12-months of increased dietary intake does not exacerbate disordered eating-related attitudes, stress, or depressive symptoms in women with exercise-associated menstrual disturbances: The REFUEL randomized controlled trial

Disordered eating-related attitudes are a leading cause of energy deficiency and menstrual disturbances in exercising women. Although treatment recommendations include psychological counseling with increases in dietary intake, a key concern is whether increased dietary intake may exacerbate negative eating behaviors.

OBJECTIVE

To determine the effects of a 12-month nutritional intervention on eating-related attitudes and psychological characteristics in exercising women with oligomenorrhea/amenorrhea (Oligo/Amen).

METHODS

Intent-to-treat analysis of the REFUEL randomized controlled trial (#NCT00392873) in 113 exercising women (age [mean±SEM]:] 21.9 ± 0.4 yrs; BMI: 20.9 ± 0.2 kg/m²). Women were randomized to increase energy intake 20-40% above baseline energy needs (Oligo/Amen+Cal, n = 40) or maintain energy intake (Oligo/Amen Control, n = 36) while maintaining their exercise behaviors. A reference group of ovulatory women (OVref, n = 37) maintained diet and exercise behaviors. Body composition, eating attitudes, stress, and depressive symptoms were assessed at baseline and every 3 months.

RESULTS

At baseline, the Oligo/Amen groups had higher drive for thinness, cognitive restraint, and eating disorder risk than OVref group (p < 0.001). Increased energy intake led to increases in percent body fat and fat mass (p < 0.010), but not psychobehavioral outcomes, in the Oligo/Amen+Cal compared to Oligo/Amen Control group. Independent of group, cognitive restraint decreased (p < 0.001) and resilient coping increased (p < 0.007) over 12-months, while perceived stress (p = 0.143) and depressive symptoms (p = 0.344) were unchanged.

DISCUSSION

Long-term nutritional intervention consisting of modest increases in dietary intake with guidance from a registered dietician and a psychologist increases body and fat mass without increasing disordered eating-related attitudes, stress, or depressive symptoms in exercising women with Oligo/Amen.

The direct health care costs of eating disorders among hospitalized patients: A population-based study

OBJECTIVE

To estimate the direct health care costs of eating disorders in Ontario, Canada, in 2012, using a prevalence-based cost-of-illness approach.

METHOD

We selected a population-based sample of all patients eligible for public health care insurance over the age of 4 with a hospitalization for an eating disorder at any point since 1988. We estimated total and mean direct net costs per patient in 2012, from the third public payer perspective, by sex, age group, and health service type.

RESULTS

In 2012, there were 6,326 patients ever hospitalized for an eating disorder. They had a mean age of 31 at hospitalization, were mostly female (93%), and generally from high-income, urban neighborhoods. Direct total costs were just under $63 million CAD; direct net costs were roughly $48 million CAD. Mean net costs per patient were higher for females than males ($7,743.40 and $6,340.50, respectively), and higher for patients under 20 and patients 65+ ($17,961.50 and $14,953.90, respectively). The main cost drivers were psychiatric hospitalizations and physician visits, although this varied by age group. For younger patients, net costs were mainly because of psychiatric hospitalizations, while for older patients net costs were mainly because of psychiatric and nonpsychiatric hospitalizations, and other care.

DISCUSSION

The cost of eating disorders is substantial and varies by sex and age group. Our findings suggest that, from a health care utilization/cost perspective, the effect of eating disorders is likely to persist over the lifespan.

Cost evaluation of out-of-country care for patients with eating disorders in Ontario: a population-based study

BACKGROUND

Eating disorders, specifically anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified, represent a substantial burden to the health care system. Our goal was to estimate the economic burden of patients who received specialized inpatient care for an eating disorder out of country.

METHOD

We conducted a cost-of-illness study evaluating health care costs among patients in Ontario who received specialized inpatient care for an eating disorder out of country from 2003 to 2011, from the public third-party payer perspective. Using linked administrative databases, we estimated net costs of eating disorders for 2 patient groups: those who received specialized inpatient care both out of country and in province (n = 160), and those who received specialized inpatient care out of country only (n = 126).

RESULTS

Patients approved for specialized out-of-country inpatient care were mostly girls and young women from high-income, urban neighbourhoods. Total net costs varied annually and were higher for patients treated both out of country and in province (about $11 million before 2007, $6.5 million after) than for those treated out of country alone (about $5 million and $2 million, respectively). The main cost drivers were out-of-country care and physician services.

INTERPRETATION

Costs associated with eating disorder care represent a substantial economic burden to the Ontario health care system. Given the high costs of out-of-country care, there may be opportunity to redirect these funds to increase capacity and expertise for eating disorder treatment within Ontario.

Reductions in Cortico-Striatal Hyperconnectivity Accompany Successful Treatment of Obsessive-Compulsive Disorder with Dorsomedial Prefrontal rTMS

Obsessive-compulsive disorder (OCD) is a disabling illness with high rates of nonresponse to conventional treatments. OCD pathophysiology is believed to involve abnormalities in cortico-striatal-thalamic-cortical circuits through regions such as dorsomedial prefrontal cortex (dmPFC) and ventral striatum. These regions may constitute therapeutic targets for neuromodulation treatments, such as repetitive transcranial magnetic stimulation (rTMS). However, the neurobiological predictors and correlates of successful rTMS treatment for OCD are unclear. Here, we used resting-state functional magnetic resonance imaging (fMRI) to identify neural predictors and correlates of response to 20-30 sessions of bilateral 10 Hz dmPFC-rTMS in 20 treatment-resistant OCD patients, with 40 healthy controls as baseline comparators. A region of interest in the dmPFC was used to generate whole-brain functional connectivity maps pre-treatment and post treatment. Ten of 20 patients met the response criteria (⩾50% improvement on Yale-Brown Obsessive-Compulsive Scale, YBOCS); response to dmPFC-rTMS was sharply bimodal. dmPFC-rTMS responders had higher dmPFC-ventral striatal connectivity at baseline. The degree of reduction in this connectivity, from pre- to post-treatment, correlated to the degree of YBOCS symptomatic improvement. Baseline clinical and psychometric data did not predict treatment response. In summary, reductions in fronto-striatal hyperconnectivity were associated with treatment response to dmPFC-rTMS in OCD. This finding is consistent with previous fMRI studies of deep brain stimulation in OCD, but opposite to previous reports on mechanisms of dmPFC-rTMS in major depression. fMRI could prove useful in predicting the response to dmPFC-rTMS in OCD.

Increases in frontostriatal connectivity are associated with response to dorsomedial repetitive transcranial magnetic stimulation in refractory binge/purge behaviors

Background

Conventional treatments for eating disorders are associated with poor response rates and frequent relapse. Novel treatments are needed, in combination with markers to characterize and predict treatment response. Here, resting-state functional magnetic resonance imaging (rs-fMRI) was used to identify predictors and correlates of response to repetitive transcranial magnetic stimulation (rTMS) of the dorsomedial prefrontal cortex (dmPFC) at 10 Hz for eating disorders with refractory binge/purge symptomatology.

Methods

28 subjects with anorexia nervosa, binge−purge subtype or bulimia nervosa underwent 20–30 sessions of 10 Hz dmPFC rTMS. rs-fMRI data were collected before and after rTMS. Subjects were stratified into responder and nonresponder groups using a criterion of ≥50% reduction in weekly binge/purge frequency. Neural predictors and correlates of response were identified using seed-based functional connectivity (FC), using the dmPFC and adjacent dorsal anterior cingulate cortex (dACC) as regions of interest.

Results

16 of 28 subjects met response criteria. Treatment responders had lower baseline FC from dmPFC to lateral orbitofrontal cortex and right posterior insula, and from dACC to right posterior insula and hippocampus. Responders had low baseline FC from the dACC to the ventral striatum and anterior insula; this connectivity increased over treatment. However, in nonresponders, frontostriatal FC was high at baseline, and dmPFC-rTMS suppressed FC in association with symptomatic worsening.

Conclusions

Enhanced frontostriatal connectivity was associated with responders to dmPFC-rTMS for binge/purge behavior. rTMS caused paradoxical suppression of frontostriatal connectivity in nonresponders. rs-fMRI could prove critical for optimizing stimulation parameters in a future sham-controlled trial of rTMS in disordered eating.

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dmPFC-rTMS was performed on patients with treatment-refractory AN and BN.

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Resting-state fMRI was collected to identify predictors and correlates of response.

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dmPFC-rTMS achieves robust improvement on bingeing and purging in AN and BN.

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Responders have lower baseline corticostriatal connectivity compared to nonresponders.

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Increased corticostriatal connectivity is associated with treatment response.

2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.

Inpatients with severe anorexia nervosa and their siblings: non-shared experiences and family functioning

OBJECTIVES

The aims of this study were the following: to identify perceptions of patients with anorexia nervosa (AN) and their siblings regarding differential experiences within and external to the family including sibling interactions, parental treatment, relationships with peers and events that are unique to each sibling; (2) to compare how patients and their siblings perceive eating disorder symptoms, parental affection/control, social support and stigma; and (3) to test associations with family functioning for patients with AN and their siblings.

METHOD

A total of 26 patients paired with their siblings were recruited from an Eating Disorder Program and administered standardized instruments measuring different experiences within and external to the family, the impact of eating disorder behaviours, stigma, social support and family functioning.

RESULTS

Patients rated high on the differential experience of jealousy in contrast to their siblings. Patients scored higher than their siblings on eating symptoms, whereas siblings scored higher on social support. The impact of AN on the family, stigma towards the individual and family, and social support accounted for 37% of the variance in family functioning from the sibling perspective after controlling for age and gender. Of these variables, impact of AN on the family made the largest contribution.

DISCUSSION

Family-based and sibling-based interventions that aim to reduce the effects of the illness on the sibling relationship and the family are recommended.

The slippery slope: prediction of successful weight maintenance in anorexia nervosa

BACKGROUND

Previous research has found that many patients with anorexia nervosa (AN) are unable to maintain normal weight after weight restoration. The objective of this study was to identify variables that predicted successful weight maintenance among weight-restored AN patients.

METHOD

Ninety-three patients with AN treated at two sites (Toronto and New York) through in-patient or partial hospitalization achieved a minimally normal weight and were then randomly assigned to receive fluoxetine or placebo along with cognitive behavioral therapy (CBT) for 1 year. Clinical, demographic and psychometric variables were assessed after weight restoration prior to randomization and putative predictors of successful weight maintenance at 6 and 12 months were examined.

RESULTS

The most powerful predictors of weight maintenance at 6 and 12 months following weight restoration were pre-randomization body mass index (BMI) and the rate of weight loss in the first 28 days following randomization. Higher BMI and lower rate of weight loss were associated with greater likelihood of maintaining a normal BMI at 6 and 12 months. An additional predictor of weight maintenance was site; patients in Toronto fared better than those in New York.

CONCLUSIONS

This study found that the best predictors of weight maintenance in weight-restored AN patients over 6 and 12 months were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. These results suggest that outcome might be improved by achieving a higher BMI during structured treatment programs and on preventing weight loss immediately following discharge from such programs.

Drive for thinness score is a proxy indicator of energy deficiency in exercising women

The purpose of this study was to determine the association between drive for thinness (DT) and adaptations to energy deficiency in exercising women. This observational study evaluated psychometric and metabolic factors in sedentary (n=9, 27.9+/-2.0 yr) and exercising women (n=43, 24.0+/-1.1 yr). Volunteers were retrospectively grouped according to exercise status (sedentary or exercising) and a DT score of normal (sedentary or exercising) or high (exercising only). Resting energy expenditure (REE) and metabolic hormones (triiodothyronine, (TT3), ghrelin, leptin, insulin) were measured repeatedly over a 2-3 month period. The DT subscale successfully discriminated the groups based on energy status. Although the groups did not differ in body weight, the high DT group exhibited adaptations to chronic energy deficiency, including a REE below 90% of their predicted REE (86+/-3.0%), significantly lower TT3 levels and significantly higher ghrelin levels than the normal DT groups. Since energy deficiency plays a causal role in the Female Athlete Triad, DT may serve as a proxy indicator of underlying energy deficiency and may be useful for identifying individuals at risk for Triad disorders prior to the development of serious clinical sequelae.

Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial

CONTEXT

Antidepressant medication is frequently prescribed for patients with anorexia nervosa.

OBJECTIVE

To determine whether fluoxetine can promote recovery and prolong time-to-relapse among patients with anorexia nervosa following weight restoration.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled trial. From January 2000 until May 2005, 93 patients with anorexia nervosa received intensive inpatient or day-program treatment at the New York State Psychiatric Institute or Toronto General Hospital. Participants regained weight to a minimum body mass index (calculated as weight in kilograms divided by the square of height in meters) of 19.0 and were then eligible to participate in the randomized phase of the trial.

INTERVENTIONS

Participants were randomly assigned to receive fluoxetine or placebo and were treated for up to 1 year as outpatients in double-blind fashion. All patients also received individual cognitive behavioral therapy.

MAIN OUTCOME MEASURES

The primary outcome measures were time-to-relapse and the proportion of patients successfully completing 1 year of treatment.

RESULTS

Forty-nine patients were assigned to fluoxetine and 44 to placebo. Similar percentages of patients assigned to fluoxetine and to placebo maintained a body mass index of at least 18.5 and remained in the study for 52 weeks (fluoxetine, 26.5%; placebo, 31.5%; P = .57). In a Cox proportional hazards analysis, with prerandomization body mass index, site, and diagnostic subtype as covariates, there was no significant difference between fluoxetine and placebo in time-to-relapse (hazard ratio, 1.12; 95% CI, 0.65-2.01; P = .64).

CONCLUSIONS

This study failed to demonstrate any benefit from fluoxetine in the treatment of patients with anorexia nervosa following weight restoration. Future efforts should focus on developing new models to understand the persistence of this illness and on exploring new psychological and pharmacological treatment approaches.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00288574.

Weight-related other evaluation in eating disorders

Weight-related self-evaluation has been described as the fundamental maladaptive cognitive feature of disordered eating. It is not clear, however, whether the process of determining personal-worth based on an evaluation of body size is specific to the self, or whether it is relevant to the evaluation of people in general. Thirty-three eating disordered patients and 54 undergraduates read an article about a woman who was described as either overweight or slender and evaluated the woman on several dimensions. Both undergraduates and eating disordered patients rated the heavy woman as less attractive than the thin woman. However, the patients' evaluation of the overweight target's attractiveness was significantly more negative than the undergraduates'. Patients also rated the overweight woman as less popular and claimed that they liked the overweight woman less than the thin woman. These effects were not present among the undergraduate students. Finally, the eating disorder participants rated the overweight woman as more overweight and less intelligent than did the undergraduate students. The results suggest that weight-related evaluation in eating disorders extends beyond the self to include the evaluation of other people.

Disturbed eating behavior and eating disorders in preteen and early teenage girls with type 1 diabetes: a case-controlled study

OBJECTIVE

To compare the prevalence of eating disturbances in preteen and early teenage girls with type 1 diabetes to their nondiabetic peers.

RESEARCH DESIGN AND METHODS

A cross-sectional, case-controlled study of 101 girls with type 1 diabetes, ages 9-14 years, and 303 age-matched, female nondiabetic control subjects was conducted. Participants completed a Children's Eating Disorder Examination interview. Socioeconomic status, BMI, and diabetes-related variables were assessed. Groups were compared using chi(2) analyses.

RESULTS

Binge eating; the use of intense, excessive exercise for weight control; the combination of two disturbed eating-related behaviors; and subthreshold eating disorders were all more common in girls with type 1 diabetes. Metabolic control was not related to eating behavior in this study population.

CONCLUSIONS

Eating disturbances, though mostly mild, were significantly more common in preteen and early teenage girls with type 1 diabetes. Screening and prevention programs for this high-risk group should begin in the preteen years.

Metabolic control in adolescent girls: links to relationality and the female sense of self

OBJECTIVE

This study investigated whether intimacy and autonomy in mother-daughter interactions and relational aspects of the self are associated with metabolic control in adolescent girls with type 1 diabetes.

RESEARCH DESIGN AND METHODS

This cross-sectional study included 88 girls with diabetes (mean age 14.9 +/- 2.2 years, diabetes duration 7.1 +/- 3.9 years, and HbA1c 8.9 +/- 1.6%) from the Diabetes Clinic at the Hospital for Sick Children in Toronto and their mothers. Teens completed a self-report measure assessing self-concept in eight domain-specific areas. Mothers and daughters engaged in a 7-min, videotaped, problem-solving task involving a diabetes-related conflict issue. Interactions were rated using a macroanalytic rating system to assess intimacy and autonomy in parent-teen relationships. Metabolic control was measured using HbA1c.

RESULTS

Self-concept in domains of perceived behavioral conduct (P=0.003), social acceptance (P=0.03), romantic appeal (P=0.03), and close friendships (P=0.04) independently predicted HbA1c levels, together accounting for 30% of the variance. Also, the experience of emotional closeness (i.e., intimacy) rather than separateness (i.e., autonomy) in mother-daughter relationships was associated with lower HbA1c (P=0.03).

CONCLUSIONS

Relational aspects of the self and the experience of emotional closeness in relationships are associated with metabolic control in adolescent girls. Efforts to improve metabolic control in girls should include enhancing the self-concept and the experience of relatedness in familial, peer, and patient-caregiver relationships.

Eating problems and the observed quality of mother-daughter interactions among girls with type 1 diabetes

This study examined how eating problems are linked to autonomy and intimacy in the observed interactions of 88 diabetic girls (M = 14.9 years) and their mothers. On the basis of self-reported symptoms, teens were classified as having no eating problems (n = 40), mild eating problems (n = 30), and frequent eating problems (n = 18). Mothers and daughters participated in 2 videotaped problem-solving tasks (1 diabetes related and I a general parent-teen issue) that were rated with a macroanalytic coding system (Autonomy and Intimacy Rating System). Compared with interactions among mothers and daughters with no eating problems, interactions among mothers and daughters with eating problems simultaneously constrained the expression of autonomy and intimacy. Findings support clinical theory that links eating problems to emotional misattunement in the mother-daughter relationship, which is postulated to interfere with the teen's capacity for individuation.

Eating disorders in young women with type 1 diabetes. Prevalence, problems and prevention

Disordered eating attitudes and behavior are common and persistent in adolescent and young adult females with type 1 diabetes, and are associated with impaired metabolic control and a higher risk of diabetes-related complications. Specific aspects of diabetes and its management, e.g. weight gain associated with initiation of insulin treatment or improved metabolic control, and dietary restraint, may trigger the body dissatisfaction and drive for thinness that accompany eating disturbances. Health care providers should be aware of the possible association between eating disturbances and diabetes, and also of the types of behavior, particularly insulin omission for weight loss, that are common in these young women. Therapy will depend on the severity of the eating disturbance. Group psychoeducation, incorporating a nondeprivational approach to eating, may prove effective, especially in those with milder degrees of eating and weight psychopathology.

Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression

This study reports on the relationship of therapist competence to the outcome of cognitive-behavioral treatment in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Outpatients suffering from major depressive disorder were treated by cognitive-behavioral therapists at each of 3 U.S. sites using a format of 20 sessions in 16 weeks. Findings provide some support for the relationship of therapist competence (as measured by the Cognitive Therapy Scale) to reduction of depressive symptomatology when controlling for therapist adherence and facilitative conditions. The results are, however, not as strong or consistent as expected. The component of competence that was most highly related to outcome is a factor that reflects the therapist's ability to structure the treatment.

Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression

This study reports on the relationship of therapist competence to the outcome of cognitive-behavioral treatment in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Outpatients suffering from major depressive disorder were treated by cognitive-behavioral therapists at each of 3 U.S. sites using a format of 20 sessions in 16 weeks. Findings provide some support for the relationship of therapist competence (as measured by the Cognitive Therapy Scale) to reduction of depressive symptomatology when controlling for therapist adherence and facilitative conditions. The results are, however, not as strong or consistent as expected. The component of competence that was most highly related to outcome is a factor that reflects the therapist's ability to structure the treatment.

A randomized controlled trial of guided imagery in bulimia nervosa

BACKGROUND

The objective of this study was to test a guided imagery therapy designed to enhance self-comforting in bulimia nervosa.

METHODS

A randomized controlled trial compared 6 weeks of individual guided imagery therapy with a control group. Fifty participants who met DSM-III-R criteria for bulimia nervosa completed the study. Measures of eating disorder symptoms, psychological functioning and the experience of guided imagery therapy were administered.

RESULTS

The guided imagery treatment had substantial effects on the reduction of bingeing and purging episodes; the imagery group had a mean reduction of binges of 74% and of vomiting of 73%. The imagery treatment also demonstrated improvement on measures of attitudes concerning eating, dieting and body weight in comparison to the control group. In addition, the guided imagery demonstrated improvement on psychological measures of aloneness and the ability for self-comforting.

CONCLUSIONS

Evidence from this study suggests that guided imagery was an effective treatment for bulimia nervosa, at least in the short-term.

A randomized controlled trial of fluoxetine and cognitive behavioral therapy for bulimia nervosa: short-term outcome

This study compared and combined fluoxetine and individual cognitive behavioral therapy in the treatment of bulimia nervosa. Participants were 76 women who sought treatment at the Eating Disorders Program of the Toronto Hospital and who met DSM-III-R criteria for bulimia nervosa. Subjects were randomly assigned to receive fluoxetine alone, cognitive behavior therapy alone, or the two in combination and were treated over 16 weeks. Short-term outcome revealed that all three treatment conditions were associated with clinical improvement across a wide range of parameters. The combination of pharmacotherapy and psychotherapy was superior to pharmacotherapy alone on specific parameters and there was no statistically significant advantage to the combination over psychotherapy alone. Limitations to the study include the absence of a placebo pill group and a waiting list control group as well as a substantial dropout rate across all three treatment conditions.

Group psychoeducation for bulimia nervosa with and without additional psychotherapy process sessions

OBJECTIVE

The present study examined whether additional sessions of group psychotherapy process (PP) would incrementally benefit bulimia nervosa (BN) subjects over and above that which is achieved through a course of brief group psychoeducation (PE).

METHOD

Utilizing a quasi-experimental design, the first cohort of 40 BN subjects completed five-session PE-alone groups that were highly didactic and explicitly devoid of group process work. The second cohort of 41 BN subjects completed 12-session PE + PP groups that integrated PE with more conventional cognitive-behavioral group process interventions.

RESULTS

Both treatments were associated with comparable levels of change on measures of specific and nonspecific psychopathology. Furthermore, the two treatments did not differ in rates of premature termination, in rates of remission in eating symptoms, in rates of normalization of scores on psychometric measures, or in consumer evaluation of the treatments.

DISCUSSION

While subjects value the opportunity to engage in psychotherapy process with other group members, the addition of seven such sessions offers no enhanced therapeutic benefit over five sessions of group PE.