Envisioning the Future of Well-Being Efforts for Health Care Workers-Successes and Lessons Learned From the COVID-19 Pandemic

Importance

The National Academy of Medicine's National Plan for Health Workforce Well-Being provides recommendations for supporting the mental health and well-being of health care workers. This article aims to guide implementation of National Academy of Medicine recommendations by describing 2 programs at Columbia University Irving Medical Center and the University of California, San Francisco (UCSF), designed early in the COVID-19 pandemic to respond to the behavioral health needs of the health care workforce. The development of these programs, their similarities and differences, and the key lessons learned are discussed.

Observations

The well-being programs, CopeColumbia and UCSF Cope, shared key elements. Both efforts were led by their respective departments of psychiatry and used similar frameworks. Teams created strategic cross-university partnerships to share difficulties and successes across both programs. Moreover, both programs addressed compounding stressors of racial and political unrest, evaluated program components, and created resources for employee self-management. CopeColumbia and UCSF Cope differed in approaches to identifying high-risk employees and formal assessment and treatment pathways. From the authors' experience implementing these programs and having knowledge regarding health care workforce burnout, this article offers recommendations for the development of well-being programs. These include structural changes and resources to promote group and individual well-being emphasizing equity and justice, intentional involvement of psychiatry on well-being leadership teams, and bold efforts to destigmatize mental health care alongside clear paths to mental health treatment.

Conclusions and Relevance

The impact of the COVID-19 pandemic revealed a need for institutions to support the mental health and emotional well-being of health care workers. By outlining the development and implementation of 2 well-being programs in large academic health care settings and making recommendations to promote workforce well-being, it is the authors' hope that leaders will be empowered to carry forward critical changes. Most importantly, implementing plans now will provide the resilience needed both for the long shadow of the pandemic and future crises.

The association between leptin and weight maintenance outcome in anorexia nervosa

OBJECTIVE

Relapse after weight restoration in anorexia nervosa (AN) is a critical problem. Higher body fat percentage after weight gain has been shown to predict better weight maintenance outcome. Leptin, a fat-derived hormone, has been associated with progress during weight gain, but its association with weight maintenance is unknown. This study aims to determine whether leptin levels after weight restoration in AN are associated with weight maintenance.

METHOD

Participants were 41 women with AN hospitalized for inpatient treatment. Participants were evaluated 2-4 weeks after weight restoration to body mass index (BMI) ≥ 19.5 kg/m² for plasma leptin and body composition. Weight maintenance outcome was defined by whether a participant maintained a BMI of at least 18.5 kg/m² at the end of 1 year following hospital discharge.

RESULTS

Twenty (48.8%) out of 41 patients maintained their weight at 1 year. Percent body fat and leptin were significantly higher in the group who maintained weight (body fat, p = .004, Hedges' g = 0.944; log-leptin, p = .010, Hedges' g = 0.821), but there were no differences in predischarge BMI, duration of illness, and duration of amenorrhea. Using regression modeling, only higher log-leptin (p_Wald = .021) and percent body fat (p_Wald = .010), as well as fat-adjusted leptin (p_Wald = .029), independently predicted weight maintenance at 1 year.

DISCUSSIONS

Our findings suggest that for acutely-weight restored women with AN, higher predischarge leptin measurements are associated with better outcome in the year following treatment. Prospective studies examining leptin as well as other parameters of metabolic health could offer insights into biomarkers that may improve clinical outcomes.

Differential glucose metabolism in weight restored women with anorexia nervosa

Women with anorexia nervosa (AN) develop visceral adiposity associated with insulin resistance after partial weight restoration, but little is known about the glucose homeostasis after full weight restoration. In this investigation, we studied glucose homeostasis in twenty-four women with AN before (AN) and after weight restoration (WR) at a single institution, with both restricting and binge-purge subtypes (>70% binge-purge), compared to gender-, age- and BMI-matched healthy controls (HC). Participants underwent fasting plasma hormone analysis, oral glucose tolerance test (OGTT), and body composition analysis. Glucose homeostasis was assessed by the homeostasis model assessment (HOMA) and OGTT, and parameters were analyzed for association with body composition. We observed that a subset of the WR patients (21%) had metabolically unhealthy HOMA insulin resistance estimates (HOMA-IR), while this was not seen in the control group. Overall mean HOMA-IR between groups were not significantly different. Mean glucose reactivity was higher in the WR group than HC women (p = 0.008, Hedges' g = 0.811), and time-adjusted glucose reactivity in the WR group was inversely associated with visceral adiposity (r = -0.559, p = 0.006), but not with fat mass (r = -273, p = 0.208) or lean mass (r = -0.002, p = 0.994). Our findings suggest that glucose response during the OGTT in women with AN is altered in association with visceral adiposity acutely after full weight restoration, but that they do not develop overt insulin resistance. Glucometabolic profiling could offer novel insights to energy homeostasis acutely after weight restoration.

The FTO Gene and Measured Food Intake in 5- to 10-Year-Old Children Without Obesity

OBJECTIVE

Genetic variation in the first intron of FTO (e.g., single-nucleotide polymorphism [SNP] rs9939609) is strongly associated with adiposity. This effect is thought to be mediated (at least in part) via increasing caloric intake, although the precise molecular genetic mechanisms are not fully understood. Prior pediatric studies of FTO have included youth with overweight and obesity; however, they have not informed whether a genotypic effect on ingestive behavior is present prior to obesity onset. Therefore, this study investigated the association between FTO and caloric intake in children aged 5 to 10 years without obesity (adiposity ≤ 95th percentile).

METHODS

A total of 122 children were genotyped for rs9939609 and ate ad libitum from a laboratory lunch buffet following a standardized breakfast. Linear regressions, adjusting for body mass, were used to examine the association between FTO "dose" (number of copies of SNP rs9939609) and intake variables.

RESULTS

There was a significant association between FTO and total intake. Each risk allele predicted an additional 64 calories, accounting for 3% of the variance. There were no associations between FTO and macronutrient preference, energy density, or diet variety. Results were influenced by race.

CONCLUSIONS

Results corroborate and extend prior work by showing a dose-dependent effect on food intake in children without obesity.

Fat preference and fat intake in individuals with and without anorexia nervosa

Fat restriction is a characteristic eating behavior among individuals with anorexia nervosa (AN), and laboratory meal studies demonstrate restricted fat intake among low-weight patients. The Geiselman Food Preference Questionnaire-I^© (FPQ) is a validated self-report measure that yields a fat preference score (FPS). Prior research reported that patients with AN had a significantly lower FPS than did healthy control (HC) participants. The goal of the current study was to compare self-reported fat preference (FPS) to fat intake (multi-item meal (MIM) study) in low-weight ANs and HCs. Specific aims were 1) to determine if the FPS differed between ANs and HCs; 2) to determine if fat and energy intakes differed between ANs and HCs; and 3) to determine if the FPS was associated with fat and energy intakes in ANs and HCs. Forty-four female AN inpatients and 48 female HCs completed the FPQ and participated in a MIM study. Compared to HCs, ANs consumed less energy (469.1 ± 397.7 vs. 856.4 ± 346.8 kcal, p < 0.001), less fat (16.4 ± 20.4 vs. 36.7 ± 18.9 g, p < 0.001), and a smaller percentage of calories from fat (22.9 ± 13.8 vs. 36.6 ± 8.0%, p < 0.001) at the MIM. Compared to HCs, ANs also had a lower FPS (79.7 ± 27.4 vs. 102.3 ± 18.9, p < 0.001). The FPS was significantly and positively correlated with caloric intake (r = 0.481, p < 0.01), total fat (r = 0.453, p < 0.01), and the percentage of calories from fat (r = 0.37, p < 0.05) in ANs as well as in HCs (kcal: r = 0.583, p < 0.001; fat: r = 0.621, p < 0.001; % fat kcal: r = 0.601, p < 0.001). The FPS is related to objective measures of energy and fat intake in patients with AN as well as in healthy individuals.

Relationship between three factor eating questionnaire-restraint subscale and food intake

OBJECTIVE

Dietary restraint refers to an individual's intention to restrict food intake, measured via self-report questionnaires, whereas dietary restriction refers to actual reduction in caloric intake. The aim of this research was to investigate the association between dietary restraint scales and actual caloric restriction.

METHOD

Data were collected from six previously published or two ongoing eating behavior studies in which participants (n = 183) completed the Three Factor Eating Questionnaire (TFEQ) and Eating Disorders Examination Questionnaire (EDE-Q) and participated in a laboratory-based research lunch meal. Participants were individuals with anorexia nervosa (AN), bulimia nervosa (BN), and healthy controls (HC). The primary analysis was the association between TFEQ Restraint subscale and caloric intake in the meal.

RESULTS

There was a significant negative correlation between total caloric intake and TFEQ Restraint scores (r = -.60, p < .001) and EDE-Q Restraint scores (r = -.54, p < .001). For TFEQ Restraint score, this relationship was significant within each diagnostic group (HC: r = -.32, p = .007; AN: r = -.38, p < .001; BN: r = -.43, p = .02).

DISCUSSION

These results suggest that the TFEQ Restraint scale is a useful measure of dietary restriction, especially among individuals with eating disorders.

Rigor and reproducibility via laboratory studies of eating behavior: A focused update and conceptual review

OBJECTIVE

The eating behavior of individuals with eating disorders has been examined in laboratory settings over the last 30 years. In this focused review, we build on prior research and highlight several feeding laboratory paradigms that have successfully demonstrated quantifiable and observable behavioral disturbances, and thereby add rigor and reproducibility to the examination of disturbances of eating behavior. This review describes the measures commonly obtained via these laboratory techniques. Supporting Information Appendices with detailed information about implementation are provided to allow for the reproducible execution of these techniques across labs.

METHODS/RESULTS

Literature documenting the existence of objective abnormalities in eating behavior among individuals with eating disorders or in comparison to healthy controls (n > 40) is briefly summarized. These protocols, conducted across at least 17 independent labs, are sensitive and reproducible, can be used to assess subjective and physiological parameters associated with eating, and elucidate the impact of treatment. Laboratory studies from patients with eating disorders compared with healthy controls reproducibly demonstrate both that patients with Anorexia Nervosa ingest fewer calories and that individuals with Bulimia Nervosa and Binge-Eating Disorder ingest more calories when asked to binge-eat.

DISCUSSION

Feeding laboratory studies have the potential for quantifying the characteristic behavioral psychopathology of patients with eating disorders, and may provide a useful tool to explore the potential utility of new treatments for individuals with Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder.

Patients with bulimia nervosa do not show typical neurodevelopment of cognitive control under emotional influences

Bulimia nervosa (BN) emerges in the late teen years and is characterized by binge eating and related compensatory behaviors. These behaviors often co-occur with periods of negative affect suggesting an association between emotions and control over eating behavior. In the current study, we examined how cognitive control and neural processes change under emotional states of arousal in 46 participants with (n=19) and without (n=27) BN from the ages of 18-33 years. Participants performed a go/nogo task consisting of brief negative, positive and neutral emotional cues and sustained negative, positive and neutral emotional states of arousal during functional magnetic resonance imaging (fMRI). Overall task performance improved with age for healthy participants, but not for patients with BN. These age-dependent behavioral effects were paralleled by diminished recruitment of prefrontal control circuitry in patients with BN with age. Although patients with BN showed no difference in performance on the experimental manipulations of negative emotions, sustained positive emotions related to improved performance among patients with BN. Together the findings highlight a neurodevelopmental approach towards understanding markers of psychopathology and suggest that sustained positive affect may have potential therapeutic effects on maintaining behavioral control in BN.

The effect of acute weight restoration on dietary fat preference in hospitalized patients with anorexia nervosa

OBJECTIVE

Individuals with anorexia nervosa (AN) restrict fat intake. The Geiselman Food Preference Questionnaire-I© (FPQ) is a validated self-report instrument that yields a fat preference score (>100 = high fat preference, <100 = low fat preference). The goal of the study was to assess the utility of the FPQ in patients with AN.

SPECIFIC AIMS

(1) to examine change in fat preference scores before and after weight restoration in hospitalized patients; and (2) to compare patients' scores before and after weight restoration to scores from healthy participants (HPs).

METHOD

The FPQ was completed by 88 patients and 115 HPs.

RESULTS

Compared with HPs, patients had significantly lower fat preference scores before (74.03 ± 32.03 vs. 102.93 ± 16.89, P < 0.001) and after (81.51 ± 26.89 vs. 102.92 ± 16.89, P < 0.001) weight restoration. Fat preference scores increased with weight gain (74.03 + 32.03 vs. 81.51 + 26.89, P < 0.01) but did not normalize in AN.

DISCUSSION

Acutely weight restored patients continue to endorse decreased preference for high fat foods. The FPQ may be a useful metric by which to assess improvements in diet during treatment. Further study is warranted to validate the FPQ against observed food intake in AN. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:148-151).

Assessment of the motivation to use artificial sweetener among individuals with an eating disorder

Eating disorders are associated with a range of abnormalities in eating behavior. Some individuals consume large amounts of non-caloric artificial sweeteners, suggesting abnormalities in appetitive responding. The current study aimed to quantify hedonic and motivating effects of artificial sweetener in individuals with and without an eating disorder. Two laboratory studies were conducted. Hedonic preference was estimated using the number of artificial sweetener packets (0-10) added to unsweetened cherry flavored Kool-Aid (study 1). Motivation to obtain sweetener was assessed by a progressive ratio (PR) work task (study 2). Ninety-three participants (25 anorexia nervosa restricting type (AN-R), 23 AN binge/purge type (AN-B/P), 20 bulimia nervosa (BN), and 25 normal controls (NC)) completed the study. No significant difference in hedonic preference was found among participant groups. Work completed at the PR task ranged from 0 to 9500 key-board presses. The AN-B/P group had a significantly higher breakpoint and performed significantly more work for sweetener compared to the BN and NC groups. Among AN-B/P and AN-R participants, the preferred number of Equal packets was significantly correlated with the breakpoint and total work. The increased amount of work for sweetener among individuals with AN-B/P supports an enhanced reward value of sweet taste in this population, and suggests that the characteristic food avoidance in AN cannot be accounted for by decreased reward value of all taste-related stimuli. This study also supports the novel application of a PR ratio task to quantify the motivating effect of sweet taste among individuals with an eating disorder.

Dietary energy density and diet variety as risk factors for relapse in anorexia nervosa: a replication

OBJECTIVE

To replicate our previous findings of an association between energy density and diet variety in recently weight-restored patients with anorexia nervosa (AN) and clinical outcome in the year following treatment.

METHOD

Nineteen hospitalized, weight-restored women with AN completed a food record, from which a diet energy density score (DEDS) and a diet variety score (DVS) were calculated. After hospital discharge, patients were contacted regularly; at the end of one year, clinical outcome was determined using modified Morgan-Russell criteria. As in our previous study, outcome was dichotomized into "full, good, or fair" and "poor" groups.

RESULTS

Data from 16 subjects were available. The DEDS was significantly lower (p < .05) in the poor outcome group (0.7 ± 1) compared with the "full, good, or fair" outcome group (0.9 ± 1). Although the DVS was also lower in the poor outcome group (13.9 ± 2) compared with the "full, good or fair" outcome group (15.7 ± 1.8), this difference was not statistically significant.

DISCUSSION

In recently weight-restored patients with AN, a lower DEDS, but not DVS, is associated with poor clinical outcome after inpatient treatment. This finding may be important in the assessment of risk for relapse in patients with AN.

Brain tissue volume changes following weight gain in adults with anorexia nervosa

OBJECTIVE

To measure brain volume deficits among underweight patients with anorexia nervosa (AN) compared to control participants and evaluate the reversibility of these deficits with short-term weight restoration.

METHOD

Brain volume changes in gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) were examined in 32 adult women with AN and compared to 21, age and body mass index-range matched control women.

RESULTS

Patients with AN had a significant increase in GM (p = .006, η(2) = 0.14) and WM volume (p = .001, η(2) = 0.19) following weight restoration. Patients on average had lower levels of GM at low weight (647.63 ± 62.07 ml) compared to controls (679.93 ± 53.31 ml), which increased with weight restoration (662.64 ± 69.71 ml), but did not fully normalize.

DISCUSSION

This study suggests that underweight adult patients with AN have reduced GM and WM volumes that increase with short-term weight restoration.

Adipose tissue distribution after weight restoration and weight maintenance in women with anorexia nervosa

BACKGROUND

Body image distortions are a core feature of anorexia nervosa (AN). We, and others, previously reported abnormalities in adipose tissue distribution after acute weight restoration in adult women with AN compared with body mass index-matched healthy control women. Whether these abnormalities persist over time remains unknown.

OBJECTIVES

We aimed to 1) replicate previous findings that showed preferential central accumulation of adipose tissue in recently weight-restored AN women compared with control subjects, 2) describe the change within patients with longer-term (1-y) weight maintenance, and 3) compare adipose tissue distribution after 1-y maintenance with that of control subjects.

DESIGN

Body composition and adipose tissue distribution were assessed by whole-body magnetic resonance imaging in women with AN shortly after weight normalization (n = 30) and again 1 y after hospital discharge (n = 16) and in 8 female control subjects at 2 time points.

RESULTS

With acute weight restoration, AN patients had significantly greater visceral and intermuscular adipose tissue compared with control women [visceral: 0.75 +/- 0.26 compared with 0.51 +/- 0.26 kg in AN patients and controls, respectively (P = 0.02); intermuscular: 0.46 +/- 0.17 compared with 0.29 +/- 0.13 kg in AN patients and controls, respectively (P = 0.01)]. With maintenance of normal weight for approximately 1 y, visceral adipose tissue distribution in AN patients was not different from that in healthy control subjects.

CONCLUSIONS

In adult women with AN, normalization of weight in the short term is associated with a distribution of adipose tissue that is consistent with a central adiposity phenotype. This abnormal distribution appears to normalize within a 1-y period of weight maintenance. This research was registered at clinicaltrials.gov as NCT 00271921 and NCT 00368667.

The clinical significance of amenorrhea as a diagnostic criterion for anorexia nervosa

OBJECTIVE

Amenorrhea is a DSM-IV criterion for the diagnosis of anorexia nervosa (AN). Several studies have reported few differences between patients who meet the full DSM-IV criteria for AN and those who meet all but the amenorrhea criterion. Although this suggests that the absence of menses does not provide critical diagnostic information, many of these studies are limited by small sample sizes. This study aims to examine the clinical utility of amenorrhea as a criterion for the diagnosis of AN.

METHOD

A chart review was conducted of 240 consecutive patients admitted for inpatient treatment at the NY State Psychiatric Institute from 1993 to 2006. Menstrual data were collected from the Eating Disorder Examination conducted upon admission. Independent samples t-tests were performed to evaluate differences in clinical variables, including age, lifetime lowest body mass index (BMI), admission and discharge BMI, previous number of hospitalizations, duration of illness, Beck Depression Inventory total score, Beck Anxiety Inventory total score, and Eating Disorder Examination subscale scores.

RESULTS

The amenorrheic and menstruating groups differed significantly only on lowest lifetime BMI and admission BMI, with individuals with amenorrhea having lower BMIs on both measures.

CONCLUSION

These results indicate that amenorrhea does not distinguish between groups on a number of important measures of clinical severity. It may be that amenorrhea reflects weight and nutritional status, rather than providing useful diagnostic information. Future studies are needed to examine the potential prognostic value of menstrual status.

Does percent body fat predict outcome in anorexia nervosa?

OBJECTIVE

The goal of this study was to investigate the relationship of body composition and neuroendocrine levels with clinical outcome in women with anorexia nervosa in a relapse-prevention trial.

METHOD

Body composition and fasting cortisol and leptin levels were assessed before random assignment in 32 weight-recovered subjects with anorexia nervosa from the New York site of the Fluoxetine to Prevent Relapse in Women With Anorexia Nervosa trial. Clinical outcome at the end of study participation was defined using modified Morgan-Russell criteria (full, good, fair, poor), then dichotomized into treatment "success" or "failure."

RESULTS

In a binary logistic regression model examining the effect of percent body fat, body mass index, anorexia nervosa subtype, waist-to-hip ratio, and serum cortisol and leptin levels on treatment outcome, only percent body fat was significantly associated with outcome.

CONCLUSIONS

In recently weight-restored women with anorexia nervosa, lower percent body fat was associated with poor long-term outcome.

Physical activity and cortisol in anorexia nervosa

Elevated physical activity is commonly observed among patients with Anorexia Nervosa (AN) and can manifest in several forms. While elevated physical activity may play a key role in the pathophysiology of this disorder, much remains unknown about it, including the relationship among its various manifestations, and their underlying mechanism(s). The purposes of the current study were to (1) quantify locomotor activity in inpatients with AN using an accelerometer, (2) determine the association between locomotor activity and exercise history and (3) determine the association between urinary cortisol and physical activity. Thirty-six women hospitalized with AN wore activity armbands for 48 h during the first 2 weeks of hospitalization, collected 24-h urine to measure cortisol, and completed rating forms. Activity counts varied more than four-fold among individuals but were consistent within individuals over the 2 monitoring days (p<0.001). Averaged 24-h activity counts were positively correlated with pre-hospitalization attitude towards exercise as measured by the Commitment to Exercise Scale (CES; p=0.032). Forty-two percent of women reported "high" exercise in the 3 months before hospitalization; compared to non-high-exercising patients, these women demonstrated a higher CES score (p<0.001) and a trend toward greater activity counts (p=0.059). Urinary cortisol was positively associated with activity counts (p=0.044) and CES score (p=0.018). These data suggest that some women with AN have a higher "drive" for physical activity that persists into early hospitalization. HPA axis abnormalities may be associated with this state.