Anorexia nervosa: Outpatient treatment and medical management

Bone Fracture History in Women With First Episode or With Persistent Anorexia Nervosa

OBJECTIVE

To investigate fractures history in women with first episode anorexia nervosa (AN) (FE-AN: ≤ 3 years duration) and those with persistent AN (P-AN: ≥ 7 years), compared to healthy controls (HC).

METHOD

One hundred nineteen women (FE-AN = 49, P-AN = 46 and HC = 24) completed online questionnaires on eating disorders symptoms, their menstrual and their fracture history.

RESULTS

Average illness duration was 1.9 years (SD = 0.8) in FE-AN and 15.3 years (SD = 8.5) in P-AN. Lifetime history of all fractures, including stress fractures, was higher in AN groups (FE-AN = 33.3%; P-AN = 37.8%) than in HC (4.2%, p < 0.001). P-AN participants were 13.4 times more likely to report a fracture compared to HC, irrespective of age, whereas F-AN participants were 10.3 times more likely. In P-AN, higher BMI, shorter duration of amenorrhoea and history of pregnancy were inversely associated with fracture number.

CONCLUSIONS

There is an increased risk of bone fracture even in the early stages of AN. This could be related to a time lapse between the initial symptoms of AN and formal diagnosis. This suggests guidelines recommending bone screening after 2-years of persistent low weight for adults should be revisited, and the risk of bone problems should be part of the dialogue between clinicians, patients and carers at the earliest opportunity.

Brain morphology in adolescent girls with first-onset anorexia nervosa

This study aimed to assess whether a young, first-onset cohort of girls with anorexia nervosa (AN) demonstrate similar findings of reduced gray and white matter volume reductions as reported in older women with chronic AN. We compared adolescents and young adults with first-onset AN to typically developing (TD) girls and investigated associations between brain volume measures and clinical symptoms. Whole-brain T1-weighted structural imaging was performed in 58 young persons with AN and 63 age, sex-, and education-matched TD participants. Participants with AN were further divided into underweight (undAN) and restored weight (restAN) groups based on body mass index length/weight standard deviation score (BMI-SDS). Eating disorder symptoms were measured by the Eating Disorder Examination (EDE) and the Eating Disorder Inventory-3 (EDI-3). Differences in brain volume measures were analyzed using separate linear regression analyses. Within the AN group, associations between brain volumes, BMI-SDS, and EDE/EDI-3 scores were analyzed. The undAN group showed significant reductions in total and cortical gray matter volumes compared to the TD group, primarily in the frontal and parietal cortices. No significant associations were found between brain volume and BMI-SDS or EDE/EDI-3 scores. Frontal and parietal cortices in adolescents and young adults with undAN are particularly affected by malnutrition, showing gray matter volume reductions even in early stages of AN. Longitudinal studies are needed to explore the effects of malnutrition on brain development and its association with clinical features of AN over time.

Eyes on the body: Assessing attentional bias toward body-related stimuli in Anorexia Nervosa

OBJECTIVE

The aim of the present study was to assess whether patients with Anorexia Nervosa (AN) presented an attentional bias toward pictures of other women's bodies, as this bias could implicitly promote self-other comparisons thus increasing body/weight concerns.

METHODS

The sample included 48 healthy controls (HC) and 54 patients with AN. All participants performed a dot-probe task with pictures of bodies or body parts of underweight (UWB), normal weight (NWB) and overweight (OWB) women, while their gaze was recorded with an eye-tracking system. Two indices of attentional bias, a gaze direction bias and a gaze duration bias were extracted.

RESULTS

The models conducted on both direction bias and duration bias showed a significant main effect of group, revealing a stronger attentional bias toward bodies in patients as compared to controls. One sample t-tests conducted on the direction bias of patients with AN revealed that they presented a significant positive bias at 500 ms toward all the bodies. At 1500 ms, instead, they presented a positive bias toward UWB and an avoidance bias of OWB. HC instead presented an initial avoidance of all body stimuli, and an avoidance of NWB and OWB at 1500 ms.

DISCUSSION

Our results revealed a stronger attentional bias toward other women's bodies in patients than in HC. Moreover, patients presented a tendency to focalize their attention on UWB while they avoided maintaining their attention on OWB. This pattern might promote upward social comparisons, which are usually associated with negative self-evaluation and increased levels of body dissatisfaction.

A Complex Presentation of Anorexia Nervosa and Takotsubo Cardiomyopathy in a Patient of East Asian Descent

Anorexia nervosa is an eating disorder characterized by severely low body weight due to psychological reasons. Its presentation and ideal management may differ depending on the cultural background of the patient. We present a 52-year-old female of East Asian descent with a unique presentation of anorexia nervosa and takotsubo cardiomyopathy. An extensive medical workup revealed no medical abnormalities, she reported negative answers to most questions posed in eating disorder screening surveys, and she wished to be discharged against medical advice despite having a BMI of 10 kg/mg2. Her desire to leave as well as her perception of her eating disorder were likely influenced by her collectivist culture mentality, and factoring in her cultural background was vital in managing her care. Patient autonomy vs. beneficence was considered throughout her stay, and she was determined to have the capacity to leave against medical advice two weeks after presenting. This case aims to demonstrate that providers should consider cultural components when caring for patients with eating disorders to better understand causes, treatment preferences, and guide care.

Early intervention for adolescents with anorexia nervosa: Pilot evaluation of an outpatient group therapy prior to inpatient treatment

OBJECTIVE

An increasing demand for inpatient treatment for adolescents with anorexia nervosa (AN) during and after the Covid-19 pandemic contrasts with limited capacity and long waiting times. The current pilot study evaluated an outpatient group therapy (GT) as early intervention for adolescents with AN prior to inpatient treatment.

METHODS

Seventeen female adolescents who participated at the GT (intervention group, INT) were compared to 16 adolescents without GT (treatment-as-usual, TAU). BMI, eating disorder psychopathology and motivation of change (MoC) were assessed at three timepoints.

RESULTS

Comparing pre- versus post- group participation, we identified a significant increase of MoC and a trend towards a decreased AN-specific psychopathology. Comparing INT with TAU adolescents, we found a significant lower AN psychopathology at inpatient admission for the INT group and a trend for different BMI courses: While the BMI of the TAU group decreased during waiting time, the INT group did not show a decrease during GT resulting in a higher BMI at admission.

CONCLUSIONS

Results of the current pilot study suggest positive effects of an early outpatient intervention in a group setting for adolescents with AN prior to inpatient treatment. Further research with larger sample sizes is necessary to validate the current pilot results.

Investigating the Prevalence of Eating Disorders, Factors Contributing to Eating Disorders and Weight Control Methods: A Cross-Sectional Study on the Residents of Qassim Region, Saudi Arabia

Background: Eating disorders significantly affect quality of life, body image, self-esteem, and relationships. Previous studies have mainly focused on Western populations, leaving a gap in our understanding of the cultural, social, and environmental factors in non-western populations. This cross-sectional study aimed to investigate the prevalence of eating disorders and its risk factors and examine the common methods for weight control used by affected individuals within the Qassim region of Saudi Arabia. Materials and methods: Recognizing the importance of understanding the landscape of eating disorders in this population, we used diagnostic criteria from the validated Arabic version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to assess the severity and patterns of eating disorders. Data were collected remotely over one year using a self-administered questionnaire distributed at schools, colleges, parks, and malls. The questionnaire covered demographics, weight control methods, and diagnostic criteria. This study included 404 undiagnosed cases (n = 404) to provide a comprehensive overview of the prevalence and severity of eating disorders in this region. Statistical significance was set at p < 0.05. Results: Of the participants, 12 (2.9%) reported having a diagnosed eating disorder, and the severity levels varied across different disorders. Anorexia nervosa exhibited predominantly moderate severity (264, 65.3%), with lower percentages classified as low (119, 29.5%) or high severity (21, 5.2%). Avoidant/restrictive food intake disorder demonstrated a varied distribution, with 131 (32.4%) classified as high severity, whereas bulimia nervosa was predominantly of low severity (242, 59.9%). Binge eating disorders were observed in a significant proportion of patients with moderate severity (203, 50.2%). Conclusion: There is an urgent need for heightened awareness, early detection, and intervention strategies tailored to the diverse spectrum of eating disorders in this region. Furthermore, understanding common methods that affect individuals' utilization of food and the severity and distribution of different disorders provides valuable insights into tailored interventions and support systems that promote healthier relationships between food and body image within the community.

Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm

BACKGROUND

Anorexia nervosa is a serious and potentially lethal psychiatric disorder. Furthermore, there is significant evidence that some individuals develop a very long-standing form of the illness that requires a variety of different treatment interventions over time.

OBJECTIVE

The primary goal of this paper was to provide a review of treatment strategies for severe and enduring anorexia nervosa (SE-AN) with the particular focus on treatments involving hospital care. Additionally, we wish to highlight a contemporary approach to such care and provide qualitative reactions to this model from both staff and patients.

METHODS

A selective and strategic review of the treatment literature for SE-AN was conducted for the current paper. Emphasis was placed on clinical or scientific papers related to hospital-based care. Additionally, staff who work on a specific inpatient eating disorder unit with a substantial treatment program for SE-AN, along with a number of SE-AN patients were surveyed regarding their experiences working on, or receiving treatment on the unit. Importantly, the staff of this unit created a specific treatment protocol for individuals receiving hospital care. The results of the highlight both advantages and challenges of a hospital-based protocol oriented toward emphasizing quality of life, medical stability, and a health-promoting meal plan.

DISCUSSION

While there is general inconsistency with the type of treatment that is best suited to individuals with SE-AN, this is particularly true for higher levels of care that rely on inpatient hospital units or residential treatment settings. This is a highly significant clinical topic in need of further clinical and scientific examination.

Anorexia nervosa and bulimia nervosa: a Mendelian randomization study of gut microbiota

Background

Anorexia nervosa (AN) and bulimia nervosa (BN) poses a significant challenge to global public health. Despite extensive research, conclusive evidence regarding the association between gut microbes and the risk of AN and BN remains elusive. Mendelian randomization (MR) methods offer a promising avenue for elucidating potential causal relationships.

Materials and methods

Genome-wide association studies (GWAS) datasets of AN and BN were retrieved from the OpenGWAS database for analysis. Independent single nucleotide polymorphisms closely associated with 196 gut bacterial taxa from the MiBioGen consortium were identified as instrumental variables. MR analysis was conducted utilizing R software, with outlier exclusion performed using the MR-PRESSO method. Causal effect estimation was undertaken employing four methods, including Inverse variance weighted. Sensitivity analysis, heterogeneity analysis, horizontal multivariate analysis, and assessment of causal directionality were carried out to assess the robustness of the findings.

Results

A total of 196 bacterial taxa spanning six taxonomic levels were subjected to analysis. Nine taxa demonstrating potential causal relationships with AN were identified. Among these, five taxa, including Peptostreptococcaceae, were implicated as exerting a causal effect on AN risk, while four taxa, including Gammaproteobacteria, were associated with a reduced risk of AN. Similarly, nine taxa exhibiting potential causal relationships with BN were identified. Of these, six taxa, including Clostridiales, were identified as risk factors for increased BN risk, while three taxa, including Oxalobacteraceae, were deemed protective factors. Lachnospiraceae emerged as a common influence on both AN and BN, albeit with opposing effects. No evidence of heterogeneity or horizontal pleiotropy was detected for significant estimates.

Conclusion

Through MR analysis, we revealed the potential causal role of 18 intestinal bacterial taxa in AN and BN, including Lachnospiraceae. It provides new insights into the mechanistic basis and intervention targets of gut microbiota-mediated AN and BN.

Outcomes and associated clinical features of people with eating disorders participating in residential treatment facilities: a scoping review

Residential treatment programs for eating disorders (EDs) have gained popularity in recent years, expanding beyond the United States to countries such as Canada, Italy, and the United Kingdom. These programs offer a "home-like" environment where individuals reside for several weeks or months, emphasising both physical restoration and psychological recovery. This scoping review aimed to provide an update since the most recent reviews on the literature regarding outcomes of residential treatment programs for EDs and to explore clinical features that were associated with these outcomes. Methods used followed the Joanna Briggs Institute guidelines for scoping reviews. A systematic search of electronic databases was conducted, and 12 studies met the inclusion criteria. All studies reported improvements in various outcomes from admission to discharge, including changes in eating psychopathology, weight restoration, depression, anxiety, and quality of life. Additionally, three studies reported positive outcomes at intervals after discharge and three predictive factors (self-compassion, personality organisation, and resistance to emotional vulnerability) were reported in a small number of studies. While residential treatment facilities consistently showed positive outcomes, the review highlights the need for randomised controlled studies to establish the efficacy of these programs for EDs. Future research should include controlled studies comparing residential facilities to other treatment settings and incorporate long-term follow-up outcomes and further studies of emergent predictive factors identified in this review.

Similarities and differences regarding acute anorexia nervosa and semi-starvation: does behavioral thermoregulation play a central role?

Objective

To clarify the association between acute anorexia nervosa (AN) and semi-starvation (SS) by focusing on similarities and differences in physiology, mood, and behavior.

Method

A comparison of published literature between these two groups.

Results

Both groups show similar hormonal and metabolic changes in response to caloric restriction and extreme weight loss (~25%). Associated changes result in a reduced body temperature (Tcore-low). Maintenance of body temperature within a specific range is crucial to survival. However, both groups cannot activate autonomic strategies to maintain their Tcore-low, such as increasing metabolic rate, constricting skin blood vessels, or shivering. Furthermore, Tcore-low increases the individuals' "coldness sensations" throughout the body, hence the frequent reports from ANs and SSs of "feeling cold." To eliminate these uncomfortable "coldness sensations" and, importantly, to maintain Tcore-low, ANs, and SSs "select" different thermoregulatory behavioral strategies. It is proposed that the primary differences between AN and SS, based on genetics, now manifest due to the "selection" of different thermo-regulatory behaviors. AN patients (ANs) "select" hyperactive behavior (HyAc), which increases internal metabolic heat and thus assists with maintaining Tcore-low; in harmony with hyperactive behavior is a lively mood. Also related to this elevated arousal pattern, ANs experience disrupted sleep. In contrast, SS individuals "select" a passive thermo-behavioral strategy, "shallow torpor," which includes reduced activity, resulting in energy conservation. In addition, this inactivity aids in the retention of generated metabolic heat. Corresponding to this lethargic behavior, SS individuals display a listless mood and increased sleep.

Conclusion

Initial similarities between the two are attributable to physiological changes related to extreme weight loss. Differences are most likely attributable to genetically programmed "selection" of alternate thermoregulatory strategies, primarily to maintain Tcore-low. However, if acute AN is prolonged and evolves into a chronic condition, AN will more closely align with starvation and more precisely reflect SS symptomology.

Virtually Accompanied Eating in the Outpatient Therapy of Anorexia Nervosa

BACKGROUND

Normalizing the eating pattern and weight recovery are the main objectives in treating anorexia nervosa (AN). Eating accompaniment through shared mealtimes is a common strategy in eating disorder management programs. This study aims to examine the impact on weight gain of an internet-delivered meal support group on patients with AN who were under ambulatory treatment with the Eating Disorders Unit of the UC Christus Health Network, Chile.

METHODS

An observational study of 54 female patients with AN diagnosis who participated in Online Meal Support Groups (OMSGs) three times a week was performed. Their weight, BMI and BMI%, was reviewed at the beginning of the sessions and at 45- and 90-day follow-up.

RESULTS

Patients showed significant weight gain during follow-up. At the 90-day follow-up, patients had gained 4.41 (SD ± 2.82) kg with an effect size of -1.563.

CONCLUSIONS

Statistically significant differences were found between the weight at the beginning of the intervention and at the 45- and 90-day follow-up, meaning that eating support online groups may be an effective intervention for weight gain and maintenance in patients with AN. These findings highlight the viability of developing cost-effective and more accessible interventions for AN and thus help reduce the duration of untreated disease and its consequences.

Prevalence and Associated Factors of Eating Disorders Among Female Students at Jazan University, Kingdom of Saudi Arabia: A Survey Study

BACKGROUND AND OBJECTIVE

Concerns about the incidence of eating disorders (EDs) among university students are spreading throughout the world. In Saudi Arabia, little is known about the prevalence and associated factors of EDs among female university students. Thus, this study investigated the prevalence, common types, and potential associated factors of EDs among female students of Jazan University.  Methods: A cross-sectional survey was conducted between August 31, 2020, and November 2, 2020. The snowball technique was used to recruit female students via an electronic survey distributed in Arabic. The survey collected information about demographic characteristics, and SCOFF (Sick, Control, One, Fat, Food) and Eating Attitudes Test (EAT-26) scales. Cronbach's alpha for the SCOFF and EAT-26 scales was calculated to be 0.78 and 0.58, respectively, in this study.

RESULTS

A total of 566 female students participated in the survey, with a mean age of 22.12 ± 2.93 years. The results showed that 47.9% of participants were at risk for EDs based on SCOFF scores, while 26.5% were at risk based on EAT-26 scores. The most common types of EDs were bulimia nervosa and binge eating disorder. Furthermore, the study identified several sociodemographic characteristics, including year of study (p = 0.042), college type (p = 0.004), body weight (p = 0.001), and BMI (p = 0.001), that are significantly associated with EDs. However, no significant relationships were observed between marital status (p = 0.103), age (p = 0.147), and height (p = 0.509) with SCOFF scores. Some students reported frequent binge eating, purging, or laxative/diet pill misuse.

CONCLUSIONS

The study revealed a moderate to high prevalence of risk for EDs among female university students in Jazan, Saudi Arabia, associated with higher study years, college majors, and body weight and BMI. Dangerous ED behaviors reported by some students signal an urgent need for resources to identify and support those suffering from these disorders. Targeted interventions and services may help address this critical issue on campuses and support vulnerable students in need. Continued research and public health action are needed to curb the spread of these disorders.

Association of anorexia/appetite loss with malnutrition and mortality in older populations: A systematic literature review

Anorexia/appetite loss in older subjects is frequently underrecognized in clinical practice, which may reflect deficient understanding of clinical sequelae. Therefore, we performed a systematic literature review to assess the morbidity and mortality burden of anorexia/appetite loss in older populations. Following PRISMA guidelines, searches were run (1 January 2011 to 31 July 2021) in PubMed, Embase® and Cochrane databases to identify English language studies of adults aged ≥ 65 years with anorexia/appetite loss. Two independent reviewers screened titles, abstracts and full text of identified records against pre-defined inclusion/exclusion criteria. Population demographics were extracted alongside risk of malnutrition, mortality and other outcomes of interest. Of 146 studies that underwent full-text review, 58 met eligibility criteria. Most studies were from Europe (n = 34; 58.6%) or Asia (n = 16; 27.6%), with few (n = 3; 5.2%) from the United States. Most were conducted in a community setting (n = 35; 60.3%), 12 (20.7%) were inpatient based (hospital/rehabilitation ward), 5 (8.6%) were in institutional care (nursing/care homes) and 7 (12.1%) were in other (mixed or outpatient) settings. One study reported results separately for community and institutional settings and is counted in both settings. Simplified Nutritional Appetite Questionnaire (SNAQ Simplified, n = 14) and subject-reported appetite questions (n = 11) were the most common methods used to assess anorexia/appetite loss, but substantial variability in assessment tools was observed across studies. The most commonly reported outcomes were malnutrition and mortality. Malnutrition was assessed in 15 studies, with all reporting a significantly higher risk of malnutrition in older individuals with anorexia/appetite loss (vs. without) regardless of country or healthcare setting (community n = 9, inpatient n = 2, institutional n = 3, other n = 2). Of 18 longitudinal studies that assessed mortality risk, 17 (94%) reported a significant association between anorexia/appetite loss and mortality regardless of either healthcare setting (community n = 9, inpatient n = 6, institutional n = 2) or method used to assess anorexia/appetite loss. This association between anorexia/appetite loss and mortality was observed in cohorts with cancer (as expected) but was also observed in older populations with a range of comorbid conditions other than cancer. Overall, our findings demonstrate that, among individuals aged ≥ 65 years, anorexia/appetite loss is associated with increased risk of malnutrition, mortality and other negative outcomes across community, care home and hospital settings. Such associations warrant efforts to improve and standardize screening, detection, assessment and management of anorexia/appetite loss in older adults.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Are the Effects of Malnutrition on the Gut Microbiota–Brain Axis the Core Pathologies of Anorexia Nervosa?

Anorexia nervosa (AN) is a disabling, costly, and potentially deadly illness. Treatment failure and relapse after treatment are common. Several studies have indicated the involvement of the gut microbiota–brain (GMB) axis. This narrative review hypothesizes that AN is driven by malnutrition-induced alterations in the GMB axis in susceptible individuals. According to this hypothesis, initial weight loss can voluntarily occur through dieting or be caused by somatic or psychiatric diseases. Malnutrition-induced alterations in gut microbiota may increase the sensitivity to anxiety-inducing gastrointestinal hormones released during meals, one of which is cholecystokinin (CCK). The experimental injection of a high dose of its CCK-4 fragment in healthy individuals induces panic attacks, probably via the stimulation of CCK receptors in the brain. Such meal-related anxiety attacks may take part in developing the clinical picture of AN. Malnutrition may also cause increased effects from appetite-reducing hormones that also seem to have roles in AN development and maintenance. The scientific background, including clinical, microbiological, and biochemical factors, of AN is discussed. A novel model for AN development and maintenance in accordance with this hypothesis is presented. Suggestions for future research are also provided.