Olanzapine for young PEople with aNorexia nervosa (OPEN): A protocol for an open-label feasibility study

INTRODUCTION

Antipsychotics are routinely prescribed off-label for anorexia nervosa (AN) despite limited evidence. This article presents a protocol of a study aiming to assess the feasibility of a future definitive trial on olanzapine in young people with AN.

METHODS AND ANALYSIS

In an open-label, one-armed feasibility study, 55 patients with AN or atypical AN, aged 12-24, receiving outpatient, inpatient or day-care treatment who are considered for olanzapine treatment will be recruited from NHS sites based in England. Assessments will be conducted at screening, baseline and at 8-, 16 weeks, 6- and 12 months. Primary feasibility parameters will be proportions of patients who agree to take olanzapine and who adhere to treatment and complete study assessments. Qualitative methods will be used to explore acceptability of the intervention and study design. Secondary feasibility parameters will be changes in body mass index, psychopathology, side effects, health-related quality of life, carer burden and proportion of participants who would enrol in a future randomised controlled trial. The study is funded by the National Institute for Health Research via Health Technology Assessment programme.

DISCUSSION

Olanzapine for young PEople with aNorexia nervosa will inform a future randomised controlled trial on the efficacy and safety of prescribing olanzapine in young people with AN.

Weight gain and eating disorder symptoms among individuals with atypical anorexia nervosa

OBJECTIVE

The purpose of this study was to examine the association between weight gain and eating disorder (ED) symptoms among adults receiving treatment for atypical anorexia nervosa (AAN), to determine whether those who had a higher percent of expected body weight (%EBW) at discharge exhibited lower ED symptoms than those who gained less weight, and to compare this group to a matched sample of patients with anorexia nervosa (AN).

METHOD

Participants were 96 adults receiving treatment at an ED treatment facility between December 2020 and May 2023. The Eating Disorder Examination-Questionnaire (EDE-Q) was completed at admission and discharge, and %EBW was obtained at admission and discharge.

RESULTS

All EDE-Q subscale scores improved from admission to discharge for patients with AAN and patients with AN. Neither %EBW at discharge nor weight gain were associated with EDE-Q subscale scores for those with AAN. For patients with AN, %EBW at discharge and weight gain were associated with EDE-Q Restraint at discharge.

CONCLUSIONS

Weight restoring to a higher level and gaining more weight were not associated with EDE-Q scores at discharge for AAN. Further research is needed to determine how weight restoration using intensive treatment settings affects remission and recovery in patients with AAN.

Emotion coaching skills as an augmentation to family-based therapy for adolescents with anorexia nervosa: A pilot effectiveness study with families with high expressed emotion

OBJECTIVE

To examine the feasibility and acceptability of augmenting family-based treatment (FBT) for adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) with a parent emotion coaching intervention (EC) focused on reducing parent expressed emotion.

METHOD

In this pilot effectiveness trial, families of adolescents with AN/AAN exhibiting high expressed emotion received standard FBT with either (1) EC group or (2) support group (an attention control condition focused on psychoeducation).

RESULTS

Forty-one adolescents with AN or AAN were recruited (88% female, Mage  = 14.9 ± 1.6 years, 95% White: Non-Hispanic, 1% White: Hispanic, 1% Bi-racial: Asian). Most study adolescents were diagnosed with AN (59%) while 41% were diagnosed with AAN. Participating parents were predominantly mothers (95%). Recruitment and retention rates were moderately high (76% and 71%, respectively). High acceptability and feasibility ratings were obtained from parents and interventionists with 100% reporting the EC intervention was "beneficial"-"very beneficial." The FBT + EC group demonstrated higher parental warmth scores at post-treatment compared to the control group (standardized effect size difference, d = 1.58), which was maintained at 3-month follow-up. Finally, at post-treatment, the FBT + EC group demonstrated higher rates of full remission from AN/AAN (40%) compared to FBT + support (27%), and were nine times more likely to be weight restored by 3-month follow-up.

DISCUSSION

Augmenting FBT with emotion coaching for parents with high expressed emotion is acceptable, feasible, and demonstrates preliminary effectiveness.

PUBLIC SIGNIFICANCE

Family based treatment for AN/AAN is the recommended treatment for youth but families with high criticism/low warmth are less likely to respond to this treatment. Adding a parent emotion coaching group (EC) where parents learn to talk to their adolescents about tough emotions is feasible and well-liked by families.

Mapping length of inpatient treatment duration and year-wise relapse rates in eating disordered populations in a well-defined Western-European healthcare region across 1998-2020

OBJECTIVES

Updated international guideline recommendations for AN inpatient care rely on expert opinions/observational evidence and promote extended inpatient stays, warranting investigation using higher-level ecological evidence.

METHODS

The study was conducted according to Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Data encompassing 13,885 ED inpatients (5336 adolescents and 8549 adults) was retrieved from Swedish public health registries. Variables analyzed included (1) ED inpatient care opportunities, (2) unique number of ED inpatients and (3) mean length of ED-related inpatient stays in age groups 15-19 and 20-88+, across 1998-2020.

RESULTS

Mean length of inpatient stays was inversely correlated to relapse to ED-related inpatient care within the same year (p < 0.001, R-squaredadj  = 0.5216 and p < 0.00001, R-squaredadj  = 0.5090, in the 15-19 and 20-88+ age groups, respectively), independent of number of ED inpatients treated within a year in both age groups. Extending mean adolescent inpatient duration from 35 to 45 days was associated with a ∼30% reduction in the year-wise relapse rate.

CONCLUSIONS

Mean length of ED-related inpatient treatment stays was associated with reduced relapses to inpatient care within the same year, which could be interpreted as support for recommendations to include a stabilization phase in inpatient ED treatment.

Rapid refeeding in anorexia nervosa: A dialectic balance

OBJECTIVE

To examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion.

METHOD

This cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m² and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant.

RESULTS

Total length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol.

DISCUSSION

This is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life.

PUBLIC SIGNIFICANCE

This study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost-savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life.

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

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.

Weight Gain in Adults with Avoidant/Restrictive Food Intake Disorder Compared to Restrictive Anorexia Nervosa-Pilot Findings from a Longitudinal Study

BACKGROUND

Avoidant/Restrictive Food Intake Disorder (ARFID) is characterized by persistent failure to meet nutritional needs, absence of body image distortion and often low body weight. Weight restorative treatment in ARFID-adults is provided for as in Anorexia Nervosa (AN), while the effect is unknown. The aim was to compare weight gain between ARFID and restrictive subtype of AN (AN-R), including exploring impact of medical factors and psychopathology.

METHODS

Individuals with ARFID (n = 7; all cases enrolled over 5 years) and AN-R (n = 80) were recruited from the Prospective Longitudinal All-comers inclusion study in Eating Disorders (PROLED) during 5 years. All underwent weight restorative inpatient treatment. Clinical characteristics at baseline and weekly weight gain were recorded and compared.

RESULTS

There were no significant differences at baseline weight, nor in weight gain between groups. Anxiety was statistically significantly higher in AN-R at baseline.

CONCLUSIONS

Although there were differences in several clinical measures at baseline (Autism Quotient, symptom checklist, mood scores and Morgan Russel Outcome Scale), only anxiety was higher in AN-R. No differences in weight gain were observed, although mean values indicate a faster weight gain in the ARFID group. Standard weight restorative treatment in this study in adults with ARFID has similar weight gaining effect as in AN-R.

Fertility and Reproduction after Recovery from Anorexia Nervosa: A Systematic Review and Meta-Analysis of Long-Term Follow-Up Studies

Reproductive health is compromised during anorexia nervosa (AN). However, it is still unclear whether this medical complication is reversible after recovery from AN. The purpose of this paper was to conduct a systematic review of the major reproductive health outcomes in females after recovery from AN. The review was conducted in adherence to preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. Data were collated using meta-analysis and a narrative approach. Of the 1186 articles retrieved, five studies met the inclusion criteria and were reviewed. These studies monitored weight-restored females who had recovered from AN for a follow-up period of between six and 18 years. Their narrative analysis revealed that appropriate treatment of AN leads to the normalization of reproductive function, especially in terms of fertility, pregnancy, and childbirth rates. The meta-analysis confirmed this finding, where the pooled odds of childbirth rates between the AN group and the general population was not statistically significant (OR = 0.75, 95% CI: 0.43–1.29, p = 0.41). We conclude that if patients undergo appropriate eating-disorder treatment and weight restoration, it appears to be unlikely that reproductive health is affected by AN. However, since this finding is derived from only a few studies, it requires replication and confirmation.

Acceptability and tolerability of a meal-based, rapid refeeding, behavioral weight restoration protocol for anorexia nervosa

OBJECTIVE

Safe, tolerable, effective approaches to weight restoration are needed for adults with anorexia nervosa (AN). We examined weight outcomes and patient satisfaction with an integrated, inpatient-partial hospitalization, meal-based behavioral program that rapidly weight restores a majority of patients.

METHOD

Consecutively discharged inpatients (N = 149) treated on weight gain protocol completed an anonymous questionnaire assessing treatment satisfaction at inpatient discharge. Responders (107/149) rated their satisfaction with program components, feeling included in treatment, and likelihood of returning, or recommending the program to others. Clinical and demographic data were abstracted by chart review on all cases.

RESULTS

Over 70% of adult patients met BMI≥19 kg/m² by program discharge. Mean inpatient rate of gain was 1.85 kg/week (SD = 0.89). A majority (83.2%) would recommend the program to others and 71.4% endorsed a willingness to return if needed. The behavioral treatment focus was rated highly by 82.9% of respondents and was the strongest predictor of likelihood of referring others.

DISCUSSION

Results indicate a behaviorally focused, integrated, meal-based specialty program for eating disorders that includes rapid weight gain is acceptable to most participants. Data have implications for quality care, outcome reporting, and cost-effectiveness of inpatient behavioral weight restoration programs for individuals with AN.

How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians

OBJECTIVE

Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians.

METHOD

We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston Children's Hospital, University of Michigan C. S. Mott Children's Hospital, and Penn State Hershey Children's Hospital. In-depth, semi-structured, qualitative interviews explored participants' definitions of recovery. Interviews were analyzed using inductive data-driven thematic analysis. Statistical analyses followed to examine the distribution within each theme by respondent type.

RESULTS

Qualitative analysis resulted in the emergence of four overarching themes of ED recovery: (a) psychological well-being, (b) eating-related behaviors/attitudes, (c) physical markers, and (d) self-acceptance of body image. Endorsement of themes two and four did not significantly differ between patients, parents, and clinicians. Clinicians were significantly more likely to endorse theme one (χ² = 9.90, df = 2, p = .007, φ_c = 0.356) and theme three (χ² = 6.42, df = 2, p = .04, φ_c = 0.287) than patients and parents.

DISCUSSION

Our study demonstrates overwhelming support for psychological markers as indicators of ED recovery by all three groups. Clinicians should remain open to additional markers of recovery such as body acceptance and eating-related behaviors/emotions that may be of critical importance to patients and their caregivers.

Parents know best: Caregiver perspectives on eating disorder recovery

OBJECTIVE

This study used mixed methods to evaluate caregiver perspectives on recovery from an eating disorder.

METHOD

Caregivers (N = 387) completed an online survey about their child's weight history, treatment history, illness trajectory, and recovery.

RESULTS

Children were predominantly females with adolescent onset anorexia nervosa and currently 18.4 years old on average. Qualitative analysis of caregivers' open-ended definitions of recovery revealed seven distinct recovery domains, including (a) weight (45%); (b) body image, eating disorder cognitions, and related emotions (54%); (c) eating behavior (71%); (d) independence and responsibility in eating disorder management (28%); (e) physical health (21%); (f) psychological well-being (31%); and (g) life worth living (27%). Most (72%) reported that their child had achieved partial or full recovery at some point in their lifetime. Only 20% reported that their child had ever achieved full recovery, but 93% of those had sustained recovery over time (i.e., no relapses since achieving recovery). Physical recovery occurred on average 2.7 years after eating disorder onset, followed shortly by social and emotional recovery (2.9 years), and finally behavioral (3.4 years) and cognitive (3.9 years) recovery, which occurred at weights 6-7 pounds higher than those at which physical recovery was achieved.

DISCUSSION

Findings suggest that caregivers hold a multifaceted view of recovery that includes not only weight restoration and symptom reduction, but also full engagement in social and occupational activities, establishment of a meaningful life, cognitive flexibility, and emotional well-being. These data support clinical observations that physical and behavioral recovery precede cognitive recovery.

Medical Complications of Anorexia Nervosa

OBJECTIVE

The purpose of this study was to describe the medical complications of anorexia nervosa (AN) to enable a consult-liaison psychiatrist to be familiar with these complications when involved with the care of a hospitalized patient with AN.

METHODS

Comprehensive PubMed search of English language publications of adult patients with AN was carried out using keywords, phrases, and medical subject headings of anorexia nervosa-medical complications, cardiac, osteoporosis, gastrointestinal, hematological, and endocrine. The database search was restricted by time of publication of studies from 2005 to 2020.

RESULTS

Every organ system can be adversely affected by AN. Most are fully reversible with time and informed medical care. A multidisciplinary team is needed to optimally care for patients who are hospitalized as a result of the medical complications of their AN.

CONCLUSIONS

Consult-liaison psychiatrists are asked to help in the care of patients with AN who are admitted to a hospital because of a medical complication of their illness. Being familiar with these complications and their treatments will optimize their hospital stays and the care provided. In addition, involving other relevant ancillary services is an important care consideration.

Body composition in anorexia nervosa: Meta-analysis and meta-regression of cross-sectional and longitudinal studies

OBJECTIVE

Clinically, anorexia nervosa (AN) presents with altered body composition. We quantified these alterations and evaluated their relationships with metabolites and hormones in patients with AN longitudinally.

METHOD

In accordance with PRISMA guidelines, we conducted 94 meta-analyses on 62 samples published during 1996-2019, comparing up to 2,319 pretreatment, posttreatment, and weight-recovered female patients with AN with up to 1,879 controls. Primary outcomes were fat mass, fat-free mass, body fat percentage, and their regional distribution. Secondary outcomes were bone mineral density, metabolites, and hormones. Meta-regressions examined relationships among those measures and moderators.

RESULTS

Pretreatment female patients with AN evidenced 50% lower fat mass (mean difference [MD]: -8.80 kg, 95% CI: -9.81, -7.79, Q = 1.01 × 10-63 ) and 4.98 kg (95% CI: -5.85, -4.12, Q = 1.99 × 10-28 ) lower fat-free mass, with fat mass preferentially stored in the trunk region during early weight restoration (4.2%, 95% CI: -2.1, -6.2, Q = 2.30 × 10-4 ). While the majority of traits returned to levels seen in healthy controls after weight restoration, fat-free mass (MD: -1.27 kg, 95% CI: -1.79, -0.75, Q = 5.49 × 10-6 ) and bone mineral density (MD: -0.10 kg, 95% CI: -0.18, -0.03, Q = 0.01) remained significantly altered.

DISCUSSION

Body composition is markedly altered in AN, warranting research into these phenotypes as clinical risk or relapse predictors. Notably, the long-term altered levels of fat-free mass and bone mineral density suggest that these parameters should be investigated as potential AN trait markers.

RESUMENOBJETIVO

Clínicamente, la anorexia nervosa (AN) se presenta con alteraciones en la composición corporal. Cuantificamos estas alteraciones y evaluamos longitudinalmente su relación con metabolitos y hormonas en pacientes con AN. MÉTODO: De acuerdo con las pautas PRISMA, realizamos 94 meta-análisis en 62 muestras publicadas entre 1996-2019, comparando hasta 2,319 pacientes mujeres en pre-tratamiento, post-tratamiento, y recuperadas en base al peso con hasta 1,879 controles. Las principales medidas fueron masa grasa, masa libre de grasa, porcentaje de grasa corporal y su distribución regional. Las medidas secundarias fueron densidad mineral ósea, metabolitos y hormonas. Las meta-regresiones examinaron las relaciones entre esas medidas y moderadores.

RESULTADOS

Las pacientes femeninas con AN pre-tratamiento mostraron un 50% menos de masa grasa (MD: -8.80 kg, CI 95%: -9.81, -7.79, Q = 1.01 × 10-63 ) y 4.98 kg (CI 95%: -5.85, -4.12, Q = 1.99 × 10-28 ) menos de masa libre de grasa, con masa grasa preferentemente almacenada en la región del tronco durante la recuperación temprana del peso (4.2%, CI 95%: -2.1, -6.2, Q = 2.30 × 10-4 ). Aunque la mayoría de los rasgos regresaron a los niveles vistos en los controles sanos después de la restauración del peso, la masa libre de grasa (MD: -1.27 kg, CI 95%: -1.79, -0.75, Q = 5.49 × 10-6 ) y la densidad mineral ósea (MD: -0.10 kg, CI 95%: -0.18, -0.03, Q = 0.01) permanecieron significativamente alteradas. DISCUSIÓN: La composición corporal es marcadamente alterada en la AN, lo que garantiza la investigación en estos fenotipos como predictores de riesgo clínico o de recaída. Notablemente, la alteración a largo plazo de los niveles de masa libre de grasa y densidad mineral ósea sugieren que estos parámetros debe ser investigados como potenciales rasgos indicadores de AN.

Increased lipid and lipoprotein concentrations in anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

Alterations in blood lipid concentrations in anorexia nervosa (AN) have been reported; however, the extent, mechanism, and normalization with weight restoration remain unknown. We conducted a systematic review and a meta-analysis to evaluate changes in lipid concentrations in acutely-ill AN patients compared with healthy controls (HC) and to examine the effect of partial weight restoration.

METHOD

A systematic literature review and meta-analysis (PROSPERO: CRD42017078014) were conducted for original peer-reviewed articles.

RESULTS

Forty-eight studies were eligible for review; 33 for meta-analyses calculating mean differences (MD). Total cholesterol (MD = 22.7 mg/dL, 95% CI = 12.5, 33.0), high-density lipoprotein (HDL; MD = 3.4 mg/dL, CI = 0.3, 7.0), low-density lipoprotein (LDL; MD = 12.2 mg/dL, CI = 4.4, 20.1), triglycerides (TG; MD = 8.1 mg/dL, CI = 1.7, 14.5), and apolipoprotein B (Apo B; MD = 11.8 mg/dL, CI = 2.3, 21.2) were significantly higher in acutely-ill AN than HC. Partially weight-restored AN patients had higher total cholesterol (MD = 14.8 mg/dL, CI = 2.1, 27.5) and LDL (MD = 16.1 mg/dL, CI = 2.3, 30.0). Pre- versus post-weight restoration differences in lipid concentrations did not differ significantly.

DISCUSSION

We report aggregate evidence for elevated lipid concentrations in acutely-ill AN patients compared with HC, some of which persist after partial weight restoration. This could signal an underlying adaptation or dysregulation not fully reversed by weight restoration. Although concentrations differed between AN and HC, most lipid concentrations remained within the reference range and meta-analyses were limited by the number of available studies.

Hospital course of underweight youth with ARFID treated with a meal-based behavioral protocol in an inpatient-partial hospitalization program for eating disorders

OBJECTIVE

Information on nutritional rehabilitation for underweight patients with avoidant/restrictive food intake disorder (ARFID) is scarce. This study characterized hospitalized youth with ARFID treated in an inpatient (IP)-partial hospitalization behavioral eating disorders (EDs) program employing an exclusively meal-based rapid refeeding protocol and compared weight restoration outcomes to those of patients with anorexia nervosa (AN).

METHOD

Data from retrospective chart review of consecutive underweight admissions (N = 275; age 11-26 years) with ARFID (n = 27) were compared to those with AN (n = 248) on clinical features, reason for discharge, and weight restoration variables. For patients with ARFID, presenting phenomenology was further characterized by detailed chart review.

RESULTS

At admission, 53% of patients with ARFID were vomiting regularly. The predominant ARFID subtype was ARFID-aversive, with close to a third being mixed subtype. Gastrointestinal (GI) symptomatology (81.5%) was the most commonly endorsed reason for restriction. A third had undergone unsuccessful parenteral or enteral tube feeding. Patients with ARFID were more likely male, had higher admission BMI, and slower IP weight gain (1.36 kg /week vs 1.92) compared to patients with AN. Fewer patients with ARFID transitioned to the partial hospitalization program, although the proportion discharged for clinical improvement did not differ and both groups had a mean program discharge BMI >18.5.

DISCUSSION

GI symptoms appear a common contributor to restrictive eating amongst hospitalized youth with ARFID. Despite a slightly lower rate of IP weight gain, clinical improvement and weight restoration at discharge were similar for patients with ARFID compared to AN.

Trajectories of Change in Body Weight During Inpatient Treatment for Anorexia Nervosa

BACKGROUND

Identifying distinct trajectories of change in body weight during inpatient treatment for anorexia nervosa (AN) may provide knowledge about the process of weight restoration and may help detect optimal body weight response patterns among individuals who are at risk for not achieving weight restoration or leaving treatment prematurely.

OBJECTIVE

This study explored the extent to which distinct trajectories of change in body weight existed among individuals during inpatient treatment for AN.

DESIGN

Group-based trajectory modeling was used to identify distinct trajectories of change in body weight among 500 individuals receiving inpatient treatment for AN.

RESULTS

Four distinct trajectories were identified: weight gain ( n = 197), treatment resistant ( n = 177), weight plateau ( n = 82), and weight fluctuate ( n = 44).

CONCLUSION

Clinically, it is important to consider the heterogeneity of changes in body weight during inpatient treatment to help guide interventions and outcomes.

Adjunctive Use of Olanzapine in the Treatment of Avoidant Restrictive Food Intake Disorder in Children and Adolescents in an Eating Disorders Program

OBJECTIVE

There is little information about the pharmacological treatment of avoidant and restrictive food intake disorder (ARFID), a challenging feeding disorder associated with marked impairment and developmental arrest. This brief clinical report seeks to fill this gap.

METHODS

A retrospective chart review of nine patients with ARFID treated in an eating disorder (ED) program (residential, partial hospital, and intensive outpatient levels of care) with adjunctive olanzapine was undertaken.

RESULTS

The mean initial and final olanzapine doses were 0.9 + 0.63 mg/day and 2.8 + 1.47 mg/day, respectively. There was a statistically significant difference in weight gain pre- versus post-olanzapine treatment (3.3 ± 7.3 lbs vs. 13.1 ± 7.9 lbs [2.99 ± 6.62 lb SI vs. 11.88 ± 7.17 lb SI], paired t-test (p < 0.04, t = -2.48). Clinically, adjunctive olanzapine was helpful for not only weight gain but also reduction of associated anxious, depressive, and cognitive symptoms. Clinical Global Impressions scale scores indicated marked improvement in patients receiving adjunctive olanzapine.

CONCLUSION

These cases illustrate that judicious use of low-dose olanzapine, when used as an adjunct to other treatment modalities, may facilitate eating, weight gain, and the reduction of anxious, depressive, and cognitive symptoms in ARFID patients. Future randomized, placebo-controlled studies in ARFID are warranted.

Intensive treatment for adults with anorexia nervosa: The cost of weight restoration

OBJECTIVE

Weight restoration in anorexia nervosa (AN) is associated with lower relapse risk; however rate of weight gain and percent of patients achieving weight restoration (BMI ≥ 19 at discharge) vary among treatment programs. We compared both cost/pound of weight gained and cost of weight restoration in a hospital-based inpatient (IP)-partial hospitalization (PH) eating disorders program to estimates of these costs for residential treatment.

METHOD

All adult first admissions to the IP-PH program with AN (N = 314) from 2003 to 2015 were included. Cost of care was based on hospital charges, rates of weight gain, and weight restoration data. Results were compared with residential treatment costs extracted from a national insurance claims database and published weight gain data.

RESULTS

Average charge/day in the IP-PH program was $2295 for IP and $1567 for PH, yielding an average cost/pound gained of $4089 and $7050, respectively, with 70% of patients achieving weight restoration. Based on published mean weight gain data and conservative cost/day estimates, residential treatment is associated with higher cost/pound, and both higher cost and lower likelihood of weight restoration for most patients.

DISCUSSION

The key metrics used in this study are recommended for comparing the cost-effectiveness of intensive treatment programs for patients with AN.

Weight gain trajectories in hospital-based treatment of anorexia nervosa

Weight gain is a primary treatment goal for anorexia nervosa (AN); however little is known about heterogeneity in weight gain pattern during treatment. Preliminary evidence suggests weight gain trajectory is associated with treatment outcome. This study grouped patients using mixture modeling into weight gain trajectories, and compared predictors and treatment outcomes between trajectory groups. Women diagnosed with AN or subthreshold AN (N = 211) completed self-report measures at admission and six-months after discharge from an integrated inpatient (IP)-partial hospitalization (PH) behavioral specialty eating disorders program. Gowned weights were measured daily. Three distinct trajectories emerged: negative quadratic (Optimal), negative quadratic with fast weight gain (Fast), and positive linear with slower weight gain (Slow). The majority of patients were assigned to the Optimal group. Trajectory groups differed on admission, discharge, and follow-up variables. The Fast group emerged as most distinct. Women in this group were more than twice as likely to binge and or vomit regularly compared with the other two groups and were most likely to achieve weight restoration by discharge and to have more positive weight outcomes at short-term follow-up. There were no group differences in eating disorder behavioral frequencies at follow-up when adjusting for behavioral severity at admission. Weight gain trajectory may serve as a personalized in-treatment marker of outcome and could inform research on moderators and mediators of treatment response. Randomized controlled treatment studies, utilizing weight gain trajectories to determine group membership, may help identify subgroups of patients with differential responses to treatment interventions.

The Association between Weight Gain/Restoration and Bone Mineral Density in Adolescents with Anorexia Nervosa: A Systematic Review

Background: Reduced bone mineral density (BMD) is one of the most frequent medical complications of anorexia nervosa (AN). The purpose of this paper was to conduct a systematic review of the association between weight gain/restoration and BMD in adolescents with AN. Methods: Literature searches, study selection, method, and quality appraisal were performed independently by two authors, and data were collated using a narrative approach. Results: Of the 1156 articles retrieved, 19 studies met the inclusion criteria, and their analysis revealed four main findings. First, six studies reported that weight gain and restoration are associated with BMD stabilization after one year of follow-up from baseline. Second, seven studies with longer follow-up periods (≈16 months) reported significant improvements in BMD measures. Third, one study showed that normalization of BMD can be achieved after ≈30-month follow-up of normal-weight maintenance. Fourth, another study showed that male adolescents with AN who achieve weight gain but remain underweight may experience further BMD loss, unlike their weight-restored counterparts (BMI ≥ 19 kg/m²), who show a significant increase in BMD and bone mineral accrual rates that double those of healthy male adolescents. The first two findings can be considered robust, as they are supported by strong evidence. The third and fourth findings, however, derive from single studies and therefore require further confirmation. Conclusion: The literature supports weight gain as an effective strategy for promoting BMD increase in adolescents with AN. However, this process is slow, and improvements do not become detectable until ≈16-month follow-up.

Perceived coercion in inpatients with Anorexia nervosa: Associations with illness severity and hospital course

OBJECTIVE

The use of coercion in the treatment for anorexia nervosa (AN) is controversial and the limited studies to date have focused on involuntary treatment. However, coercive pressure for treatment that does not include legal measures is common in voluntarily admitted patients with AN. Empirical data examining the effect of non-legal forms of coerced care on hospital outcomes are needed.

METHOD

Participants (N = 202) with AN, Avoidant/Restrictive Food Intake Disorder (ARFID), or subthreshold AN admitted to a hospital-based behavioral specialty program completed questionnaires assessing illness severity and perceived coercion around the admissions process. Hospital course variables included inpatient length of stay, successful transition to a step-down partial hospitalization program, and achievement of target weight prior to program discharge.

RESULTS

Higher perceived coercion at admission was associated with increased drive for thinness and body dissatisfaction, but not with admission BMI. Perceived coercion was not related to inpatient length of stay, rate of weight gain, or achievement of target weight although it was predictive of premature drop-out prior to transition to an integrated partial hospitalization program.

DISCUSSION

These results, from an adequately powered sample, demonstrate that perceived coercion at admission to a hospital-based behavioral treatment program was not associated with rate of inpatient weight gain or achieving weight restoration, suggesting that coercive pressure to enter treatment does not necessarily undermine formation of a therapeutic alliance or clinical progress. Future studies should examine perceived coercion and long-term outcomes, patient views on coercive pressures, and the effect of different forms of leveraged treatment.

A systematic review of approaches to refeeding in patients with anorexia nervosa

OBJECTIVE

Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings.

METHODS

Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic.

RESULTS

Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown;

DISCUSSION

Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.

Comparison of standardized versus individualized caloric prescriptions in the nutritional rehabilitation of inpatients with anorexia nervosa

OBJECTIVE

Sparse research informs how caloric prescriptions should be advanced during nutritional rehabilitation of inpatients with anorexia nervosa (AN). This study compared the impact of a standardized caloric increase approach, in which increases occurred on a predetermined schedule, to an individualized approach, in which increases occurred only following insufficient weight gain, on rate, pattern, and cumulative amount of weight gain and other weight restoration outcomes.

METHOD

This study followed a natural experiment design comparing AN inpatients consecutively admitted before (n = 35) and after (n = 35) an institutional change from individualized to standardized caloric prescriptions. Authors examined the impact of prescription plan on weekly weight gain in the first treatment month using multilevel modeling. Within a subsample remaining inpatient through weight restoration (n = 40), multiple regressions examined the impact of caloric prescription plan on time to weight restoration, length of hospitalization, maximum caloric prescription, discharge BMI, and incidence of activity restriction and edema.

RESULTS

There were significant interactions between prescription plan and quadratic time on average weekly weight gain (p = .03) and linear time on cumulative weekly weight gain (p < .001). Under the standardized plan, patients gained in an accelerated curvilinear pattern (p = .04) and, therefore, gained cumulatively greater amounts of weight over time (p < .001). Additionally, 30% fewer patients required activity restriction under the standardized plan.

DISCUSSION

Standardized caloric prescriptions may confer advantage by facilitating accelerated early weight gain and lower incidence of bedrest without increasing the incidence of refeeding syndrome.

Refeeding and weight restoration outcomes in anorexia nervosa: Challenging current guidelines

OBJECTIVE

Cohort study from February 2003 through May 2011 to determine weight restoration and refeeding complication outcomes for patients with anorexia nervosa (AN) treated in an integrated inpatient-partial hospital eating disorder program designed to produce rapid weight gain and weight restoration in the majority.

METHOD

Consecutive admissions (females and males, adolescents and adults; N = 361 patients, 461 admissions) at least 1.8 kg below target weight with AN or subthreshold variants were included. Main outcome measures were rates of hypophosphatemia, transfer to medicine, or death; rates of weight gain and percent achieving weight restoration.

RESULTS

Hypophosphatemia was present in 7.9% of cases at admission and in 18.5% at some point during treatment. Hypophosphatemia was mild to moderate. Lower admission body mass index (BMI), but not rate of weight gain, predicted hypophosphatemia [OR = 0.65; p < .00001 (95% CI 0.57-0.76)]. Five patients (1.1%) were transferred to medicine or surgery, none because of refeeding. There were no deaths. Mean inpatient weight gain was 1.98 kg/week; mean partial hospital weight gain was 1.36 kg/week. By program discharge, 71.8% of adults reached a BMI of 19, 58.5% a BMI of 20. For adolescents, 80.4% came within 2 kg of their target weight; 76.1% came within 1 kg.

DISCUSSION

Refeeding patients with AN using a hospital-based, behavioral protocol may be accomplished safely and more rapidly than generally recognized, weight restoring most patients by discharge. Helpful elements may include the program's integrated, step-down structure; multidisciplinary team approach emphasizing group therapy to effect behavior change; and close medical monitoring for those with BMI < 15.

[Hematological changes in adolescent anorexia nervosa]

OBJECTIVE

Hematological changes often occur in patients with acute anorexia nervosa (AN). However, the relationship between these disturbances and other clinical parameters remains unclear.

METHOD

Leucocyte, erythrocyte, and thrombocyte counts as well as hematocrit, hemoglobin, and differential blood counts were collected at admission and after weight restoration in 88 female adolescent patients with the diagnosis of AN according to DSM-IV. These were then compared to clinical parameters.

RESULTS

At admission, there were mild changes in the blood count, most of which, however, were reversible after weight gain. Patients with a greater weight loss, a lower age-adjusted BMI, and a history of taking psychotropic drugs were more likely to develop hematological abnormalities.

CONCLUSIONS

Although most of the hematological changes in adolescent patients with AN were mild, patients with high weight loss and/or low age-adjusted BMI as well as those on psychotropic medication should be monitored carefully in order to avoid severe medical complications. An altered immune function in adult patients with chronic AN might contribute to a higher rate of infections and thus to an increased mortality.

Relationship with weight restoration and disease duration

OBJECTIVE

Starvation-induced depletion of fat stores in anorexia nervosa (AN) is known to be accompanied by alterations in some circulating adipocytokines. We analyzed a panel of circulating adipocytokines in women with AN compared with normal-weight controls and their relation with the disease duration and weight restoration.

METHOD

We analyzed circulating adipocytokine levels in 28 patients with AN and in 33 normal-weight controls who were eating healthily. We determined by enzyme-linked immunosorbent assay the circulating levels of total and high molecular weight (HMW) adiponectin, lipocalin-2 (LCN2), leptin, tumor necrosis factor receptor-II (TNFRII), interleukin-6 (IL6), adipocyte fatty acid binding protein-4 (FABP4), ghrelin, and resistin.

RESULTS

The two circulating forms of adiponectin are higher in AN women compared with controls. Both total and HMW adiponectin related negatively to the duration of the disease (r = -0.372, p = 0.033; r = -0.450, p = 0.038, respectively). Furthermore, the lipid binding-proteins LCN2 and FABP4 are lower in AN compared to the control group. Finally, leptin levels are lower in AN against controls and correlated positively with disease duration (r = 0.537, p = 0.007). Resistin, ghrelin, TNFRII, and IL6 have similar values in both groups, although TNFRII and ghrelin related negatively to body mass index variation at the end of treatment (r = -0.456, p = 0.039; r = -0.536, p = 0.015, respectively).

DISCUSSION

These results suggest there is a need to investigate if changes in adipocytokine levels could serve as weight restoration biomarkers. Further studies are warranted to elucidate the specific role of these molecules in the timing of weight restoration.

Nutritional rehabilitation in anorexia nervosa: review of the literature and implications for treatment

Restoration of weight and nutritional status are key elements in the treatment of anorexia nervosa (AN). This review aims to describe issues related to the caloric requirements needed to gain and maintain weight for short and long-term recovery for AN inpatients and outpatients.We reviewed the literature in PubMed pertaining to nutritional restoration in AN between 1960-2012. Based on this search, several themes emerged: 1. AN eating behavior; 2. Weight restoration in AN; 3. Role of exercise and metabolism in resistance to weight gain; 3. Medical consequences of weight restoration; 4. Rate of weight gain; 5. Weight maintenance; and 6. Nutrient intake.A fair amount is known about overall caloric requirements for weight restoration and maintenance for AN. For example, starting at 30-40 kilocalories per kilogram per day (kcal/kg/day) with increases up to 70-100 kcal/kg/day can achieve a weight gain of 1-1.5 kg/week for inpatients. However, little is known about the effects of nutritional deficits on weight gain, or how to meet nutrient requirements for restoration of nutritional status.This review seeks to draw attention to the need for the development of a foundation of basic nutritional knowledge about AN so that future treatment can be evidenced-based.

Implications of starvation-induced change in right dorsal anterior cingulate volume in anorexia nervosa

OBJECTIVE

Converging evidence suggests a role for the anterior cingulate cortex (ACC) in the pathophysiology of anorexia nervosa (AN). This study sought to determine whether ACC volume was affected by starvation in active AN and, if so, whether this had any clinical significance.

METHOD

Eighteen patients with active AN and age- and gender-matched normal controls underwent magnetic resonance imaging (MRI). Sixteen patients (89%) with AN had intelligence quotients (IQ) testing at intake, 14 (78%) had repeat MRIs after weight normalization, and 10 (56%) had outcome data at 1-year posthospitalization.

RESULTS

Right dorsal ACC volume was significantly reduced in active AN patients versus controls and was correlated with lower performance IQ. While ACC normalization occurred with weight restoration, smaller change in right dorsal ACC volume prospectively predicted relapse after treatment.

CONCLUSION

Reduced right dorsal ACC volume during active AN relates to deficits in perceptual organization and conceptual reasoning. The degree of right dorsal ACC normalization during treatment is related to outcome.