1
|
Salter F, Singh U, Kerr D, Zhao Y, Jeffery E. A prospective observational study examining weight and psychosocial change in adolescent and adult eating disorder inpatients admitted for nutritional rehabilitation using a high-energy re-feeding protocol. J Eat Disord 2024; 12:58. [PMID: 38745266 PMCID: PMC11094855 DOI: 10.1186/s40337-024-01015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 05/02/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND High-energy re-feeding protocols are increasingly utilised for nutritional rehabilitation in adolescents with anorexia nervosa (AN), however, concern persists that adults with AN may be at greater risk of developing complications. In addition, research on psychological outcomes of eating disorder (ED) inpatient treatment programs, and outcomes of high-energy protocols in avoidant restrictive food intake disorder (ARFID) and bulimia nervosa (BN), is limited. This study of an ED inpatient program using a high-energy protocol, compared changes in weight and psychosocial outcomes between adolescents and adults, and identified medical risk factors associated with deviation from the protocol. METHOD This prospective observational study took place in a voluntary ED treatment program in a private hospital. Weight, height, and psychosocial questionnaires (ED Examination-Questionnaire, Depression Anxiety Stress Score, Clinical Impairment Assessment and AN/BN Stage of Change) were collected from consenting adolescents (16-20 years) and adults (> 20 years) on admission and discharge. Medical tolerance to the high-energy protocol was assessed daily. Independent samples t-tests and paired samples t-tests were applied to normally distributed data, and Mann-Whitney U tests and Wilcoxon signed-rank tests to skewed data. P-values < 0.05 were considered significant statistically. RESULTS Ninety-seven participants were recruited. The majority (n = 91, 94%) were female and most (n = 80, 83%) had AN. Forty-two (43%) were adolescents and 55 (57%) were adults. In participants with AN, weight change (Δ) was significant [median Δ 8.0 (interquartile range (IQR) 4.3) kg]. There was no difference in rate of weight change between adolescents and adults with AN [mean Δ 1.8 (standard deviation (SD) 0.5) kg/week vs. Δ 1.8 (SD 0.6) kg/week; p = 0.841, respectively]. One (1%) participant with AN did not tolerate the high-energy protocol due to oedema. Participants achieved positive change in psychosocial questionnaire scores (p < 0.001) after the the specialist ED program, with no difference between adolescents and adults (p > 0.05). CONCLUSIONS This voluntary ED treatment program using a high energy re-feeding protocol was effective in achieving positive weight and psychological change for adolescents and adults with minimal adverse events. This indicates that the specialist ED program has both nutritional and psychological benefits.
Collapse
Affiliation(s)
- Fiona Salter
- School of Population Health, Curtin University, Kent Street, GPO Box U1987, Perth, WA, 6845, Australia
- Ramsay Clinic Hollywood, Hollywood Private Hospital, 95 Monash Avenue, Nedlands, WA, 6009, Australia
- Esus Centre, Centre of Excellence in the Treatment of Eating Disorders, 588, Hay Street, Subiaco, WA, 6008, Australia
| | - Urvashnee Singh
- School of Population Health, Curtin University, Kent Street, GPO Box U1987, Perth, WA, 6845, Australia
- Esus Centre, Centre of Excellence in the Treatment of Eating Disorders, 588, Hay Street, Subiaco, WA, 6008, Australia
| | - Deborah Kerr
- Ramsay Clinic Hollywood, Hollywood Private Hospital, 95 Monash Avenue, Nedlands, WA, 6009, Australia
- Curtin Health Innovation Research Institute, Curtin University, Kent Street, GPO Box U1987, Perth, WA, 6845, Australia
| | - Yun Zhao
- Ramsay Clinic Hollywood, Hollywood Private Hospital, 95 Monash Avenue, Nedlands, WA, 6009, Australia
| | - Emily Jeffery
- Ramsay Clinic Hollywood, Hollywood Private Hospital, 95 Monash Avenue, Nedlands, WA, 6009, Australia.
| |
Collapse
|
2
|
Vanzhula I, Hagan K, Duck SA, Pan I, Wang EY, Steinglass J, Attia E, Wildes JE, Guarda AS, Schreyer C. Eating disorder symptom non-endorsers in hospitalised patients with anorexia nervosa: Who are they? Eur Eat Disord Rev 2024. [PMID: 38528330 DOI: 10.1002/erv.3087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE Impaired insight and illness denial are common in anorexia nervosa (AN). Missing an AN diagnosis may delay treatment and negatively impact outcomes. METHOD The current retrospective study examined the prevalence and characteristics of AN symptom non-endorsement (i.e., scoring within the normal range on the Eating Disorder Examination Questionnaire [EDE-Q] or the Eating Disorder Examination [EDE] interview) in three independent samples of hospitalised patients with AN (N1 = 154; N2 = 300; N3 = 194). A qualitative chart review of a subsample of non-endorsers (N4 = 32) extracted reports of disordered eating behaviours observed by the treatment team. RESULTS The prevalence of non-endorsement ranged from 11% to 34% across sites. Non-endorsers were more likely to be diagnosed with AN restricting type (AN-R) and reported fewer symptoms of co-occurring psychopathology than endorsers. Groups benefitted equally from treatment. The qualitative chart review indicated that objective symptoms of AN were recorded by staff in over 90% of non-endorsers. CONCLUSIONS Eating disorder symptom assessments using the EDE-Q or EDE may miss symptomatology in up to a third of individuals hospitalised with AN. This study highlights the potential utility of multi-modal assessment including patient interviews, collateral informants, and behavioural observation to circumvent non-endorsement.
Collapse
Affiliation(s)
- Irina Vanzhula
- University of Kansas, LifeSpan Institute, Lawrence, Kansas, USA
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelsey Hagan
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Psychiatry, Columbia University Irving Medical Center, Columbia, New York, USA
| | - Sarah Ann Duck
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Isabella Pan
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erin Y Wang
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joanna Steinglass
- Department of Psychiatry, Columbia University Irving Medical Center, Columbia, New York, USA
| | - Evelyn Attia
- Department of Psychiatry, Columbia University Irving Medical Center, Columbia, New York, USA
| | - Jennifer E Wildes
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago Medicine, Chicago, Illinois, USA
| | - Angela S Guarda
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Colleen Schreyer
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
3
|
Vanzhula IA, Wang E, Martinelli MK, Schreyer C, Guarda AS. Inpatient hospital course and self-reported symptomatology in underweight adults with ARFID compared to age- and sex-matched controls with anorexia nervosa. J Eat Disord 2023; 11:206. [PMID: 37986115 PMCID: PMC10658840 DOI: 10.1186/s40337-023-00912-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/12/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE Avoidant restrictive food intake disorder (ARFID) has similar prevalence to anorexia nervosa (AN) in adults, but research in this population is lacking. Although inpatient or residential treatment involving nutritional rehabilitation is increasingly recommended for malnourished individuals with ARFID, best practices remain poorly defined. Existing studies on self-reported symptomatology and treatment course and outcome are primarily in child and adolescent cohorts and demonstrate inconsistent findings. This study aimed to compare hospital course and self-reported symptomatology of underweight adult inpatients with ARFID and sex- and age-matched patients with AN. METHOD Underweight adult patients with ARFID or AN admitted to a specialized, hospital-based behavioral treatment program completed measures of body dissatisfaction, drive for thinness, bulimic symptoms, anxiety, depression, and personality traits. Demographic and treatment course data were abstracted from electronic medical records. Patients with ARFID (n = 69) were matched to those with AN (n = 69) based on sex and age. RESULTS Adults with ARFID were closer to target weight at admission, but gained weight at a slower rate, were discharged at lower BMI, and were less likely to reach target weight by discharge than adults with AN. Patients with ARFID reported less weight and shape-related eating disorder, state anxiety, and depression symptoms and lower neuroticism. DISCUSSION Adults with ARFID progress through treatment more slowly and achieve less favorable weight outcomes by hospital discharge than patients with AN, but long-term outcomes are unclear. Describing clinical presentations and course of illness of adult ARFID may help inform treatment protocols.
Collapse
Affiliation(s)
- Irina A Vanzhula
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
| | - Erin Wang
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Mary K Martinelli
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Colleen Schreyer
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Angela S Guarda
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| |
Collapse
|
4
|
Miskovic-Wheatley J, Bryant E, Ong SH, Vatter S, Le A, Touyz S, Maguire S. Eating disorder outcomes: findings from a rapid review of over a decade of research. J Eat Disord 2023; 11:85. [PMID: 37254202 DOI: 10.1186/s40337-023-00801-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/05/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality. METHODS This paper forms part of a Rapid Review series scoping the evidence for the field of ED, 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 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review. RESULTS Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates. CONCLUSION Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.
Collapse
Affiliation(s)
- Jane Miskovic-Wheatley
- Faculty of Medicine and Health, InsideOut Institute for Eating Disorders, University of Sydney, Level 2, Charles Perkins Centre (D17), Sydney, NSW, 2006, Australia.
- Sydney Local Health District, Sydney, Australia.
| | - Emma Bryant
- Faculty of Medicine and Health, InsideOut Institute for Eating Disorders, University of Sydney, Level 2, Charles Perkins Centre (D17), Sydney, NSW, 2006, Australia
- Sydney Local Health District, Sydney, Australia
| | - Shu Hwa Ong
- Faculty of Medicine and Health, InsideOut Institute for Eating Disorders, University of Sydney, Level 2, Charles Perkins Centre (D17), Sydney, NSW, 2006, Australia
- Sydney Local Health District, Sydney, Australia
| | - Sabina Vatter
- Faculty of Medicine and Health, InsideOut Institute for Eating Disorders, University of Sydney, Level 2, Charles Perkins Centre (D17), Sydney, NSW, 2006, Australia
- Sydney Local Health District, Sydney, Australia
| | - Anvi Le
- Healthcare Management Advisors, Melbourne, Australia
| | - Stephen Touyz
- Faculty of Medicine and Health, InsideOut Institute for Eating Disorders, University of Sydney, Level 2, Charles Perkins Centre (D17), Sydney, NSW, 2006, Australia
- Sydney Local Health District, Sydney, Australia
| | - Sarah Maguire
- Faculty of Medicine and Health, InsideOut Institute for Eating Disorders, University of Sydney, Level 2, Charles Perkins Centre (D17), Sydney, NSW, 2006, Australia
- Sydney Local Health District, Sydney, Australia
| |
Collapse
|
5
|
Duck SA, Guarda AS, Schreyer CC. Parental dieting impacts inpatient treatment outcomes for adolescents with restrictive eating disorders. Eur Eat Disord Rev 2023. [PMID: 36934407 DOI: 10.1002/erv.2977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/13/2023] [Accepted: 03/08/2023] [Indexed: 03/20/2023]
Abstract
OBJECTIVE Parental feeding practices and disordered eating are potential risk factors for the development of disordered eating in children and adolescents. This study measured the relationship between parental dieting behaviours and inpatient treatment outcomes for adolescents with restrictive eating disorders (EDs). METHOD Parents of adolescents with restrictive EDs (N = 45) admitted to a specialty integrated inpatient-partial hospital meal-based ED treatment programme completed questionnaires assessing parental eating and exercise behaviours. Adolescent clinical data, including percentage median body mass index (%mBMI) at admission and discharge and rate of weight gain, were abstracted from the electronic medical record. RESULTS Adolescents whose parents reported dieting had a slower rate of weight gain (3.47 lbs./week) compared to participants whose parents were not dieting (4.54 lbs./week; p = 0.017). Additionally, participants whose parents reported dieting had a lower %mBMI at programme discharge (M = 93.56) than participants whose parents did not report dieting (M = 95.99; p = 0.033). CONCLUSION Parental dieting behaviours may impact an adolescent's response to inpatient ED treatment. Findings suggest a need to assess parental dieting behaviour, and when appropriate, provide additional psychoeducation regarding the potential risks of weight or shape-focussed dialogue and the benefits of modelling adaptive meal behaviours.
Collapse
Affiliation(s)
- Sarah Ann Duck
- Department of Psychological and Brain Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
6
|
Accurso EC, Cheng J, Machen VI, Buckelew S, Kreiter A, Adams S, Le Grange D, Golden NH, Garber AK. Hospital-based higher calorie refeeding and mealtime distress in adolescents and young adults with anorexia nervosa or atypical anorexia nervosa. Int J Eat Disord 2023. [PMID: 36919264 DOI: 10.1002/eat.23931] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE The StRONG study demonstrated that higher calorie refeeding (HCR) restored medical stability faster in patients hospitalized with anorexia nervosa (AN) and atypical AN (AAN), with no increased safety events compared with standard-of-care lower calorie refeeding (LCR). However, some clinicians have expressed concern about potential unintended consequences of HCR (e.g., greater mealtime distress). The purpose of this study was to examine patient treatment preference and compare mealtime distress, food refusal, and affective states between treatments. METHOD Participants (N = 111) in this multisite randomized clinical trial were ages 12-24 years, with AN or AAN, admitted to hospital with medical instability who received assigned study treatment (HCR or LCR). Treatment preference was assessed prior to randomization in the full sample. In a subset of participants (n = 45), linear mixed effect models were used to analyze momentary ratings of mealtime distress (pre, during, and post-meals) and daily affective state during the hospitalization. RESULTS About half (55%) of participants reported a preference for LCR. Treatment assignment was not associated with food refusal, mealtime distress, or affective states in the subsample. Food refusal increased significantly over the course of refeeding (p = .018). Individuals with greater depression experienced more negative affect (p = .033), with worsening negative affect over time for individuals with higher eating disorder psychopathology (p = .023). DISCUSSION Despite understandable concerns about potential unintended consequences of HCR, we found no evidence that treatment acceptability for HCR differed from LCR for adolescents and young adults with AN and AAN. PUBLIC SIGNIFICANCE The efficacy and safety of higher calorie refeeding in hospitalized patients with anorexia nervosa has been demonstrated. However, it is not known whether higher calorie refeeding (HCR) increases meal-time distress. This study demonstrated that HCR was not associated with increased mealtime distress, food refusal, or affective states, as compared with lower calorie refeeding. These data support HCR treatment acceptability for adolescents/young adults with anorexia nervosa and atypical anorexia nervosa.
Collapse
Affiliation(s)
- Erin C Accurso
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Jing Cheng
- Department of Preventive & Restorative Dental Sciences, University of California, San Francisco, California, USA
| | - Vanessa I Machen
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Sara Buckelew
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Anna Kreiter
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sally Adams
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA.,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
| | - Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andrea K Garber
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| |
Collapse
|
7
|
Schreyer CC, Pletch A, Vanzhula IA, Guarda AS. Evaluating individual- and sample-level response to treatment for inpatients with eating disorders: Is change clinically significant? Int J Eat Disord 2023; 56:452-457. [PMID: 36300553 DOI: 10.1002/eat.23842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Evaluating treatment efficacy solely on whether sample-level change is statistically significant does not indicate whether clinically significant change (CSC) has occurred at the individual-level. We assessed whether change in measures of eating disorder psychopathology was statistically significant at the sample-level and clinically significant at the individual-level for inpatients treated in a hospital-based eating disorder program. METHOD Participants (N = 143) were consecutive underweight distinct admissions diagnosed with anorexia nervosa or other specified feeding and eating disorder. The Eating Disorder Examination Questionnaire (EDEQ) and Eating Disorder Recovery Self-efficacy Questionnaire (EDRSQ) were assessed at admission and program discharge. CSC was defined as individual score change that was both statistically reliable and shifted from dysfunctional to normative. RESULTS Mean EDRSQ and EDEQ scores significantly improved with treatment across the sample; effect sizes were moderate to large. Individual-level analyses demonstrated that 85%, 50%, and 20-35% of participants had CSC or statistically reliable change in BMI, eating symptomatology, and body image respectively. One-third of participants showed CSC on BMI and on at least one self-report measure. DISCUSSION Individual-level analyses offer more nuanced outcome data that could identify patients at higher risk of relapse who may benefit from adjunctive interventions during or immediately post-discharge. PUBLIC SIGNIFICANCE STATEMENT This study examined change in eating pathology for inpatients with eating disorders using sample- and individual-level analyses, including whether change was statistically reliable and clinically significant (scores statistically improved and moved into the healthy range). Only half of patients responded robustly to treatment, which may be related to high relapse rates following discharge. Individual-level analyses provided a detailed view of treatment response and may identify patients at higher relapse risk.
Collapse
Affiliation(s)
| | - Allisyn Pletch
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Irina A Vanzhula
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Angela S Guarda
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
8
|
Schreyer CC, Vanzhula IA, Guarda AS. Evaluating the impact of COVID-19 on severity at admission and response to inpatient treatment for adult and adolescent patients with eating disorders. Int J Eat Disord 2023; 56:182-191. [PMID: 36394170 DOI: 10.1002/eat.23855] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The COVID-19 pandemic has been associated with increased hospitalization rates and worsened symptom severity in patients with eating disorders (ED), but most studies focused exclusively on adolescents. Further, research evaluating the impact of COVID-19 on response to inpatient treatment for ED is limited. This study aimed to compare demographic characteristics, symptom severity at admission, and discharge outcomes for adult and adolescent inpatients with EDs admitted before and after onset of the COVID-19 pandemic. We expected the post-COVID cohort would report elevated symptomatology and poorer response to treatment compared to the pre-COVID cohort and that this effect would be amplified for adolescents. METHOD Patients were consecutively hospitalized adults and adolescents treated in a specialized behavioral integrated inpatient-partial hospitalization program for eating disorders between March 2018 and March 2022 (N = 261). RESULTS The effect of COVID-19 on symptomatology was moderated by age group such that adolescents in the post-COVID cohort, but not adults, reported higher levels of eating disorder and depressive symptoms compared to the pre-COVID cohort. No group differences were observed for discharge outcomes (rate of weight gain, length of stay, or percent target weight). DISCUSSION Findings with respect to elevated symptomatology in adolescents but not adults may reflect the particularly negative impact of social isolation on adolescents. Future research is needed to assess the impact of COVID-19 on long-term treatment outcomes including relapse at 1-year, as well as the potential impact of COVID-19 on treatment availability for chronically ill adults or those with public insurance. PUBLIC SIGNIFICANCE Patients with eating disorders (ED) admitted to a specialty inpatient program after the start of the COVID-19 pandemic were younger and more likely to be male than those admitted pre-pandemic. Adolescents admitted post-COVID, but not adults, reported elevated ED and depressive symptoms compared to the pre-COVID cohort. Group differences were not observed for treatment response. Future research should evaluate the impact of COVID-19 on relapse risk in EDs.
Collapse
Affiliation(s)
| | - Irina A Vanzhula
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Angela S Guarda
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
9
|
Fischer LK, Schreyer CC, Pletch A, Cooper M, Vanzhula IA, Redgrave GW, Guarda AS. Monitoring and treating hypoglycemia during meal-based rapid nutritional rehabilitation in patients with extreme anorexia nervosa. Eat Weight Disord 2022; 27:3301-3308. [PMID: 35994205 DOI: 10.1007/s40519-022-01460-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 07/23/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Hypoglycemia, a complication of prolonged starvation, can be life-threatening and is presumed to contribute to the high mortality of anorexia nervosa. Furthermore, early refeeding in severe anorexia nervosa can precipitate paradoxical post-prandial hypoglycemia. Few studies have analyzed the course of hypoglycemia during nutritional rehabilitation in patients with extremely low-weight anorexia nervosa. No standard practice guidelines exist and recommended strategies for managing hypoglycemia (i.e., nasogastric feeds, high-fat diets) have limitations. METHODS This cohort study assessed prevalence and correlates of hypoglycemia in 34 individuals with very low body mass index (BMI < 14.5 kg/m2) anorexia nervosa treated in an intensive eating disorders program with an exclusively meal-based rapid weight gain nutritional protocol. Hypoglycemia was monitored with frequent point of care (POC) glucose testing and treated with oral snacks and continuous slow intravenous 5% dextrose in 0.45% saline (IV D5 1/2 NS) infusion. RESULTS POC hypoglycemia was detected in 50% of patients with highest prevalence noted on the day of admission. Hypoglycemia resolved during the first week of hospitalization in most cases and was generally asymptomatic. Seven patients (20.6%) experienced at least one episode of severe hypoglycemia with POC glucose < 50 mg/dl. Lower admission BMI was associated with higher likelihood of developing hypoglycemia and longer duration of hypoglycemia. CONCLUSION Meal-based management of hypoglycemia supplemented by continuous IV D5 1/2 NS appears a viable alternative to alternate strategies such as enteral tube feeding. We discuss recommendations for hypoglycemia monitoring during nutritional rehabilitation and directions for future research. LEVEL OF EVIDENCE Level III, retrospective cohort study.
Collapse
Affiliation(s)
- Laura K Fischer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA.,Childrens National Hospital, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA
| | - Allisyn Pletch
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA
| | - Marita Cooper
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA.,Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19104, USA
| | - Irina A Vanzhula
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA
| | - Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA. .,Department of Psychiatry and Behavioral Science, Johns Hopkins Eating Disorders Program, The Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 101, Baltimore, MD, 21287, USA.
| |
Collapse
|
10
|
Akgül S, Bonny AE, Manos BE, Jackson K, Holland-Hall C. Rapid refeeding does not worsen anxiety in adolescents with anorexia nervosa: a pilot study. Eat Disord 2022; 30:587-601. [PMID: 34184971 DOI: 10.1080/10640266.2021.1939920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The study aimed to describe the progression of state anxiety in adolescents with anorexia nervosa (AN) hospitalized on a high calorie refeeding (HCR) protocol. Participants, 12-21 years, admitted for malnutrition due to AN were placed on a HCR protocol in which calories were advanced by 300 kcal/day. The State-Trait Anxiety Inventory for Children (STAIC) was given to participants within 24 hours of hospitalization and the state anxiety component of the STAIC was administered daily immediately before and after breakfast until discharge. Of 22 patients enrolled, 86% were female, mean age was 14.9 ± 2.0 years, and 95% had AN-restrictive type. The median state and trait anxiety scores at time of admission were 37.0 (28-55) and 35.5 (23-51), respectively. There was no significant difference in median pre-meal state anxiety from hospital day 1 to 6 (34.0(26-55) vs. 38.5(25-55), p-value = 0.079) or in median post-meal state anxiety from hospital day 1 to 6 (35.5(29-56) vs. 37(24-56), p-value = 0.484). Similarly, we found minimal correlation between change in caloric intake and change in pre-meal S-anxiety (Spearman correlation coefficient = -0.032) or post-meal S-anxiety (Spearman correlation = 0.032). While this was a small sample observing anxiety over one week, we found no evidence that state anxiety increased with advancing calories, providing additional support for the use of more rapid refeeding protocols.
Collapse
Affiliation(s)
- Sinem Akgül
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Andrea E Bonny
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,The Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA.,The Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brittny E Manos
- The Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kenneth Jackson
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, Ohio, USA.,Biostatistics Resource at Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Cynthia Holland-Hall
- The Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| |
Collapse
|
11
|
Cooper M, Guarda AS, Petterway F, Schreyer CC. Change in normative eating self-efficacy is associated with six-month weight restoration following inpatient treatment for anorexia nervosa. Eat Behav 2021; 42:101518. [PMID: 33989938 DOI: 10.1016/j.eatbeh.2021.101518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 04/29/2021] [Accepted: 05/04/2021] [Indexed: 11/22/2022]
Abstract
Anorexia nervosa (AN) is a disorder characterized by rigid and restrictive eating behaviors, resulting in significantly low body weight. While specialized behavioral intensive treatment programs can reliably support individuals with AN to normalize eating and weight control behaviors and achieve weight restoration, prognostic factors predicting relapse following treatment are unclear. We examined whether changes in (i) normative eating self-efficacy, (ii) body image self-efficacy, (iii) drive for thinness, and (iv) body dissatisfaction from inpatient admission to six-month follow-up were associated with weight restoration status at program discharge and at six-month follow-up. The sample comprised 146 participants with AN admitted to a meal-based inpatient-partial hospitalization program. Participants completed questionnaires at inpatient admission and six months following program discharge. Additionally, at follow-up, participants reported the frequency of engaging in normalized eating behaviors since discharge (e.g. eating with others and preparing a balanced meal). The majority (73.3%) of participants attained a BMI > 19 at discharge and 59.6% were weight restored at six-month follow-up. Change in normative eating self-efficacy was significantly associated with weight restoration at follow-up, whereas change in body image self-efficacy, drive for thinness, and body dissatisfaction were not. For each one unit increase in normative eating self-efficacy, patients were 4.65 times more likely to be weight restored at follow-up (p = .002). Additionally, individuals reporting a higher frequency of normalized eating behaviors at follow-up were more likely to be weight restored. Normative eating self-efficacy and normalized eating behaviors may represent vital treatment targets for relapse prevention interventions for this high-risk population.
Collapse
|
12
|
Cooper M, Collison AO, Collica SC, Pan I, Tamashiro KL, Redgrave GW, Schreyer CC, Guarda AS. Gastrointestinal symptomatology, diagnosis, and treatment history in patients with underweight avoidant/restrictive food intake disorder and anorexia nervosa: Impact on weight restoration in a meal-based behavioral treatment program. Int J Eat Disord 2021; 54:1055-1062. [PMID: 33973254 DOI: 10.1002/eat.23535] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Gastrointestinal (GI) concerns are often presumed to complicate nutritional rehabilitation for restrictive eating disorders, yet their relationship to weight restoration outcomes is unclear. This retrospective chart review examined GI history and weight-related discharge outcomes in primarily adult, underweight inpatients with anorexia nervosa (AN, N = 107) or avoidant/restrictive food intake disorder (ARFID, N = 22) treated in a meal-based, behavioral eating disorder program. METHOD Lifetime GI symptomatology, diagnoses, diagnostic tests, and procedures were abstracted from medical records. Generalized linear models examined associations of GI diagnoses, tests, and procedures with discharge BMI and rate of weight gain. RESULTS Ninety-nine percent of patients reported GI symptomatology and 83% had one or more GI diagnoses; with constipation and GERD most common. GI diagnoses (p <.01) and testing (p <.001) were more common in ARFID than AN. Average inpatient weight gain (1.59 kg/week), and discharge BMI (18.5 kg/m2 ), did not differ by group. Slower weight gain in patients with (1.3 kg/week), versus without (1.7 kg/week), history of tube feeding (p = .02), accounted for a main effect of GI procedures on inpatient rate of gain (p = .01). DISCUSSION Despite ubiquitous GI symptomatology, meal-based weight restoration achieved average weekly weight gain above recommended APA guidelines for hospitalized patients with an eating disorder. History of tube feeding was associated with slower mean weight gain, which remained, however, within recommended APA guidelines.
Collapse
Affiliation(s)
- Marita Cooper
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Amira O Collison
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sarah C Collica
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Isabella Pan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kellie L Tamashiro
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
13
|
Redgrave GW, Schreyer CC, Coughlin JW, Fischer LK, Pletch A, Guarda AS. Discharge Body Mass Index, Not Illness Chronicity, Predicts 6-Month Weight Outcome in Patients Hospitalized With Anorexia Nervosa. Front Psychiatry 2021; 12:641861. [PMID: 33716836 PMCID: PMC7946839 DOI: 10.3389/fpsyt.2021.641861] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/02/2021] [Indexed: 12/28/2022] Open
Abstract
Proposed treatments for severe and enduring anorexia nervosa (SE-AN) focus on quality of life, and psychological and social functioning. By de-emphasizing weight restoration as a priority, however, premature diagnosis of SE-AN may reduce potential for recovery. The present study assessed the effect of weight restoration, illness duration, and severity on treatment outcome 6 months after discharge from an intensive, meal-based behavioral treatment program. Participants included hospitalized adult women (N = 191) with AN or underweight other specified feeding and eating disorder (OSFED). Participants were characterized as short-term (ill <7 years; n = 74) or long-term ill (ill ≥ 7 years; n = 117). Compared with short-term ill, long-term ill patients were older, had lower lifetime body mass index (BMI), more prior admissions, and exhibited greater depression and neuroticism. Long-term vs. short-term ill patients gained weight at the same rate (~2 kg/wk) and were equally likely to be weight restored by discharge (>75% reached BMI ≥ 19 kg/m2 in both groups). At 6-month follow-up (n = 99), both groups had equivalent self-reported BMI, and depression, drive for thinness, body dissatisfaction, and bulimia scores. The only predictor of BMI ≥ 19 kg/m2 at follow-up was discharge BMI. The likelihood of a BMI ≥ 19 kg/m2 at follow-up was 5-fold higher for those with discharge BMI ≥ 19 kg/m2. Few studies of long-term ill inpatients with AN have examined the impact of full weight restoration on short-term outcomes. This study supports the therapeutically optimistic stance that, regardless of illness duration, hospitalized patients with AN benefit from gaining weight to a BMI ≥ 19 kg/m2.
Collapse
Affiliation(s)
- Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Laura K Fischer
- Children's National Medical Center, Clinical and Translational Science Institute, Washington, DC, United States
| | - Allisyn Pletch
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|