Children and adolescents with eating disorders: the state of the art

Undergraduate perspectives of the awareness, diagnosis and management of patients with eating disorders

Introduction Patients with eating disorders (EDs) may present with potentially life-threatening complications due to missed and late diagnoses. Dentists can play a fundamental role in the early identification and signposting of patients with suspected EDs.Aims To investigate the awareness of final-year dental students of the aetiology, diagnosis and management of EDs.Methods An anonymous electronic questionnaire was distributed to final-year dental students at the University of Manchester. Respondents reported their knowledge, confidence and education related to the management of patients with EDs.Results Over 50% of students felt they had an above average awareness of the clinical signs and oral manifestations of EDs. The majority of students lacked confidence in discussing a suspected ED diagnosis with patients (75%) and referring them to appropriate services (71%). Additionally, 58% were not confident in planning treatment for and treating a patient with an ED. In total, 100% of students reported that they would benefit from further teaching related to the management of patients with EDs.Conclusion Participants highlighted the need for further teaching related to the diagnosis and management of patients with EDs. This study supports the development of an educational resource of undergraduate dental students.

DETECTION OF EATING DISORDERS IN MALE AND FEMALE ARTISTIC GYMNASTS

The purpose of this study was to investigate the trend of eating disorders in competitive male and female artistic gymnasts. The study involved 23 male and 42 female gymnasts, aged 7-27, from sports clubs throughout Greece. The EAT-26 Diet Attitudes scale was used to investigate participants' eating habits. The data collection process included communication with sports organizations throughout Greece on the content and purpose of the research. After consultation, the questionnaire was due to the COVID-19 pandemic provided in an electronic form and also included the consent form for participation in the research. The results of the study indicated that eleven of the sixty-five gymnasts had a total score of >20 on the EAT-26, a rate higher among female gymnasts (~ 24%) compared to male gymnasts (~ 4.4%) (p <.05). Although female gymnasts develop more eating disorders and bulimia than male gymnasts, no significant differences were found in the subscales of the questionnaire (p > .05). Therefore, this finding in combination with the fact that most of the gymnasts were teenagers (15.23 ± 6.35 years old) requires particular importance and attention from coaches and the family environment.

Evaluation of Web-Based Health Information From the Perspective of Women With Eating Disorders: Thematic Analysis

Background

Users with experience of eating disorders use the internet as a source of information, whether for prorecovery activities (such as web-based treatment, looking for information, support, and sharing) or activities that promote eating disorder behavior as a desirable lifestyle choice (such as pro–eating disorder communities and reading and creating pro–eating disorder posts). Their assessment of web-based eating disorder–related information is crucial for understanding the context of the illness and for health professionals and their web-based interventions.

Objective

This study aimed to understand the criteria young women with the experience of eating disorders use in evaluating eating disorder–related web-based information and what eating disorder–related characteristics of these women are involved in their evaluation.

Methods

We analyzed 30 semistructured individual interviews with Czech women aged 16 to 28 years with past or present eating disorder experience using a qualitative approach. Thematic analysis was adopted as an analytical tool.

Results

The specifics of eating disorder phases (the disorder stage and the treatment process) emerged as important aspects in the process of information assessment. Other specific characteristics of respondents (eg, motivation, abilities, and resources) addressed how the respondents arrived at certain web-based information and how they evaluated it. In addition, the respondents described some content cues as features of information (eg, novelty and social information pooling). Another finding is that other users’ attitudes, experiences, activities, and personal features are involved in the information evaluation of these users and the information presented by them. Finally, the respondents evaluated the websites’ visual look and graphic components.

Conclusions

This study shows that web-based information evaluation reported by women with experience of eating disorders is a complex process. The assessment is influenced by current personal characteristics related to the illness (mainly the motivation for maintaining or curing the eating disorder) using cues associated with information content, other users, and website look. The study findings have important implications for health professionals, who should ask their clients questions about web-based communities and their needs to understand what information and sources they choose.

Relationship between Trauma History and Eating Disorders in Adolescents

Reasons for developing an eating disorder (ED) are complex, yet one plausible risk factor gaining more relevance in adolescents with EDs is childhood trauma. The current study is the first to examine the presence of childhood trauma in relation to ED symptomatology in adolescents using DSM-5 criteria. It was hypothesized that patients with more traumatic experiences also have more severe ED symptoms. 112 therapists currently treating adolescent patients diagnosed with an ED completed an online survey consisting of a DSM-5 ED symptom checklist and a childhood trauma questionnaire on a current adolescent patient whom they have seen for at least eight sessions. Children with multiple traumatic experiences and the severity of those experiences demonstrated a relationship to overall ED (r = .179, p = .059) and bulimia symptoms (r = .183, p = .054), specifically binging (r = .188, p = .047). and purging (r = .217, p = .021). In addition, logistic regression analyses indicated that adolescents high on bulimia nervosa (B = 4.694, p = .044) were more likely to have been traumatized victims of violence. Exploratory analyses support prior literature that suggest similarities between adolescents' lack of control of the experienced trauma(s) with lack of control of ED symptoms. These findings highlight the importance of exploring trauma history when treating an adolescent with an ED, especially bulimia.

Emergency Management in Eating Disorders

Aims and Scope::

Eating disorders commonly present during the adolescent and young adult years, and are complex in that they are a group of psychiatric diagnoses with medical complications.

Methods::

The diagnosis of an eating disorder can often go undetected while a patient is being evaluated for organic causes of weight loss. Anorexia nervosa, in particular, has the highest mortality rate of any psychiatric diagnosis. In the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), there are several diagnoses that are classified as eating or feeding disorders.

Conclusion::

This article will discuss anorexia nervosa and bulimia nervosa, with a focus on medical and psychiatric emergencies that are important for primary care providers to keep in mind when caring for adolescents and young adults.

A scoping review of the role of primary care providers and primary care-based interventions in the treatment of pediatric eating disorders

Youth with eating disorders are often cared for by specialized interdisciplinary teams in pediatric tertiary care centers. Enhanced involvement of primary care providers may provide added benefits to patients because it offers improved access, better continuity of care, and possibly less financial burden. This paper aims to synthesize and assess the literature on the role of the primary care provider in treating pediatric eating disorders in order to identify an optimal model of shared care. Sources were identified by entering search terms in 10 databases. Eligible sources were English publications focusing on primary care-based interventions for eating disorders in youth (=<24 years). The search yielded 5,516 unique citations. Of these, 61 were ultimately included. Sources fell into two categories: (1) primary research (n = 3) and (2) reviews with recommendations for primary care providers (n = 58). The primary studies considered the primary care provider conducting behavioral therapy and guided self-help. Review articles suggested providing education, assessing for hospitalization, aiding in weight restoration, managing complications, referring, and coordinating care. Limited evidence exists that can guide effective primary care-based interventions for the treatment of pediatric eating disorders. Further research is needed to develop and evaluate interventions for the treatment of pediatric eating disorders in primary care settings so that best practices can be identified.

Feasibility of Implementing a Family-Based Inpatient Program for Adolescents With Anorexia Nervosa: A Retrospective Cohort Study

Background: Manualized Family Based Therapy (FBT) is the treatment of choice for adolescent anorexia nervosa, but it is an outpatient treatment. Very little research has examined whether or how the principles of FBT might be successfully adapted to an inpatient setting, and there is little other evidence in the literature to guide us on how to best treat children and adolescents with eating disorders (EDs) while in hospital. This paper describes and provides treatment outcomes for an intensive inpatient program that was designed for the treatment of adolescents less than 18 years of age with severe anorexia nervosa, based on the principles of FBT. Each patient's family was provided with FBT adapted for an inpatient setting for the duration of the admission. Parents were encouraged to provide support for all meals in hospital and to plan meal passes out of hospital. Methods: A retrospective cohort study was conducted that examined the outcomes of 153 female patients admitted over a 5-year period. Outcome data focused primarily on weight change as well as psychological indicators of health (i.e., depression, anxiety, ED psychopathology). Results: Paired t-tests with Bonferroni corrections showed significant weight gain associated with a large effect size. In addition, patients showed improvements in scores of mood, anxiety, and ED psychopathology (associated with small to medium effect sizes), though they continued to display high rates of body dissatisfaction and some ongoing suicidality at the time of discharge. Conclusion: This study shows that a specialized inpatient program for adolescents with severe EDs that was created using the principles of FBT results in positive short-term medical and psychological improvements as evidenced by improved weight gain and decreased markers of psychological distress.

Efficacy of a Parent-Based, Indicated Prevention for Anorexia Nervosa: Randomized Controlled Trial

Background

Web-based preventive interventions can reduce risk and incidence of bulimia and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak.

Objective

The primary objective of this study was to evaluate the efficacy of an indicated, parent-based, Web-based preventive program Eltern als Therapeuten (E@T) in reducing risk factors and symptoms of AN.

Methods

Girls aged between 11 and 17 years were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to E@T or an assessment-only control condition. Assessments took place at pre- and postintervention (6 weeks later) and at 6- and 12-month follow-up (FU).

Results

A total of 12,377 screening questionnaires were handed out in 86 German schools, and 3941 including consent returned. Overall, 477 (447/3941, 12.10%) girls were identified as at risk for AN and 256 of those could be contacted. In all, 66 families (66/256, 25.8% of those contacted) were randomized to the E@T or a wait-list control condition, 43 (43/66, 65%) participated in postassessments, and 27 (27/66, 41%) in 12-month FUs. Due to low participation and high dropout rates of parents, recruitment was terminated prematurely. At 12-month FU, girls’ expected body weight (EBW) percentage was significantly greater for intervention participants compared with control participants (group by time interaction beta=21.0 [CI 5.81 to 36.13], P=.007; group by time squared interaction beta=−15.5 [CI −26.6 to −4.49], P=.007; estimated Cohen d=0.42]. No other significant effects were found on risk factors and attitudes of disturbed eating.

Conclusions

Despite a significant increase in girls’ EBW percentage, parental participation and adherence to the intervention were low. Overall, parent-based, indicated prevention for children at risk for AN does not seem very promising, although it might be useful for parents who engage in the intervention.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 18614564; http://www.isrctn.com/ISRCTN18614564 (Archived by WebCite at http://www.webcitation.org/74FTV1EpF).

Enteral Nutrition via Nasogastric Tube for Refeeding Patients With Anorexia Nervosa: A Systematic Review

Weight restoration is an important first step in treating patients with anorexia nervosa (AN), because it is essential for medical stabilization and reversal of long-term complications. Tube feeding may help facilitate weight restoration, but its role in treatment remains unclear. This study aimed to review the literature describing the efficacy, safety, tolerance, and long-term effects of nasogastric (NG) refeeding for patients with AN. Four electronic databases were systematically searched through May 2018. Boolean search terms included "anorexia nervosa," "refeeding," and "nasogastric tube feeding." Ten studies were eligible for inclusion: 8 retrospective chart reviews, 1 prospective cohort, and 1 randomized controlled trial. Nine of the studies were performed in-hospital. In 8 studies, NG nutrition resulted in an average rate of weight gain exceeding 1 kg/wk. In 4 of 5 studies including an oral-only control group, mean weekly weight gain and caloric intake were significantly higher in tube-fed patients. Six studies provided prophylactic phosphate supplementation, all with <1% occurrence rate of refeeding hypophosphatemia. Seven studies reported on other physiological disturbances, 6 evaluated medical and gastrointestinal side effects, 3 considered psychological outcomes, and 4 assessed patients postdischarge. Results indicated that NG feeding was not associated with an increased risk for adverse outcomes. Overall, in these studies, NG nutrition was considered safe and well tolerated, and effectively increased caloric intake and rate of weight gain in patients with AN. However, results are limited by weaknesses in study designs, and more rigorous methods are needed for development of evidence-based, standardized refeeding protocols.

Longitudinal Associations Among Bullying by Peers, Disordered Eating Behavior, and Symptoms of Depression During Adolescence

Importance

Bullying by peers has been associated with disordered eating behavior and symptoms of depression among adolescents as both an antecedent and an outcome. Identification of the temporal pattern of associations among bullying by peers, disordered eating behavior, and depression in adolescence is needed for the optimal targeting of intervention and prevention.

Objective

To assess the concurrent and longitudinal associations among bullying by peers, disordered eating behavior, and symptoms of depression using a cascade model that controlled for within-time and across-time (ie, stability paths) associations while examining cross-lag effects.

Design, Setting, and Participants

In this 5-year longitudinal cohort study, 612 participants of the McMaster Teen Study were included. This ongoing Canadian study examines the associations among bullying, mental health, and educational outcomes. Data collection began in 2008 when students were in grade 5 (10 years of age) and have since been collected annually. Data analysis was performed between August 20 and October 18, 2017.

Exposures

Bullying by peers was assessed in grades 7 to 11 using a composite measure of 5 items.

Main Outcomes and Measures

Disordered eating behavior was assessed in grades 7 to 11 using the Short Screen for Eating Disorders, and depressive symptoms were assessed in grades 7 to 11 using the Behavior Assessment System for Children-Second Edition.

Results

The 612 students included in the analytic sample had a mean age (SD) of 13.03 (0.38) years in grade 7; 331 (54.1%) were girls and 392 (71.1%) were white. Bullying by peers was concurrently associated with disordered eating behavior and depressive symptoms at every time point during the 5-year period (r range [SE], 0.15-0.48 [0.04-0.08]; P < .01). Disordered eating behavior was associated longitudinally with depressive symptoms at every time point (β range [SE], 0.14-0.19 [0.06-0.08]; P < .02) and bullying by peers at 2 time points (β range [SE], 0.12-0.22 [0.06-0.07]; P < .04) in girls and boys.

Conclusions and Relevance

Bullying by peers was proximally associated with multiple psychopathologic symptoms, whereas symptoms of disordered eating behavior were a key risk factor for future depressive symptoms and bullying by peers. Interventions aimed at reducing problematic eating behavior in adolescents may attenuate the risk of future depressive symptoms and relational problems.

Body Image and Eating Disorders Among Lesbian, Gay, Bisexual, and Transgender Youth

Adolescence is a crucial period for emerging sexual orientation and gender identity and also body image disturbance and disordered eating. Body image distortion and disordered eating are important pediatric problems affecting individuals along the sexual orientation and gender identity spectrum. Lesbian, gay, bisexual, transgender (LGBT) youth are at risk for eating disorders and body dissatisfaction. Disordered eating in LGBT and gender variant youth may be associated with poorer quality of life and mental health outcomes. Pediatricians should know that these problems occur more frequently in LGBT youth. There is evidence that newer treatment paradigms involving family support are more effective than individual models of care.

Extracting body image symptom dimensions among eating disorder patients: the Profile Analysis via Multidimensional Scaling (PAMS) approach

The present study employs Profile Analysis via Multidimensional Scaling (PAMS), a procedure for extracting dimensions, in order to identify core eating disorder symptoms in a clinical sample. A large sample of patients with eating disorders (N=5193) presenting for treatment completed the Eating Disorders Inventory-2 (EDI-2; Garner, 1991), and PAMS was then employed to estimate individual profile weights that reflect the degree to which an individual's observed symptom profile approximates the pattern of the dimensions. The findings revealed three symptom dimensions: Body Thinness, Body Perfectionism, and Body Awareness. Subsequent analysis using individual level data illustrate that the PAMS profiles properly operate as prototypical profiles that encapsulate all individuals' response patterns. The implications of these dimensional findings for the assessment and diagnosis of eating disorders are discussed.

Examining Validity and Reliability of the Emotional Reactions Checklist with Hospitalized Children

Fear, anxiety, and emotional upset are common experiences for hospitalized children. To identify and treat children's emotional reactions, health care professionals must be able to differentiate emotional reactions from pain and other symptoms. Clinical assessment of emotions requires the use of valid and reliable instruments in acute care settings. This study examined internal consistency, construct, and concurrent validity of the Emotional Reactions Checklist (ERC). A descriptive correlational design guided the psychometric approach. Children answered a sociodemographic questionnaire and responded to self-generated scenarios of pleasant and unpleasant events using two self-report scales of emotions. The convenience sample comprised 59 children admitted to an inpatient unit in a large children's hospital or to a community hospital emergency department. Construct validity was supported by significantly different ERC mean responses to recalled pleasant prehospitalization experiences and unpleasant hospitalization experiences (p < .001) for both ERC item responses and total scale scores. Children's explanations for seemingly inconsistent item responses further supported their ability to use the ERC to convey their emotions. Concurrent validity was supported by moderate (r = 0.32) to strong (r = 0.70) correlations between the Facial Affective Scale and ERC items and scale scores. Internal consistency was better supported for the recalled unpleasant experience (α = 0.77) than for the pleasant experience (α = 0.60). Results supported construct and concurrent validity and beginning internal consistency reliability for the ERC in an acute care setting. Further research is required to establish feasibility of repeated use with ill children.

Patients with eating disorders showed no signs of coeliac disease before and after nutritional intervention

AIM

This study assessed the presence of specific antibodies for coeliac disease in outpatients suffering from eating disorders before and after nutritional intervention. We also evaluated whether those patients should undergo regular screening for coeliac disease.

METHODS

The sample consisted of 154 patients with a mean age of 16.7 years - ranging from one to 19 years of age - suffering from eating disorders. Serology screening for coeliac disease and total immunoglobulin A (IgA) levels was evaluated in the 154 children before the nutritional intervention and in 104 patients after the intervention. The patients consumed an adequate amount of gluten in both phases.

RESULTS

Postintervention evaluation revealed that 92 patients (88.5%) achieved a normal body weight, while the remaining 12 (11.5%) became obese. Postprandial abdominal discomfort and pain were resolved. The serology tests were negative in all patients, before and after intervention. None displayed IgA deficiency.

CONCLUSION

To the best of our knowledge, this was the first prospective study where patients underwent a screening serology for coeliac disease before and after nutritional intervention. No indication of the coexistence of eating disorders and coeliac disease was documented, and the patients in our study were unlikely to require regular screening for coeliac disease.

Body fat in children and adolescents participating in organized sports: Descriptive epidemiological study of 6048 Latvian athletes

BACKGROUND

Pressure among young athletes to meet body composition goals may lead to poor nutrition and affect growth.

AIMS

To examine the proportion of body fat (%BF), measured by bioimpedance analysis, among Latvian children and adolescents participating in organized sports.

METHODS

Our study had a nationally representative sample of 6048 young athletes, aged 10-17 years. Their %BF was measured using a multifrequency, 8-pole, bioelectrical impedance leg-to-hand analyzer.

RESULTS

About 19.2% (CI 14.4-20.0) of boys and 15.1% (CI 14.0-16.3) of girls had a %BF value below the recommended levels. The %BF in young female athletes participating in aesthetic sports was lower than among their peers participating in other sports. Young male athletes participating in aesthetic sports had lower %BF levels at 10 and 12 years of age, compared with participants in weight-class sports; and lower levels of %BF from age 10-14 years, compared with participants in non-weight-sensitive sports.

CONCLUSIONS

Almost every fifth child and adolescent participating in organized sports displayed critically low body fat levels. Body fat needs to be assessed regularly in young athletes, to prevent negative consequences on health.

2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.

Assessing the impact of an eating disorders treatment team approach with college students

An interdisciplinary treatment team approach is considered the standard of care for individuals with eating disorders; however, there is limited research on the efficacy of such teams. This study used retrospective chart review to compare client characteristics and treatment utilization for college students treated with psychotherapy alone versus an interdisciplinary treatment team approach (i.e., a mental health counselor, a physician, and a dietitian). Clients with prior counseling histories, a bulimia nervosa diagnosis, or a personality disorder diagnosis were more likely to be referred to the eating disorders treatment team. Female counselors were more likely than male counselors to refer clients to the team. Overall, findings suggest that the team approach is associated with students staying in therapy longer and terminating therapy in a planned fashion.

My sister's keeper: identifying eating pathology through peer networks

This study evaluated a novel intervention designed to teach middle and high school girls to inform adults of the early signs of an eating disorder. Students completed measures assessing the likelihood of talking to a peer about her eating behavior, encouraging a peer to talk to an adult, sharing concerns about a peer with an adult, or talking to an adult about concerns related to herself. Participants demonstrated increased likelihood of talking to an adult about a friend's eating following intervention. Results indicate it may be possible to significantly increase girls' willingness to address or share concerns about a friend's eating.

Menstruation disorders in adolescents with eating disorders-target body mass index percentiles for their resolution

Objective:

To analyse the progression of body mass index in eating disorders and to determine the percentile for establishment and resolution of the disease.

Methods:

A retrospective descriptive cross-sectional study. Review of clinical files of adolescents with eating disorders.

Results:

Of the 62 female adolescents studied with eating disorders, 51 presented with eating disorder not otherwise specified, 10 anorexia nervosa, and 1 bulimia nervosa. Twenty-one of these adolescents had menstrual disorders; in that, 14 secondary amenorrhea and 7 menstrual irregularities (6 eating disorder not otherwise specified, and 1 bulimia nervosa). In average, in anorectic adolescents, the initial body mass index was in 75th percentile; secondary amenorrhea was established 1 month after onset of the disease; minimum weight was 76.6% of ideal body mass index (at 4th percentile) at 10.2 months of disease; and resolution of amenorrhea occurred at 24 months, with average weight recovery of 93.4% of the ideal. In eating disorder not otherwise specified with menstrual disorder (n=10), the mean initial body mass index was at 85th percentile; minimal weight was in average 97.7% of the ideal value (minimum body mass index was in 52nd percentile) at 14.9 months of disease; body mass index stabilization occured at 1.6 year of disease; and mean body mass index was in 73rd percentile. Considering eating disorder not otherwise specified with secondary amenorrhea (n=4); secondary amenorrhea occurred at 4 months, with resolution at 12 months of disease (mean 65th percentile body mass index).

Conclusion:

One-third of the eating disorder group had menstrual disorder – two-thirds presented with amenorrhea. This study indicated that for the resolution of their menstrual disturbance the body mass index percentiles to be achieved by female adolescents with eating disorders was 25–50 in anorexia nervosa, and 50–75, in eating disorder not otherwise specified.

We don't know how to help: an online survey of school staff

BACKGROUND

Eating disorders (ED) have a peak rate of onset in school-aged children. Little is known about teachers' experiences of ED.

METHOD

A total of 826 school staff completed an online questionnaire exploring their Eating Disorder experiences. Responses were analysed using content analysis principles.

RESULTS

74 per cent of respondents' schools had received no training on ED, 40% did not know how to follow up pupils' Eating Disorder concerns and 89% of respondents felt uncomfortable teaching pupils about ED.

CONCLUSIONS

School staff feel ill-equipped to support ED. Training in the recognition, support and teaching of ED would be welcomed and could improve outcomes for young people.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

Nutrition therapy during initiation of refeeding in underweight children and adolescent inpatients with anorexia nervosa: a systematic review of the evidence

Restoration of weight and nutritional rehabilitation are recognized as fundamental steps in the therapeutic treatment of children and adolescent inpatients with anorexia nervosa (AN). However, current recommendations on initial energy requirements for this population are inconsistent, with a clear lack of empirical evidence. Thus, the aim of our study was to systematically review, assess, and summarize the available evidence on the effect of differing nutrition therapies prescribed during refeeding on weight restoration in hospitalized children and adolescents (aged 19 years and younger) with diagnosed AN. Searches were conducted in Scopus, Web of Science, Global Health (CABI), PubMed, and the Cochrane database for articles published in English up to May 2012, and complemented by a search of the reference lists of key publications. Seven observational studies investigating a total of 403 inpatients satisfied the inclusion criteria. The range of prescribed energy intakes varied from 1,000 kcal to >1,900 kcal/day with a progressive increase during the course of hospitalization. It appeared that additional tube feeding increased the maximum energy intake and led to greater interim or discharge weight; however, this was also associated with a higher incidence of adverse effects. Overall, the level of available evidence was poor, and therefore consensus on the most effective and safe treatment for weight restoration in inpatient children and adolescents with AN is not currently feasible. Further research on refeeding methods is crucial to establish the best practice approach to treatment of this population.

Process evaluation of a school-based overweight and obesity screening strategy in adolescents

The PRALIMAP (PRomotion de l'ALIMentation et de l'Activité Physique) trial highlights the effectiveness of implementing a screening strategy in high schools to prevent overweight/obesity among adolescents. The strategy comprises three steps: i) body measurements to detect overweight/obese adolescents, ii) a medical interview with each adolescent identified to discuss the findings, and iii) an adapted care management consisting of seven group educational sessions. A process evaluation was conducted in the PRALIMAP trial to assess the effective implementation of the screening strategy activities, and the participation of adolescents and school professionals in them, from a qualitative and a quantitative point of view. The present paper describes the process and the implementation of the screening strategy as performed in the PRALIMAP trial, and discusses the feasibility of such an intervention in high school settings. The ability of nurses to explain the screening results improved with the addition of specialist support. The ability of adolescents to take part in the screening strategy improved when the adapted care management was conducted inside schools and could be increased even further if the waiting time between the three steps could be minimised.

Dealing with the devil: weight loss concerns in young adult women with type 1 diabetes

AIMS AND OBJECTIVES

To examine the weight loss concerns of young adults with type 1 diabetes.

BACKGROUND

Eating disorders are prevalent in young women with type 1 diabetes.

DESIGN

Qualitative.

METHODS

Interviews with 35 young adults (23-30 years of age) with type 1 diabetes and 13 healthcare professionals.

RESULTS

Most female interviewees were concerned about the difficulties of losing weight when having diabetes. Six female interviewees developed severe eating disturbances when they were younger. These women initially regarded their disturbed eating behaviour positively and engaged in weight loss activities intermittently. However, over time, they lost control of their behaviour, and it came to dominate their lives. Family conflict often intensified disordered eating behaviours. Eventually all of these women managed to transition away from their behaviour, although this process took, for some of them, several years. Several of them (now in their early to late twenties), however, continued to struggle with weight loss impulses. Healthcare professionals felt that eating- and weight-related issues often went undiagnosed and undocumented in young adult women with type 1 diabetes.

CONCLUSION

Many young women with type 1 diabetes are worried about their weight, but will not engage in risky weight loss activities because of concerns about their health. A minority of young adult women will develop more severe eating-related disturbances. These eating disturbances may last a significant amount of time before clinicians become aware of them. These women may also experience disordered weight loss impulses for sometime after clinical interventions.

RELEVANCE TO CLINICAL PRACTICE

Clinicians should screen young adult women with type 1 diabetes for eating disorders and monitor young adult women who have developed eating disorders over the longer term. There may be a need to provide asymptomatic young women with diabetes with information about the potential risks of insulin omission.

Validierung einer deutschen Version des ATHLETE Fragebogens für Hochleistungssportlerinnen

Der ATHLETE ( Hinton & Kubas, 2005 ) ist ein speziell für Sportlerinnen entwickelter Fragebogen, der sportspezifische psychosoziale Risikofaktoren für gestörtes Essverhalten erfasst. Ein vergleichbares deutschsprachiges Instrument existiert bisher nicht. Die vorliegende Studie entwickelte eine deutsche Version des ATHLETE und überprüfte dessen Faktorenstruktur und psychometrische Kennwerte für Hochleistungssportlerinnen. Daten von 103 deutschen Athletinnen wurden mittels mehrerer Fragebögen und klinischem Interview an zwei Messzeitpunkten erhoben. Mit drei der ursprünglichen und drei neuen Faktoren weicht die Faktorenstruktur des deutschen ATHLETE von der der Originalversion ab. Reliabilität und konvergente Validität der Skalen sind akzeptabel bis sehr gut. Ergebnisse zur Kriteriumsvalidität fallen heterogen aus: Skalen zu Sportleridentität, Misstrauen, Perfektionismus und Elternverhalten zeigen keine oder mäßige Zusammenhänge zu Essstörungsproblemen. Nur die neuen Skalen Körper und Sport und Training zur Gewichtsregulation überzeugen als Maße zur Abschätzung der Gefährdung für gestörtes Essverhalten. Sie sind Prädiktoren für die Essstörungspsychopathologie nach 12 Monaten.

Evaluation of a nutrition rehabilitation protocol in hospitalized adolescents with restrictive eating disorders

PURPOSE

Nutritional rehabilitation is an essential part of inpatient treatment for adolescents with restrictive eating disorders (ED). The purpose of this study was to examine weight gain, prevalence of refeeding syndrome, and nutritional composition of the diet in hospitalized adolescents with anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS), restrictive type, on a structured nutrition rehabilitation protocol (NRP).

METHODS

An evidence-based NRP was implemented on the inpatient eating disorders unit at the Hospital for Sick Children in June 2011. Adolescents 12-18 years of age with AN or EDNOS, an ideal body weight (IBW) of 70% or greater, no clinical or metabolic signs of refeeding syndrome, and on their first admission were assigned to the NRP. A retrospective chart review between June 2011 and June 2012 was completed. A repeated measures analysis was used to determine the mean rate of weight gain. Mean cumulative % change in body mass index (BMI) was plotted against days to assess daily weight trajectory.

RESULTS

Twenty-nine patients, mean age of 14.7 (SD ± 1.5) years, were included in the study. A total of 3.5% developed hypophosphatemia on day 1. Mean weight gain was .24 kg/day (p < .0001) and 1.7 kg/week. An increase in mean cumulative % change in BMI was observed from days 2-14. Actual caloric intake was 98%-113% of the prescribed intake. Macronutrient distribution was within acceptable limits based on dietary reference intakes.

CONCLUSIONS

The NRP is considered effective, efficient, and safe. Further research is needed to explore the effectiveness and safety of NRPs in other populations.

A Pilot Study of an Acceptance-Based Separated Family Treatment for Adolescent Anorexia Nervosa

The treatment of adolescent anorexia nervosa (AN) has improved significantly with the increased emphasis on family-based intervention. Yet despite advances, a substantial number of adolescents do not respond optimally to existing treatment models and thus there is a need for treatment alternatives that address barriers to recovery. We developed and piloted an acceptance-based separated family treatment (ASFT) with 6 adolescents with AN or subthreshold AN (eating disorder not otherwise specified, with the primary symptoms of restriction and severe weight loss). Treatment acceptability was adequate. Overall, parents rated the treatment as credible and expected improvement in their child's condition. Five of the 6 adolescents treated with ASFT restored weight to their ideal body mass index as indicated by age, height, and sex and determined by individual growth charts. Many demonstrated improved psychological health and adaptive functioning. There was evidence of broad effects, with parents reporting decreased anxiety and caregiver burden. ASFT holds promise as a treatment option for AN. The efficacy of this therapeutic approach should be tested in larger trials and compared to current family-based interventions to determine unique effects.

Effect of nutritional rehabilitation on gastric motility and somatization in adolescents with anorexia

OBJECTIVE

To examine gastric function, as well as the presence of somatic complaints, anxiety symptoms, and functional gastrointestinal disorders (FGIDs), in adolescents with anorexia nervosa (AN) before and after nutritional rehabilitation.

STUDY DESIGN

Sixteen females with AN and 22 healthy controls with similar demographic profiles were included. Gastric emptying (measured as residual gastric volume) and gastric accommodation (measured as postprandial antral diameter) were assessed with abdominal ultrasonography. Participants completed the Children's Somatization Inventory (CSI), the Screen for Child Anxiety-Related Emotional Disorders, and the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III version. All testing was repeated 3-4 months later.

RESULTS

Body mass index in the AN group improved over time (P = .012). Fasting gastric parameters were similar in the 2 groups. Maximum postprandial antral diameter was significantly greater in controls compared with the AN group (P = .008). Only adolescents with AN demonstrated a significant increase in maximum postprandial diameter at repeat testing (P = .009). There was no difference in residual gastric volume between the 2 groups. Initial CSI scores were higher in adolescents with AN (P < .0001), including higher scores for nausea and abdominal pain. CSI scores were significantly lower in adolescents with AN (P = .035). Initial scores on the Screen for Child Anxiety-Related Emotional Disorders were significantly higher in adolescents with AN (P = .0005), but did not change over time. Adolescents with AN met significantly more criteria for FGIDs (P = .003).

CONCLUSION

Adolescents with AN have impaired gastric accommodation that improves after nutritional rehabilitation, have significantly more somatic complaints, and meet more criteria for anxiety disorders and FGIDs. After nutritional rehabilitation, somatization improves and FGIDs become less common, but symptoms of anxiety persist.

Effectiveness of a multimodal inpatient treatment for adolescents with anorexia nervosa in comparison with adults: an analysis of a specialized inpatient setting : treatment of adolescent and adult anorexics

OBJECTIVE

There is evidence for an increased prevalence and an earlier onset of anorexia nervosa (AN) in adolescents. Early specialized treatment may improve prognosis and decrease the risk of a chronic course. The current study evaluates the effectiveness of a multimodal inpatient treatment for adolescent AN patients treated in a highly specialized eating disorder unit for adults.

METHOD

177 adolescents and 1,064 adult patients were included. The evaluation focused on eating behavior, depressive symptoms and general psychopathology.

RESULTS

All measured variables decreased significantly in both groups during inpatient treatment. No differences were found concerning weight gain, improvement of global eating disorder symptomatology as well as depressive symptoms. However, adults showed a higher psychological distress and in this regard also a greater improvement.

CONCLUSION

Results indicate that treating adolescent AN patients in a highly specialized eating disorder unit for adults can be an effective treatment setting for these patients.

Clinical outcomes of a novel, family-centered partial hospitalization program for young patients with eating disorders

AIM

Eating disorders (ED) in children and younger adolescents are becoming more evident, but there is a small evidence base for their management in this population. We hypothesized that a new family-centered partial hospital program for young patients would be effective in promoting weight gain, as well as improvement in psychiatric symptoms.

METHODS

A retrospective chart review of 56 patients treated in the program between August 2008 and November 2009 was performed. Historical data, anthropometric variables and scores from psychological instruments [Children's Eating Attitudes Test (ChEAT), Children's Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS)] were collected on admission and at discharge. After exclusion, 30 patients were available for statistical analysis, using paired t-tests. The primary outcome variables were improvement in weight and change in total ChEAT score. Secondary outcomes included improvements in the CDI and RCMAS scores. Multivariate analysis included linear regression models that controlled for patient-specific fixed effects.

RESULTS

The cohort was 87% female with a mean age of 12.8±2 years; 60% were diagnosed with ED not otherwise specified. Two-thirds had a co-morbid depressive and/or anxiety disorder. Change in weight was significant (p<0.0001), as were improvements on total ChEAT (p<0.0001), CDI (p=0.0002), and RCMAS (p<0.0001) scores. No historical factors were correlated with improvement, nor was use of psychotropic medications. Length of stay in weeks significantly predicted greater weight gain (p=0.004, R2=0.26).

CONCLUSIONS

Patients treated in a family-centered partial hospital program had significant improvements in weight and psychological parameters. This approach holds significant promise for the management of young ED patients.

Adolescent bulimia nervosa

Onset of bulimia nervosa (BN) typically occurs in adolescence and is frequently accompanied by medical and psychiatric sequelae that may have detrimental effects on adolescent development. Potentially serious medical consequences and high comorbid rates of mood disorders and suicidality underscore the need for early recognition and effective treatments. Research among adolescents with BN has lagged behind that of adults, although evidence is accumulating to support the efficacy of family-based interventions and cognitive behavioral treatments that are adapted for use with adolescent populations. The aim of the current article is to provide an overview of recent research on epidemiology, risk factors, diagnostic issues, and treatment interventions focusing on adolescent BN, and to highlight areas for future research.

Calculation of expected body weight in adolescents with eating disorders

OBJECTIVE

To examine the agreement between three methods to calculate expected body weight (EBW) for adolescents with eating disorders: (1) BMI percentile, (2) McLaren, and (3) Moore methods.

METHODS

The authors conducted a cross-sectional analysis of baseline information from adolescents seeking treatment of disordered eating at The University of Chicago. Adolescents (N = 373) aged 12 to 18 years (mean = 15.84, SD = 1.72), with anorexia nervosa (n = 130), bulimia nervosa (n = 59), or eating disorder not otherwise specified (n = 184). Concurrence between the BMI percentile, McLaren, and Moore methods was assessed for agreement above or below arbitrary cut points used in relation to hospitalization (75%), diagnosis (85%), and healthy weight (100%). Patterns of absolute discrepancies were examined by height, age, gender, and menstrual status. Limitations to some of these methods allowed comparison between all 3 methods in only 204 participants.

RESULTS

Moderate agreement was seen between the 3 methods (κ values, 0.48-0.74), with pairwise total classification accuracy at each cut point ranging from 84% to 98%. The most discrepant calculations were observed among the tallest (>75th percentile) and shortest (<20th percentile) cases and older ages (>16 years). Many of the most discrepant cases fell above and below 85% EBW when comparing the BMI percentile and Moore methods, indicating disagreement on possible diagnosis of anorexia nervosa.

CONCLUSIONS

These methods largely agree on percent EBW in terms of clinically significant cut points. However, the McLaren and Moore methods present with limitations, and a commonly agreed-upon method for EBW calculation such as the BMI percentile method is recommended for clinical and research purposes.

Family-based treatment of children and adolescents with anorexia nervosa: Guidelines for the community physician

Anorexia nervosa (AN) is a serious life-threatening illness that typically has its onset during the adolescent years. Evidence regarding the optimal treatment of AN in children and teenagers is growing; however, much remains unknown. Although current treatment approaches vary in Canada and elsewhere, the evidence to date indicates that family-based treatment (FBT) is the most effective treatment for children and teenagers with AN. A key component of the FBT model is that the parents are given the responsibility to return their child to physical health and ensure full weight restoration. An understanding of the basic principles and philosophy underlying FBT allows the physician to initiate elements of this evidence-based intervention to young patients with AN and their families.

Prevalence of eating disorder risk and body image distortion among National Collegiate Athletic Association Division I varsity equestrian athletes

CONTEXT

Participation in appearance-based sports, particularly at the collegiate level, may place additional pressures on female athletes to be thin, which may increase the likelihood of their resorting to drastic weight control measures, such as disordered eating behaviors.

OBJECTIVES

(1) To estimate the prevalence and sources of eating disorder risk classification by academic status (freshman, sophomore, junior, or senior) and riding discipline (English and Western), (2) to examine riding style and academic status variations in body mass index (BMI) and silhouette type, and (3) to examine these variations across eating disorder risk classification type (eg, body image disturbances).

DESIGN

Cross-sectional study.

SETTING

Seven universities throughout the United States.

PATIENTS OR OTHER PARTICIPANTS

A total of 138 participants volunteered (mean age = 19.88 ± 1.29 years). They represented 2 equestrian disciplines English riding (n = 91) and Western riding (n = 47).

MAIN OUTCOME MEASURE(S)

Participants self-reported menstrual cycle history, height, and weight. We screened for eating disorder risk behaviors with the Eating Attitudes Test and for body disturbance with sex-specific BMI silhouettes.

RESULTS

Based on the Eating Attitudes Test, estimated eating disorder prevalence was 42.0% in the total sample, 38.5% among English riders, and 48.9% among Western riders. No BMI or silhouette differences were found across academic status or discipline in disordered eating risk. Overall, participants perceived their body images as significantly larger than their actual physical sizes (self-reported BMI) and wanted to be significantly smaller in both normal clothing and competitive uniforms.

CONCLUSIONS

Disordered eating risk prevalence among equestrian athletes was similar to that reported in other aesthetic sports and lower than that in nonaesthetic sports. Athletic trainers working with these athletes should be sensitive to these risks and refer athletes as needed to clinicians knowledgeable about disordered eating. Professionals working with this population should avoid making negative comments about physical size and appearance.

Eating disorders: screening in the dental office

BACKGROUND

Eating disorders are serious illnesses that often are not detected by health care professionals. The author presents techniques that the oral health care professional (OHCP) can use to screen at-risk patients for eating disorders during routine preventive care appointments.

CONCLUSIONS

OHCPs often are the first health care professionals to encounter patients with undiagnosed eating disorders. Because early detection of eating disorders is challenging, screening tools can be helpful. Early detection of eating disorders, with appropriate referral, is associated with fewer dental and systemic adverse effects and a more favorable prognosis.

CLINICAL IMPLICATIONS

OHCPs are in an ideal position to screen patients for eating disorders. They can accomplish this via a valid, reliable, brief questionnaire and careful patient assessment.

The use of a parent support group in the outpatient treatment of children and adolescents with eating disorders

Our objective was to measure parents' level of satisfaction and perceived benefits gained from participating in a parent support group as part of an outpatient treatment program. We mailed surveys to 261 parent/guardian participants. Results reflected high satisfaction with the support group. Parents indicated that it assisted them in understanding eating disorders symptoms and treatment and supporting their child struggling with an eating disorder. Additionally, the group was a source of emotional support. Results suggest that inclusion of a parent support group in the outpatient treatment of children and adolescents with eating disorders has important implications for parents.

Are diagnostic criteria for eating disorders markers of medical severity?

OBJECTIVE

The objective of this study was to compare the medical severity of adolescents who had eating disorders not otherwise specified (EDNOS) with those who had anorexia nervosa (AN) and bulimia nervosa (BN).

METHODS

Medical records of 1310 females aged 8 through 19 years and treated for AN, BN, or EDNOS were retrospectively reviewed. Patients with EDNOS were subcategorized into partial AN (pAN) and partial BN (pBN) when they met all Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria but 1 for AN or BN, respectively. Primary outcome variables were heart rate, systolic blood pressure, temperature, and QTc interval on electrocardiogram. Additional physiologically significant medical complications were also reviewed.

RESULTS

A total of 25.2% of females had AN, 12.4% had BN, and 62.4% had EDNOS. The medical severity of patients with EDNOS was intermediate to that of patients with AN and BN in all primary outcomes. Patients with pAN had significantly higher heart rates, systolic blood pressures, and temperatures than those with AN; patients with pBN did not differ significantly from those with BN in any primary outcome variable; however, patients with pAN and pBN differed significantly from each other in all outcome variables. Patients with pBN and BN had longer QTc intervals and higher rates of additional medical complications reported at presentation than other groups.

CONCLUSIONS

EDNOS is a medically heterogeneous category with serious physiologic sequelae in children and adolescents. Broadening AN and BN criteria in pediatric patients to include pAN and pBN may prove to be clinically useful.

Medical providers' screening, training and intervention practices for eating disorders

Individuals struggling with an eating disorder are typically first seen by their family physician, yet little is known about how medical providers are trained to work with eating disorders or about their screening and intervention practices (Clarke & Polimeni-Walker, 2004). This study sought to examine frontline medical providers' eating disorder screening and intervention practices as well as their training needs. Medical providers' perspectives were elicited through survey data and semi-structured interview data. Seventy-eight percent of survey respondents reported that they had patients with eating disorders who they were unsure how to treat and 54% reported either moderately or strongly supporting universal screening for eating disorders with all patients regardless of presenting issue. Qualitative themes including challenges and barriers to effective screening, desire for increased eating disorder trainings, and fear of incompetence emerged from the interviews. Training implications and future research directions are discussed.