003 (N=268) and 2005-2006 (N=472). Wilk's lambda was used to test discrimination. The most discriminating psychological questions were: 'feeling unhappy and unable to cope as well as usual', 'unease attending social functions', 'fearing loss of control over emotions'; and for eating questions were: 'feeling uneasy if other people saw you eating', 'feeling preoccupied with food/eating', 'fearing loss of control over eating'. For body image only 'feeling preoccupied with body weight/shape' and 'fearing loss of control over your body' discriminated. Questions relating to weight and shape for self-esteem ('feeling fat', 'fearing weight gain' and 'wanting to lose weight') discriminated poorly. Results for both cohorts were consistent. Preoccupation with thoughts of eating or body image and fear of loss of control of these would be useful additions to eating disorders criteria. Psychological impairment should also be present.

When energy in does not equal energy out: disordered energy control

OBJECTIVE

To explore women's fear of loss of control and excessive inappropriate control of eating, exercise or their body in relation to patient/nonpatient status. To examine the utility of a concept of Disordered Energy Control (DEC).

METHODS

Comparison of the features of DEC of 169 female eating disorder, first admission inpatients, 61 previous inpatients ('recovering') and 225 female students who completed computer questions including the Quality of Life Eating Disorder (QOL ED).

RESULTS

Fear of loss of control was reported by 89% of inpatients, 36% of 'recovering' patients and 34% of students. Fear of loss of control or excessive controlling behaviour (defined as BMI <15.5, vomiting >7 days/month) was reported by 96% of inpatients (97% anorexia nervosa, 100% bulimia nervosa, 89% EDNOS), 51% of 'recovering' patients and 35% of students. There was significantly more impact on QOL ED psychological aspects, daily living, and acute medical health for student and patient groups reporting control issues compared to those who did not. DEC was present in 13% of students, 94% of inpatients and 28% of recovering patients.

DISCUSSION

The concept of disordered energy control warrants further investigation particularly in overweight and obese groups. A biological measure of inappropriate energy control associated with medical and psychological problems would be useful.

Quality of life: eating disorders

OBJECTIVE

There is a lack of measurements with predictive validity that are specific for quality of life (QOL) in patients with eating disorders.

METHOD

A total of 306 eating disorder patients treated as inpatients completed the Quality of Life for Eating Disorders (QOL ED): 109 at both admission and discharge from hospital, 65 at both admission and after 12 months. Patients also completed well-validated measures of eating disorders, psychological dysfunction and general physical and mental QOL. QOL ED consists of 20 self-report questions that provide scores for the domains of behaviour, eating disorder feelings, psychological feelings, effects on daily life, effects on acute medical status and body weight, and a global score.

RESULTS

QOL ED domain scores correlated appropriately with previously validated well-known measures of eating disorders, psychological dysfunction, general QOL and behaviour and body weight (p < 0.001). The QOL ED shows high reliability (Cronbach's alpha = 0.93). All scores changed significantly and appropriately during inpatient hospital treatment and between admission and 12 months after discharge from hospital (p < 0.001). The scores differed for anorexia nervosa, bulimia, eating disorder not specified (EDNOS) and no diagnosis. All no diagnosis (recovered) domain and global scores were significantly different from all diagnoses scores (p < 0.001).

CONCLUSION

This quick, simple instrument fulfils all potential uses for QOL assessments in the clinical and research settings associated with eating disorders, including outcome.

Predictors of functional and exercise amenorrhoea among eating and exercise disordered patients

BACKGROUND

The aim of this study was to investigate the predictors of amenorrhoea self-reported by patients who are suffering or recovering from eating or exercise disorders.

METHODS

Menstrual status, eating and exercise behaviours and feelings, and weight history of 268 female patients, 16-40 years old and not taking oral contraception or hormone replacement, were assessed on admission to hospital or 12 months later.

RESULTS

Most (134) had secondary amenorrhoea, 39 had oligomenorrhoea and 95 regular spontaneous menses. Amenorrhoea occurs in women with all types of eating disorder diagnoses including EDNOS (eating disorder not otherwise classified). The predictors of secondary amenorrhoea were: lower current BMI [odds ratio (OR) 0.59, confidence interval (CI) 0.50-0.68); a greater amount of body weight lost (OR 1.19, CI 1.06-1.33); exercising for mood, to burn up energy or for body image reasons (OR 1.50, CI 1.14-1.97); and younger age (OR 0.93, CI 0.87-1.00). Eating disorder patients with an exercise disorder were significantly more likely to report trying to reduce their food intake, to feel compelled to exercise and to have amenorrhoea/ oligomenorrhoea than eating disorder patients without an exercise disorder.

CONCLUSION

The greater the self-report behaviours and feelings associated with energy debt, the more likely menstruation is to be disturbed. Energy balance needs to be assessed in all amenorrhoeic patients.

Psychological features are important predictors of functional gastrointestinal disorders in patients with eating disorders

OBJECTIVE

Gastrointestinal symptoms that occur without evidence of structural gastrointestinal disease are a well-recognized feature of patients with eating disorders (EDs). Despite this, the spectrum and predictors of specific functional gastrointestinal disorders (FGIDs), documented using standardized and validated questionnaires, have received little attention. The aims of the study were to describe the prevalence and type of FGIDs in patients suffering from anorexia nervosa (AN), bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS), and to determine the relationships between psychological features, eating-disordered attitudes and behaviours, demographic characteristics and the type and number of FGIDs present.

MATERIAL AND METHODS

A total of 101 consecutive female patients admitted to an eating disorder unit (AN 44%, BN 22%, EDNOS 34%, mean age 21 years) completed the Rome II modular questionnaire and a range of other validated self-reported questionnaires detailing illness history, psychological features and eating and exercise behaviour.

RESULTS

The criteria for at least one FGID were fulfilled by 98% of the sample. The most prevalent FGIDs were irritable bowel syndrome (IBS: 52%), functional heartburn (FH: 51%), functional abdominal bloating (31%), functional constipation (FC: 24%), functional dysphagia (23%) and functional anorectal pain disorder (FAno: 22%); 52% of the sample satisfied the criteria for at least three coexistent FGIDs. Psychological variables (somatization, neuroticism, state and trait anxiety), age and binge eating were significant predictors of specific, and > or =3 coexistent FGIDs. Other disordered eating characteristics, including body mass index, were not predictors.

CONCLUSIONS

In patients with EDs, specific psychological traits predict FGID type and the presence of multiple coexistent FGIDs. These findings support the role of specific psychological features as important contributors to certain FGIDs.

A blinded laxative taper for patients with eating disorders

OBJECTIVE

To evaluate a blinded laxative taper, supervised entirely by pharmacists, in eating disorder patients with laxative dependency.

METHODS

All subjects received a blinded laxative taper according to a set protocol, in addition to the usual treatment for their eating disorder. No specific treatment was given for laxative dependency other than the pharmacist's supervisions of the blinded taper.

RESULTS

Ten patients were enrolled, of whom seven completed the study. Five of the seven patients (71%) decreased their laxative intake by at least 50%. Of these seven patients, three withdraw completely from laxative use.

DISCUSSION

A standardized blinded laxative taper shows promise as a treatment option for laxative dependency in patients with eating disorders. The laxative taper may be less costly and more available than inpatient or psychologically based treatment because it can be given on an outpatient basis under the supervision of a pharmacist.

Oral contraception and cyclic changes in premenstrual and menstrual experiences

Despite the widespread use of oral contraceptives (OC) there is no consensus regarding their effect on menstrual cycle experiences. This study examines the cyclic changes of prospectively collected, daily menstrual cycle experiences of two groups of 'healthy women' using monophasic and triphasic OC compared with a group using non-hormonal contraception. A total of 119 'healthy women' using monophasic, triphasic or non-hormonal contraception for three months, made daily ratings over at least two complete menstrual cycles. Cyclic changes of ratings within and between the groups were analyzed. The three groups showed significant cyclic changes in abdominal fullness, abdominal discomfort, breast fullness, general 'premenstrual syndrome-like symptoms' and in at least two mood ratings. Maximal changes in ratings occurred during the late premenstrual and menstrual phases. There were no significant differences between the three groups in cyclic changes for any physical rating, but there were for tiredness or fatigue (non-OC users reported experiencing tiredness or fatigue more frequently than the OC users) and sadness or depression (non-OC users experienced sadness or depression less frequently than OC users during the early part of the cycle, followed by a sharp rise from early premenstrual to the menstrual phase). There were no significant cyclic differences in ratings between the monophasic and triphasic groups. In conclusion, 'healthy women' using OC experience premenstrual and menstrual changes. Any differences between OC formulations are subtle and not of clinical significance in 'healthy women' already established on monophasic or triphasic hormonal contraception.

Dieting, body weight, body image and self-esteem in young women: doctors' dilemmas

Many young women feel that body image and exercise are important for their self-esteem, want to lose weight, are afraid they might gain weight, and feel fat. Interventions that improve self-esteem, encourage communication and help adolescents to be supportive of each other may prevent some of these women from developing eating disorders. If an eating disorder is suspected, it may be useful for physicians to ask about fear of loss of control over the body, eating, weight and shape; and preoccupation with food, eating, nutrition, body weight and shape, as these issues may differentiate those at greater risk.