Restrictive eating disorders among adolescent inpatients

A prospective observational study comparing rates of medical instability between adolescents with typical and atypical anorexia nervosa

BACKGROUND

Recognition of atypical anorexia nervosa (AAN) has challenged underweight as a defining factor of illness severity in anorexia nervosa (AN). The present study aimed to compare rates of medical instability in adolescents with underweight (AN) and non-underweight (AAN) anorexia nervosa.

METHODS

The study examined assessment data from specialist eating disorder services in the UK between January and December 2022. Participants (n = 205) aged 11-18 years were recruited across eight eating disorder clinics and diagnosed with AN (n = 113) or AAN (n = 92) after clinical assessment. Parameters associated with risk of medical instability were compared between AN and AAN groups, using t tests and regression analysis.

RESULTS

Rates of bradycardia and hypotension did not differ significantly between AN and AAN groups (p = 0.239 and p = 0.289). Although white blood cell counts were lower in the AN group, rates of leukopaenia could not be statistically compared as a result of there being too few counts in at least one group. No incidences of hypophosphataemia were found in the sample. A significant regression equation was found for percentage median body mass index, but not rate of weight loss, as a predictor of blood pressure, serum phosphorous and magnesium.

CONCLUSIONS

Our findings indicate that medical instability occurs across a range of body weights in young people with AN and AAN. Although certain parameters of risk such as blood pressure, serum phosphorous and magnesium may be worsened at lower weight, both AN and AAN are serious mental health conditions that can lead to medical instability.

Psychopathological and Organic Features of Atypical Anorexia Nervosa in Developmental Age: A Systematic Review

PURPOSE

This study aimed to comprehensively report the epidemiological and clinical features of atypical anorexia nervosa (AAN) in children and adolescents.

METHODS

In May 2024, a systematic review was performed using Medline, Cochrane Library, ClinicalTrials.gov, and relevant websites. Following PRISMA guidelines, 234 articles were screened for studies on DSM-5-defined AAN. A standardized checklist-the JBI critical appraisal tool-was adopted in assessing methodology, and 13 retained studies passed the screening and critical appraisal process for the final review. The Newcastle-Ottawa Scale was utilized to assess the risk of bias in cohort and case-control studies, ensuring a comprehensive evaluation of methodological quality.

RESULTS

AAN prevalence in young age groups is 2.8%, with a cumulative 2.8% incidence over 8 years. Incidence is 366 per 100,000 person-years, and the average episode duration is 11.6 months, with a 71% remission rate. Diagnostic persistence for AAN is less stable than other restrictive feeding and eating disorders (FEDs). AAN individuals exhibit higher EDE-Q scores, more severe distress, and distinct BMI differences compared to those with anorexia nervosa and controls. The diagnostic transition from the DSM-IV to the DSM-5 shows that AAN patients are predominantly female, slightly older, and with higher weight.

CONCLUSIONS

This study yields concrete insights into the features of AAN in the developmental age, highlighting demographic variations, clinical presentations, and treatment outcomes. Recognizing the unique challenges faced by AAN individuals is vital for tailoring effective interventions and improving overall care within the FED spectrum.

Associations between presenting weight and premorbid weight and the medical sequelae in hospitalized youth with anorexia nervosa or atypical anorexia nervosa

PURPOSE

To identify unique treatment considerations for youth with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) and premorbid overweight or obesity, we examined unique relationships between premorbid and presenting weight status and medical sequelae in youth with AN/AAN requiring medical hospitalization.

DESIGN AND METHODS

We performed a retrospective study of 150 youth aged mean [SD] of 14.1[2.3] years, hospitalized for AN/AAN. Independent t-tests and Fischer's exact tests assessed differences in demographic and clinical characteristics by premorbid weight status. Logistic regressions assessed associations between premorbid and presenting weight status and vital sign or laboratory abnormalities.

RESULTS

Compared to youth with premorbid 'normal' weights, youth with premorbid overweight/obesity demonstrated greater percent (p = .042) and faster rate (p < .001) of weight loss and had 10.9 times the odds of having anemia (p = .025). Youth with AN (<5th percentile for body mass index [BMI]) were more likely to experience hypoglycemia (p < .018) than youth with AAN (≥5th percentile BMI). Greater percent of weight loss significantly predicted bradycardia (p < .001) and hypoglycemia (p = .002), independent of premorbid or presenting weight status.

CONCLUSION

Acute medical management of AN/AAN should be commensurate for hospitalized patients, regardless of premorbid weight status. However, those with more significant weight loss and those presenting as underweight may warrant particular monitoring for complications such as bradycardia and hypoglycemia.

PRACTICE IMPLICATIONS

In youth with AN/AAN, high percent of weight loss warrants closer monitoring for medical complications during hospitalization. Those with premorbid overweight/obesity may need additional monitoring for anemia, as there may be additional contributors to anemia aside from malnutrition.

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.

Comparisons between atypical anorexia nervosa and anorexia nervosa: Psychological and comorbidity patterns

OBJECTIVE

Literature comparing "atypical" anorexia nervosa (atypical AN) and anorexia nervosa (AN) suggests these diagnoses share significant similarities in eating disorder (ED) pathology and psychiatric comorbidities. This study evaluated potential differences in ED pathology, psychiatric comorbidity, associated mechanisms (i.e., ED fears and perfectionism), and demographic factors (i.e., ethnicity and age) between individuals with atypical AN and AN.

METHOD

Data from seven protocols were combined for a total 464 individuals diagnosed with atypical AN (n = 215) or AN (n = 249). Between-group differences in ED severity and behaviors, psychiatric comorbidities, ED fears, perfectionism, and demographic factors were assessed using t-tests, Wilcoxon rank-sum tests, and Fisher's exact test.

RESULTS

Participants with atypical AN reported higher levels of overvaluation of weight and shape than those with AN. Participants with AN scored higher on food-related fears (anxiety about eating, food avoidance behaviors, and feared concerns) and fears of social eating, as well as obsessive-compulsive symptoms. Participants with AN were more likely to identify as Asian or Pacific Islander. No other statistically significant differences were found between groups for overall ED severity, ED behaviors, psychiatric comorbidities, general ED fears, perfectionism, or demographic factors.

DISCUSSION

Overall, results support previous literature indicating limited differences between individuals with atypical AN and AN, though individuals with atypical AN reported more overvaluation of weight and shape and those with AN reported higher food and social eating fears and obsessive-compulsive symptoms. Relatively few overall differences between atypical AN and AN highlight the importance of exploring dimensional conceptualizations of AN as an alternative to the current categorical conceptualization.

PUBLIC SIGNIFICANCE

This study assessed differences among individuals with atypical anorexia nervosa and anorexia nervosa in eating disorder severity and behaviors, comorbid psychiatric diagnoses, associated mechanisms, and demographic factors. Few differences emerged, though participants with atypical anorexia nervosa reported more overvaluation of weight and shape, while those with anorexia nervosa reported more food and social eating fears and higher obsessive-compulsive symptoms. Results support exploration of these diagnoses as a spectrum disorder.

Premorbid body weight predicts weight loss in both anorexia nervosa and atypical anorexia nervosa: Further support for a single underlying disorder

OBJECTIVE

For adolescents, DSM-5 differentiates anorexia nervosa (AN) and atypical AN with the 5th BMI-centile-for-age. We hypothesized that the diagnostic weight cut-off yields (i) lower weight loss in atypical AN and (ii) discrepant premorbid BMI distributions between the two disorders. Prior studies demonstrate that premorbid BMI predicts admission BMI and weight loss in patients with AN. We explore these relationships in atypical AN.

METHOD

Based on admission BMI-centile < or ≥5th, participants included 411 female adolescent inpatients with AN and 49 with atypical AN from our registry study. Regression analysis and t-tests statistically addressed our hypotheses and exploratory correlation analyses compared interrelationships between weight loss, admission BMI, and premorbid BMI in both disorders.

RESULTS

Weight loss in atypical AN was 5.6 kg lower than in AN upon adjustment for admission age, admission height, premorbid weight and duration of illness. Premorbid BMI-standard deviation scores differed by almost one between both disorders. Premorbid BMI and weight loss were strongly correlated in both AN and atypical AN.

DISCUSSION

Whereas the weight cut-off induces discrepancies in premorbid weight and adjusted weight loss, AN and atypical AN overall share strong weight-specific interrelationships that merit etiological consideration. Epidemiological and genetic associations between AN and low body weight may reflect a skewed premorbid BMI distribution. In combination with prior findings for similar psychological and medical characteristics in AN and atypical AN, our findings support a homogenous illness conceptualization. We propose that diagnostic subcategorization based on premorbid BMI, rather than admission BMI, may improve clinical validity.

PUBLIC SIGNIFICANCE

Because body weights of patients with AN must drop below the 5th BMI-centile per DSM-5, they will inherently require greater weight loss than their counterparts with atypical AN of the same sex, age, height and premorbid weight. Indeed, patients with atypical AN had a 5.6 kg lower weight loss after controlling for these variables. In comparison to the reference population, we found a lower and higher mean premorbid weight in patients with AN and atypical AN, respectively. Considering previous psychological and medical comparisons showing little differences between AN and atypical AN, we view a single disorder as the most parsimonious explanation. Etiological models need to particularly account for the strong relationship between weight loss and premorbid body weight.

Eating disorder psychopathology, psychiatric impairment, and symptom frequency of atypical anorexia nervosa versus anorexia nervosa: A systematic review and meta-analysis

OBJECTIVES

Restrictive eating disorders (EDs) occur across the weight spectrum, but historically more focus has been given to anorexia nervosa (AN) than atypical anorexia nervosa (atypAN). AtypAN's relegation to a diagnosis in the "other specified feeding and eating disorder" (OSFED) category and paucity of research surrounding atypAN invariably implies a less clinically severe ED. However, a growing body of research has begun to question the assumption that atypAN is less severe than AN. The current review and meta-analysis aimed to provide a comprehensive review to compare atypAN and AN on measures of eating disorder psychopathology, impairment, and symptom frequency to test whether atypAN is truly less clinically severe than AN.

METHODS

Twenty articles that reported on atypAN and AN for at least one of the variables of interest were retrieved from PsycInfo, PubMed, and ProQuest.

RESULTS

For eating-disorder psychopathology, results indicated that differences were nonsignificant for most indicators; however, atypAN was associated with significantly higher shape concern, weight concern, drive for thinness, body dissatisfaction, and overall eating-disorder psychopathology than AN. Results indicated that atypAN and AN did not significantly differ on clinical impairment or the frequency of inappropriate compensatory behaviors, whereas there was a significantly higher frequency of objective binge episodes in AN (vs. atypAN).

DISCUSSION

Overall, findings indicated that, in contrast to the current classification system, atypAN and AN were not clinically distinct. Results underscore the need for equal access to treatment and equal insurance coverage for restrictive EDs across the weight spectrum.

PUBLIC SIGNIFICANCE

The current meta-analysis found that atypAN was associated with higher drive for thinness, body dissatisfaction, shape concern, weight concern, and overall eating-disorder psychopathology than AN; whereas AN was associated with higher frequency of objective binge eating. Individuals with AN and atypAN did not differ on psychiatric impairment, quality-of-life, or frequency of compensatory behaviors, highlighting the need for equal access to care for restrictive EDs across the weight spectrum.

Eating behavior in atypical anorexia nervosa

OBJECTIVE

Atypical anorexia nervosa (AN) has been increasingly identified in the community and in clinical settings. Initial studies indicate that psychological symptoms are similar or more severe among patients with atypical AN, as compared with AN. This study examined whether eating behavior differed among patients with AN (n = 98), patients with atypical AN (n = 18), and healthy controls (HC, n = 75).

METHOD

Adults and adolescents chose what to eat from a standardized, laboratory-based multi-item meal. Total intake, macronutrient composition, diet variety, and energy density were compared between groups.

RESULTS

Both AN and atypical AN severely restricted caloric intake as compared with HC (431 ± 396 kcal and 340 ± 338 kcal vs. 879 ± 350 kcal, F2,188 = 35.4, p < .001). Individuals with AN and atypical AN did not differ in the mean intake of total calories or percentage of calories from fat (15.2 ± 25.2% vs. 11.5 ± 16.9%).

DISCUSSION

This study demonstrates that individuals with atypical AN are at least as restrictive in their food intake as individuals with AN, and the restriction of dietary fat is particularly notable. Examination of eating behavior in a larger sample would be useful to replicate these findings. The current study highlights the need to understand maladaptive eating behavior in atypical AN in order to develop appropriate treatment recommendations.

PUBLIC SIGNIFICANCE

Atypical anorexia nervosa is emerging as a prevalent eating disorder in community and clinical populations. The findings that patients with atypical anorexia nervosa limit calorie and fat intake in a pattern similar to that of patients with anorexia nervosa highlights the need for research to identify appropriate treatment strategies for normalization of eating patterns.

Naturalistic symptom trajectories of atypical anorexia nervosa, anorexia nervosa, and bulimia nervosa in a prospective cohort study of United States college students

OBJECTIVE

Research on the natural course of symptoms of atypical anorexia nervosa (AN) relative to AN and bulimia nervosa (BN) is limited yet needed to inform nosology and improve understanding of atypical AN. This study aimed to 1) characterize trajectories of eating disorder and internalizing (anxiety, depression) symptoms in college students with and without a history of atypical AN, AN, and BN; and 2) compare sex and race/ethnicity distributions across groups.

METHOD

United States college students who participated in Spit for Science™, a prospective cohort study, were classified as having a history of atypical AN (n = 125), AN (n = 160), BN (n = 617), or as non-eating-disorder controls (NCs, n = 5876). Generalized and linear mixed-effects models assessed group differences in eating and internalizing symptom trajectories, and logistic regression compared groups on sex and race/ethnicity distributions.

RESULTS

Atypical AN participants demonstrated elevated eating disorder and internalizing symptoms compared to NCs during college, but less severe symptoms than AN and BN participants. Although all eating disorder groups showed signs of improvement in fasting and driven exercise, purging and depression remained elevated. Atypical AN participants showed increasing anxiety and stable binge-eating trajectories compared to AN and/or BN participants. The atypical AN group comprised significantly more people of color than the AN group.

DISCUSSION

Findings underscore that atypical AN is a severe psychiatric disorder. As atypical AN may present as less severe than AN and BN and disproportionately affects people of color, clinicians should be mindful of biases that could delay diagnosis and care.

PUBLIC SIGNIFICANCE

College students with histories of atypical AN, AN, and BN demonstrated improvements in fasting and driven exercise and stable purging and depression levels. Atypical AN students showed worsening anxiety and stable binge-eating trajectories compared to favorable changes among AN and BN students. A higher percentage of atypical AN (vs. AN) students were people of color. Findings may improve the detection of atypical AN in college students.

Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with atypical anorexia nervosa

OBJECTIVE

The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose.

METHOD

Patients were enrolled upon admission and randomized to meal-based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t-tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight).

RESULTS

Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p = .008, Cohen's d = -.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p < .001, Cohen's d = .51) and greater hypomagnesemia (29% vs. 11%, p = .03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p < .001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p < .001), weight gain was 1.6%mBMI (.8, 2.4) greater (p < .001), and hypomagnesemia odds were 70% (12, 128) lower (p = .02).

DISCUSSION

Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group.

PUBLIC SIGNIFICANCE

The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital.

Associations between low body weight, weight loss, and medical instability in adults with eating disorders

OBJECTIVE

The physical complications of atypical anorexia nervosa remain understudied, with most studies completed in adolescents. This study seeks to examine the impact of various weight measures as predictors of medical instability in a large cohort of adult eating disorder patients.

METHODS

In this retrospective cohort study, the impact of admission body mass index (BMI), weight suppression, and recent weight loss (the rate of weight loss within the last 12 months) toward the development of medical complications of malnutrition were examined. Multivariable logistic regression assessed the association of binary clinical outcomes of interest with recent weight loss and weight suppression (adjusting for age, admission BMI, gender, and purging behaviors). Odds ratios (OR) and 99% confidence intervals were reported.

RESULTS

Greater recent weight loss increased the odds of developing low prealbumin and reduced hand grip strength. A greater weight suppression was associated with increased likelihood of amenorrhea, reduced systolic blood pressure, nadir hemoglobin, and weekly weight gain upon nutritional rehabilitation. Lower admission BMI was predictive of all the medical outcomes examined, with the exception of bradycardia, and was generally the strongest predictor based on standardized coefficients.

DISCUSSION

Recent weight loss and weight suppression are predictive of some of the physiologic changes of malnutrition, although low BMI is seemingly the greatest predictor for the development of these complications. These findings suggest that some patients with aggressive weight suppression and/or acute weight loss would benefit from medical stabilization, although this needs to be further defined.

PUBLIC SIGNIFICANCE

In adults, low BMI seems to be a better predictor of medical complications than weight suppression or aggressive recent weight loss. In adults, greater weight suppression is associated with increased likelihood of amenorrhea, reduced systolic blood pressure, nadir hemoglobin, and weight gain upon nutritional rehabilitation.

Prevalence of suicide attempt, suicide ideation and self-harm at diagnosis in adolescents with eating disorders

BACKGROUND

Data concerning the suicide prevalence of eating disorder (ED) subtypes and predictive factors are lacking in youth. This study aimed to examine suicide attempts (SA), suicide ideation (SI) and self-harm (SH) upon diagnosis in adolescents with EDs.

METHODS

The prevalence of SA, SI and SH in ED subtypes was evaluated by retrospectively assessing the Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidal ideation and Safety (HEEADSSS) instrument of adolescents diagnosed with an ED. Clinical predictors of SI in anorexia nervosa (AN) and atypical AN (AAN) were assessed.

RESULTS

Among all participants (398), 41 (10.3%) reported SA, 126 (31.7%) SI and 60 (15.1%) SH. While SA did not differ statistically between ED subgroups (p = .123), they were two times more prevalent in the bulimia nervosa (BN) group (17.5%) than in the AN group (8.5%). In the BN group, SI was 2.3 times more prevalent than in the AN group (p = .001). The AN and ARFID groups exhibited substantially less SH (p = .036). Having a higher body mass index (BMI) was the only significant predictor of SI.

CONCLUSIONS

This study demonstrates that adolescents with EDs are at an increased risk for suicidality, highlighting the need for close screening, particularly in those with BN, AN-BP and AN with a higher BMI.

Cross-sectional assessment of body composition and detection of malnutrition risk in participants with low body mass index and eating disorders using 3D optical surface scans

BACKGROUND

New recommendations for the assessment of malnutrition and sarcopenia include body composition, specifically reduced muscle mass. Three-dimensional optical imaging (3DO) is a validated, accessible, and affordable alternative to dual X-ray absorptiometry (DXA).

OBJECTIVE

Identify strengths and weaknesses of 3DO for identification of malnutrition in participants with low body mass index (BMI) and eating disorders.

DESIGN

Participants were enrolled in the cross-sectional Shape Up! Adults and Kids studies of body shape, metabolic risk, and functional assessment and had BMI of <20 kg/m2 in adults or <85% of median BMI (mBMI) in children and adolescents. A subset was referred for eating disorders evaluation. Anthropometrics, scans, strength testing, and questionnaires were completed in clinical research centers. Lin's Concordance Correlation Coefficient (CCC) assessed agreement between 3DO and DXA; multivariate linear regression analysis examined associations between weight history and body composition.

RESULTS

Among 95 participants, mean ± SD BMI was 18.3 ± 1.4 kg/m2 in adult women (N = 56), 19.0 ± 0.6 in men (N = 14), and 84.2% ± 4.1% mBMI in children (N = 25). Concordance was excellent for fat-free mass (FFM, CCC = 0.97) and strong for appendicular lean mass (ALM, CCC = 0.86) and fat mass (FM, CCC = 0.87). By DXA, 80% of adults met the low FFM index criterion for malnutrition, and 44% met low ALM for sarcopenia; 52% of children and adolescents were <-2 z-score for FM. 3DO identified 95% of these cases. In the subset, greater weight loss predicted lower FFM, FM, and ALM by both methods; a greater percentage of weight regained predicted a higher percentage of body fat.

CONCLUSIONS

3DO can accurately estimate body composition in participants with low BMI and identify criteria for malnutrition and sarcopenia. In a subset, 3DO detected changes in body composition expected with weight loss and regain secondary to eating disorders. These findings support the utility of 3DO for body composition assessment in patients with low BMI, including those with eating disorders. This trial was registered at clinicaltrials.gov as NCT03637855.

Anorexia Nervosa in Adolescence: A Comprehensive Study of Multidimensional Factors Associated with Symptom Severity 1 Year Following the Diagnosis

The overarching goal of this study was to examine the unique contribution of psychological, familial, and friendship factors in explaining anorexia nervosa (AN) symptom severity 1 year following diagnosis among a sample of adolescent girls. A second objective was to determine whether friendship factors mediated the association between psychological and/or familial factors and AN symptom severity. This study included 143 adolescent girls under the age of 18 diagnosed with AN (M = 14.84, SD = 1.31). Participants were recruited from specialized eating disorder treatment programs. At admission (T1), participants completed a set of self-report questionnaires measuring psychological, familial, and friendship factors. AN symptom severity was assessed 1 year later (T2). Results of hierarchical regression analysis revealed that greater general psychological maladjustment at T1 (b = .26; se = .03; p = .00) was associated with greater AN symptom severity at T2. Greater alienation from friends at T1 (b = 1.20, se = .53, p = .03) also predicted greater AN symptom severity at T2, above and beyond the influence of adolescent girls' general psychological maladjustment. Finally, the mediating role of alienation from friends in the association between general psychological maladjustment at T1 and AN symptom severity at T2 was also identified. AN is a multidimensional disorder with a prognosis that involves both psychological and social factors. The results stemming from the present study shed light on the role of peer as a mechanism through which general psychological maladjustment is linked to AN symptom severity 1 year following diagnosis.

Eating Disorders in Youth with Chronic Health Conditions: Clinical Strategies for Early Recognition and Prevention

Youth with chronic health conditions face an elevated risk of eating disorders and disordered eating behaviors. Contributors to this phenomenon may include the unique threats faced by this vulnerable population to their body image, their relationships with food and eating, and their mental health and self-esteem. However, youth with chronic health conditions may also experience more severe medical complications and mortality from eating disorder behaviors because of the additional risks conveyed by their underlying conditions. In this review, clinical strategies are provided to support youth with chronic health conditions through early recognition of eating disorder behaviors and prompt referral to treatment, which is important for a better prognosis. Suggestions are also given to mitigate their risk of developing eating disorders by proactively addressing risk factors and offering thoughtful anticipatory guidance that promotes a positive relationship with food and eating.

Analysis of symptom clusters amongst adults with anorexia nervosa: Key severity indicators

This study used cluster analysis to explore clinically relevant subgroups of adult patients with anorexia nervosa (AN). Patients were clustered based on their body mass index (BMI), eating disorder symptomatology, anxiety and depression symptoms and autistic characteristics. The difference between clusters in work and social functioning, duration of illness, bingeing and purging behaviour, previous hospitalisations and number of comorbidities was also investigated. Two meaningful clusters emerged: a higher symptoms cluster with more severe eating pathology, anxiety, depression, and more autistic traits, and a second cluster with lower symptoms. BMI did not make major contributions to cluster formation. The higher symptoms cluster also reported lower self-efficacy to change, more previous hospitalisations, comorbid diagnoses, binge eating and purging behaviours and use of psychotropic medication. Our findings suggest that weight alone may not be a significant severity indicator amongst inpatients with AN, and targeted treatment of AN should consider a broader range of symptom severity indicators.

An exploration of the association between premorbid weight status on patient and caregiver factors at pre and post-treatment among youth with anorexia nervosa/atypical anorexia nervosa

Patients with atypical anorexia nervosa (AAN) or anorexia nervosa (AN) with premorbid history of higher weight (PHW; median BMI ≥ 85th %ile) may report greater eating disorder (ED) pathology, anxiety, and depression, than patients with premorbid history of lower weight (PLW; mBMI <85th %ile). Less is known about caregiver attitudes or treatment outcome related to premorbid weight history. The current study examined associations between premorbid weight history and patient/caregiver factors at presentation, during treatment, and end of treatment among adolescents (N = 138) diagnosed with AN/AAN and their caregivers who received interdisciplinary ED treatment. The sample comprised adolescents with PHW (n = 58, 40.6 %) or PLW (n = 82, 59.4 %). Adolescents with PHW did not differ with regard to patient- or caregiver-reported ED symptoms, comorbid psychopathology, rates of treatment completion, and attainment of estimated body weight compared to PLW (ps > .05). Adolescents with PHW (vs. PLW) were more likely to be diagnosed with AAN (67.9 %, p < .001), identify as cisgender male (p < .001) and to have lost more weight prior to presentation (p < .001). Perceived caregiver burden was lower among adolescents with PHW vs. PLW (p < .001). Further research should expand on this preliminary study exploring associations between premorbid weight history on patient and caregiver factors at treatment presentation and conclusion to enhance the efficacy of evidence-based treatment across the weight-spectrum.

Medical instability in typical and atypical adolescent anorexia nervosa: a systematic review and meta-analysis

This review investigates the relationship between weight and risk of medical instability (specifically bradycardia, hypotension, hypothermia, and hypophosphatemia) in adolescents with typical and atypical anorexia nervosa. Atypical anorexia nervosa, listed as an example under the DSM-5 category of Other Specified Feeding and Eating Disorders (OSFED), describes patients who are not clinically underweight but otherwise meet criteria for anorexia nervosa. There is a lack of empirical evidence exploring medical complications in adolescents presenting with atypical anorexia nervosa. The small number of studies that do exist in this area indicate that medical instability exists across a range of weights, with weight loss being associated with increased medical risk, independent of underweight. The aim of this review was to collate and analyse results from available studies and identify indicators of medical risk in these two groups of adolescents with restrictive eating disorders. Studies were identified by systematic electronic search of medical databases, including PubMed and EMBASE. All studies investigated the relationship between weight and medical instability and included adolescents diagnosed with anorexia nervosa or atypical anorexia nervosa. One randomised controlled trial, five cohort studies and three chart reviews were included, with a total sample size of 2331 participants. Between 29 and 42% of participants presented with medical instability requiring hospitalisation, in the absence of underweight. Underweight adolescents were significantly more likely to have lower blood pressures (p < 0.0001) and bradycardia was significantly associated with greater weight loss (p < 0.05). There were no statistically significant associations found between degree of underweight and heart rate, temperature, or rate of weight loss (p = 0.31, p = 0.46 and p = 0.16, respectively). Adolescents that were less than 70% median body mass index were significantly more likely to have hypophosphatemia (p < 0.05). The findings of this review support the hypothesis that medical instability can occur across a range of weights in adolescent eating disorders, with rapid weight loss being an important indicator of increasing medical risk. Results were limited by the small number of existing studies that contained data for statistical analysis. Rapid weight loss should be considered as an important indicator of medical instability in adolescents presenting with both typical and atypical anorexia nervosa.

Unique considerations for the medical care of restrictive eating disorders in children and young adolescents

BACKGROUND

The medical complications of eating disorders are often approached through an age-neutral lens. However, children and young adolescents may have unique medical complications related to the energy needs and timing of growth and development. Providers caring for patients in this vulnerable age range should understand how to identify, approach, and manage these potential age-related complications.

REVIEW

Evidence continues to accumulate that increasingly younger patients are being diagnosed with eating disorders. These children and young adolescents have significant risk for unique and potentially irreversible medical complications. Without early identification and treatment, restrictive eating disorders may negatively impact linear growth, bone development and brain maturation in children and young adolescents. Additionally, due to the energy needs of growth and development, unique considerations exist for the use of acute medical stabilization and the identification of patients at risk for refeeding syndrome with initial nutritional rehabilitation. This review presents an approach to the evaluation and management of children and young adolescents with eating disorders.

CONCLUSION

Children and young adolescents with restrictive eating disorders may have unique medical complications related to the energy needs and timing of linear growth and pubertal development. Significant risk exists for irreversible medical complications of impaired growth, bone, and brain health. Increased awareness of the energy needs for growth and development may improve early recognition, appropriate intervention, and future outcomes for children and young adolescents with restrictive eating disorders.

Acceptability of using a nasogastric refeeding protocol with adult patients with medically unstable eating disorders

RATIONALE, AIMS AND OBJECTIVES

Nasogastric feeding is becoming commonly used to support patients with medically compromised eating disorders. Previous research has demonstrated the safety of this approach, however there is limited evidence as to how adult patients and staff perceive this feeding method. This study aimed to describe the acceptability of a nasogastric refeeding protocol with adult patients with medically unstable eating disorders and the staff involved in their treatment.

METHOD

This was a qualitative exploratory study using semi-structured interviews conducted in acute medical wards of a tertiary hospital where nasogastric nutrition is the sole source of nutrition for the first 7 days of the eating disorder admission. Data were analysed using the Framework method.

RESULTS

Eight patients (100% female, median: 22 years old, n = 6 diagnosed with anorexia nervosa) and 12 staff members (medical n = 5, nursing n = 5, dietitians n = 2; median: 8.5 years clinical experience) were interviewed. Patients reported that nasogastric feeding was tolerable, however concerns were raised regarding communication and the desire for concurrent oral feeding. Acceptability from staff was influenced by perceived competence, confidence, tensions around patient-centred care, and working with stigma and ambivalence.

CONCLUSIONS

Consideration needs to be given as to whether a 'nil by mouth' status during nasogastric feeding further impacts recommencing an oral diet to progress treatment. Improvements are required within the current service, including improved communication, additional educational resources for patients, and allowing patients to partake in decision-making as able.

Considerations in Evidence-Based Treatment of Adolescents With Atypical Anorexia Nervosa

There is emerging evidence suggesting atypical anorexia nervosa (AAN), an eating disorder (ED) introduced in the DSM-5, is as serious an ED as anorexia nervosa (AN) in terms of medical risk and ED pathology. Medical hospitalizations among individuals with AAN have significantly increased over the years and individuals with AAN are noted to have longer illness durations and greater weight loss prior to receiving care than individuals with AN. Additionally, AAN is noted to be two to three times more common than AN in community samples of adolescents. Given that AAN is a newer diagnosis, research knowledge and evidence-based treatment guidelines are emerging, yet pivotal. Thus, this article discusses specific considerations during assessment and treatment using Family Based Treatment (FBT) among adolescents diagnosed with AAN and clinical and ethical concerns involved while providing effective care and mitigating any weight bias or stigma related to historical and current weight status.

Medical complications and management of atypical anorexia nervosa

Atypical anorexia nervosa (AAN) is a new diagnosis in the 5th edition of the Diagnostic and Statistical Manual. Patients with AAN have been recognized to have similar, if not more severe, medical and psychological complications compared with patients with typical Anorexia Nervosa; yet studies on medical complications and optimal treatment of AAN are lacking. Here we review what is known regarding medical presentation and management of patients with AAN.

Medical Management of Restrictive Eating Disorders in Adolescents and Young Adults

The medical provider plays an important role in the management of adolescents and young adults (AYAs) with restrictive eating disorders (EDs), including anorexia nervosa (AN), atypical anorexia nervosa, and avoidant/restrictive food intake disorder. The focus of this article is the medical management of AYAs with restrictive EDs, which can be performed by a number of different medical providers, including pediatricians, family physicians, internists, nurse practitioners, and, in some countries, psychiatrists. This position paper clarifies the role of the medical provider in diagnosing and managing restrictive EDs in AYAs and advocates for consistent standardized terminology for clinical and research purposes when describing the degree of malnutrition and differentiating the degree of malnutrition from treatment goal weight. Boys and men with restrictive EDs are frequently underdiagnosed and may have distinct clinical presentations with important implications for medical management. The medical and psychological complications of AYAs with avoidant/restrictive food intake disorder and atypical anorexia nervosa can be just as severe as those with AN. Scientific evidence supports weight restoration as an important early goal of treatment in AN. Most AYAs with restrictive EDs can be treated as outpatients, and family-based therapy is a first-line outpatient psychological treatment for adolescents with AN. Recent research has demonstrated that inpatient refeeding protocols can start with higher caloric content and advance more rapidly than previously recommended.

Atypical anorexia nervosa: Rethinking the association between target weight and rehospitalization

OBJECTIVE

Bodyweight restoration is one of the most important targets in adolescent inpatient treatment of anorexia nervosa (AN). This study examined the association between achieving target weight and rehospitalization in two groups of adolescents with AN and atypical anorexia nervosa (AAN) admitted to a specialized inpatient unit.

METHOD

Included were 202 adolescent patients hospitalized in a specialized eating disorder unit, 10-18 years old. One hundred fifty-four adolescents were diagnosed with AN, and 48 with AAN. We examined the patients' demographic and clinical characteristics, the achievement of treatment goals, and their rehospitalization history within a year of discharge from the unit.

RESULTS

Log-linear regression indicated a significant association between achieving target weight during the inpatient program and rehospitalization at one-year follow-up in the AN group; this association was not significant in the AAN group.

DISCUSSION

This study emphasizes the importance of differentiating patients with AAN from those with classical AN. Specifically, it raises questions about the predictive power of target weight at discharge in preventing relapse and its centrality in determining AAN patients' treatment plans.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

Atypical Anorexia in Youth: Cautiously Bridging the Treatment Gap

Atypical anorexia nervosa (AAN) is a restrictive eating disorder (ED) that describes individuals who may be normal weighted or overweight; many have a premorbid history of obesity. Pediatric care providers are trained to identify and provide best practices for youth with pediatric obesity; however, most pediatric care providers are not trained to assess and treat restrictive EDs which typically present in youth aged 10 and 14 years. Although individuals with AAN may appear to be within a ‘healthy weight’, many experience malnutrition, psychological symptoms, and severe physiological complications after weight loss. These individuals are presenting to pediatric services at an increasing rate and exhibit acute medical instability along with severe ED psychopathology. One complicating factor is youth with AAN may take longer to be identified by pediatric providers and may be reluctant to engage in treatment. Delayed treatment for AAN, along with all EDs often results in poorer treatment outcomes. A greater understanding of this complex illness is essential to inform medical decisions, such as labs, vitals, hospital admissions, and psychological therapy. Currently, there are no standardized guidelines for treating AAN in youths. This review is designed to present evidence-based treatment to inform and guide best treatment practices.

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders

OBJECTIVE

Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group - anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder.

METHOD

Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13-60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis).

RESULTS

Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group.

CONCLUSION

Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.

Exploring the experience of being viewed as "not sick enough": a qualitative study of women recovered from anorexia nervosa or atypical anorexia nervosa

BACKGROUND

Despite common misconceptions, an individual may be seriously ill with a restrictive eating disorder without an outwardly recognizable physical sign of the illness. The aim of this qualitative study was to investigate the perspectives of individuals who have previously battled a restrictive eating disorder who were considered "not sick enough" by others (e.g., peers, families, healthcare professionals) at some point during their illness, and to understand the perceived impact on the illness and recovery. Such misconceptions are potentially damaging, and have been previously linked with delayed help-seeking and poorer clinical outcomes.

METHODS

Seven women who had recovered from anorexia nervosa or atypical anorexia nervosa participated in semi-structured interviews. Interviews were transcribed and interpretive phenomenological analysis was used.

RESULTS

Three main themes emerged: (1) dealing with the focus upon one's physical appearance while battling a mental illness, (2) "project perfect": feeling pressure to prove oneself, and (3) the importance of being seen and understood. Participants reported that their symptoms were occasionally met with trivialization or disbelief, leading to shame, confusion, despair, and for some, deterioration in eating disorder symptoms which drove further weight loss. In contrast, social support and being understood were viewed as essential for recovery.

CONCLUSION

To facilitate treatment seeking and engagement, and to optimize chances of recovery, greater awareness of diverse, non-stereotypical presentations of restrictive eating disorders is needed which challenge the myth that weight is the sole indicator of the presence or severity of illness.

A meta-analysis of the relationship between eating restraint, impaired cognitive control and cognitive bias to food in non-clinical samples

AIM

Food restriction is argued to be a precursor for unhealthy preoccupation with food, possibly leading to the development of an eating disorder. We updated previous meta-analyses that examined the relationship between eating restraint and deficits in either general or food-related attentional and inhibitory control. We hypothesized that inconsistencies in the literature around eating restraint, impaired cognitive control, impulsivity and cognitive biases for food could be attributed to the scale used to measure eating restraint.

METHOD

A (preregistered) subgroup meta-analysis examined whether patterns of impaired cognitive control and cognitive bias for food in predominantly healthy (non-clinical) samples differed as a function of the scale used to measure eating restraint. A series of exploratory meta-analyses were carried out for specific attentional bias tasks. In total 57 datasets were included.

RESULTS

The subgroup analysis did not provide evidence that the relationship between eating restraint and impaired or biased cognitions differed significantly as a function of restraint scale. Heterogeneity across studies was high. When examining specific attentional bias tasks there was no evidence that increased eating restraint was associated with increased attentional bias or distraction by food cues, regardless of which scale was used to measure eating restraint.

CONCLUSIONS

There is little experimental evidence for the common narrative that increased eating restraint is related to impaired cognitive control generally or increased cognitive bias for food, in non-clinical samples.

Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature

OBJECTIVE

Currently, there is debate in the eating disorders field regarding how to define atypical anorexia (AAN), how prevalent it is in community and clinical settings, and how AAN rates compare with low-weight AN. This systematic review assesses AAN literature from 2007 to 2020, to investigate: (a) the demographic characteristics of AAN studies, (b) the prevalence of AAN compared with AN, (c) the range of operational definitions of AAN and the implications of these definitions, and (d) the proportion of patients with AAN and AN represented in consecutive admission and referral samples.

METHOD

PsychINFO, CINAHL, PubMed, Greylit.org, and ProQuest databases were searched according to methods for Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic reviews, yielding 3,184 potential articles. Seventy-five eligible studies were coded for sixty-one variables.

RESULTS

Clinical samples predominantly included younger, female, white samples with limited diversity. In epidemiological designs, AAN was typically as common or more common than AN, and AAN rates varied significantly based on the population studied and operational definitions. In consecutive clinical samples, AAN was frequently less represented.

DISCUSSION

Although AAN appears to occur more frequently than AN in communities, fewer patients with AAN are being referred and admitted to eating disorder specific care, particularly in the United States. Given the significant medical and psychosocial consequences of AAN, and the importance of early intervention, this represents a crucial treatment gap. Additionally, results suggest the need for fine-tuning diagnostic definitions, greater diversity in AAN studies, and increased screening and referral for this vulnerable population.

Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial

IMPORTANCE

The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome.

OBJECTIVE

To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach.

INTERVENTIONS

Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day.

MAIN OUTCOMES AND MEASURES

Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay.

RESULTS

Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant.

CONCLUSIONS AND RELEVANCE

In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02488109.

Identifying research priorities for the study of atypical anorexia nervosa: A Delphi study

OBJECTIVE

Individuals meeting all criteria for anorexia nervosa (AN) except that weight falls within or above the normal range despite significant weight loss are categorized as having atypical AN (AAN). Existing research has provided mixed evidence concerning the diagnostic demarcation of AN and AAN. The aim of the present study was to identify research priorities for furthering the understanding of AN and AAN as diagnostic entities.

METHOD

Employing the Delphi methodology, experts in the field were invited to suggest research questions that need to be explored in the demarcation of AN from AAN. This yielded 24 research areas, that were presented in subsequent rounds where panelists were asked to prioritize areas of primary interest.

RESULTS

Fifty-three panelists completed all three Delphi rounds. Consensus was only reached on three items considered to be of primary interest: medical, neurobiological, and neurological factors; epidemiology and natural course; and treatment response in AAN compared to AN. In contrast, questions of premorbid weight and determining the need for and nature of a body mass index cutoff differentiating between AAN and AN were seen as being of low priority.

DISCUSSION

These findings reveal a relatively low degree of consensus on the demarcation of AN from AAN in the field of eating disorders. A reason could be that the definition and use of the AAN category vary in research and clinical practice. In order to achieve further diagnostic clarity, research on the demarcation of AAN and AN should focus on the identified prioritized research areas.

Return of Menses in Previously Overweight Patients with Eating Disorders

STUDY OBJECTIVE

Adolescents with eating disorders and a history of overweight present with higher weights, longer duration of disease, but equally severe symptomatology compared with previously normal weight patients. To better delineate treatment goals for this understudied population, we compared weight at menses resumption with premorbid maximum weight among previously overweight and normal weight patients.

DESIGN

Retrospective cohort study.

SETTING

Outpatient adolescent medicine clinic at an eating disorder referral center.

PARTICIPANTS

Postmenarchal patients meeting criteria for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition eating disorders. History of overweight was defined as a body mass index (BMI) greater than or equal to the 85th percentile or 25 or more.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Weight characteristics at presentation and menses resumption (BMI, BMI z-score, change from maximum weight to presentation weight) RESULTS: Previously overweight patients presented with greater mean weight, longer duration of disease, and higher BMI than previously normal weight patients. No difference was found in rates of amenorrhea at presentation or menses resumption. Previously overweight patients resumed menses at a younger age and higher BMI z-scores. The difference between weight at menses resumption and premorbid maximum weight was greater for previously overweight patients.

CONCLUSION

Previously overweight patients with eating disorders present differently than their normal-weight peers, so reliance on weight status as a screening criterion might result in underdiagnosis. Although BMI z-scores associated with menses resumption are higher for previously overweight patients, there is no difference in weight gain between presentation and menses resumption and time to menses resumption compared with previously normal-weight patients. Moreover, menses resumption occurred at weights significantly lower than premorbid maximum weight for previously overweight patients, so restoration to highest premorbid weight is not necessary.

Weight Loss and Illness Severity in Adolescents With Atypical Anorexia Nervosa

BACKGROUND

Lower weight has historically been equated with more severe illness in anorexia nervosa (AN). Reliance on admission weight to guide clinical concern is challenged by the rise in patients with atypical anorexia nervosa (AAN) requiring hospitalization at normal weight.

METHODS

We examined weight history and illness severity in 12- to 24-year-olds with AN (n = 66) and AAN (n = 50) in a randomized clinical trial, the Study of Refeeding to Optimize Inpatient Gains (www.clinicaltrials.gov; NCT02488109). Amount of weight loss was the difference between the highest historical percentage median BMI and admission; rate was the amount divided by duration (months). Unpaired t tests compared AAN and AN; multiple variable regressions examined associations between weight history variables and markers of illness severity at admission. Stepwise regression examined the explanatory value of weight and menstrual history on selected markers.

RESULTS

Participants were 16.5 ± 2.6 years old, and 91% were of female sex. Groups did not differ by weight history or admission heart rate (HR). Eating Disorder Examination Questionnaire global scores were higher in AAN (mean 3.80 [SD 1.66] vs mean 3.00 [SD 1.66]; P = .02). Independent of admission weight, lower HR (β = -0.492 [confidence interval (CI) -0.883 to -0.100]; P = .01) was associated with faster loss; lower serum phosphorus was associated with a greater amount (β = -0.005 [CI -0.010 to 0.000]; P = .04) and longer duration (β = -0.011 [CI -0.017 to 0.005]; P = .001). Weight and menstrual history explained 28% of the variance in HR and 36% of the variance in serum phosphorus.

CONCLUSIONS

Weight history was independently associated with markers of malnutrition in inpatients with restrictive eating disorders across a range of body weights and should be considered when assessing illness severity on hospital admission.

Medical Complications of Eating Disorders in Youth

Eating disorders affect a significant number of individuals across the life span and are found among all demographic groups (including all genders, socioeconomic statuses, and ethnicities). They can cause malnutrition, which can have significant effects on every organ system in the body. Cardiovascular complications are particularly dangerous and cause eating disorders to have the highest mortality rate of all mental illnesses. This article outlines the medical assessment and treatment of malnutrition due to disordered eating.

Tackling mixed messages: Practitioner reflections on working with adolescents with atypical anorexia and their families

The treatment of atypical anorexia nervosa (AN) poses new research and practice challenges for the field of eating disorders. The objective of this study was to describe frontline practitioners' perceptions of differences between adolescents living with atypical versus typical AN, as well as the intervention challenges they experience when working with these adolescents and their families. We followed the principles of fundamental qualitative description and recruited a purposeful sample of practitioners treating adolescent eating disorders to complete a one-on-one semi-structured interview. Conventional content analysis and the constant comparison technique were used for data analysis. A total of 23 practitioners from four countries participated in this study. Practitioners described that adolescents with atypical AN present with higher pre-morbid weights and rates of weight-based teasing compared to their AN peers. Clinical challenges perceived by practitioners to be specific to working with adolescents with atypical AN included: addressing conflicting messages about eating disorders and weight loss, empathizing with a justified fear of weight gain, and increased risk for parental and therapist collusion with the eating disorder. Findings have implications for delivering interventions to adolescents seeking care for atypical AN.

Obsessions are strongly related to eating disorder symptoms in anorexia nervosa and atypical anorexia nervosa

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are highly comorbid. However, little research has examined which specific cognitive-behavioral aspects (e.g., checking, obsessing) of OCD are most relevant in those with AN. Furthermore, there is no research examining aspects of OCD in Atypical AN. The current two studies (N = 139 and N = 115 individuals diagnosed with AN/Atypical AN) examined a) which aspects of OCD were most related to AN symptomatology and b) if there were differences in OCD between individuals diagnosed with AN vs Atypical AN. We found that obsessing was most related to AN symptoms. We also found that there were no substantial significant differences between AN and Atypical AN. These findings add to the literature suggesting minimal differences between AN and Atypical AN, specifically regarding OCD symptomatology. These findings clarify that obsessions (rather than compulsions) may be the specific aspect of OCD most warranting treatment intervention in AN and Atypical AN.

Comparisons of bone density and body composition among adolescents with anorexia nervosa and atypical anorexia nervosa

OBJECTIVE

To compare bone mineral density (BMD) and body composition among adolescents: (a) with atypical anorexia nervosa (AAN) versus anorexia nervosa (AN) and (b) those with and without a prior history of overweight.

METHOD

Electronic medical records of patients 9-20 years with AN or AAN who underwent dual-energy x-ray absorptiometry scans were retrospectively reviewed and analyzed.

RESULTS

A total of 286 adolescents with AN or AAN were included. In linear regression models, AAN was associated with greater Z-scores in whole body bone mineral content (BMC, B = 0.88, p < 0.001), lumbar spine BMD (B = 0.79, p = 0.002), femoral neck BMD (B = 0.670, p = 0.009); fat mass index (B = 1.33, p = 0.003), and lean body mass index (LBMI, B = 1.10, p < 0.001) compared to AN, adjusting for age, sex, and duration of illness. A prior overweight history was associated with greater Z-scores in whole body BMC; lumbar spine BMD, total hip BMD, femoral neck BMD, and LBMI.

DISCUSSION

Adolescents with AAN had higher BMD Z-scores than adolescents with AN; adolescents with a prior overweight history had greater BMD Z-scores than adolescents without a prior overweight history. These findings may inform clinical guidelines for the medical management of AAN.

Stay the course: practitioner reflections on implementing family-based treatment with adolescents with atypical anorexia

BACKGROUND

Atypical anorexia nervosa (AN) has received minimal empirical attention regarding effective diagnosis and treatment. Family-based treatment (FBT) might be a promising treatment for atypical AN, yet it is unclear as to what adaptations are needed to the current manualized FBT for AN model. The objective of the current study was to identify how FBT practitioners applied FBT for atypical AN for adolescents in their clinical practice, and if there were any implementation challenges and adaptations to the model for this population.

METHODS

The current study employed fundamental qualitative description, with the aim of capturing practitioners' reflections on working with adolescents with atypical AN in clinical practice. A purposeful sample of practitioners with training in FBT were recruited and each participant completed an individual, semi-structured interview. Data was analyzed using conventional content analysis.

RESULTS

A total of 23 practitioners participated in this study. The results indicate that practitioners maintained some fidelity to manualized FBT in treating atypical AN, but they differed in their discussions around target weights, what constitutes weight restoration, and the dosage for FBT phases. Salient practice challenges included operationalizing the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-5) definition of atypical AN, identifying a 'goal weight' for adolescents and activating parents to take charge of the re-nourishment process.

CONCLUSIONS

The results of this qualitative study demonstrate practitioner reflections on the delivery and adaptations of FBT for adolescents with atypical AN. These reflections highlight the need to establish the delivery of coherent and consistent treatment and messaging with patients and families. Further, practitioners' reflections highlight common strategies to increase the sense of urgency in parents to support their child with atypical AN.

What's Weight Got to Do With It? Mental Health Trainees' Perceptions of a Client With Anorexia Nervosa Symptoms

This study examined the effect of client body mass index (BMI) on diagnostic impressions and perceptions of mental health trainees. Participants read a vignette of a mock female client presenting for treatment with symptoms of anorexia nervosa. Participants were randomly assigned to one of three conditions in which the client was described as “underweight,” “normal weight,” or “overweight.” Results revealed that participants assigned to the “underweight” condition diagnosed the client with anorexia nervosa or atypical anorexia nervosa more frequently than participants assigned to the “overweight” or “normal weight” conditions. There was no difference based on client BMI when the more general diagnosis of other specified feeding or eating disorder (OSFED; previously known as eating disorder not otherwise specified [EDNOS]) was included, however. Participants in the “overweight” and “normal weight” conditions recommended fewer therapy sessions for the client than participants in the “underweight” condition. Furthermore, participants more strongly endorsed weight-based stereotypes to describe the client when she was “overweight” than “normal weight” or “underweight.” Contrary to hypotheses, however, participants reported moderately positive attitudes toward treating the client regardless of BMI. These preliminary findings support initiatives aimed at providing training on weight stigma and eating disorders to mental health professionals.

Predictors of Complications in Anorexia Nervosa and Atypical Anorexia Nervosa: Degree of Underweight or Extent and Recency of Weight Loss?

PURPOSE

Adolescents with atypical anorexia nervosa (AAN) can experience severe physical complications despite not being underweight, posing questions about the contribution of weight loss to complications experienced in restrictive eating disorders (EDs). This study compared total weight loss and recent weight loss with admission weight as predictors of physical and psychological complications.

METHODS

Retrospective (2005-2010) and prospective (2011-2013) studies were undertaken of 12- to 19-year-old hospitalized adolescents with anorexia nervosa (AN) or AAN, defined as meeting criteria for AN except underweight (≥85% median body mass index). Predictors were total weight loss (from lifetime maximum), recent weight loss (past 3 months), and admission weight. Outcomes were hypophosphatemia, clinical, anthropometric, and psychometric markers during admission.

RESULTS

In 171 participants (AN, 118 [69%]; AAN, 53 [31%]), there was little evidence of an association between weight measures and hypophosphatemia. Greater total weight loss (regression coefficient [Coeff]: -1.70, 95% confidence interval [CI]: -2.77, -.63, p = .002) and greater recent weight loss (Coeff: -3.37, 95% CI: -5.77, -.97, p = .006), but not admission weight, were associated with a lower pulse rate nadir. Greater total weight loss (odds ratio [OR]: 1.70, 95% CI: 1.19, 2.24, p = .003) and greater recent weight loss (OR: 2.12, 95% CI: 1.11, 4.02, p = .02) were also associated with a higher incidence of bradycardia.

CONCLUSIONS

In adolescents with restrictive EDs, total weight loss and recent weight loss were better predictors than admission weight of many physical complications. This suggests that future diagnostic criteria for AN place greater emphasis on weight loss.

Weight restoration in atypical anorexia nervosa: A clinical conundrum

The determination of the treatment goal weight for adolescents with a restrictive eating disorder (ED) and a prior history of obesity, such as in atypical anorexia nervosa (AAN), represents an ongoing challenge for clinicians. This determination is particularly complex given competing interests of physical recovery from significant weight loss, mental recovery from ED psychopathology, and the medical comorbidities associated with obesity. We report the case of a 15-year old female with a history of obesity and irregular periods who presented with significant weight loss and absence of menses for 3 months. She was hospitalized for severe malnutrition and bradycardia, initiated family based treatment, and regained periods. However, her vital sign instability and eating disorder cognitions did not resolve until she reached a weight at which point her periods again ceased due to polycystic ovary syndrome. This case highlights the need for regular monitoring during weight recovery and the clinical challenge of determining the treatment goal weight in adolescents with EDs and prior obesity.

A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using "start low, go slow" refeeding methods (∼1,000 kcal/day, advancing ∼500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts.

OBJECTIVE

To compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs.

DESIGN

This was a retrospective pre-test-post-test study.

PARTICIPANTS/SETTING

One hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n=26, HC: n=93). The HC refeeding protocol was implemented in September 2013.

MAIN OUTCOME MEASURES

Differences in prevalence of electrolyte disturbances, hypoglycemia, edema, and RFS diagnoses were examined.

STATISTICAL ANALYSIS PERFORMED

χ² tests, Kruskal-Wallis H test, analysis of variance, and independent t tests were used to compare data between the two protocols.

RESULTS

Descriptors were similar between groups (LC: 28±9 years, 96% female, 85% with anorexia nervosa, 31% admitted primarily because of clinical symptoms of exacerbated ED vs HC: 27±9 years, 97% female, 84% with anorexia nervosa, 44% admitted primarily because of clinical symptoms of exacerbated ED, P>0.05). Participants refed using the LC protocol had higher incidence rates of hypoglycemia (LC: 31% vs HC: 10%, P=0.012), with no statistical or clinical differences in electrolyte disturbances (LC: 65% vs HC: 45%, P=0.079), edema (LC: 8% vs HC: 6%, P=0.722) or diagnosed RFS (LC: 4% vs HC: 1%, P=0.391).

CONCLUSIONS

A higher-calorie refeeding protocol appears to be safe, with no differences in rates of electrolyte disturbances or clinically diagnosed RFS and a lower incidence of hypoglycemia. Future research examining higher-calorie intakes, similar to those studied in adolescent patients, may be beneficial.

Fifteen minute consultation: A structured approach to the management of children and adolescents with medically unstable anorexia nervosa

Assessing and managing children who are underweight is an integral part of paediatric practice. Young people with anorexia nervosa (AN) are mainly cared for in the community by specialist eating disorder services. However, increasing numbers require admission to paediatric wards with medical instability due to the complications of starvation. Despite recommendations published in the junior MARSIPAN report in 2012, many paediatricians still feel poorly equipped to care for these high-risk patients. This article aims to provide a safe and structured approach to the assessment and management of children and adolescents with medically unstable AN.

The Anorexia Nervosa Genetics Initiative: Study description and sample characteristics of the Australian and New Zealand arm

OBJECTIVES

Anorexia nervosa is a severe psychiatric disorder with high mortality rates. While its aetiology is poorly understood, there is evidence of a significant genetic component. The Anorexia Nervosa Genetics Initiative is an international collaboration which aims to understand the genetic basis of the disorder. This paper describes the recruitment and characteristics of the Australasian Anorexia Nervosa Genetics Initiative sample, the largest sample of individuals with anorexia nervosa ever assembled across Australia and New Zealand.

METHODS

Participants completed an online questionnaire based on the Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) eating disorders section. Participants who met specified case criteria for lifetime anorexia nervosa were requested to provide a DNA sample for genetic analysis.

RESULTS

Overall, the study recruited 3414 Australians and 543 New Zealanders meeting the lifetime anorexia nervosa case criteria by using a variety of conventional and social media recruitment methods. At the time of questionnaire completion, 28% had a body mass index ⩽ 18.5 kg/m². Fasting and exercise were the most commonly employed methods of weight control, and were associated with the youngest reported ages of onset. At the time of the study, 32% of participants meeting lifetime anorexia nervosa case criteria were under the care of a medical practitioner; those with current body mass index < 18.5 kg/m² were more likely to be currently receiving medical care (56%) than those with current body mass index ⩾ 18.5 kg/m² (23%). Professional treatment for eating disorders was most likely to have been received from general practitioners (45% of study participants), dietitians (42%) and outpatient programmes (42%).

CONCLUSIONS

This study was effective in assembling the largest community sample of people with lifetime anorexia nervosa in Australia and New Zealand to date. The proportion of people with anorexia nervosa currently receiving medical care, and the most common sources of treatment accessed, indicates the importance of training for general practitioners and dietitians in treating anorexia nervosa.

History of Overweight/Obesity as Predictor of Care Received at 1-year Follow-Up in Adolescents With Anorexia Nervosa or Atypical Anorexia Nervosa

PURPOSE

Previous research has indicated that patients with anorexia nervosa (AN) or atypical AN with premorbid history of overweight/obesity have greater weight loss and longer illness duration than patients with no such history. However, little is known about the association of premorbid overweight/obesity and receiving inpatient medical care during treatment for an eating disorder.

METHODS

Using logistic regression, we sought to determine if history of overweight/obesity was associated with receiving inpatient medical care in a sample of 522 patients (mean age 15.5 years, 88% female) with AN/atypical AN.

RESULTS

Binary results demonstrated greater percent weight loss (27.4% vs. 16.2%) and higher percent median body mass index (%mBMI, 99.8% vs. 85.2%) at presentation in those with a history of overweight/obesity (p < .001) but no difference in duration of illness (p = .09). In models adjusted for demographics and percent weight loss, history of overweight/obesity was associated with lower odds of receiving inpatient medical care (odds ratio .60 [95% confidence interval: .45-.80]) at 1-year follow-up. However, these associations were no longer significant after adjusting for %mBMI. Mediation results suggest that %mBMI fully mediates the relationship between history of overweight/obesity and inpatient medical care, in that those with a history of overweight/obesity are less likely to receive care due to presenting at a higher weight.

CONCLUSIONS

Our findings suggest that, despite greater degree of weight loss and no difference in duration of illness, participants with a history of overweight/obesity are less likely to receive inpatient medical care.