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Golden NH, Kapphahn CJ, Cheng J, Kreiter A, Downey AE, Accurso EC, Machen VI, Adams SH, Buckelew SM, Moscicki AB, Le Grange D, Garber AK. Course and outcome in individuals with atypical anorexia nervosa: Findings from the Study of Refeeding to Optimize iNpatient Gains (StRONG). Int J Eat Disord 2024; 57:799-808. [PMID: 37507351 PMCID: PMC10822019 DOI: 10.1002/eat.24029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVE We previously reported that participants with atypical anorexia nervosa (atypical AN) had higher historical and admission weights, greater eating disorder psychopathology, but similar rates of amenorrhea and weight suppression at baseline as compared to anorexia nervosa (AN); here, we compare 1-year outcomes. METHOD Weight, % median body mass index (%mBMI), Eating Disorder Examination Questionnaire (EDE-Q) scores, resumption of menses, and rehospitalizations were examined at 3, 6, and 12 months post-discharge. Analyses (N = 111) compared changes in %mBMI, weight suppression, and EDE-Q scores over time between atypical AN and AN. RESULTS Among the participants (48 atypical AN, 63 AN), both groups gained weight but those with atypical AN had lower gains than those with AN in %mBMI (p = .02) and greater weight suppression (p = .002) over time. EDE-Q scores improved over time, independent of weight suppression, with no significant difference between atypical AN and AN. Groups did not differ by rates of resumption of menses (80% atypical AN, 76.9% AN) or rehospitalization (29.2% atypical AN, 37.9% AN). Greater weight suppression predicted longer time to restore menses and more days of rehospitalization. DISCUSSION Individuals with atypical AN regained a smaller proportion of body mass and were more weight suppressed over time. Change in eating disorder cognitions, resumption of menses, and rehospitalization rates at 1-year follow-up did not differ between groups. There was no significant difference in weight suppression between groups for those who were psychologically improved at 12 months. Findings highlight limitations in our understanding of weight recovery in atypical AN. New metrics for recovery are urgently needed. PUBLIC SIGNIFICANCE Little is known about outcome in atypical anorexia nervosa (atypical AN). We examined recovery metrics in young people with atypical AN and anorexia nervosa (AN) 1 year after medical hospitalization. Individuals with atypical AN showed slower weight gain and remained further from their pre-illness weight. There were no differences in the rates of psychological recovery, resumption of menses, or rehospitalization. New metrics are needed to assess recovery in atypical AN.
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Affiliation(s)
- Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
| | - Cynthia J Kapphahn
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
| | - Jing Cheng
- Department of Preventive & Restorative Dental Sciences, University of California, San Francisco, California, USA
| | - Anna Kreiter
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
| | - Amanda E Downey
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Erin C Accurso
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Vanessa I Machen
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Sally H Adams
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Sara M Buckelew
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Anna-Barbara Moscicki
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, Los Angeles, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
| | - Andrea K Garber
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
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2
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Golden NH, Walsh BT. Time to revisit the definition of atypical anorexia nervosa. Int J Eat Disord 2024; 57:757-760. [PMID: 38390637 DOI: 10.1002/eat.24174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024]
Abstract
In this special issue, international researchers investigate how atypical anorexia nervosa (atypical AN) differs from anorexia nervosa (AN) and other eating disorders with respect to demographics, psychological and physiological morbidity, as well as treatment course and outcome. Manuscripts in this special issue report that atypical AN is associated with substantial medical and psychological morbidity, and the majority of studies find few differences between atypical AN and AN. While much remains to be learned about the long-term course and treatment response of individuals with atypical AN to psychological and pharmacological interventions, the evidence supports conceptualization of atypical AN as part of a spectrum-based restrictive eating disorder. These findings together with the potentially stigmatizing use of the term "atypical" suggest it may be time to revise the existing definition of atypical AN.
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Affiliation(s)
- Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
| | - B Timothy Walsh
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, New York, USA
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Garber AK, Cheng J, Accurso EC, Buckelew SM, Downey AE, Le Grange D, Gorrell S, Kapphahn CJ, Kreiter A, Moscicki AB, Golden NH. Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with atypical anorexia nervosa. Int J Eat Disord 2024; 57:859-868. [PMID: 38179719 DOI: 10.1002/eat.24115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose. METHOD Patients were enrolled upon admission and randomized to meal-based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t-tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight). RESULTS Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p = .008, Cohen's d = -.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p < .001, Cohen's d = .51) and greater hypomagnesemia (29% vs. 11%, p = .03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p < .001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p < .001), weight gain was 1.6%mBMI (.8, 2.4) greater (p < .001), and hypomagnesemia odds were 70% (12, 128) lower (p = .02). DISCUSSION Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group. PUBLIC SIGNIFICANCE The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital.
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Affiliation(s)
- Andrea K Garber
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco, California, USA
| | - Erin C Accurso
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Sara M Buckelew
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Amanda E Downey
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago (Emeritus), Chicago, Illinois, USA
| | - Sasha Gorrell
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Cynthia J Kapphahn
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, Los Angeles, California, USA
| | - Anna Kreiter
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, Los Angeles, California, USA
| | - Anna-Barbara Moscicki
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, Los Angeles, California, USA
| | - Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, Stanford, California, USA
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Golden NH. Atypical Anorexia Nervosa is not atypical at all! Commentary on Walsh et al. (2022). Int J Eat Disord 2023; 56:826-827. [PMID: 36513600 PMCID: PMC10089956 DOI: 10.1002/eat.23871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022]
Abstract
The introduction of atypical anorexia nervosa (atypAN) as a new diagnosis in DSM-5 has advanced the field by expanding awareness that individuals of all weights can have an eating disorder. However, many clinical and research questions remain, particularly pertaining to whether atypAN and anorexia nervosa (AN) are different conditions or the same condition across the weight spectrum. In this issue of the journal, Walsh et al. describe the results of their systematic review demonstrating that the level of eating disorder-specific psychopathology is significantly higher among individuals with atypAN than among controls, and as high or higher than among individuals with AN. Levels of noneating disorder psychopathology are similar. Individuals with atypAN experience many of the medical complications associated with AN but at a lower frequency. The finding that the clinical features of atypAN are not substantially different from AN supports the possibility that atypAN and AN are the same condition. Further research on epidemiology, genetics, treatment, course and outcome is required to determine whether atypAN and AN are the same or different, but there is a need to update and refine existing terminology and diagnostic classification.
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Affiliation(s)
- Neville H Golden
- The Marron and Mary Elizabeth Kendrick Professor of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Accurso EC, Cheng J, Machen VI, Buckelew S, Kreiter A, Adams S, Le Grange D, Golden NH, Garber AK. Hospital-based higher calorie refeeding and mealtime distress in adolescents and young adults with anorexia nervosa or atypical anorexia nervosa. Int J Eat Disord 2023. [PMID: 36919264 DOI: 10.1002/eat.23931] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE The StRONG study demonstrated that higher calorie refeeding (HCR) restored medical stability faster in patients hospitalized with anorexia nervosa (AN) and atypical AN (AAN), with no increased safety events compared with standard-of-care lower calorie refeeding (LCR). However, some clinicians have expressed concern about potential unintended consequences of HCR (e.g., greater mealtime distress). The purpose of this study was to examine patient treatment preference and compare mealtime distress, food refusal, and affective states between treatments. METHOD Participants (N = 111) in this multisite randomized clinical trial were ages 12-24 years, with AN or AAN, admitted to hospital with medical instability who received assigned study treatment (HCR or LCR). Treatment preference was assessed prior to randomization in the full sample. In a subset of participants (n = 45), linear mixed effect models were used to analyze momentary ratings of mealtime distress (pre, during, and post-meals) and daily affective state during the hospitalization. RESULTS About half (55%) of participants reported a preference for LCR. Treatment assignment was not associated with food refusal, mealtime distress, or affective states in the subsample. Food refusal increased significantly over the course of refeeding (p = .018). Individuals with greater depression experienced more negative affect (p = .033), with worsening negative affect over time for individuals with higher eating disorder psychopathology (p = .023). DISCUSSION Despite understandable concerns about potential unintended consequences of HCR, we found no evidence that treatment acceptability for HCR differed from LCR for adolescents and young adults with AN and AAN. PUBLIC SIGNIFICANCE The efficacy and safety of higher calorie refeeding in hospitalized patients with anorexia nervosa has been demonstrated. However, it is not known whether higher calorie refeeding (HCR) increases meal-time distress. This study demonstrated that HCR was not associated with increased mealtime distress, food refusal, or affective states, as compared with lower calorie refeeding. These data support HCR treatment acceptability for adolescents/young adults with anorexia nervosa and atypical anorexia nervosa.
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Affiliation(s)
- Erin C Accurso
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Jing Cheng
- Department of Preventive & Restorative Dental Sciences, University of California, San Francisco, California, USA
| | - Vanessa I Machen
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Sara Buckelew
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Anna Kreiter
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sally Adams
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA.,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
| | - Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andrea K Garber
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, California, USA
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6
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Hartman-Munick SM, Lin JA, Milliren CE, Braverman PK, Brigham KS, Fisher MM, Golden NH, Jary JM, Lemly DC, Matthews A, Ornstein RM, Roche A, Rome ES, Rosen EL, Sharma Y, Shook JK, Taylor JL, Thew M, Vo M, Voss M, Woods ER, Forman SF, Richmond TK. Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume. JAMA Pediatr 2022; 176:1225-1232. [PMID: 36342721 PMCID: PMC9641596 DOI: 10.1001/jamapediatrics.2022.4346] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
IMPORTANCE The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking. OBJECTIVE To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre- and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data. EXPOSURES Onset of the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES Monthly number of patients seeking inpatient/outpatient ED-related care. RESULTS Aggregate total inpatient ED admissions were 81 in January 2018 and 109 in February 2020. Aggregate total new outpatient assessments were 195 in January 2018 and 254 in February 2020. Before the COVID-19 pandemic, the relative number of pooled inpatient ED admissions were increasing over time by 0.7% per month (95% CI, 0.2%-1.3%). After onset of the pandemic, there was a significant increase in admissions over time of 7.2% per month (95% CI, 4.8%-9.7%) through April 2021, then a decrease of 3.6% per month (95% CI, -6.0% to -1.1%) through December 2021. Prepandemic, pooled data showed relative outpatient ED assessment volume was stable over time, with an immediate 39.7% decline (95% CI, -50.4% to -26.7%) in April 2020. Subsequently, new assessments increased by 8.1% (95% CI, 5.3%-11.1%) per month through April 2021, then decreased by 1.5% per month (95% CI, -3.6% to 0.7%) through December 2021. The nonhospital-based ED program did not demonstrate a significant increase in the absolute number of admissions after onset of the pandemic but did see a significant increase of 8.2 (95% CI, 6.2-10.2) additional inquiries for care per month in the first year after onset of the pandemic. CONCLUSIONS AND RELEVANCE In this study, there was a significant COVID-19 pandemic-related increase in both inpatient and outpatient volume of patients with EDs across sites, particularly in the first year of the pandemic. Given inadequate ED care availability prior to the pandemic, the increased postpandemic demand will likely outstrip available resources. Results highlight the need to address ED workforce and program capacity issues as well as improve ED prevention strategies.
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Affiliation(s)
- Sydney M. Hartman-Munick
- Boston Children’s Hospital, Boston, Massachusetts,UMass Memorial Children’s Medical Center, Worcester, Massachusetts,UMass Chan Medical School, Worcester, Massachusetts
| | - Jessica A. Lin
- Boston Children’s Hospital, Boston, Massachusetts,Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | | | - Paula K. Braverman
- Baystate Children’s Hospital, Springfield, Massachusetts,UMass Chan Medical School-Baystate, Springfield, Massachusetts
| | - Kathryn S. Brigham
- MassGeneral Hospital for Children, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Diana C. Lemly
- MassGeneral Hospital for Children, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Abigail Matthews
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Ellen S. Rome
- Cleveland Clinic Children’s Hospital, Cleveland, Ohio,Cleveland Clinic Lerner College of Medicine at Case, Cleveland, Ohio
| | | | - Yamini Sharma
- UCLA Mattel Children’s Hospital, Los Angeles, California
| | | | - Jaime L. Taylor
- Beaumont Children’s Hospital, Royal Oak, Michigan,Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Margaret Thew
- Children’s Wisconsin, Milwaukee,Medical College of Wisconsin, Milwaukee
| | - Megen Vo
- Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Michaela Voss
- Children’s Mercy Hospital, Kansas City, Missouri,University of Missouri–Kansas City, Kansas City
| | - Elizabeth R. Woods
- Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Sara F. Forman
- Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Tracy K. Richmond
- Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
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Downey AE, Cheng J, Adams SH, Buckelew SM, Kapphahn CJ, Machen VI, Rosen EL, Moscicki AB, Golden NH, Garber AK. Renal Function in Patients Hospitalized With Anorexia Nervosa Undergoing Refeeding: Findings From the Study of Refeeding to Optimize Inpatient Gains. J Adolesc Health 2022; 71:432-437. [PMID: 35705423 PMCID: PMC10863996 DOI: 10.1016/j.jadohealth.2022.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/19/2022] [Accepted: 04/23/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Among complications of malnutrition secondary to anorexia nervosa (AN) or atypical anorexia nervosa (AAN), renal impairment remains poorly elucidated. Evaluating renal function in hospitalized pediatric patients with AN and AAN undergoing refeeding will yield important information to guide clinicians in screening and managing renal dysfunction in this population. METHODS This is a secondary analysis of data from the Study of Refeeding to Optimize Inpatient Gains trial, a multicenter randomized clinical trial comparing higher calorie refeeding versus lower calorie refeeding in 120 adolescents and young adults hospitalized with medical instability secondary to AN or AAN. Baseline disease characteristics were obtained. Vital sign measurements, weight, electrolytes, and fluid status were evaluated daily to ascertain medical stability. Renal function on admission and throughout hospitalization was quantified using daily creatinine measurement and calculation of the estimated glomerular filtration rate (eGFR) using the modified Schwartz equation. Regression analysis and mixed linear models were utilized to evaluate factors associated with eGFR. RESULTS Of the 111 participants who completed treatment protocol, 33% had a baseline eGFR less than 90, suggesting renal impairment. Patients who experienced more rapid weight loss and more severe bradycardia were more likely to have low admission eGFR. While eGFR improved during refeeding, eGFR change by day based on refeeding treatment assignment did not reach statistical significance (95% confidence interval, -1.61, 0.15]; p = .095). DISCUSSION Renal impairment is evident on admission in a significant number of adolescents and young adults hospitalized with AN and AAN. We demonstrate that short-term medical refeeding yields improvement in renal function.
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Affiliation(s)
- Amanda E Downey
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California; Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California.
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco, California
| | - Sally H Adams
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Sara M Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Cynthia J Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Vanessa I Machen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Elaine L Rosen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, California
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, California
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Andrea K Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
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Tenforde AS, Katz NB, Sainani KL, Carlson JL, Golden NH, Fredericson M. Female Athlete Triad Risk Factors Are More Strongly Associated With Trabecular-Rich Versus Cortical-Rich Bone Stress Injuries in Collegiate Athletes. Orthop J Sports Med 2022; 10:23259671221123588. [PMID: 36157087 PMCID: PMC9502250 DOI: 10.1177/23259671221123588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Bone stress injuries (BSIs) are common in athletes. Risk factors for BSI may differ by skeletal anatomy and relative contribution of trabecular-rich and cortical-rich bone. Hypothesis: We hypothesized that Female Athlete Triad (Triad) risk factors would be more strongly associated with BSIs sustained at trabecular-rich versus cortical-rich skeletal sites. Study Design: Cohort study; Level of evidence, 2. Methods: The study population comprised 321 female National Collegiate Athletic Association Division I athletes participating in 16 sports from 2008 to 2014. Triad risk factors and a Triad cumulative risk score were assessed using responses to preparticipation examination and dual energy x-ray absorptiometry to measure lumbar spine and whole-body bone mineral density (BMD). Sports-related BSIs were diagnosed by a physician and confirmed radiologically. Athletes were grouped into those sustaining a subsequent trabecular-rich BSI, a subsequent cortical-rich BSI, and those without a BSI. Data were analyzed with multinomial logistic regression adjusted for participation in cross-country running versus other sports. Results: A total of 19 participants sustained a cortical-rich BSI (6%) and 10 sustained a trabecular-rich BSI (3%) over the course of collegiate sports participation. The Triad cumulative risk score was significantly related to both trabecular-rich and cortical-rich BSI. However, lower BMD and weight were associated with significantly greater risk for trabecular-rich than cortical-rich BSIs. For every value lower than 1 SD, the odds ratios (95% CIs) for trabecular-rich versus cortical-rich BSI were 3.08 (1.25-7.56) for spine BMD; 2.38 (1.22-4.64) for whole-body BMD; and 5.26 (1.48-18.70) for weight. Taller height was a significantly better predictor of cortical-rich than trabecular-rich BSI. Conclusion: The Triad cumulative risk score was significantly associated with both trabecular-rich and cortical-rich BSI, but Triad-related risk factors appeared more strongly related to trabecular-rich BSI. In particular, low BMD and low weight were associated with significantly higher increases in the risk of trabecular-rich BSI than cortical-rich BSI. These findings suggest Triad risk factors are more common in athletes sustaining BSI in trabecular-rich than cortical-rich locations.
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Affiliation(s)
- Adam S Tenforde
- Spaulding Rehabilitation Hospital, Spaulding National Running Center, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Nicole B Katz
- Spaulding Rehabilitation Hospital, Spaulding National Running Center, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Kristin L Sainani
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Jennifer L Carlson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Michael Fredericson
- Boswell Human Performance Laboratory, Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA.,Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
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9
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Affiliation(s)
- Jason M Nagata
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
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10
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Kohn MR, Golden NH. Management of the malnourished patient: it's now time to revise the guidelines. J Eat Disord 2022; 10:56. [PMID: 35440063 PMCID: PMC9019959 DOI: 10.1186/s40337-022-00539-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Michael R Kohn
- AYA Medical Services WSLHD, AYA Medicine, Westmead Hospital, CRASH Centre for Research Into Adolescent'S Health, Faculty of Medicine and Dentistry, Sydney University, Sydney, Australia.
| | - Neville H Golden
- Division of Adolescent Medicine, The Marron and Mary Elizabeth Kendrick Professor of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 210, Palo Alto, CA, 94304, USA
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11
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Finn EE, Tenforde AS, Fredericson M, Golden NH, Carson TL, Karvonen-Gutierrez CA, Carlson JL. Markers of Low-Iron Status Are Associated with Female Athlete Triad Risk Factors. Med Sci Sports Exerc 2021; 53:1969-1974. [PMID: 33731653 DOI: 10.1249/mss.0000000000002660] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The Female Athlete Triad (Triad) is common in female athletes. The Triad is caused by low-energy availability (EA), which is often difficult to measure and has been postulated to be associated with low-iron status. Here, we explore whether markers of low-iron status may be associated with indicators of low EA including Triad risk factors. METHODS A total of 239 female National Collegiate Athletic Association Division I athletes completed preparticipation examinations that included Triad risk factors, medication/supplement use, diagnosis of anemia, and elected to complete dual-energy x-ray absorptiometry scan to measure bone mineral density. The association of markers of low iron (defined as self-report of iron supplementation and/or history of anemia) with each component of the Triad risk assessment score was assessed by stratifying low-iron status across different levels of Triad risk category. Differences across iron status groups were assessed using Fisher exact testing. RESULTS Every component of the Triad risk assessment score excluding delayed menarche was associated with low-iron status. The proportion of women who reported low iron was 11.5% in the low-risk EA group compared with 50% in the moderate-risk and 66.7% in the high-risk EA groups (P = 0.02); respectively. These numbers were 11.6%, 25.0%, and 66.7% (P = 0.02) for body mass index; 9.7%, 16.7%, and 25.0% (P < 0.05) for oligomenorrhea; 10.3%, 45.5%, and 50.0% (P < 0.01) for bone mineral density; and 10.4%, 20.8%, and 30.8% (P = 0.03) for history of stress reaction or fracture. Lean/endurance athletes were more likely to have low-iron status than other athletes (15.5% vs 3.4%, P = 0.02). CONCLUSIONS Markers for low-iron status were associated with Triad risk factors. Our study suggests that female athletes with a history of anemia or iron supplementation may require further screening for low EA.
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Affiliation(s)
- Erin E Finn
- University of Michigan Medical School, Ann Arbor, MI
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA
| | - Michael Fredericson
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Traci L Carson
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| | | | - Jennifer L Carlson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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12
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Frank GKW, Golden NH, Murray HB. Introduction to a special issue on eating disorders and gastrointestinal symptoms-The chicken or the egg? Int J Eat Disord 2021; 54:911-912. [PMID: 34028860 DOI: 10.1002/eat.23558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/14/2021] [Accepted: 05/14/2021] [Indexed: 01/06/2023]
Affiliation(s)
- Guido K W Frank
- Department of Psychiatry, University of California at San Diego, San Diego, California, USA.,UC San Diego Health Eating Disorders Center for Treatment and Research, San Diego, CA, USA
| | - Neville H Golden
- Department of Pediatrics, Adolescent Medicine Stanford University, Palo Alto, California, USA
| | - Helen Burton Murray
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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13
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Golden NH, Cheng J, Kapphahn CJ, Buckelew SM, Machen VI, Kreiter A, Accurso EC, Adams SH, Le Grange D, Moscicki AB, Sy AF, Wilson L, Garber AK. Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial. Pediatrics 2021; 147:peds.2020-037135. [PMID: 33753542 PMCID: PMC8015147 DOI: 10.1542/peds.2020-037135] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We recently reported the short-term results of this trial revealing that higher-calorie refeeding (HCR) restored medical stability earlier, with no increase in safety events and significant savings associated with shorter length of stay, in comparison with lower-calorie refeeding (LCR) in hospitalized adolescents with anorexia nervosa. Here, we report the 1-year outcomes, including rates of clinical remission and rehospitalizations. METHODS In this multicenter, randomized controlled trial, eligible patients admitted for medical instability to 2 tertiary care eating disorder programs were randomly assigned to HCR (2000 kcals per day, increasing by 200 kcals per day) or LCR (1400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and 12 months post discharge. Clinical remission at 12 months post discharge was defined as weight restoration (≥95% median BMI) plus psychological recovery. With generalized linear mixed effect models, we examined differences in clinical remission over time. RESULTS Of 120 enrollees, 111 were included in modified intent-to-treat analyses, 60 received HCR, and 51 received LCR. Clinical remission rates changed over time in both groups, with no evidence of significant group differences (P = .42). Medical rehospitalization rates within 1-year post discharge (32.8% [19 of 58] vs 35.4% [17 of 48], P = .84), number of rehospitalizations (2.4 [SD: 2.2] vs 2.0 [SD: 1.6]; P = .52), and total number of days rehospitalized (6.0 [SD: 14.8] vs 5.1 [SD: 10.3] days; P = .81) did not differ by HCR versus LCR. CONCLUSIONS The finding that clinical remission and medical rehospitalization did not differ over 1-year, in conjunction with the end-of-treatment outcomes, support the superior efficacy of HCR as compared with LCR.
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Affiliation(s)
- Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco, San Francisco, California
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | | | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Daniel Le Grange
- Psychiatry and Behavioral Sciences,,Department of Psychiatry and Behavioral Neuroscience, School of Medicine, The University of Chicago, Chicago, Illinois; and
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Allyson F. Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Leslie Wilson
- Medicine, and Clinical Pharmacy, University of California, San Francisco, San Francisco, California
| | - Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
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14
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Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, Kreiter A, Le Grange D, Machen VI, Moscicki AB, Sy A, Wilson L, Golden NH. Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial. JAMA Pediatr 2021; 175:19-27. [PMID: 33074282 PMCID: PMC7573797 DOI: 10.1001/jamapediatrics.2020.3359] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome. OBJECTIVE To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa. DESIGN, SETTING, AND PARTICIPANTS In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach. INTERVENTIONS Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day. MAIN OUTCOMES AND MEASURES Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay. RESULTS Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant. CONCLUSIONS AND RELEVANCE In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02488109.
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Affiliation(s)
- Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco
| | - Erin C. Accurso
- Department of Psychiatry and Behavioral Medicine, University of California, San Francisco
| | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Daniel Le Grange
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco,Department of Psychiatry and Behavioral Medicine, University of California, San Francisco,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois (emeritus)
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles
| | - Allyson Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Leslie Wilson
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
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15
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Tenforde AS, Carlson JL, Sainani KL, Chang AO, Kim JH, Diaz R, Golden NH, Fredericson M. Lower Trabecular Bone Score and Spine Bone Mineral Density Are Associated With Bone Stress Injuries and Triad Risk Factors in Collegiate Athletes. PM R 2020; 13:945-953. [PMID: 33037847 DOI: 10.1002/pmrj.12510] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Determinants of bone health and injury are important to identify in athletes. Bone mineral density (BMD) is commonly measured in athletes with Female Athlete Triad (Triad) risk factors; the trabecular bone score (TBS) has been proposed to predict fracture risk independent of BMD. Evaluation of TBS and spine BMD in relation bone stress injury (BSI) risk has not been studied in female collegiate athletes. OBJECTIVE We hypothesized that spine BMD and TBS would each independently predict BSI and that the combined measures would improve injury prediction in female collegiate athletes. We also hypothesized that each measure would be correlated with Triad risk factors. DESIGN Retrospective cohort. SETTING Academic Institution. METHODS Dual energy x-ray absorptiometry (DXA) of the lumbar spine was used to calculate BMD and TBS values. Chart review was used to identify BSI that occurred after the DXA measurement and to obtain Triad risk factors. We used logistic regression to examine the ability of TBS and BMD alone or in combination to predict prospective BSI. RESULTS Within 321 athletes, 29 (9.0%) sustained a BSI after DXA. BMD and TBS were highly correlated (Pearson correlation r = 0.62, P < .0001). Spine BMD and TBS had similar ability to predict BSI; the C-statistic and 95% confidence intervals were 0.69 (0.58 to 0.81) for spine BMD versus 0.68 (0.57 to 0.79) for TBS. No improvement in discrimination was observed with combined BMD + TBS (C-statistic 0.70, 0.59 to 0.81). Both TBS and BMD predicted trabecular-rich BSI (defined as pelvis, femoral neck, and calcaneus) better than cortical-rich BSI. Both measures had similar correlations with Triad risk factors. CONCLUSION Lower BMD and TBS values are associated with elevated risk for BSI and similar correlation to Triad risk factors. TBS does not improve prediction of BSI. Collectively, our findings suggest that BMD may be a sufficient measure of skeletal integrity from DXA in female collegiate athletes.
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Affiliation(s)
- Adam S Tenforde
- Spaulding Rehabilitation Hospital, Spaulding National Running Center, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, MA, 02129
| | - Jennifer L Carlson
- Stanford University, Department of Pediatrics, Division of Adolescent Medicine, Stanford, CA
| | - Kristin L Sainani
- Stanford University, Department of Epidemiology and Population Health, Stanford, CA
| | | | - Jae Hyung Kim
- Boswell Human Performance Laboratory, Department of Orthopaedic Surgery, Stanford, CA
| | - Robert Diaz
- Kaiser Permanente, Department of Orthopedics and Sports Medicine, Santa Clara, CA
| | - Neville H Golden
- Stanford University, Department of Pediatrics, Division of Adolescent Medicine, Stanford, CA
| | - Michael Fredericson
- Boswell Human Performance Laboratory, Department of Orthopaedic Surgery, Stanford, CA.,Stanford University, Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford, CA
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Abstract
Peak bone mass acquisition during adolescence is an important determinant of adult bone health. Knowledge about the effects of different contraceptives on peak bone mass acquisition could influence choice of method recommended. This review summarizes normal bone acquisition during adolescence, discusses methods of assessing bone health in this age group, and reviews the effects of different contraceptive options on bone health, both in adults and in adolescents. Based on the evidence, long-acting reversible contraceptives do not appear to affect peak bone mass acquisition or future fracture risk and remain the first-line contraceptive choice for adolescents. Oral contraceptives with doses of ethinyl estradiol greater than 30 μg should be used in preference to lower-dose preparations, and the adverse effects of depo medroxyprogesterone acetate (DMPA) on bone health are reversible on discontinuation of the medication. Concerns about bone health should not prevent use of DMPA in an adolescent who prefers this method.
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Affiliation(s)
- Neville H Golden
- Lucile Packard Children's Hospital, Stanford, Stanford University School of Medicine, Palo Alto, California.
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17
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Affiliation(s)
- Neville H Golden
- Chief, Division of Adolescent Medicine; The Marron and Mary Elizabeth Kendrick Professor of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Philip S Mehler
- Founder and Executive Medical Director, ACUTE; President, Eating Recovery Center, Department of Internal Medicine, Denver Health Medical Center, Denver, CO
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Abstract
PURPOSE Body dissatisfaction in transgender youth (TY) may increase the risk for eating disorders. This is the first study using the Eating Disorders Examination Questionnaire (EDE-Q) to assess for eating disorder psychopathology in TY. METHODS Youth aged 13-22 years (n = 106) presenting to a gender clinic from January 2018 to January 2019 completed the EDE-Q and answered questions on weight manipulation for gender-affirming purposes. RESULTS Respondents identified as transmasculine (61%), transfeminine (28%), or nonbinary (11%). Mean age was 16.5 years (standard deviation = 2.0), mean weight was 119.9% median body mass index (standard deviation = 32.9), and 32% were on hormonal therapy. Of the participants, 15% had elevated EDE-Q scores. Most (63%) disclosed weight manipulation for gender-affirming purposes, with 11% of assigned females doing so for menstrual suppression. These behaviors had poor concordance with elevated EDE-Q scores (κ = .137 and .148). CONCLUSIONS Disordered eating behaviors are relatively common among TY. Further studies are needed to validate the EDE-Q in TY and establish meaningful cutoff score values.
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Affiliation(s)
- Jonathan T Avila
- Division of Adolescent Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Tandy Aye
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, Kreiter A, Le Grange D, Machen VI, Moscicki AB, Saffran K, Sy AF, Wilson L, Golden NH. Weight Loss and Illness Severity in Adolescents With Atypical Anorexia Nervosa. Pediatrics 2019; 144:peds.2019-2339. [PMID: 31694978 PMCID: PMC6889949 DOI: 10.1542/peds.2019-2339] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Lower weight has historically been equated with more severe illness in anorexia nervosa (AN). Reliance on admission weight to guide clinical concern is challenged by the rise in patients with atypical anorexia nervosa (AAN) requiring hospitalization at normal weight. METHODS We examined weight history and illness severity in 12- to 24-year-olds with AN (n = 66) and AAN (n = 50) in a randomized clinical trial, the Study of Refeeding to Optimize Inpatient Gains (www.clinicaltrials.gov; NCT02488109). Amount of weight loss was the difference between the highest historical percentage median BMI and admission; rate was the amount divided by duration (months). Unpaired t tests compared AAN and AN; multiple variable regressions examined associations between weight history variables and markers of illness severity at admission. Stepwise regression examined the explanatory value of weight and menstrual history on selected markers. RESULTS Participants were 16.5 ± 2.6 years old, and 91% were of female sex. Groups did not differ by weight history or admission heart rate (HR). Eating Disorder Examination Questionnaire global scores were higher in AAN (mean 3.80 [SD 1.66] vs mean 3.00 [SD 1.66]; P = .02). Independent of admission weight, lower HR (β = -0.492 [confidence interval (CI) -0.883 to -0.100]; P = .01) was associated with faster loss; lower serum phosphorus was associated with a greater amount (β = -0.005 [CI -0.010 to 0.000]; P = .04) and longer duration (β = -0.011 [CI -0.017 to 0.005]; P = .001). Weight and menstrual history explained 28% of the variance in HR and 36% of the variance in serum phosphorus. CONCLUSIONS Weight history was independently associated with markers of malnutrition in inpatients with restrictive eating disorders across a range of body weights and should be considered when assessing illness severity on hospital admission.
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Affiliation(s)
- Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Jing Cheng
- Preventive and Restorative Dental Sciences
| | | | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Daniel Le Grange
- Psychiatry, and,Professor Emeritus, Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois; and
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Departments of Pediatrics
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Kristina Saffran
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Allyson F. Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Leslie Wilson
- Clinical Pharmacy, University of California, San Francisco, San Francisco, California
| | - Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
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Nagata JM, Carlson JL, Golden NH, Murray SB, Long J, Leonard MB, Peebles R. Associations between exercise, bone mineral density, and body composition in adolescents with anorexia nervosa. Eat Weight Disord 2019; 24:939-945. [PMID: 29949128 PMCID: PMC6286679 DOI: 10.1007/s40519-018-0521-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/28/2018] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify the effect of duration of weight-bearing exercise and team sports participation on bone mineral density (BMD) and body composition among adolescents with anorexia nervosa (AN). METHOD We retrospectively reviewed electronic medical records of all patients 9-20 years old with a DSM-5 diagnosis of AN evaluated by the Stanford Eating Disorders Program (1997-2011) who underwent dual-energy X-ray absorptiometry. RESULTS A total of 188 adolescents with AN were included (178 females and 10 males). Using multivariate linear regression, duration of weight-bearing exercise (B = 0.15, p = 0.005) and participation in team sports (B = 0.53, p = 0.001) were associated with higher BMD at the hip and team sports (B = 0.39, p = 0.006) were associated with higher whole body BMC, controlling for covariates. Participation in team sports (B = - 1.06, p = 0.007) was associated with greater deficits in FMI Z-score. LBMI Z-score was positively associated with duration of weight-bearing exercise (B = 0.10, p = 0.018) and may explain the relationship between exercise and bone outcomes. CONCLUSION Duration of weight-bearing exercise and team sports participation may be protective of BMD at the hip and whole body BMC, while participation in team sports was associated with greater FMI deficits among adolescents with AN. LEVEL OF EVIDENCE Level V, descriptive retrospective study.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA. .,Department of Pediatrics, University of California, San Francisco, 3333 California Street, Suite 245, Box 0503, San Francisco, CA, 94143, USA.
| | - Jennifer L Carlson
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Neville H Golden
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Stuart B Murray
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rebecka Peebles
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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21
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Tenforde AS, Carlson JL, Sainani KL, Chang AO, Kim JH, Golden NH, Fredericson M. Sport and Triad Risk Factors Influence Bone Mineral Density in Collegiate Athletes. Med Sci Sports Exerc 2019; 50:2536-2543. [PMID: 29975299 DOI: 10.1249/mss.0000000000001711] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Athletes in weight-bearing sports may benefit from higher bone mineral density (BMD). However, some athletes are at risk for impaired BMD with female athlete triad (Triad). The purpose of this study is to understand the influence of sports participation and Triad on BMD. We hypothesize that athletes in high-impact and multidirectional loading sports will have highest BMD, whereas nonimpact and low-impact sports will have lowest BMD. Triad risk factors are expected to reduce BMD values independent of sports participation. METHODS Two hundred thirty-nine female athletes participating in 16 collegiate sports completed dual-energy x-ray absorptiometry (DXA) scans to measure BMD z-scores of the lumbar spine (LS) and total body (TB). Height and weight were measured to calculate body mass index (BMI). Triad risk assessment variables were obtained from preparticipation examination. Mean BMD z-scores were compared between sports and by sport category (high-impact, multidirectional, low-impact, and nonimpact). Multivariable regression analyses were performed to identify differences of BMD z-scores accounting for Triad and body size/composition. RESULTS Athlete populations with lowest average BMD z-scores included synchronized swimming (LS, -0.34; TB, 0.21) swimming/diving (LS, 0.34; TB, -0.06), crew/rowing (LS, 0.27; TB, 0.62), and cross-country (LS, 0.29; TB, 0.91). Highest values were in gymnastics (LS, 1.96; TB, 1.37), volleyball (LS, 1.90; TB, 1.74), basketball (LS, 1.73; TB, 1.99), and softball (LS, 1.68; TB, 1.78). All Triad risk factors were associated with lower BMD z-scores in univariable analyses; only low BMI and oligomenorrhea/amenorrhea were associated in multivariable analyses (all P < 0.05). Accounting for Triad risk factors and body size/composition, high-impact sports were associated with higher LS and TB BMD z-scores and nonimpact sports with lower LS and TB BMD z-scores compared to low-impact sport (all P < 0.05). CONCLUSIONS Both sport type and Triad risk factors influence BMD. Athletes in low-impact and nonimpact sports and athletes with low BMI and oligomenorrhea/amenorrhea are at highest risk for reduced BMD.
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Affiliation(s)
- Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Spaulding National Running Center, Harvard Medical School, Cambridge, MA
| | - Jennifer L Carlson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, CA
| | - Kristin L Sainani
- Division of Epidemiology, Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Audrey O Chang
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jae Hyung Kim
- Department of Orthopaedic Surgery, Boswell Human Performance Laboratory, Stanford, CA
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, CA
| | - Michael Fredericson
- Department of Orthopaedic Surgery, Boswell Human Performance Laboratory, Stanford, CA.,Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, CA
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22
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Nagata JM, Carlson JL, Golden NH, Long J, Murray SB, Peebles R. Comparisons of bone density and body composition among adolescents with anorexia nervosa and atypical anorexia nervosa. Int J Eat Disord 2019; 52:591-596. [PMID: 30771231 PMCID: PMC6613651 DOI: 10.1002/eat.23048] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/12/2019] [Accepted: 02/01/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To compare bone mineral density (BMD) and body composition among adolescents: (a) with atypical anorexia nervosa (AAN) versus anorexia nervosa (AN) and (b) those with and without a prior history of overweight. METHOD Electronic medical records of patients 9-20 years with AN or AAN who underwent dual-energy x-ray absorptiometry scans were retrospectively reviewed and analyzed. RESULTS A total of 286 adolescents with AN or AAN were included. In linear regression models, AAN was associated with greater Z-scores in whole body bone mineral content (BMC, B = 0.88, p < 0.001), lumbar spine BMD (B = 0.79, p = 0.002), femoral neck BMD (B = 0.670, p = 0.009); fat mass index (B = 1.33, p = 0.003), and lean body mass index (LBMI, B = 1.10, p < 0.001) compared to AN, adjusting for age, sex, and duration of illness. A prior overweight history was associated with greater Z-scores in whole body BMC; lumbar spine BMD, total hip BMD, femoral neck BMD, and LBMI. DISCUSSION Adolescents with AAN had higher BMD Z-scores than adolescents with AN; adolescents with a prior overweight history had greater BMD Z-scores than adolescents without a prior overweight history. These findings may inform clinical guidelines for the medical management of AAN.
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer L. Carlson
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Neville H. Golden
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Stuart B. Murray
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
| | - Rebecka Peebles
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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23
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Golden NH. Predictors of bone health in a community sample of mid-life adult women - The effects of disordered eating, a past history of anorexia nervosa and lowest ever BMI. J Psychosom Res 2019; 116:123-124. [PMID: 30528072 DOI: 10.1016/j.jpsychores.2018.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 11/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Neville H Golden
- Division of Adolescent Medicine, The Marron and Marty Elizabeth Kendrick Professor of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States.
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24
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Baiocchi M, Omondi B, Langat N, Boothroyd DB, Sinclair J, Pavia L, Mulinge M, Githua O, Golden NH, Sarnquist C. A Behavior-Based Intervention That Prevents Sexual Assault: the Results of a Matched-Pairs, Cluster-Randomized Study in Nairobi, Kenya. Prev Sci 2018; 18:818-827. [PMID: 27562036 DOI: 10.1007/s11121-016-0701-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
DESIGN The study's design was a cluster-randomized, matched-pairs, parallel trial of a behavior-based sexual assault prevention intervention in the informal settlements. METHODS The participants were primary school girls aged 10-16. Classroom-based interventions for girls and boys were delivered by instructors from the same settlements, at the same time, over six 2-h sessions. The girls' program had components of empowerment, gender relations, and self-defense. The boys' program promotes healthy gender norms. The control arm of the study received a health and hygiene curriculum. The primary outcome was the rate of sexual assault in the prior 12 months at the cluster level (school level). Secondary outcomes included the generalized self-efficacy scale, the distribution of number of times victims were sexually assaulted in the prior period, skills used, disclosure rates, and distribution of perpetrators. Difference-in-differences estimates are reported with bootstrapped confidence intervals. RESULTS Fourteen schools with 3147 girls from the intervention group and 14 schools with 2539 girls from the control group were included in the analysis. We estimate a 3.7 % decrease, p = 0.03 and 95 % CI = (0.4, 8.0), in risk of sexual assault in the intervention group due to the intervention (initially 7.3 % at baseline). We estimate an increase in mean generalized self-efficacy score of 0.19 (baseline average 3.1, on a 1-4 scale), p = 0.0004 and 95 % CI = (0.08, 0.39). INTERPRETATION This innovative intervention that combined parallel training for young adolescent girls and boys in school settings showed significant reduction in the rate of sexual assault among girls in this population.
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Affiliation(s)
| | | | | | | | | | - Lee Pavia
- No Means No Worldwide, San Francisco, CA, USA
| | - Munyae Mulinge
- School of Humanities and Social Sciences, United States International University, Nairobi, Kenya
| | - Oscar Githua
- School of Humanities and Social Sciences, United States International University, Nairobi, Kenya
| | | | - Clea Sarnquist
- Stanford University School of Medicine, Stanford, CA, USA
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25
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Schwarzenberg SJ, Georgieff MK, Daniels S, Corkins M, Golden NH, Kim JH, Lindsey CW, Magge SN. Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood Development and Adult Health. Pediatrics 2018; 141:peds.2017-3716. [PMID: 29358479 DOI: 10.1542/peds.2017-3716] [Citation(s) in RCA: 300] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Maternal prenatal nutrition and the child's nutrition in the first 2 years of life (1000 days) are crucial factors in a child's neurodevelopment and lifelong mental health. Child and adult health risks, including obesity, hypertension, and diabetes, may be programmed by nutritional status during this period. Calories are essential for growth of both fetus and child but are not sufficient for normal brain development. Although all nutrients are necessary for brain growth, key nutrients that support neurodevelopment include protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. Failure to provide key nutrients during this critical period of brain development may result in lifelong deficits in brain function despite subsequent nutrient repletion. Understanding the complex interplay of micro- and macronutrients and neurodevelopment is key to moving beyond simply recommending a "good diet" to optimizing nutrient delivery for the developing child. Leaders in pediatric health and policy makers must be aware of this research given its implications for public policy at the federal and state level. Pediatricians should refer to existing services for nutrition support for pregnant and breastfeeding women, infants, and toddlers. Finally, all providers caring for children can advocate for healthy diets for mothers, infants, and young children in the first 1000 days. Prioritizing public policies that ensure the provision of adequate nutrients and healthy eating during this crucial time would ensure that all children have an early foundation for optimal neurodevelopment, a key factor in long-term health.
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Affiliation(s)
| | | | - Stephen Daniels
- University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Mark Corkins
- University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Neville H. Golden
- University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Jae H. Kim
- University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - C. Wesley Lindsey
- University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Sheela N. Magge
- University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
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26
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Nagata JM, Carlson JL, Kao JM, Golden NH, Murray SB, Peebles R. Characterization and correlates of exercise among adolescents with anorexia nervosa and bulimia nervosa. Int J Eat Disord 2017; 50:1394-1403. [PMID: 29112280 PMCID: PMC5761671 DOI: 10.1002/eat.22796] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/06/2017] [Accepted: 10/18/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To characterize exercise behaviors among adolescents with anorexia nervosa (AN), atypical AN, or bulimia nervosa (BN), and determine associations between exercise and medical risk. STUDY DESIGN Cross-sectional electronic medical records of all patients evaluated by the Eating Disorder Program at Stanford between January 1997 and February 2011 were retrospectively reviewed. RESULTS 1,083 subjects (961 females, 122 males; mean age 15.6) met eligibility criteria. Most patients (89.7%) reported exercise (mean 7.0 h per week over mean 5.4 days per week) prior to presentation. Running (49.9%), calisthenics (40.7%), walking (23.4%), soccer (20.9%), and swimming (18.2%) were the most common exercises; a majority (60.6%) reported team sport participation. Males were less likely to report team exercise (p = .005). Bradycardia (heart rate <50) at presentation was associated with team sport participation (adjusted odds ratio [AOR] 1.66, 95% confidence interval [CI] 1.02-2.72) and hours of exercise per week (AOR 1.05, 95% CI 1.02-1.09), controlling for diagnosis, sex, age, duration of illness, rate of weight loss, and percent median body mass index (%mBMI). DISCUSSION Adolescents with AN, atypical AN, and BN reported high levels of exercise. Females reported more team sport participation. Greater exercise frequency and team sport participation were associated with bradycardia. Further studies assessing the relationship between exercise and bradycardia may help inform the medical management of adolescents with these eating disorders who are more physically active.
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, Stanford University, Palo Alto, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | | | - Jessica M. Kao
- Sloan School of Management, Massachusetts Institute of Technology, Boston, Massachusetts
| | - Neville H. Golden
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Stuart B. Murray
- Department of Psychiatry, University of California, San Francisco, San Francisco, California
| | - Rebecka Peebles
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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27
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Kapphahn CJ, Graham DA, Woods ER, Hehn R, Mammel KA, Forman SF, Fisher M, Robinson KA, Rome ES, Hergenroeder A, Golden NH. Effect of Hospitalization on Percent Median Body Mass Index at One Year, in Underweight Youth With Restrictive Eating Disorders. J Adolesc Health 2017; 61:310-316. [PMID: 28587796 DOI: 10.1016/j.jadohealth.2017.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 03/24/2017] [Accepted: 03/25/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Data from low-weight patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED treatment programs were analyzed to determine whether there was an association between hospitalization and gain to at least 90% median body mass index (mBMI) at 1-year follow-up. METHODS Data were retrospectively collected for 322 low-weight (<85% mBMI at intake) patients aged 9-21 years, who presented with restrictive EDs to 14 adolescent medicine-based ED programs in 2010. Positive outcome was defined as being at least 90% mBMI (%mBMI = patient's body mass index/mBMI for age × 100) at 1-year follow-up. Association between treatment at a higher level of care and gain to at least 90% mBMI was analyzed for 140 patients who were <85% mBMI at the time of presentation, had not been previously hospitalized, and had 1-year follow-up data available. RESULTS For patients presenting at <85% mBMI, those who were hospitalized in the year following intake had 4.0 (95% confidence interval: 1.6-10.1) times the odds of gain to at least 90% mBMI, compared with patients who were not hospitalized, when controlling for baseline %mBMI. CONCLUSION In this national cohort of patients with restrictive EDs presenting to adolescent medicine-based ED programs at <85% mBMI, those who were hospitalized had greater odds of being at least 90% mBMI at 1-year follow-up.
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Affiliation(s)
- Cynthia J Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.
| | - Dionne A Graham
- Center for Patient Safety and Quality Research, Boston Children's Hospital, Boston, Massachusetts
| | - Elizabeth R Woods
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Rebecca Hehn
- Center for Patient Safety and Quality Research, Boston Children's Hospital, Boston, Massachusetts
| | - Kathleen A Mammel
- Division of Adolescent Medicine, Department of Pediatrics, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Formerly of Department of Adolescent Pediatrics, Beaumont Children's Hospital, Royal Oak, Michigan
| | - Sara F Forman
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Martin Fisher
- Division of Adolescent Medicine, Steven and Alexandra Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York; Department of Pediatrics, Hofstra-Northwell Health School of Medicine, Hempstead, New York
| | - Kelly A Robinson
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Ellen S Rome
- Department of General Pediatrics, Center for Adolescent Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Albert Hergenroeder
- Section of Adolescent Medicine and Sports Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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28
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Magge SN, Goodman E, Armstrong SC, Daniels S, Corkins M, de Ferranti S, Golden NH, Kim JH, Magge SN, Schwarzenberg SJ, Sills IN, Casella SJ, DeMeglio LA, Gonzalez JL, Kaplowitz PB, Lynch JL, Wintergerst KA, Bolling CF, Armstrong SC, Muth ND, Rausch JC, Rogers VW, Schwartz RP. The Metabolic Syndrome in Children and Adolescents: Shifting the Focus to Cardiometabolic Risk Factor Clustering. Pediatrics 2017; 140:peds.2017-1603. [PMID: 28739653 DOI: 10.1542/peds.2017-1603] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Metabolic syndrome (MetS) was developed by the National Cholesterol Education Program Adult Treatment Panel III, identifying adults with at least 3 of 5 cardiometabolic risk factors (hyperglycemia, increased central adiposity, elevated triglycerides, decreased high-density lipoprotein cholesterol, and elevated blood pressure) who are at increased risk of diabetes and cardiovascular disease. The constellation of MetS component risk factors has a shared pathophysiology and many common treatment approaches grounded in lifestyle modification. Several attempts have been made to define MetS in the pediatric population. However, in children, the construct is difficult to define and has unclear implications for clinical care. In this Clinical Report, we focus on the importance of screening for and treating the individual risk factor components of MetS. Focusing attention on children with cardiometabolic risk factor clustering is emphasized over the need to define a pediatric MetS.
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Affiliation(s)
- Sheela N. Magge
- Division of Endocrinology and Diabetes, and Center for Translational Science, Children's National Health System, Washington, District of Columbia
| | - Elizabeth Goodman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
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29
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Denburg MR, Leonard MB, Jemielita TO, Golden NH, Tasian G, Copelovitch L. Risk of Urolithiasis in Anorexia Nervosa: A Population-Based Cohort Study Using the Health Improvement Network. Eur Eat Disorders Rev 2017; 25:406-410. [DOI: 10.1002/erv.2526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/27/2017] [Accepted: 05/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Michelle R. Denburg
- The Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | | | - Thomas O. Jemielita
- Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | | | - Gregory Tasian
- The Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | - Lawrence Copelovitch
- The Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
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30
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Kennedy GA, Forman SF, Woods ER, Hergenroeder AC, Mammel KA, Fisher MM, Ornstein RM, Callahan ST, Golden NH, Kapphahn CJ, Garber AK, Rome ES, Richmond TK. History of Overweight/Obesity as Predictor of Care Received at 1-year Follow-Up in Adolescents With Anorexia Nervosa or Atypical Anorexia Nervosa. J Adolesc Health 2017; 60:674-679. [PMID: 28284563 PMCID: PMC8375315 DOI: 10.1016/j.jadohealth.2017.01.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 11/14/2016] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Previous research has indicated that patients with anorexia nervosa (AN) or atypical AN with premorbid history of overweight/obesity have greater weight loss and longer illness duration than patients with no such history. However, little is known about the association of premorbid overweight/obesity and receiving inpatient medical care during treatment for an eating disorder. METHODS Using logistic regression, we sought to determine if history of overweight/obesity was associated with receiving inpatient medical care in a sample of 522 patients (mean age 15.5 years, 88% female) with AN/atypical AN. RESULTS Binary results demonstrated greater percent weight loss (27.4% vs. 16.2%) and higher percent median body mass index (%mBMI, 99.8% vs. 85.2%) at presentation in those with a history of overweight/obesity (p < .001) but no difference in duration of illness (p = .09). In models adjusted for demographics and percent weight loss, history of overweight/obesity was associated with lower odds of receiving inpatient medical care (odds ratio .60 [95% confidence interval: .45-.80]) at 1-year follow-up. However, these associations were no longer significant after adjusting for %mBMI. Mediation results suggest that %mBMI fully mediates the relationship between history of overweight/obesity and inpatient medical care, in that those with a history of overweight/obesity are less likely to receive care due to presenting at a higher weight. CONCLUSIONS Our findings suggest that, despite greater degree of weight loss and no difference in duration of illness, participants with a history of overweight/obesity are less likely to receive inpatient medical care.
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Affiliation(s)
- Grace A. Kennedy
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts,Department of Psychology, Florida State University, Tallahassee, Florida,Address correspondence to: Grace A. Kennedy, Department of Psychology, Florida State University, 1107 West Call Street, Tallahassee, FL 32304. (G.A. Kennedy)
| | - Sara F. Forman
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Elizabeth R. Woods
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Albert C. Hergenroeder
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Kathleen A. Mammel
- Division of Adolescent Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan,Formerly at the Division of Adolescent Pediatrics, Beaumont Children’s Hospital, Royal Oak, Michigan
| | - Martin M. Fisher
- Division of Adolescent Medicine, Steven and Alexandra Cohen Children’s Medical Center, North Shore-Long island Jewish Health System, New Hyde Park, New York,Department of Pediatrics, Hofstra Northwell School of Medicine, Hempstead, New York
| | - Rollyn M. Ornstein
- Division of Adolescent Medicine and Eating Disorders, Penn State Children’s Hospital, Hershey, Pennsylvania
| | - S. Todd Callahan
- Division of Adolescent and Young Adult Health, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neville H. Golden
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Andrea K. Garber
- Division of Adolescent Medicine, University of California San Francisco, San Francisco, California
| | - Ellen S. Rome
- Center for Adolescent Medicine, Department of General Pediatrics, Cleveland Clinic Children’s Hospital, Cleveland, Ohio
| | - Tracy K. Richmond
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
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31
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Heyman MB, Abrams SA, Heitlinger LA, Cabana MD, Gilger MA, Gugig R, Hill ID, Lightdale JR, Daniels SR, Corkins MR, de Ferranti SD, Golden NH, Magge SN, Schwarzenberg SJ. Fruit Juice in Infants, Children, and Adolescents: Current Recommendations. Pediatrics 2017; 139:peds.2017-0967. [PMID: 28562300 DOI: 10.1542/peds.2017-0967] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Historically, fruit juice was recommended by pediatricians as a source of vitamin C and as an extra source of water for healthy infants and young children as their diets expanded to include solid foods with higher renal solute load. It was also sometimes recommended for children with constipation. Fruit juice is marketed as a healthy, natural source of vitamins and, in some instances, calcium. Because juice tastes good, children readily accept it. Although juice consumption has some benefits, it also has potential detrimental effects. High sugar content in juice contributes to increased calorie consumption and the risk of dental caries. In addition, the lack of protein and fiber in juice can predispose to inappropriate weight gain (too much or too little). Pediatricians need to be knowledgeable about juice to inform parents and patients on its appropriate uses.
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Affiliation(s)
- Melvin B. Heyman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, California
- UCSF Benioff Children’s Hospital, San Francisco, California; and
| | - Steven A. Abrams
- Department of Pediatrics, Dell Pediatric Research Institute, University of Texas at Austin, Austin, Texas
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32
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Nagata JM, Golden NH, Leonard MB, Copelovitch L, Denburg MR. Assessment of Sex Differences in Fracture Risk Among Patients With Anorexia Nervosa: A Population-Based Cohort Study Using The Health Improvement Network. J Bone Miner Res 2017; 32:1082-1089. [PMID: 28019700 PMCID: PMC5413380 DOI: 10.1002/jbmr.3068] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 12/20/2022]
Abstract
Though previous studies have demonstrated an increased fracture risk in females with anorexia nervosa (AN), fracture risk in males is not well characterized. The objective of this study was to examine sex differences in fracture risk and site-specific fracture incidence in AN. We performed a population-based retrospective cohort study using The Health Improvement Network (THIN; a large database of anonymized electronic medical records collected at primary care clinics throughout the United Kingdom). The median calendar year for the start of the observation period was 2004-2005. We identified 9239 females and 556 males <60 years of age with AN, and 97,889 randomly selected sex-, age-, and practice-matched participants without eating disorders (92,329 females and 5560 males). Multivariable Cox regression was used to estimate the hazard ratio (HR) for incident fracture. Median age at start of observation was 29.8 years in females and 30.2 years in males. The HR for fracture associated with AN differed by sex and age (interaction p = 0.002). Females with AN had an increased fracture risk at all ages (HR, 1.59; 95% confidence interval [CI], 1.45 to 1.75). AN was associated with a higher risk of fracture among males >40 years of age (HR, 2.54; 95% CI, 1.32 to 4.90; p = 0.005) but not among males ≤40 years. Females with AN had a higher risk of fracture at nearly all anatomic sites. The greatest excess fracture risk was noted at the hip/femur (HR, 5.59; 95% CI, 3.44 to 9.09) and pelvis (HR, 4.54; 95% CI, 2.42 to 8.50) in females and at the vertebrae (HR, 7.25; 95% CI, 1.21 to 43.45) for males with AN. AN was associated with higher incident fracture risk in females across all age groups and in males >40 years old. Sites of highest fracture risk include the hip/femur and pelvis in females and vertebrae in males with AN. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Neville H Golden
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lawrence Copelovitch
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle R Denburg
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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33
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Affiliation(s)
| | - K T Park
- Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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34
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Seetharaman S, Golden NH, Halpern-Felsher B, Peebles R, Payne A, Carlson JL. Effect of a Prior History of Overweight on Return of Menses in Adolescents With Eating Disorders. J Adolesc Health 2017; 60:469-471. [PMID: 27998699 PMCID: PMC6402567 DOI: 10.1016/j.jadohealth.2016.10.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/23/2016] [Accepted: 10/22/2016] [Indexed: 01/17/2023]
Abstract
PURPOSE The purpose of this study was to determine whether a history of overweight, weight suppression, and weight gain during treatment have an effect on return of menses (ROM) in adolescents with eating disorders (EDs). METHODS Retrospective chart review of female adolescents presenting to an ED program from January 2007 to June 2009. RESULTS One hundred sixty-three participants (mean age, 16.6 ± 2.1 years) met eligibility criteria. The mean median body mass index percent at ROM for those previously overweight was 106.1 ± 11.7 versus 94.2 ± 8.9 for those not previously overweight (p < .001). Both groups needed to gain weight for ROM. Greater weight suppression (odds ratio, 0.90; 95% confidence interval, 0.84-0.98; p = .013) was associated with lower likelihood of ROM, and greater weight gain during treatment (odds ratio, 1.20; 95% confidence interval, 1.07-1.36; p = .002) was associated with higher likelihood of ROM in those not previously overweight. CONCLUSIONS Previously overweight amenorrheic patients with EDs needed to be at a higher median body mass index percent for ROM compared to those who were not previously overweight.
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Affiliation(s)
- Sujatha Seetharaman
- Division of Adolescent Medicine, Stanford University Medical Center, Palo Alto, California
| | - Neville H. Golden
- Division of Adolescent Medicine, Stanford University Medical Center, Palo Alto, California
| | - Bonnie Halpern-Felsher
- Division of Adolescent Medicine, Stanford University Medical Center, Palo Alto, California
| | - Rebecka Peebles
- The Craig Dalsimer Division of Adolescent Medicine, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Allison Payne
- Pacific Northwest University of Health Sciences, Yakima, Washington
| | - Jennifer L. Carlson
- Division of Adolescent Medicine, Stanford University Medical Center, Palo Alto, California,Address correspondence to: Jennifer L. Carlson, M.D., Division of Adolescent Medicine, Stanford University Medical Center, 770 Welch Road, Suite 100, Palo Alto, CA 94304. (J.L. Carlson)
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Nagata JM, Golden NH, Peebles R, Long J, Leonard MB, Chang AO, Carlson JL. Assessment of sex differences in bone deficits among adolescents with anorexia nervosa. Int J Eat Disord 2017; 50:352-358. [PMID: 27611361 PMCID: PMC6613779 DOI: 10.1002/eat.22626] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/19/2016] [Accepted: 08/21/2016] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The objective of this study was to compare sex differences in bone deficits among adolescents with anorexia nervosa (AN) and to identify other correlates of bone health. METHOD Electronic medical records of all patients 9-20 years of age with a DSM-5 diagnosis of AN who were evaluated by the eating disorders program at Stanford with dual-energy X-ray absorptiometry (DXA) between March 1997 and February 2011 were retrospectively reviewed. Whole body bone mineral content Z-scores and bone mineral density (BMD) Z-scores at multiple sites were recorded using the Bone Mineral Density in Childhood Study (BMDCS) reference data. RESULTS A total of 25 males and 253 females with AN were included, with median age 15 years (interquartile range [IQR] 14-17) and median duration of illness 9 months (IQR 5-13). Using linear regression analyses, no significant sex differences in bone deficits were found at the lumbar spine, total hip, femoral neck, or whole body when controlling for age, %mBMI, and duration of illness. Lower %mBMI was significantly associated with bone deficits at all sites in adjusted models. DISCUSSION This is the first study to evaluate sex differences in bone health among adolescents with AN, using novel DSM-5 criteria for AN and robust BMDCS reference data. We find no significant sex differences in bone deficits among adolescents with AN except for a higher proportion of females with femoral neck BMD Z-scores <-1. Degree of malnutrition was correlated with bone deficits at all sites. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:352-358).
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Neville H. Golden
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Rebecka Peebles
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Mary B. Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Audrey O. Chang
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer L. Carlson
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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Keller J, Mboya BO, Sinclair J, Githua OW, Mulinge M, Bergholz L, Paiva L, Golden NH, Kapphahn C. A 6-Week School Curriculum Improves Boys' Attitudes and Behaviors Related to Gender-Based Violence in Kenya. J Interpers Violence 2017; 32:535-557. [PMID: 26063788 DOI: 10.1177/0886260515586367] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This study investigated the effects of a gender-based violence (GBV) educational curriculum on improving male attitudes toward women and increasing the likelihood of intervention if witnessing GBV, among adolescent boys in Nairobi, Kenya. In total, 1,543 adolescents participated in this comparison intervention study: 1,250 boys received six 2-hr sessions of the "Your Moment of Truth" (YMOT) intervention, and 293 boys comprised the standard of care (SOC) group. Data on attitudes toward women were collected anonymously at baseline and 9 months after intervention. At follow-up, boys were also asked whether they encountered situations involving GBV and whether they successfully intervened. Compared with baseline, YMOT participants had significantly higher positive attitudes toward women at follow-up, whereas scores for SOC participants declined. At follow-up, the percentage of boys who witnessed GBV was similar for the two groups, except for physical threats, where the intervention group reported witnessing more episodes. The percentage of boys in the intervention group who successfully intervened when witnessing violence was 78% for verbal harassment, 75% for physical threat, and 74% for physical or sexual assault. The percentage of boys in the SOC group who successfully intervened was 38% for verbal harassment, 33% for physical threat, and 26% for physical or sexual assault. Results from the logistic regression demonstrate that more positive attitudes toward women predicted whether boys in the intervention group would intervene successfully when witnessing violence. This standardized 6-week GBV training program is highly effective in improving attitudes toward women and increasing the likelihood of successful intervention when witnessing GBV.
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Affiliation(s)
| | | | | | - Oscar W Githua
- 3 United States International University, Nairobi, Kenya
| | - Munyae Mulinge
- 3 United States International University, Nairobi, Kenya
| | | | - Lee Paiva
- 5 No Means No Worldwide, San Francisco, CA, USA
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Tenforde AS, Carlson JL, Chang A, Sainani KL, Shultz R, Kim JH, Cutti P, Golden NH, Fredericson M. Association of the Female Athlete Triad Risk Assessment Stratification to the Development of Bone Stress Injuries in Collegiate Athletes. Am J Sports Med 2017; 45:302-310. [PMID: 28038316 DOI: 10.1177/0363546516676262] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The female athlete triad (referred to as the triad) contributes to adverse health outcomes, including bone stress injuries (BSIs), in female athletes. Guidelines were published in 2014 for clinical management of athletes affected by the triad. PURPOSE This study aimed to (1) classify athletes from a collegiate population of 16 sports into low-, moderate-, and high-risk categories using the Female Athlete Triad Cumulative Risk Assessment score and (2) evaluate the predictive value of the risk categories for subsequent BSIs. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 323 athletes completed both electronic preparticipation physical examination and dual-energy x-ray absorptiometry scans. Of these, 239 athletes with known oligomenorrhea/amenorrhea status were assigned to a low-, moderate-, or high-risk category. Chart review was used to identify athletes who sustained a subsequent BSI during collegiate sports participation; the injury required a physician diagnosis and imaging confirmation. RESULTS Of 239 athletes, 61 (25.5%) were classified into moderate-risk and 9 (3.8%) into high-risk categories. Sports with the highest proportion of athletes assigned to the moderate- and high-risk categories included gymnastics (56.3%), lacrosse (50%), cross-country (48.9%), swimming/diving (42.9%), sailing (33%), and volleyball (33%). Twenty-five athletes (10.5%) assigned to risk categories sustained ≥1 BSI. Cross-country runners contributed the majority of BSIs (16; 64%). After adjusting for age and participation in cross-country, we found that moderate-risk athletes were twice as likely as low-risk athletes to sustain a BSI (risk ratio [RR], 2.6; 95% confidence interval [95% CI], 1.3-5.5) and high-risk athletes were nearly 4 times as likely (RR, 3.8; 95% CI, 1.8-8.0). When examining the 6 individual components of the triad risk assessment score, both the oligomenorrhea/amenorrhea score ( P = .0069) and the prior stress fracture/reaction score ( P = .0315) were identified as independent predictors for subsequent BSIs (after adjusting for cross-country participation and age). CONCLUSION Using published guidelines, 29% of female collegiate athletes in this study were classified into moderate- or high-risk categories using the Female Athlete Triad Cumulative Risk Assessment Score. Moderate- and high-risk athletes were more likely to subsequently sustain a BSI; most BSIs were sustained by cross-country runners.
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Affiliation(s)
- Adam S Tenforde
- Spaulding Rehabilitation Hospital, Spaulding National Running Center, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Jennifer L Carlson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Audrey Chang
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kristin L Sainani
- Division of Epidemiology, Department of Health Research and Policy, Stanford University, Stanford, California, USA
| | - Rebecca Shultz
- Boswell Human Performance Laboratory, Department of Orthopaedic Surgery, Stanford, California, USA
| | - Jae Hyung Kim
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Phil Cutti
- Boswell Human Performance Laboratory, Department of Orthopaedic Surgery, Stanford, California, USA
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Michael Fredericson
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
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Martin SPK, Bachrach LK, Golden NH. Controlled Pilot Study of High-Impact Low-Frequency Exercise on Bone Loss and Vital-Sign Stabilization in Adolescents With Eating Disorders. J Adolesc Health 2017; 60:33-37. [PMID: 27836532 DOI: 10.1016/j.jadohealth.2016.08.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 08/13/2016] [Accepted: 08/15/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Adolescents with anorexia nervosa (AN) face an increased lifetime risk of bone fragility. This randomized controlled study examined the efficacy and safety of a high-impact activity program on markers of bone turnover and stabilization of vital signs (VSS). METHODS Forty-one hospitalized adolescents with AN were randomly assigned to routine care or routine care plus 20 jumps twice daily. Bone markers were measured at baseline days 1-3 (T1), days 4-6 (T2), and days 7-9 (T3). The primary outcome was change in bone-specific alkaline phosphatase (BSAP) at T3 adjusted for BSAP and % median body mass index at T1. Secondary outcomes were serum N-telopeptide (NTX) and osteocalcin at T3. Safety was determined by comparing weight gain, time to VSS and length of stay for each group. RESULTS BSAP, NTX, or osteocalcin did not differ between groups at baseline or at T3. BSAP and NTX at T3 were not associated with group of enrollment or % median body mass index. VSS was significantly reduced in the intervention group compared with the control group (11.6 ± 5.7 days vs. 17 ± 10.5 days, p = .049). There was no significant difference in weight gain or length of stay between groups. CONCLUSIONS Twice-daily jumping activity failed to influence markers of bone turnover in adolescents with AN but was well tolerated, shortened time to vital-sign stabilization and did not slow weight gain.
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Affiliation(s)
- Susanne P K Martin
- Division of Adolescent Medicine, Stanford University School of Medicine, Palo Alto, California.
| | - Laura K Bachrach
- Division of Pediatric Endocrinology, Stanford University School of Medicine, Palo Alto, California
| | - Neville H Golden
- Division of Adolescent Medicine, Stanford University School of Medicine, Palo Alto, California
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Abstract
Nutrition is a critical factor for appropriate child and adolescent development. Appropriate nutrition changes according to age. Nutrition is an important element for prevention of disease development, especially for chronic diseases. Many children and adolescents live in environments that do not promote optimum nutrition. Families must work to provide improved food environments to encourage optimum nutrition. Early primordial prevention of risk factors for chronic disease, such as cardiovascular disease, is important, and dietary habits established early may be carried through adult life.
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Affiliation(s)
- Mark R Corkins
- Pediatric Gastroenterology, University of Tennessee Health Sciences Center, 49 North Dunlap Street, Memphis, TN 38105, USA
| | - Stephen R Daniels
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B065, Aurora, CO 80045, USA.
| | - Sarah D de Ferranti
- Preventive Cardiology Clinic, Department of Cardiology, Children's Hospital Boston, Harvard University Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, 770 Welch Road, Palo Alto, CA 94304, USA
| | - Jae H Kim
- Neonatal-Perinatal Medicine Fellowship, Supporting Premature Infant Nutrition Program, Rady Children's Hospital of San Diego, University of California San Diego Health, 3020 Children's Way, San Diego, CA 92123, USA
| | - Sheela N Magge
- Division of Endocrinology and Diabetes, Center for Translational Science, Patient and Clinical Interactions (formerly CRC), CTSI, Children's National Health System, The George Washington University School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010, USA
| | - Sarah Jane Schwarzenberg
- Pediatric Gastroenterology, Hepatology and Nutrition, Masonic Children's Hospital, University of Minnesota, 2450 Riverside Avenue, Pediatric Ambulatory Services East Building, Minneapolis, MN 55454, USA
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Abstract
Obesity and eating disorders (EDs) are both prevalent in adolescents. There are concerns that obesity prevention efforts may lead to the development of an ED. Most adolescents who develop an ED did not have obesity previously, but some teenagers, in an attempt to lose weight, may develop an ED. This clinical report addresses the interaction between obesity prevention and EDs in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs.
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Sarnquist C, Sinclair J, Omondi Mboya B, Langat N, Paiva L, Halpern-Felsher B, Golden NH, Maldonado YA, Baiocchi MT. Evidence That Classroom-Based Behavioral Interventions Reduce Pregnancy-Related School Dropout Among Nairobi Adolescents. Health Educ Behav 2016; 44:297-303. [PMID: 27486178 DOI: 10.1177/1090198116657777] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the effect of behavioral, empowerment-focused interventions on the incidence of pregnancy-related school dropout among girls in Nairobi's informal settlements. METHOD Retrospective data on pregnancy-related school dropout from two cohorts were analyzed using a matched-pairs quasi-experimental design. The primary outcome was the change in the number of school dropouts due to pregnancy from 1 year before to 1 year after the interventions. RESULTS Annual incidence of school dropout due to pregnancy decreased by 46% in the intervention schools (from 3.9% at baseline to 2.1% at follow-up), whereas the comparison schools remained essentially unchanged ( p < .029). Sensitivity analysis shows that the findings are robust to small levels of unobserved bias. CONCLUSIONS Results suggest that these behavioral interventions significantly reduced the number of school dropouts due to pregnancy. As there are limited promising studies on behavioral interventions that decrease adolescent pregnancy in low-income settings, this intervention may be an important addition to this toolkit.
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Affiliation(s)
| | | | | | | | - Lee Paiva
- 4 No Means No Worldwide, San Francisco, CA, USA
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Golden NH. Optimizing bone health in Brazilian teens: using a population‐based survey to guide targeted interventions to increase dietary calcium intake. Jornal de Pediatria (Versão em Português) 2016. [DOI: 10.1016/j.jpedp.2016.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Golden NH. Optimizing bone health in Brazilian teens: using a population-based survey to guide targeted interventions to increase dietary calcium intake. J Pediatr (Rio J) 2016; 92:220-2. [PMID: 26945345 DOI: 10.1016/j.jped.2016.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Neville H Golden
- School of Medicine, Stanford University, Palo Alto, United States.
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Garber AK, Sawyer SM, Golden NH, Guarda AS, Katzman DK, Kohn MR, Le Grange D, Madden S, Whitelaw M, Redgrave GW. A systematic review of approaches to refeeding in patients with anorexia nervosa. Int J Eat Disord 2016; 49:293-310. [PMID: 26661289 PMCID: PMC6193754 DOI: 10.1002/eat.22482] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2015] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Andrea K. Garber
- Division of Adolescent & Young Adult Medicine, University of California, San Francisco Benioff Children’s Hospital
| | - Susan M Sawyer
- Centre for Adolescent Health, Royal Children’s Hospital; , Department of Paediatrics, The University of Melbourne, Faculty of Medicine, Dentistry, Health Sciences, The University of Melbourne, and Murdoch Childrens Research Institute
| | - Neville H. Golden
- Division of Adolescent Medicine The Marron and Mary Elizabeth Kendrick; Stanford University
| | - Angela S. Guarda
- Johns Hopkins School of Medicine; Johns Hopkins Eating Disorders Program The Johns Hopkins Hospital
| | - Debra K. Katzman
- Division of Adolescent Medicine, Department of Pediatrics The Hospital for Sick Children and University of Toronto
| | - Michael R Kohn
- Adolescent Medicine, Sydney Children’s Hospital Network, Westmead; The University of Sydney
| | - Daniel Le Grange
- Eating Disorders Program Departments of Psychiatry and Pediatrics University of California, San Francisco
| | - Sloane Madden
- Eating Disorder Coordinator Sydney Children’s Hospital Network
| | - Melissa Whitelaw
- Department of Nutrition and Food Services Centre for Adolescent Health The Royal Children’s Hospital Melbourne
| | - Graham W. Redgrave
- Johns Hopkins School of Medicine, Johns Hopkins Eating Disorders Program Department of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine
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Golden NH, Jacobson MS. Oestradiol, amenorrhoea and lipids in adolescent girls with eating disorders: do they affect long-term cardiovascular risk? Acta Paediatr 2016; 105:232-3. [PMID: 26859419 DOI: 10.1111/apa.13292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Neville H Golden
- Division of Adolescent Medicine, Stanford University School of Medicine - Pediatrics, Palo Alto, CA, USA.
| | - Marc S Jacobson
- Nassau University Medical Center - Pediatrics, Center for Lipid Disorders and Weight Management, East Meadow, NY, USA
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Abstract
OBJECTIVE Low bone mineral density (BMD) is a known consequence of anorexia nervosa (AN) and is particularly concerning during adolescence, a critical time for bone accrual. A comprehensive synthesis of available data regarding impaired bone health, its determinants, and associated management strategies in AN is currently lacking. This systematic review aims to synthesize information from key physiologic and prospective studies and trials, and provide a thorough understanding of impaired bone health in AN and its management. METHOD Search terms included "anorexia nervosa" AND "bone density" for the period 1995-2015, limited to articles in English. Papers were screened manually based on journal impact factor, sample size, age of participants, and inclusion of a control group. When necessary, we included seminal papers published before 1995. RESULTS AN leads to low BMD, impaired bone quality and increased fracture risk. Important determinants are low lean mass, hypogonadism, IGF-1 deficiency, and alterations in other hormones that impact bone health. Weight gain and menses restoration are critical for improving bone outcomes in AN. Physiologic estrogen replacement as the transdermal patch was shown to increase bone accrual in one study in adolescent females with AN; however, residual deficits persist. Bisphosphonates are potentially useful in adults with AN. DISCUSSION To date, evidence suggests that the safest and most effective strategy to improve bone health in AN is normalization of weight with restoration of menses. Pharmacotherapies that show promise include physiologic estradiol replacement (as the transdermal estradiol patch), and in adults, bisphosphonates. Further studies are necessary to determine the best strategies to normalize BMD in AN.
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Affiliation(s)
- Madhusmita Misra
- Division of Pediatric Endocrinology and the Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts,Correspondence to: Madhusmita Misra, MD, MPH, Division of Pediatric Endocrinology and the Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts.
| | - Neville H. Golden
- Division of Adolescent Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Debra K. Katzman
- Division of Adolescent Medicine, Hospital for Sick Children and University of Toronto, Toronto, Canada
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Golden NH, Carey DE. Vitamin D in Health and Disease in Adolescents: When to Screen, Whom to Treat, and How to Treat. Adolesc Med State Art Rev 2016; 27:125-139. [PMID: 27363237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The existing guidelines on screening and treatment are confusing because different guidelines target different populations. The IOM and AAP guidelines target generally healthy populations, whereas the Endocrine Society and other subspecialty guidelines target individuals with specific medical conditions associated with increased bone fragility. These distinctions have not always been well articulated. For healthy adolescents, the AAP does not recommend universal screening or screening of obese or dark-skinned individuals. Increased dietary intake of vitamin D is recommended, and vitamin D supplementation can be considered if the RDA cannot be met. For adolescents with chronic medical illnesses associated with increased fracture risk, screening for vitamin D deficiency should be performed by obtaining a serum 25-OHD level. Those found to be deficient (25-OHD level < 20 ng/mL) should be treated with doses of vitamin D2 or vitamin D3 higher than the daily requirement (as discussed in the section on vitamin D and chronic disease), followed by a maintenance dose. A repeat 25-OHD level should be obtained after the therapeutic course is completed. Some experts advocate for achievement of 25-OHD levels greater than 30 ng/mL in conditions associated with increased bone fragility, and several pediatric subspecialty organizations have made recommendations specific to the diseases they treat. In such instances, the recommendations of the pediatric subspecialty organizations should take precedence over the AAP recommendations for adolescents with chronic illnesses associated with increased bone fragility because the AAP recommendations were primarily targeted at a healthy population.
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Carey DE, Golden NH. Bone Health in Adolescence. Adolesc Med State Art Rev 2015; 26:291-325. [PMID: 26999874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Osteoporosis occurs during childhood and adolescence as a heritable condition such as OI, with acquired disease (eg, IBD), or iatrogenically as a result of high-dose glucocorticoid therapy. However, the number of children affected by osteoporosis during youth is small compared to the numbers who will develop osteoporosis in adulthood. Prevention of adult osteoporosis requires that an optimal environment for the achievement of peak bone mass be established during the growing years. Detection of low BMD can be achieved using modalities such as DXA and pQCT. Standard radiologic studies, especially vertebral radiography, may also be helpful in children and adolescents at high risk for osteoporosis. It is critical to the development of healthy bones that adolescents have proper nutrition with adequate calcium and vitamin D intake and that they participate in regular physical activity (especially weight-bearing exercise). In the recent past, the dual goals of proper nutrition and exercise were not being achieved by many, if not most, adolescents. Those caring for adolescents should strive to educate teens and their families on the importance of dietary calcium and vitamin D as well as advocate for supportive environments in schools and communities that foster the development of healthy habits with regard to diet and exercise. In order to help identify the population at risk for osteoporosis, a bone health screen with assessment of calcium intake and determination of family history of adult osteoporosis (hip fracture, kyphosis) should be a routine part of adolescent health care. Universal screening of healthy adolescents with serum 25OHD levels is not recommended. Adolescents with conditions associated with reduced bone mass should undergo bone densitometry or other studies as a baseline, and BMD should be monitored at intervals no more frequently than yearly. Although controversy remains regarding the optimum dose of vitamin D for treatment of osteoporosis, all would agree that vitamin D should be provided, and in doses somewhat higher than previously recommended. Excessive vitamin D should be avoided. The use of bisphosphonates is recommended for the treatment of OI, as well as for treatment of select children with severe osteoporosis associated with chronic conditions that lead to frequent or painful fragility fractures. In such situations, bisphosphonates should be prescribed only in the context of a comprehensive clinical program with specialists knowledgeable in the management of osteoporosis in children.
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Monge MC, Forman SF, McKenzie NM, Rosen DS, Mammel KA, Callahan ST, Hehn R, Rome ES, Kapphahn CJ, Carlson JL, Romano ME, Malizio JB, Bravender TD, Sigel EJ, Rouse MR, Graham DA, Jay MS, Hergenroeder AC, Fisher MM, Golden NH, Woods ER. Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative. J Adolesc Health 2015; 57:66-72. [PMID: 26095410 DOI: 10.1016/j.jadohealth.2015.03.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/23/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities. METHODS Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2). RESULTS Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0). CONCLUSIONS Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.
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Affiliation(s)
- Maria C Monge
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts.
| | - Sara F Forman
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole M McKenzie
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - David S Rosen
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kathleen A Mammel
- Division of Adolescent Pediatrics, Beaumont Children's Hospital, Royal Oak, Michigan
| | - S Todd Callahan
- Division of Adolescent Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Hehn
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts
| | - Ellen S Rome
- Section of Adolescent Medicine, Department of General Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Cynthia J Kapphahn
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Jennifer L Carlson
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Mary E Romano
- Division of Adolescent Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joan B Malizio
- Division of Adolescent Medicine, Steven and Alexandra Cohen Children's Medical Center, North Shore-Long Island Jewish Health System, New Hyde Park, New York
| | - Terrill D Bravender
- Department of Pediatrics, The Ohio State University, Columbus, Ohio; Nationwide Children's Hospital, Columbus, Ohio
| | - Eric J Sigel
- Children's Hospital of Colorado, Section of Adolescent Medicine, University of Colorado, Aurora, Colorado
| | - Mary R Rouse
- Department of Pediatrics, Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana
| | - Dionne A Graham
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - M Susan Jay
- Division of Adolescent Medicine, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Albert C Hergenroeder
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Martin M Fisher
- Division of Adolescent Medicine, Steven and Alexandra Cohen Children's Medical Center, North Shore-Long Island Jewish Health System, New Hyde Park, New York; Department of Pediatrics, Hofstra North Shore-Long Island Jewish School of Medicine, Hempstead, New York
| | - Neville H Golden
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Elizabeth R Woods
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
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Golden NH, Katzman DK, Sawyer SM, Ornstein RM, Rome ES, Garber AK, Kohn M, Kreipe RE. Update on the medical management of eating disorders in adolescents. J Adolesc Health 2015; 56:370-5. [PMID: 25659201 DOI: 10.1016/j.jadohealth.2014.11.020] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 10/14/2014] [Accepted: 11/23/2014] [Indexed: 12/21/2022]
Abstract
The medical practitioner has an important role to play in the management of adolescents with eating disorders, usually as part of a multidisciplinary team. This article reviews the role of the medical practitioner in the diagnosis and treatment of eating disorders, updating the reader on the changing epidemiology of eating disorders, revised diagnostic criteria, newer methods of assessing degree of malnutrition, more aggressive approaches to refeeding, and current approaches to managing low bone mass.
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Affiliation(s)
- Neville H Golden
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University School of Medicine, Palo Alto, California.
| | - Debra K Katzman
- Department of Pediatrics, Division of Adolescent Medicine, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Susan M Sawyer
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Royal Children's Hospital, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Rollyn M Ornstein
- Division of Adolescent Medicine and Eating Disorders, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Ellen S Rome
- Center for Adolescent Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio; Department of Pediatrics, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Andrea K Garber
- Division of Adolescent Medicine, University of California Benioff Children's Hospital, San Francisco, California
| | - Michael Kohn
- Department of Adolescent Medicine, The Sydney Children's Hospital Network, Westmead, New South Wales, Australia; Faculty of Medicine, The University of Sydney, Westmead, New South Wales, Australia
| | - Richard E Kreipe
- Department of Pediatrics, Division of Adolescent Medicine, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York; New York State ACT for Youth Center of Excellence, Western New York Comprehensive Care Center for Eating Disorders, Rochester, New York
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