Eating disorders

Undergraduate perspectives of the awareness, diagnosis and management of patients with eating disorders

Introduction Patients with eating disorders (EDs) may present with potentially life-threatening complications due to missed and late diagnoses. Dentists can play a fundamental role in the early identification and signposting of patients with suspected EDs.Aims To investigate the awareness of final-year dental students of the aetiology, diagnosis and management of EDs.Methods An anonymous electronic questionnaire was distributed to final-year dental students at the University of Manchester. Respondents reported their knowledge, confidence and education related to the management of patients with EDs.Results Over 50% of students felt they had an above average awareness of the clinical signs and oral manifestations of EDs. The majority of students lacked confidence in discussing a suspected ED diagnosis with patients (75%) and referring them to appropriate services (71%). Additionally, 58% were not confident in planning treatment for and treating a patient with an ED. In total, 100% of students reported that they would benefit from further teaching related to the management of patients with EDs.Conclusion Participants highlighted the need for further teaching related to the diagnosis and management of patients with EDs. This study supports the development of an educational resource of undergraduate dental students.

[Effects of non-invasive neuromodulation on the cognitive profile of people with anorexia nervosa: A scoping review]

BACKGROUND

The use of non-invasive neuromodulation is emerging in the treatment of anorexia nervosa. Despite promising results, further research is needed to improve our understanding of these techniques and to adapt interventions to this population. As anorexia nervosa is associated with several cognitive difficulties and cerebral anomalies, the aim of the present study was to summarize the available data on the effects of non-invasive neuromodulation on the neuropsychological profile of people with anorexia nervosa.

METHOD

A scoping review was conducted by searching in PsycINFO, PubMed and CINAHL databases to systematically identify relevant studies published between 1994 and 2023 on the treatment of anorexia nervosa with repetitive transcranial magnetic stimulation, transcranial direct current stimulation or neurofeedback electroencephalogram.

RESULTS

Seventeen articles were included, including 12 on repetitive transcranial magnetic stimulation, four on transcranial direct current stimulation and one on neurofeedback electroencephalogram. Of these, only three studies included a neuropsychological measure to assess the impact of neuromodulation on participants' cognitive functions.

CONCLUSIONS

Including detailed neuropsychological measures in clinical trials of non-invasive neuromodulation is highly recommended and appears essential to improve our understanding of these techniques and optimize their efficacy in the treatment of anorexia nervosa.

Electroencephalographic Changes in Pregnant Women with Hyperemesis Gravidarum: A Case-Control Study

OBJECTIVE

Electroencephalogram (EEG), which is frequently used in the clinical practice of neurology, has also been investigated in eating disorders and some cortical dysfunctions have been reported. Based on this, we aimed to investigate EEG changes in pregnant women with hyperemesis gravidarum (HEG).

MATERIALS AND METHODS

This case-control study was conducted on 66 pregnant women who applied to the Umraniye Training and Research Hospital, Department of Obstetrics and Gynecology. The study group consisted of 34 pregnant women diagnosed with HEG. The control group consisted of 32 healthy pregnant women who were matched with the HEG group in terms of age and gestational week. EEGs of the participants were performed with a Micromed Brain Rapid EEG device in the Neurology Department of Umraniye Training and Research Hospital. In EEGs, all channels were selected as bipolar and samples of 18 channels (Fp2-F4, F4-C4, C4-P4, P4-O2, Fp2-F8, F8-T4, T4-T6, T6-O2, Fz-Cz, Cz-Pz, Fp1-F3, F3-C3, C3-P3, P3-O1, Fp1-F7, F7-T3, T3-T5, and T5-O1) were obtained. EEG signals were sampled with a sampling frequency of 200 Hz and digitized with 12-bit resolution. EEG signals were converted to EDF (European Data Format) extension files using the MATLAB software program and analyzed using statistical features on the time and frequency axis. HEG and control groups were compared in terms of signals obtained from these 18 selected channels.

RESULTS

Both groups were similar in terms of mean age, gestational age, and parity (p>0.05). Among the 18 channels, significant changes were detected between the two groups only in the theta, beta, and gamma bands in the C4-P4 channel and the delta, beta, and gamma bands in the T4-T6 channel (p<0.05). No significant changes were detected in the channels and bands.

CONCLUSION

Theta, beta, and gamma band abnormalities in the centro-parietal area of the right hemisphere and delta, beta, and gamma band abnormalities in the temporal area of the right hemisphere were observed on HEG. However, it is unclear whether abnormalities in EEG are primary changes responsible for the development of HEG or secondary to metabolic and hormonal changes resulting from HEG itself.

Nasogastric Tube Feeding in Anorexia Nervosa: A Propensity Score-Matched Analysis on Clinical Efficacy and Treatment Satisfaction

The choice of a refeeding strategy is essential in the inpatient treatment of Anorexia Nervosa (AN). Oral nutrition is usually the first choice, but enteral nutrition through the use of a Nasogastric Tube (NGT) often becomes necessary in hospitalized patients. The literature provides mixed results on the efficacy of this method in weight gain, and there is a scarcity of studies researching its psychological correlates. This study aims to analyze the effectiveness of oral versus enteral refeeding strategies in inpatients with AN, focusing on Body Mass Index (BMI) increase and treatment satisfaction, alongside assessing personality traits. We analyzed data from 241 inpatients, comparing a group of treated vs. non-treated individuals, balancing confounding factors using propensity score matching, and applied regression analysis to matched groups. The findings indicate that enteral therapy significantly enhances BMI without impacting treatment satisfaction, accounting for the therapeutic alliance. Personality traits showed no significant differences between patients undergoing oral or enteral refeeding. The study highlights the clinical efficacy of enteral feeding in weight gain, supporting its use in severe AN cases when oral refeeding is inadequate without adversely affecting patient satisfaction or being influenced by personality traits.

Are you how you eat? Aspects of self-awareness in eating disorders

Eating disorders (ED) are severe psychiatric disorders characterized by dysfunctional behaviors related to eating or weight control, with profound impacts on health, quality of life, and the financial burden of affected individuals and society at large. Given that these disorders involve disturbances in self-perception, it is crucial to comprehend the role of self-awareness in their prevalence and maintenance. This literature review presents different self-awareness processes, discussing their functioning across different levels of complexity. By deconstructing this concept, we can gain a better understanding of how each facet of self and personality relates to the symptoms of these disorders. Understanding the absence or impairment of self-awareness in ED holds significant implications for diagnosis, treatment, and overall management. By recognizing and comprehending the characteristics of self-awareness, clinicians can develop tailored interventions and evidence-based treatments for individuals with ED. Furthermore, this narrative review underscores the importance of considering temperament and personality factors in the context of ED, as temperament traits and personality characteristics may interact with self-awareness processes, influencing the development and maintenance of ED. Ultimately, the results highlight the pressing need for further research on the development of effective interventions and support strategies grounded in the aspects of self-awareness mechanisms for individuals affected by these disorders.

Inpatient treatments for adults with anorexia nervosa: a systematic review of literature

PURPOSE

Anorexia nervosa (AN) is a mental disorder for which hospitalization is frequently needed in case of severe medical and psychiatric consequences. We aim to describe the state-of-the-art inpatient treatment of AN in real-world reports.

METHODS

A systematic review of the literature on the major medical databases, spanning from January 2011 to October 2023, was performed, using the keywords: "inpatient", "hospitalization" and "anorexia nervosa". Studies on pediatric populations and inpatients in residential facilities were excluded.

RESULTS

Twenty-seven studies (3501 subjects) were included, and nine themes related to the primary challenges faced in hospitalization settings were selected. About 81.48% of the studies detailed the clinical team, 51.85% cited the use of a psychotherapeutic model, 25.93% addressed motivation, 100% specified the treatment setting, 66.67% detailed nutrition and refeeding, 22.22% cited pharmacological therapy, 40.74% described admission or discharge criteria and 14.81% follow-up, and 51.85% used tests for assessment of the AN or psychopathology. Despite the factors defined by international guidelines, the data were not homogeneous and not adequately defined on admission/discharge criteria, pharmacological therapy, and motivation, while more comprehensive details were available for treatment settings, refeeding protocols, and psychometric assessments.

CONCLUSION

Though the heterogeneity among the included studies was considered, the existence of sparse criteria, objectives, and treatment modalities emerged, outlining a sometimes ambiguous report of hospitalization practices. Future studies must aim for a more comprehensive description of treatment approaches. This will enable uniform depictions of inpatient treatment, facilitating comparisons across different studies and establishing guidelines more grounded in scientific evidence.

LEVEL OF EVIDENCE

Level I, systematic review.

A Scoping Review of the Prevalence of Eating Disorders in Spain

INTRODUCTION

Eating disorders (EDs) are mental health illnesses with a multifactorial origin. At present, no review of indexed publications studying their prevalence in Spain is available.

MATERIAL AND METHODS

A scoping review (PROSPERO -CRD42019140884-) was carried out through systematic searches (MEDLINE, EMBASE and PsycINFO) until January 2022. Papers published in Spanish/English analysing the prevalence of EDs in Spain (population < 65 years) were selected.

RESULTS

A total of 766 articles were identified (186 eliminated as duplicates). A total of 580 articles were analysed on the basis of title and abstract, and 67 articles were selected for full-text analysis. A total of 37 studies analysed the prevalence of EDs in Spain.

CONCLUSIONS

This is the first scoping review to analyse the prevalence of EDs in Spain. Puberty and adolescence are the most extensively studied stages. There is a high heterogeneity in the use of ED screening tools and a paucity of information on diagnostic tools.

Quality of Life and Clinical Impairment in Spanish Adolescent Anorexia Nervosa Patients

Eating disorders have serious physical, mental and social consequences that can affect the quality of life of the sufferer. This study aimed to evaluate the relationship between the severity of ED-related psychopathology and clinical impairment in adolescents with anorexia nervosa (AN) as well as their perception of health-related quality of life. Eighty-six Spanish young women with AN completed a set of questionnaires assessing eating disorder pathology, clinical impairment, and quality of life. The set included the following instruments: the Eating Disorder Examination Questionnaire, Clinical Impairment Assessment, Short Form-12 Item Health Survey, and the Eating Disorder-Specific Heath-Related Quality of Life instrument. Descriptive and regression analyses were applied to identify associations between variables. Higher scores on clinical impairment domains were associated with greater impairment of mental and physical health. Moreover, clinical impairment domains and concerns due to ED were related to a lower quality of life. In conclusion, adolescents with AN have a poor quality of life. Moreover, the findings suggest that the clinical features of impairment may serve as severity indicators of quality of life.

Cognitive training via mobile app for addressing eating disorders' cognitions in adolescents: a randomized control trial protocol

During adolescence, individuals are particularly vulnerable to developing eating disorders (EDs). To address the dysfunctional beliefs linked to these disorders, a new mobile app has been developed. This app, called GG eating disorders-Adolescents (GGED-AD), was created based on CBT to help adolescents work on their self-dialogue related to the core beliefs of eating disorders. The objective is to present the protocol for a randomized controlled trial to explore the efficacy of GGED-AD.Methods The study will be carried out in adolescents aged 13 to 16 from an educational center in the Valencian Community. The participants will be randomized into two groups: the experimental group will use the GGED-AD app during 14 consecutive days for approximately 5 min each day; and the control group will use a neutral app (GGNEUTRAL) during the same time. Both groups will complete instruments that assess dysfunctional beliefs related to eating disorders, eating symptoms, symptoms of depression and anxiety, body satisfaction and self-esteem before and after the intervention. A follow-up will be conducted one month later.Results A decrease in the degree of ascription to dysfunctional beliefs associated with eating disorders and eating symptomatology is expected, as well as an increase in body satisfaction and the self-esteem of the participants of the experimental group.Discussion The app in this study could help tackle and prevent ED-related symptoms in adolescents.Trial registration NCT06039514.

Anorexia nervosa and bulimia nervosa: a Mendelian randomization study of gut microbiota

Background

Anorexia nervosa (AN) and bulimia nervosa (BN) poses a significant challenge to global public health. Despite extensive research, conclusive evidence regarding the association between gut microbes and the risk of AN and BN remains elusive. Mendelian randomization (MR) methods offer a promising avenue for elucidating potential causal relationships.

Materials and methods

Genome-wide association studies (GWAS) datasets of AN and BN were retrieved from the OpenGWAS database for analysis. Independent single nucleotide polymorphisms closely associated with 196 gut bacterial taxa from the MiBioGen consortium were identified as instrumental variables. MR analysis was conducted utilizing R software, with outlier exclusion performed using the MR-PRESSO method. Causal effect estimation was undertaken employing four methods, including Inverse variance weighted. Sensitivity analysis, heterogeneity analysis, horizontal multivariate analysis, and assessment of causal directionality were carried out to assess the robustness of the findings.

Results

A total of 196 bacterial taxa spanning six taxonomic levels were subjected to analysis. Nine taxa demonstrating potential causal relationships with AN were identified. Among these, five taxa, including Peptostreptococcaceae, were implicated as exerting a causal effect on AN risk, while four taxa, including Gammaproteobacteria, were associated with a reduced risk of AN. Similarly, nine taxa exhibiting potential causal relationships with BN were identified. Of these, six taxa, including Clostridiales, were identified as risk factors for increased BN risk, while three taxa, including Oxalobacteraceae, were deemed protective factors. Lachnospiraceae emerged as a common influence on both AN and BN, albeit with opposing effects. No evidence of heterogeneity or horizontal pleiotropy was detected for significant estimates.

Conclusion

Through MR analysis, we revealed the potential causal role of 18 intestinal bacterial taxa in AN and BN, including Lachnospiraceae. It provides new insights into the mechanistic basis and intervention targets of gut microbiota-mediated AN and BN.

Does adult attachment mediate the relationship between primary emotion traits and eating disorder symptoms?

Objectives

Primary emotion traits and attachment patterns, have been linked to various mental disorders. This study aims to shed more light on the less studied relationship with eating disorder (ED) symptoms.

Methods

A total of 921 non-clinical subjects (69.9% females) were assessed for primary emotions traits (B-ANPS-GL), attachment insecurity (ECR-RD8), and eating disorder pathology (EDE-Q8). A theoretically derived model was evaluated by means of a path analysis with attachment anxiety as assumed mediator variable.

Results

Global problematic eating behavior showed negative correlations with the positive emotions PLAY, CARE, and LUST (r = -0.10 to -0.24), positive correlations with the negative primary emotions ANGER, FEAR, and SADNESS (r = 0.12-0.27), as well as with attachment anxiety (r = 0.22, all p < 0.01). Path analyses revealed direct effects between eating behavior pathology with LUST (β = -0.07 to -0.15) and FEAR (β = 0.12-0.19; all p < 0.05). The association of SADNESS and Weight (β = 0.05) and Shape Concern (β = 0.06, p < 0.001) was fully mediated by attachment anxiety. Overall, the path model explained 17% of the variance for attachment anxiety and 6% of the Restraint, 13% for Eating, 10% for Weight and 14% for Shape Concern Subscales.

Discussion

The findings shed light on the multifactorial relationship between affective traits, attachment security, and eating disorder pathology. In line with previous research, the results emphasize the role of attachment and affective functioning in ED symptoms.

Staging models in eating disorders: A systematic scoping review of the literature

Eating Disorders (ED) are characterized by low remission rates, treatment drop-out, and residual symptoms. To improve assessment and treatment of ED, the staging approach has been proposed. This systematic scoping review is aimed at mapping the existing staging models that explicitly propose stages of the progression of ED. A systematic search of PubMed, PsycINFO, Scopus was conducted with the terms staging, anorexia nervosa, bulimia nervosa, binge-eating disorders, eating disorders. Eleven studies met inclusion criteria presenting nine ED staging models, mostly for anorexia nervosa. Three were empirically tested, one of which was through an objective measure specifically developed to differentiate between stages. Most staging models featured early stages in which the exacerbation of EDs unfolds and acute phases are followed by chronic stages. Intermediate stages were not limited to acute stages, but also residual phases, remission, relapse, and recovery. The criteria for stage differentiation encompassed behavioral, psychological, cognitive, and physical features including body mass index and illness duration. One study recommended stage-oriented interventions. The current review underscores the need to empirically test the available staging models and to develop and test new proposals of staging models for other ED populations. The inclusion of criteria based on medical features and biomarkers is recommended. Staging models can potentially guide assessment and interventions in daily clinical settings.

Disordered Eating in Young Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) was the most prevalent endocrine disorder among women. Weight issues were commonly observed and found to be associated with comorbidities. This study aimed to compare Eating Disorder Examination Questionnaire (EDE-Q) scores and Night Eating Questionnaire (NEQ) scores in patients with and without PCOS and analyze the factors associated with disordered eating. Women aged 18-25 years with and without PCOS (n = 110 for each group) were included in the study. All patients completed the EDE-Q, NEQ, Beck Anxiety, and Beck Depression inventories. Disordered eating was found more frequently in women with PCOS than in controls (25.5% vs. 2.7%, p < 0.001). There were no significant differences in NEQ scores between the two groups. Anxiety and depression scores were higher in patients with PCOS than in controls (p = 0.002 and p = 0.001, respectively). PCOS diagnosis (OR: 7.4, CI: [1.63-33.7]; p = 0.010) and high BMI (OR: 1.24, CI: [1.10-1.39]; p < 0.001) were found to be independent factors for disordered eating (EDE-Q global score ≥ 4). Disordered eating was more common in young women with PCOS compared to the control group. PCOS diagnosis and having a high BMI (> 25) were found to be independent factors related to disordered eating in young women with PCOS. Young women with a high BMI or PCOS appear to be at a higher risk of disordered eating than women of the same age. Scanning this group may help clinicians in identifying women at high risk for eating disorders and preventing comorbidities associated with them.

Exploring Adult Eating Behaviors and Food Neophobia: A National Study in Romania

Food neophobia involves avoiding new foods due to reluctance, aversion, or disgust. The Food Neophobia Scale (FNS) is the most reliable and common adult food neophobia test. It helps compare food neophobia across cultures by being translated into numerous languages. This study adapted, translated, and validated the FNS for Romania. This translated version was piloted in November 2023 on 59 students in the medical field from two distinct Romanian cities. Between December 2023 and February 2024, 375 adults were surveyed, representing Romania's population within a 90% confidence interval. The average age of responders was 38.07 years, with a standard deviation of 10.75 and a 4:1 female-to-male sex ratio. The Cronbach's alpha test was used to validate the questionnaire. Our study found that the mean FNS value was 31.86; most Romanian respondents (69.20%) were neutral towards trying new foods, with a significant portion being neophobes (18.21%) outnumbering neophiles (12.59%). When compared to international study results, Romanian adults, on average, exhibited a higher percentage of neophobes compared to those in Korea (13%), Hungary (16.8%), Italy (17%), and Brazil (17.5%), but a lower percentage than those in Lebanon (21.5%). The findings indicate that the translated scale can be utilized to assess neophobia among Romanian speakers.

Severe enduring anorexia nervosa (SE-AN) treatment options and their effectiveness: a review of literature

INTRODUCTION

 For nearly 20% of patients diagnosed with Anorexia Nervosa (AN), the eating disorder (ED) is prolonged and becomes long-lasting. It has been reported that patients diagnosed with Severe Enduring Anorexia Nervosa (SE-AN) have worse ED symptoms, higher rates of lifetime hospitalization, and lower psychosocial well-being compared to patients with shorter disease duration.

OBJECTIVES

 This review aims to describe the treatments proposed to date and their effectiveness on SE-AN-related outcomes.

METHODS

 We conducted a PubMed search for studies addressing the issue of treatment approach to SE-AN adults, that were published between 2003 and 2023, peer-reviewed, written in the English language, and available in full-text. Next, we inductively created relevant macro-themes by synthesizing the data from the included articles.

RESULTS

 Of 251 PubMed studies, 25 articles were considered for data extraction, all published between 2003 and 2022. We identified three macro-themes. The first macro-theme, "Psychotherapy", mostly takes into consideration treatment effectiveness of cognitive behavioral therapy (CBT). Various reports determined its greater effectiveness compared to Specialist Supportive Clinical Management (SSCM), and one study proved that outpatient CBT is a valid alternative to hospitalization. The second one involves "Pharmacological Treatments". Research on dronabinol, a synthetic orexigenic cannabinoid, antipsychotics (in particular, olanzapine and haloperidol), and ketamine showed some mixed results regarding the often-complementary areas of weight gain and improvement in ED-related symptoms. Regarding the third macro-theme, "Brain Stimulation Therapies," such as Repetitive Transcranial Magnetic Stimulation (rTMS) and Deep Brain Stimulation (DBS), we found promising results in improving ED-related psychological traits (such as mood and anxiety), affective regulation, and quality of life. However, we have observed divergent results regarding outcome measures such as BMI and weight gain.

CONCLUSIONS

 SE-AN patients are predicted to encounter both medical complications and psychological distress of increasing severity that will inevitably affect their quality of life; to our knowledge, research evidence on treatment options for SE-AN remains limited, and the methodological quality of studies is generally low. These findings denote the need to focus future research efforts on effective treatment strategies specific to long-lasting EDs.

Mentalizing in psychotherapeutic processes of patients with eating disorders

Background

Improvement in the capacity to mentalize (i.e., reflective functioning/RF) is considered both, an outcome variable as well as a possible change mechanism in psychotherapy. We explored variables related to (in-session) RF in patients with an eating disorder (ED) treated in a pilot study on a Mentalization-Based Treatment (MBT) - oriented day hospital program. The research questions were secondary and focused on the psychotherapeutic process: What average RF does the group of patients show in sessions and does it change over the course of a single session? Are differences found between sections in which ED symptomatology is discussed and those in which it is not? Does RF increase after MBT-type interventions?

Methods

1232 interaction segments from 77 therapy sessions of 19 patients with EDs were rated for RF by reliable raters using the In-Session RF Scale. Additionally, content (ED symptomatology yes/no) and certain MBT interventions were coded. Statistical analysis was performed by mixed models.

Results

Patients showed a rather low RF, which increased on average over the course of a session. If ED symptomatology was discussed, this was associated with significantly lower RF, while MBT-type interventions led to a significant increase in RF.

Conclusions

Results suggest that in-session mentalizing can be stimulated by MBT-typical interventions. RF seems to be more impaired when disorder-specific issues are addressed. Further studies have to show if improving a patient´s ability to mentalize their own symptoms is related to better outcomes.

Guided self-help treatment for children and young people with threshold and subthreshold eating disorders: A pilot study protocol

BACKGROUND

Prompt access to evidence-based treatment for children and young people with eating disorders is important for outcomes, yet the gap in service provision remains pervasive. Record levels of young people are waiting for eating disorder treatment and access to care is limited. Guided self-help interventions that are brief and require minimal clinician support have the potential to meet the unprecedented demand for treatment quickly and effectively.

OBJECTIVE

To examine the feasibility, acceptability and proof of concept of a novel, CBT guided self-help intervention for children and young people with threshold and subthreshold eating disorders.

METHODS

A single-arm, proof-of-concept pilot study of the CBT guided self-help intervention will be conducted. Children and young people (aged 11-19) with threshold and subthreshold eating disorders will receive a self-help intervention covering the core components of CBT, supported by 8 weekly guidance sessions delivered remotely. Clinical outcomes (eating-related psychopathology and associated impairment, changes in weight, depression, anxiety, and behavioural difficulties) will be assessed at baseline and post-intervention (12 weeks). Feasibility and acceptability of the intervention will be measured using various outcomes, including adherence to, and engagement with the intervention, rates of recruitment and retention, measure completion and treatment satisfaction. Qualitative data will also be collected for future intervention refinement.

DISCUSSION

If the intervention is shown to produce clinical benefits in this pilot study, a fully powered randomised pilot study will be warranted with the ultimate goal of increasing access to psychological treatment for children and young people threshold and subthreshold eating disorders.

ADMINISTRATIVE INFORMATION

This study protocol (S1 File) adheres to the guidelines outlined in the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist for trial protocols [1, 2] which can be found in S1 Checklist. The numbers in parentheses in this protocol correspond to the item numbers in the SPIRIT checklist. The order of items has been modified to group similar items.

A novel whole-team training programme for adult eating disorder services in England: rationale, development and preliminary evaluation

AIMS AND METHOD

In response to recommendations for improving the quality and coordination of care delivered by eating disorder services, a whole-team training programme was commissioned by Health Education England in 2020. This paper describes the development and evaluation of the Eating Disorder Services for Adults (EDSA) whole-team training course, delivered to National Health Service adult eating disorder community teams in England. Course participants (n = 561) in the first two EDSA training cohorts (2021 and 2022) were asked to complete questionnaires at intake and after each session, asking about their views on the training.

RESULTS

All course aspects were rated as highly enjoyable, meeting participants' training needs and fostering reflective practice. Thematic analysis identified themes relating to key innovative features of the course and suggestions for improvements.

CLINICAL IMPLICATIONS

Preliminary evaluation suggests that EDSA is valued by clinicians to enhance their knowledge, skills and ability to improve eating disorder patient care.

A Bibliometric Analysis of Scientific Publications on Eating Disorder Prevention in the Past Three Decades

BACKGROUND

Eating disorders (EDs) present a growing concern due to their widespread occurrence and chronic course, the low access to evidence-based treatment, and the significant burden they place on the patients and society. This picture justifies intensive focus on the prevention of EDs. The current study provides the first bibliometric analysis of research on the prevention of EDs, focusing on trends and contributions, to prompt further prevention research.

METHODS

We conducted a bibliometric analysis of publications on the prevention of EDs using the Web of Science database, from 1993 to 2023. Focusing on universal and selective prevention strategies, our study involved a rigorous selection process, narrowing down from 10,546 to 383 relevant papers through manual screening. The analysis utilized the "bibliometrix" R package (version 4.2.2) and Python (version 3.9.6) for data processing, with VOSviewer employed for mapping collaboration networks.

RESULTS

Our analysis revealed a consistent annual growth rate of 10.85% in ED prevention research publications, with significant contributions from the "International Journal of Eating Disorders" and some notable authors. The United States emerged as the dominant contributor. The analysis also highlighted key trends, including a surge in publications between 2010 and 2017, and the role of major institutions in advancing research in this field.

DISCUSSION

The increasing rate of publications on the prevention of EDs is encouraging. However, the actual number of studies on the prevention of EDs are limited, and the majority of this work is performed by a few research groups. Given the high concentration of publications within a few countries and research groups, increased funding, facilitation of prevention research on a wider scale, and engagement of more researchers and further collaboration are called for.

Assessing motivation for treatment in eating disorders: psychometric validation of the Italian version of the Autonomous and Controlled Motivation for Treatment Questionnaire (ACMTQ-ITA)

PURPOSE

Treatment resistance is a significant challenge in addressing eating disorders (EDs). The Autonomous and Controlled Motivation for Treatment Questionnaire (ACMTQ) has been previously validated in ED populations to assess patients' motivation for treatment. This study aimed to validate the ACMTQ in the Italian language (ACMTQ-ITA) and evaluate its psychometric properties.

METHODS

We recruited a clinical sample of adults aged 18 or older, diagnosed with EDs, proficient in the Italian language, and providing written informed consent. Participants with psychiatric comorbidities such as schizophrenia, bipolar disorder, and substance use disorder were excluded from the study. Validity of the ACMTQ-ITA was assessed using reliability analysis with Cronbach's α and McDonald's ω estimates, and Confirmatory Factor Analysis (CFA).

RESULTS

Results from the reliability analysis confirmed the internal consistency of the Autonomous Motivation (AM) factor (α = 0.82, ω = 0.82), the Controlled Motivation (CM) factor (α = 0.76, ω = 0.77), and the ACMTQ-ITA overall score (α = 0.79). The CFA confirmed the two-factor solution (i.e., AM and CM) identified in the original validation of the ACMTQ (Comparative Fit Index = 0.92, Akaike Information Criterion = 3427.26, Bayesian Information Criterion = 3486.82; Root Mean Square Error of Approximation = 0.08, Standardized Root Mean Square Residual = 0.09).

CONCLUSION

The ACMTQ-ITA emerged as a valid and reliable tool for measuring motivation for treatment in individuals with EDs. Its implementation may facilitate the comprehension of treatment motivation, offering valuable clinical insights and implications for health management practices.

LEVEL OF EVIDENCE

Level V, descriptive studies.

Food Cravings and Obesity in Women with Polycystic Ovary Syndrome: Pathophysiological and Therapeutic Considerations

Polycystic ovary syndrome (PCOS), the most common endocrine disorder in women of reproductive age, constitutes a metabolic disorder frequently associated with obesity and insulin resistance (IR). Furthermore, women with PCOS often suffer from excessive anxiety and depression, elicited by low self-esteem due to obesity, acne, and hirsutism. These mood disorders are commonly associated with food cravings and binge eating. Hypothalamic signaling regulates appetite and satiety, deteriorating excessive food consumption. However, the hypothalamic function is incapable of compensating for surplus food in women with PCOS, leading to the aggravation of obesity and a vicious circle. Hyperandrogenism, IR, the reduced secretion of cholecystokinin postprandially, and leptin resistance defined by leptin receptors' knockout in the hypothalamus have been implicated in the pathogenesis of hypothalamic dysfunction and appetite dysregulation. Diet modifications, exercise, and psychological and medical interventions have been applied to alleviate food disorders, interrupting the vicious circle. Cognitive-behavioral intervention seems to be the mainstay of treatment, while the role of medical agents, such as GLP-1 analogs and naltrexone/bupropion, has emerged.

Early childhood appetitive traits and eating disorder symptoms in adolescence: a 10-year longitudinal follow-up study in the Netherlands and the UK

BACKGROUND

Obesity and eating disorders commonly co-occur and might share common risk factors. Appetite avidity is an established neurobehavioural risk factor for obesity from early life, but the role of appetite in eating disorder susceptibility is unclear. We aimed to examine longitudinal associations between appetitive traits in early childhood and eating disorder symptoms in adolescence.

METHODS

In this longitudinal cohort study, we used data from Generation R (based in Rotterdam, the Netherlands) and Gemini (based in England and Wales). Appetitive traits at age 4-5 years were measured using the parent-reported Child Eating Behaviour Questionnaire. At age 12-14 years, adolescents self-reported on overeating eating disorder symptoms (binge eating symptoms, uncontrolled eating, and emotional eating) and restrictive eating disorder symptoms (compensatory behaviours and restrained eating). Missing data on covariates were imputed using Multivariate Imputation via Chained Equations. Ordinal and binary logistic regressions were performed in each cohort separately and adjusted for confounders. Pooled results were obtained by meta-analyses. Sensitivity analyses were performed on complete cases using inverse probability weighting.

FINDINGS

The final study sample included 2801 participants from Generation R and 869 participants from Gemini. Pooled findings after meta-analyses showed that higher food responsiveness in early childhood increased the odds of binge eating symptoms (odds ratio [OR]pooled 1·47, 95% CI 1·26-1·72), uncontrolled eating (1·33, 1·21-1·46), emotional eating (1·26, 1·13-1·41), restrained eating (1·16, 1·06-1·27), and compensatory behaviours (1·18, 1·08-1·30) in adolescence. Greater emotional overeating in early childhood increased the odds of compensatory behaviours (1·18, 1·06-1·33). By contrast, greater satiety responsiveness in early childhood decreased the odds of compensatory behaviours in adolescence (0·89, 0·81-0·99) and uncontrolled eating (0·86, 0·78-0·95) in adolescence. Slower eating in early childhood decreased the odds of compensatory behaviours (0·91, 0·84-0·99) and restrained eating (0·90, 0·83-0·98) in adolescence. No other associations were observed.

INTERPRETATION

In this study, higher food responsiveness in early childhood was associated with a higher likelihood of self-reported eating disorder symptoms in adolescence, whereas greater satiety sensitivity and slower eating were associated with a lower likelihood of some eating disorder symptoms. Appetitive traits in children might be early neurobehavioural risk factors for, or markers of, subsequent eating disorder symptoms.

FUNDING

MQ Mental Health Research, Rosetrees Trust, ZonMw.

Digital health applications for eating disorders treatment

Eating disorders (EDs) are characterized by multifaceted etiologies, difficulties in accessing care (especially in regional locations), and variable responsiveness to treatments. Digital technologies are viewed as an important innovation in the assessment and treatment of EDs. We discuss current implementation of these innovations as well as important future directions for the field.

Inflammatory profiles in women with eating disorder: Linking inflammatory biomarkers to clinical phenotypes

INTRODUCTION

Eating disorders (ED) represent a group of very complex and serious diagnoses characterized by emotional dysregulation and impulsivity. New approaches are necessary to achieve effective diagnosis and treatments. Shifting biomarker research away from the constraints of diagnostic categories may effectively contribute to a dimensional differentiation across disorders according to neurobiology (e.g., inflammatory biomarkers). Thus, the aim of our study was to identify inflammatory profiles in patients with ED.

METHODS

A sample of 100 women with an ED (23.4 ± 8.55 years) and 59 healthy controls (HC) (20.22 ± 4.18 years) was used. K-means cluster analysis was followed to identify inflammatory clusters considering seven blood biomarkers (iNOS, TNFα, COX2, p38, ERK, TBARS and PPARγ). Moreover, a wide assessment of clinical features was conducted.

RESULTS

Two distinct clusters were identified. Cluster 1 patients were characterized by higher inflammatory levels of TNF-α, COX2, p38, and ERK, and had more restrictive anorexia diagnosis than cluster 2. Cluster 2 participants showed higher inflammatory levels of iNOS and were older than cluster 1 and controls and had lower BMI than HC. In addition, they had higher levels of bulimic symptoms than those from the cluster 1 and HC, and higher impulsivity than HC. All ED patients (regardless of cluster) showed higher ED symptoms and more trauma than HC.

CONCLUSIONS

Our study revealed that inflammatory dysfunction may be linked with clinical endophenotypes in ED, one more restrictive (cluster 1) with an inflammation/oxidative endophenotype more cytokine and MAPK/ERK mediated, and the other more impulsive, with more bulimic symptoms (cluster 2) with NO free radical high output source iNOS. Trauma seems to be a vulnerability factor for both endophenotypes.

Eating disorders and obesity: bridging clinical, neurobiological, and therapeutic perspectives

Eating disorders (EDs) and obesity are complex health conditions sharing various risk and maintenance factors, intensified in cases of comorbidity. This review explores the similarities and connections between these conditions, examining different facets from a multidisciplinary perspective, among them comorbidities, metabolic and psychological factors, neurobiological aspects, and management and therapy implications. We aim to investigate the common characteristics and complexities of weight and EDs and explore their interrelationships in individuals who experience both. The rising prevalence of EDs in people with obesity necessitates integrated approaches to study this comorbidity and to identify and analyze both common and distinct features of these conditions. This review may offer new opportunities for simultaneous prevention and management approaches, as well as future lines of research.

Social Media Effects Regarding Eating Disorders and Body Image in Young Adolescents

The following study investigates how eating problems and young people's body image are affected by social media. As social media becomes more pervasive, young teenagers are exposed to many pictures, messages, and influencers encouraging unachievable body and beauty ideals. The study investigates the link between social media usage and the development of binge eating disorder patterns and undesirable body image judgments. It also sheds light on the influence that so-called social media influencers and celebrities have on encouraging disordered eating patterns and forming negative body image perceptions. On websites like Instagram and TikTok, exposure to deliberately selected photographs of "ideal" body types encourages body dissatisfaction and poor self-worth. The research emphasizes social media's possible harm to this vulnerable group's physical and mental health by examining pertinent literature and empirical evidence. It also looks at potential safeguards and methods for fostering good mental and physical health in early adolescents during pervasive social networking site use. Promoting fad diets, weight-loss aids, and the exaltation of extreme thinness aids in the normalization of harmful behaviours. Social media's negative consequences on eating disorders and body image in young teenagers are highlighted by this study in its conclusion. As a critical developmental stage, early adolescence is vulnerable due to the effect of social media, which could normalize unhealthy behaviours and maintain negative body image and insecurities. The findings underscore the need for targeted interventions and educational programs to mitigate the adverse effects of eating problems and young people's body image in light of social media.

Understanding Eating Disorders and the Nurse's Role in Diagnosis, Treatment, and Support

ABSTRACT

Eating disorders (EDs) are a severe type of mental illness that nurses in many settings may encounter. The three primary eating disorders-anorexia nervosa, bulimia nervosa, and binge eating disorder-are described here. Signs, symptoms, and treatment of eating disorders are outlined, along with the importance of nurses in early identification of EDs and developing therapeutic relationships with patients. A case study and elements of spiritual care are presented.

Is cognitive behavioral therapy more effective than pharmacotherapy for binge spectrum disorders? A systematic review and meta-analysis

OBJECTIVES

Binge spectrum disorders are prevalent worldwide. Psychiatric and medical comorbidities are common, and societal costs are significant. Evidence-based treatment remains underutilized. Cognitive behavioral therapy is the recommended first-line treatment, but pharmacotherapy may be easier to access.

INTERVENTIONS

Meta-analytic evidence directly comparing cognitive behavioral therapy with pharmacotherapy is lacking. We aimed to compare the effects of cognitive behavioral therapy interventions with any pharmacological treatment for binge spectrum disorders. We searched PubMed, Embase, CENTRAL, ClinicalTrials.gov and reference lists for randomized controlled trials comparing cognitive behavioral therapy with any pharmacotherapy for bulimia nervosa/binge eating disorder and performed pairwise meta-analytic evaluations.

PRIMARY OUTCOMES

Primary outcomes are remission and frequency of binges. Secondary outcomes are frequency of purges, response, eating disorder psychopathology, weight/body mass index, depression, anxiety, quality of life and dropouts.

RESULTS

Eleven randomized controlled trials comparing cognitive behavioral therapy with fluoxetine/imipramine/desipramine/methylphenidate/sibutramine were identified (N = 531). Cognitive behavioral therapy was superior to antidepressants in terms of remission, frequency of binges and eating disorder psychopathology. There were no statistically significant differences for any of the individual cognitive behavioral therapy vs drug comparisons in terms of response/depression/anxiety/weight/quality of life/dropouts. Cognitive behavioral therapy was not superior to sibutramine/methylphenidate for the primary outcomes.

CONCLUSIONS

Data are scarce, comparisons underpowered and, considering the inherent methodological limitations of psychotherapy trials, questions arise regarding the presumed superiority of cognitive behavioral therapy. Further research is needed.

New media facilitate adolescents' body dissatisfaction and eating disorders in Mainland China

New media play a significant role in adolescents' body dissatisfaction and eating disorders in Mainland China, through shaping social standards, peers, and family dynamics. How to mitigate their adverse effects on adolescents, reduce body dissatisfaction, and prevent eating disorders is a significant social issue that demands serious consideration.

Transitions from child and adolescent to adult mental health services for eating disorders: an in-depth systematic review and development of a transition framework

BACKGROUND

Eating disorders (EDs) peak in mid-to-late adolescence and often persist into adulthood. Given their early onset and chronicity, many patients transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) for ongoing, speciality ED care. This transition typically occurs at 18 years of age, when important biological, psychosocial, and vocational changes take place. Thus, smooth and effective transitions are paramount for ensuring service continuity, as well as reducing the risk of ED relapse and premature death. Here, we synthesized evidence on transitions from CAMHS to AMHS for young people with EDs, aiming to inform future research, clinical practice, and healthcare policy.

METHODS

A systematic review of the literature was conducted. This adhered to PRISMA guidelines. PubMed, Embase, and Scopus electronic databases were queried from inception to December 3, 2023. Leveraging the PICOS framework, study eligibility was evaluated in the qualitative synthesis. Data regarding methodology, analytic approach, and associated outcomes were then extracted. The quality of evidence was examined using critical appraisal tools. Finally, concept mapping was applied to organize findings into a transition framework.

RESULTS

The search returned 76 articles. Of these, 14 were included in the final review. Articles were grouped into 'qualitative' (n = 10), 'cross-sectional' (n = 2), and 'longitudinal cohort' (n = 2) studies based on research design. Overall, ED transitions were complex, multifaceted, and challenging for patients, caregivers, and providers alike. This resulted from an interplay of temporal- (e.g., timing of ED onset and transition), stakeholder- (e.g., patient ambivalence towards recovery) and systemic- (e.g., differences between services) related factors. Most studies were of moderate-to-high quality. Findings informed the development of five transition strategies designed to facilitate effective transfers across ED care: Timely talks, Readiness, Inclusion, Preparation, and Synergy (TRIPS).

CONCLUSIONS

Transitions from CAMHS to AMHS appear problematic for young people with EDs and other involved stakeholders. The field stands to benefit from TRIPS, an actionable, evidence-based framework that aims to alleviate challenges of transitioning and subsequently improve ED trajectories. As a logical next step, future work should empirically test the TRIPS framework, exploring its predictive utility and clinical value.

Is Interoception Deficit Linking Alexithymia and Eating Spectrum Symptoms? Study on a Non-Clinical Sample of Young Adults

We investigated if interoceptive deficits could be the link between alexithymic traits and eating spectrum manifestations in a non-clinical sample. One-hundred sixty-one young adults (mean age: 23.2 ± 2.4 years) were evaluated with the Toronto Alexithymia Scale-20 (TAS-20), the Interoceptive Accuracy Scale (IAS), the Interoceptive Confusion Questionnaire (ICQ), and the Eating Attitudes Test-26 (EAT-26). Questionnaires were administered with an online procedure (Microsoft Form, Office 365 A1, Pisa, Italy) (Study Protocol #0012005/2023). We compared ICQ, IAS, and TAS-20 scores in subjects who met the threshold for a potential eating spectrum disorder according to EAT-26 scores ≥ 20 (n = 27) vs. subjects who scored <20 (n = 134), with an ANCOVA corrected for 'age' and 'gender'. Subjects with EAT-26 ≥ 20, scored significantly higher at ICQ (54.4 ± 13.2 vs. 50.2 ± 6.8; p = 0.011), TAS-20 'Total Score' (60.8 ± 11.9 vs. 58.1 ± 9.2; p = 0.006), and TAS-20 'Identifying Feelings' (21.5 ± 7.6 vs. 17.3 ± 5.8; p = 0.0001). A binary logistic regression analysis, with EAT-26 scores < 20 vs. ≥20 as the dependent variable, and ICQ, IAS, TAS-20 total scores and dimensions, age, and gender (categorical) as covariates, showed that the only variable predicting eating spectrum symptomatology was 'ICQ Total Score' (OR = 1.075, 95% CI: 1.016-1.139; p = 0.013). Interoceptive confusion was the dimension linking the occurrence of alexithymic traits and eating spectrum manifestations.

"Maze Out": a study protocol for a randomised controlled trial using a mix methods approach exploring the potential and examining the effectiveness of a serious game in the treatment of eating disorders

BACKGROUND

Eating Disorders (ED) are severe and costly mental health disorders. The effects of existing treatment approaches are limited and there is a need to develop novel interventions, including digital strategies that can increase engagement and effectiveness. Maze Out is a new serious game coproduced by patients and ED therapists, which allows patients to "play" with the reality of an ED and reflect on associated challenges.

OBJECTIVES

The present study has two main objectives: (1) to evaluate the effectiveness of adding Maze Out to treatment as usual (TAU) in a randomised controlled trial (RCT); and (2) to examine in depth the potential of Maze Out by examining how it is perceived and used in the context of an RCT.

METHODS

Participants will be recruited from mental health care services, endocrinology departments or Community Centres offering treatment for ED. Patients suffering from ED (N = 94) will be randomised to either TAU or TAU plus Maze Out. Primary outcome will be measured in terms of changes in self-efficacy, measured by a 5-item self-efficacy questionnaire (5-item SE_ED). Secondary outcome measures will include feelings of ineffectiveness and self-image, as measured by Eating Disorder Inventory, version 3 (EDI-3), Brief INSPIRE-O and Structural Analysis of Social Behaviour Intrex Questionnaire (SAS-B). Data will be collected at baseline (enrolment in the study), and subsequently 8 and 15 weeks after inclusion. Experiences of playing Maze Out will be examined in a sub-sample of participants, utilising both quantitative user analytics and qualitative interview data of patients, interview data of significant others, and healthcare professionals to explore the possible impact of Maze Out on disorder insight, communication patterns between patients and therapists and understanding of their disorder.

DISCUSSION

To our knowledge Maze Out is the first serious game coproduced by patients and therapists. It is a novel and theoretically grounded intervention that may significantly contribute to the healing process of ED. If found effective, the potential for wide-spread impact and scalability is considerable. Trial registration ClinicalTrials.gov NCT05621018.

Examining anxious temperament in anorexia nervosa: Behavioural inhibition and intolerance of uncertainty and their contribution to trait anxiety in adolescents with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a serious and complex psychiatric disorder yet treatment results are suboptimal. Insight into the etiology of this illness is much needed. Research highlights the implication of anxiety-related traits in the development and maintenance of AN. This study investigates firstly, behavioural inhibition and intolerance for uncertainty (IU) in adolescents with and without AN, and secondly relations between these traits.

METHODS

In a cross-sectional study, 165 adolescent girls (AN = 94, HC = 71) completed questionnaires measuring behavioural inhibition, IU and trait anxiety. ANOVAs tested differences between AN and HC groups, and mediation models with IU as a mediator between behavioural inhibition and trait anxiety were run.

RESULTS

AN adolescents reported significantly higher levels of behavioural inhibition, IU and trait anxiety compared to their peers. In both AN and HC, a direct and a total effect of behavioural inhibition on trait anxiety was found. However, only in the AN group IU partially mediated the relation between behavioural inhibition and trait anxiety.

LIMITATIONS

Data is cross-sectional and longitudinal studies are required. A mean illness duration of nearly 2 years may mean early effects of malnourishment and habituation and future studies should include patients with shorter illness duration.

CONCLUSIONS

Results highlight that behavioural inhibition and IU may contribute to anxiety in AN whilst their peers may have developed better executive and social-emotional skills to manage uncertainty. Adolescents with AN may benefit from interventions targeting behavioural inhibition and IU.

Activation patterns in male and female forebrain circuitries during food consumption under novelty

The influence of novelty on feeding behavior is significant and can override both homeostatic and hedonic drives due to the uncertainty of potential danger. Previous work found that novel food hypophagia is enhanced in a novel environment and that males habituate faster than females. The current study's aim was to identify the neural substrates of separate effects of food and context novelty. Adult male and female rats were tested for consumption of a novel or familiar food in either a familiar or in a novel context. Test-induced Fos expression was measured in the amygdalar, thalamic, striatal, and prefrontal cortex regions that are important for appetitive responding, contextual processing, and reward motivation. Food and context novelty induced strikingly different activation patterns. Novel context induced Fos robustly in almost every region analyzed, including the central (CEA) and basolateral complex nuclei of the amygdala, the thalamic paraventricular (PVT) and reuniens nuclei, the nucleus accumbens (ACB), the medial prefrontal cortex prelimbic and infralimbic areas, and the dorsal agranular insular cortex (AI). Novel food induced Fos in a few select regions: the CEA, anterior basomedial nucleus of the amygdala, anterior PVT, and posterior AI. There were also sex differences in activation patterns. The capsular and lateral CEA had greater activation for male groups and the anterior PVT, ACB ventral core and shell had greater activation for female groups. These activation patterns and correlations between regions, suggest that distinct functional circuitries control feeding behavior when food is novel and when eating occurs in a novel environment.

Cognitive behavioral therapy versus compassion focused therapy for adult patients with eating disorders with and without childhood trauma: A randomized controlled trial in an intensive treatment setting

OBJECTIVE

Treatments for eating disorders are moderately effective, with cognitive behavior therapy (CBT) providing the strongest evidence. However, it remains important to investigate other interventions, particularly for eating disorders with greater complexity (e.g., substantial comorbidity; trauma history) or for patients who have not responded adequately to previous treatments.

METHOD

This randomized controlled trial compared CBT against compassion-focused therapy for eating disorders (CFT-E), where half of the sample had a childhood trauma history. The study was pre-registered and adequately powered. A total of 130 patients were randomly assigned to CBT or CFT-E and were assessed at pre-treatment, post-treatment and one-year follow-up. The primary outcome measure was the total score on the Eating Disorder Examination-Interview (EDE), and secondary outcome measures were the Symptom Checklist-90, Inventory of Interpersonal Problems-64 and Post-Traumatic Symptom Scale. Attrition during treatment was low (13%), suggesting good acceptability.

RESULTS

Eating pathology (EDE scores) reduced substantially overall, with large effect sizes, and there were no differences between therapies. However, at follow-up, for patients with a childhood trauma history, CFT-E maintained benefits better than CBT.

CONCLUSION

While both CBT and CFT-E resulted in significant reductions in eating pathology, CFT-E showed superior maintenance of benefits for patients with a history of childhood trauma at one-year follow-up, underlining the necessity of tailored interventions for specific patient subgroups.

Pharmacological Studies in Eating Disorders: A Historical Review

Eating disorders (EDs) are serious mental health conditions characterised by impaired eating behaviours and nutrition as well as disturbed body image, entailing considerable mortality and morbidity. Psychopharmacological medication is an important component in the treatment of EDs. In this review, we performed a historic analysis of pharmacotherapeutic research in EDs based on the scientific studies included in the recently published World Federation of Societies for Biological Psychiatry (WFSBP) guidelines for ED treatment. This analysis focuses on early approaches and trends in the methods of clinical pharmacological research in EDs, for example, the sample sizes of randomised controlled trials (RCTs). We found the development of psychopharmacological treatments for EDs followed advancements in psychiatric pharmacotherapy. However, the application of RCTs to the study of pharmacotherapy for EDs may be an impediment as limited participant numbers and inadequate research funding impede generalisability and statistical power. Moreover, current medication usage often deviates from guideline recommendations. In conclusion, the RCT model may not effectively capture the complexities of ED treatment, and funding limitations hinder research activity. Novel genetically/biologically based treatments are warranted. A more comprehensive understanding of EDs and individualised approaches should guide research and drug development for improved treatment outcomes.

Social media use among adolescents with eating disorders: a double-edged sword

Eating disorders are on the rise with a significant impact on mental health. Misuse of social media platforms is likely a significant contributing factor. This trend is especially pronounced among adolescents, who are increasingly using social media platforms for communications, building relationships, learning and entertainment. The unsupervised sharing of social media content can have drastic consequences on the physical and psychological wellbeing of youth, which often takes the form of "thinspiration" or "fitspiration". This probably serves as a trigger for those already struggling with eating disorders. In addition, there is a lack of awareness among youth and adults on ideal knowledge-sharing practices related to an eating disorder. By addressing the unique challenges that social media presents for youth with eating disorders, communities can work towards creating a safer and more supportive online environment on a global scale. At this junction, this article aims to share the current challenges of social media use among adolescents with eating disorders and put forth recommendations for how social media could be used as a tool for positive impact in this population.

Prevalence and related factors of eating disorders in pregnancy: a systematic review and meta-analysis

PURPOSE

To reveal the prevalence of eating disorders (EDs) and related factors in pregnancy.

METHODS

The search was performed in PubMed, EBSCOhost, Web of Science, Scopus, Google Scholar, and Ovid databases search up to April 3, 2022, using the keywords combination of "(eating disorders OR anorexia nervosa OR bulimia nervosa OR binge eating disorder) AND (pregnancy OR pregnant)". Two researchers independently extracted data from the articles using a standard form. We evaluated the quality of the studies according to the Joanna Briggs Institute assessment tools.

RESULTS

The prevalence of EDs in pregnant women in the 11 studies involving 2,369,520 pregnant women was ranging between 0.5 and 10.6%. The prevalence of EDs in pregnant women was 4.3% (95% confidence interval 2%-9%; I2 = 99.5%). The prevalence of anorexia nervosa and binge eating disorder during pregnancy shows a statistically significant increase compared to pre-pregnancy, and the prevalence of bulimia nervosa during pregnancy decreases. The prevalence of EDs is higher in pregnant women under 30 years of age, secondary school graduates, married, and with normal BMI. Half of the pregnant women with EDs had anxiety and about one-third of pregnant women had depression. Excessive exercise is observed in 0.7% of pregnant women, fasting in 0.3%, laxative or diuretic use in 0.1%, and self-induced vomiting in 0.6%.

CONCLUSIONS

This study is important as it is the first systematic review and meta-analysis to reveal the global prevalence of EDs in pregnant women and related factors. Continuing routine screening tests to detect EDs during pregnancy may contribute to taking special preventive measures for risk groups and protecting mother-child health.

TRIAL REGISTRATION

PROSPERO registration number (CRD42022324721), date of registration: 10/05/2022.

The value of a multidisciplinary consensus meeting in achieving agreement on eating disorders diagnosis at a specialized referral center

OBJECTIVE

This study aimed to evaluate the concordance of eating disorders (EDs) diagnoses within a multidisciplinary team in a specialized hospital unit dedicated to the medical care of ED.

METHODS

The study analyzed data from 608 female patients who sought consultation at the Eating Disorders Referral Center between 2017 and 2021. The diagnoses were established according to the DSM-5 criteria by endocrinologists, psychiatrists, and finally confirmed or discussed within a monthly multidisciplinary consensus meeting (MCM). Fleiss' Kappa tests were conducted to assess inter-raters' agreement.

RESULTS

Overall, substantial agreement was observed between endocrinologists and psychiatrists and the MCM. A more detailed analysis revealed variations in agreement across different disorders. Certain EDs demonstrated substantial agreement (e.g., anorexia nervosa restrictive subtype), while others approached near-perfect agreement (e.g., binge-eating disorder). In contrast, agreement was fair to poor for anorexia nervosa binge-purge subtype (ANBP) and slight for other specified feeding and ED. A period of temporary disagreement was noted for ANBP, partially attributed to practitioner turnover. An improvement in interdisciplinary agreement was observed for all ED diagnoses by the end of the study period.

DISCUSSION

Variations or lower levels of inter-rater agreement may stem from atypical cases that fall on the border between two diagnoses or complex cases, as well as fluctuating symptoms. The progress observed throughout the study can be attributed in part to interdisciplinary learning, particularly facilitated by the MCM. The findings underscore the significance of striving for optimal concordance among different medical specialties to enhance patient care in ED treatment.

PUBLIC SIGNIFICANCE

This study scrutinizes the agreement levels of ED diagnoses among endocrinologists and psychiatrists within a multidisciplinary team at an Eating Disorders Referral Center. While substantial overall agreement was achieved, disparities or lower agreement levels were evident for certain diagnoses such as anorexia nervosa binge-purge subtype. However, collaborative meetings led to a progressive enhancement in agreement over time. This research underscores the crucial role of a multidisciplinary team working collectively to ensure precise diagnoses and improved care for patients with EDs.

Cardiovascular disease prevention in heterozygous familial hypercholesterolemia: how important is a healthy diet in the era of long-lasting cholesterol-lowering drug therapies?

PURPOSE OF REVIEW

This review aims to provide an in-depth perspective on the importance of diet for cardiovascular disease (CVD) prevention in heterozygous familial hypercholesterolemia (HeFH).

RECENT FINDINGS

Even though data on diet and CVD prevention in HeFH are limited, the currently available evidence supports its cholesterol-lowering effect and its favorable association with CVD risk on the long-term. However, qualitative evidence from individuals with HeFH suggests that there is a common perception that diet is useless compared to medication, and this misconception serves as a barrier to healthy eating. On the other hand, evidence also suggests that individuals with HeFH are at higher risk of eating disorders compared with unaffected individuals. Family history of premature death and the chronic nature of the disease would be in cause.

SUMMARY

Emphasizing a healthy diet needs to remain at the foundation of CVD prevention in HeFH. Evidence are limited but supportive of the cholesterol-lowering and cardioprotective potential effects of diet. Engaging in conversations about healthy dieting with individuals in HeFH is likely to help prevent misconceptions about diet. Additionally, it could help reduce the risk of eating disorders, which, altogether, is likely to improve overall CVD prevention.

Skills-based online self-help program for carers of people with an eating disorder (SupportED): A case series evaluation

OBJECTIVE

To investigate the acceptability, feasibility, and preliminary effectiveness of "SupportED," a novel, online, self-paced skills-based program for carers/support people of those with lived and/or living experience of an eating disorder (ED).

METHOD

Carers of a loved one with an ED were invited to undertake a five-module skills-based (one core module, four optional modules) online program at their own pace. Modules cover general information about EDs, communication, practical skills, treatment engagement, and recovery. Participants completed demographics and were assessed using EDSIS, CASK, and DASS-21 for caregiver burden, skills, and distress, respectively, at program completion and 3-month follow-up. Feedback on the program and modules was also collected.

RESULTS

Most carers (65%; 82/126) completed the core module of the program, which is on par with other online learning programs. Nearly half of program completers responded to the 3-month follow-up (n = 39). On average, carers rated the program as relevant and useful and found the information validating and easy to understand, albeit a few carers found the program time-consuming and technically challenging. Intent-to-treat (ITT) linear mixed models demonstrated the preliminary effectiveness of the program for improving carer burden and skills, although the change in carer distress was non-significant.

CONCLUSIONS

Results of this case series evaluation suggest SupportED is an acceptable and feasible program for carers and may improve burden and support skill development. Although the online, self-paced format was highly rated, small improvements to improve acceptability were suggested. Reasons for a lack of impact on carer distress are discussed.

PUBLIC SIGNIFICANCE

This article describes a case series evaluation of "SupportED," an online skills-based support program for families, carers, and supporters of people with lived experience of an eating disorder. This is the first online carer support program that is designed to be inclusive of all carer types (e.g., partners, siblings) for all eating disorder presentations. Findings suggest the program's suitability and helpfulness for reducing carers' load and bolstering skills and knowledge.

Alternate-day fasting ameliorated anxiety-like behavior in high-fat diet-induced obese mice

Alternate-day fasting (ADF) has been reported to reduce body weight, neuroinflammation, and oxidative stress damage. However, it is not known whether ADF affects obesity-induced anxiety-like behavior. Here, male C57BL/6 mice were given an alternate fasting and high-fat diet (HFD) or standard chow diet (SD) every other day for 16 or 5 weeks. After the intervention, the degree of anxiety of the mice was evaluated by the open field test (OFT) and the elevated plus maze (EPM) test. Pathological changes in the hippocampus, the expression of Sirt1 and its downstream protein monoamine oxidase A (MAO-A) in the hippocampus, and the expression of 5-hydroxytryptamine (5-HT) were detected. Compared with HFD-fed mice, HFD-fed mice subjected to ADF for 16 weeks had a lower body weight but more brown adipose tissue (BAT), less anxiety behavior, and less pathological damage in the hippocampus, and lower expression of Sirt1 and MAO-A protein and higher 5-HT levels in the hippocampus could be observed. In addition, we noted that long-term ADF intervention could cause anxiety-like behavior in SD mice. Next, we changed the intervention time to 5 weeks. The results showed that short-term ADF intervention could reduce the body weight and increase the BAT mass of SD mice, but it did not affect anxiety. These results indicated that long-term ADF ameliorated obesity-induced anxiety-like behavior and hippocampal damage, but caused anxiety in normal-weight mice. Short-term ADF did not produce adverse emotional reactions in normal-weight mice. Here, we might provide new ideas for the treatment of obesity-induced anxiety.

Outcomes in people with eating disorders: a transdiagnostic and disorder-specific systematic review, meta-analysis and multivariable meta-regression analysis

Eating disorders (EDs) are known to be associated with high mortality and often chronic and severe course, but a recent comprehensive systematic review of their outcomes is currently missing. In the present systematic review and meta-analysis, we examined cohort studies and clinical trials published between 1980 and 2021 that reported, for DSM/ICD-defined EDs, overall ED outcomes (i.e., recovery, improvement and relapse, all-cause and ED-related hospitalization, and chronicity); the same outcomes related to purging, binge eating and body weight status; as well as mortality. We included 415 studies (N=88,372, mean age: 25.7±6.9 years, females: 72.4%, mean follow-up: 38.3±76.5 months), conducted in persons with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding and eating disorders (OSFED), and/or mixed EDs, from all continents except Africa. In all EDs pooled together, overall recovery occurred in 46% of patients (95% CI: 44-49, n=283, mean follow-up: 44.9±62.8 months, no significant ED-group difference). The recovery rate was 42% at <2 years, 43% at 2 to <4 years, 54% at 4 to <6 years, 59% at 6 to <8 years, 64% at 8 to <10 years, and 67% at ≥10 years. Overall chronicity occurred in 25% of patients (95% CI: 23-29, n=170, mean follow-up: 59.3±71.2 months, no significant ED-group difference). The chronicity rate was 33% at <2 years, 40% at 2 to <4 years, 23% at 4 to <6 years, 25% at 6 to <8 years, 12% at 8 to <10 years, and 18% at ≥10 years. Mortality occurred in 0.4% of patients (95% CI: 0.2-0.7, n=214, mean follow-up: 72.2±117.7 months, no significant ED-group difference). Considering observational studies, the mortality rate was 5.2 deaths/1,000 person-years (95% CI: 4.4-6.1, n=167, mean follow-up: 88.7±120.5 months; significant difference among EDs: p<0.01, range: from 8.2 for mixed ED to 3.4 for BN). Hospitalization occurred in 26% of patients (95% CI: 18-36, n=18, mean follow-up: 43.2±41.6 months; significant difference among EDs: p<0.001, range: from 32% for AN to 4% for BN). Regarding diagnostic migration, 8% of patients with AN migrated to BN and 16% to OSFED; 2% of patients with BN migrated to AN, 5% to BED, and 19% to OSFED; 9% of patients with BED migrated to BN and 19% to OSFED; 7% of patients with OSFED migrated to AN and 10% to BN. Children/adolescents had more favorable outcomes across and within EDs than adults. Self-injurious behaviors were associated with lower recovery rates in pooled EDs. A higher socio-demographic index moderated lower recovery and higher chronicity in AN across countries. Specific treatments associated with higher recovery rates were family-based therapy, cognitive-behavioral therapy (CBT), psychodynamic therapy, and nutritional interventions for AN; self-help, CBT, dialectical behavioral therapy (DBT), psychodynamic therapy, nutritional and pharmacological treatments for BN; CBT, nutritional and pharmacological interventions, and DBT for BED; and CBT and psychodynamic therapy for OSFED. In AN, pharmacological treatment was associated with lower recovery, and waiting list with higher mortality. These results should inform future research, clinical practice and health service organization for persons with EDs.

Therapeutic alliance with psychotherapist versus dietician: a pilot study of eating disorder treatment in a multidisciplinary team during the COVID-19 pandemic

Little is known about the therapeutic alliance (TA) formed with different professionals in multidisciplinary eating disorder (ED) treatment, particularly in the context of online treatment during the COVID-19 pandemic. We aimed to conduct a pilot study during the COVID-19 pandemic examining characteristics of patients' TA with their dieticians and psychotherapists, associations between patients' and therapists' views of the TA, and relationships between psychological characteristics and TAs. Sixty-three patients with EDs and their treating psychotherapists and dieticians were surveyed during the COVID-19 pandemic using the Working Alliance Inventory (WAI-S). Spearman correlation tests were used to examine associations between variables. Positive associations were found between the TAs examined. Concordance was stronger in patient-dietician dyads than in patient-psychotherapist dyads. Severe ED psychopathology was associated with weaker TA (bond subscale). General psychopathology was associated with weaker TA with the dietician (task subscale). Given that several differences were found between the TAs of treatment dyads, further longitudinal studies are needed to validate our pilot findings and to investigate multidisciplinary TAs and their impact on treatment outcomes in online ED treatment settings during the COVID-19 pandemic, as well as in other treatment settings (e.g., in-person settings). This study will contribute to a deeper understanding of the dynamics of TAs in multidisciplinary ED treatment and inform the development of more effective interventions.

Early evaluation of a DBT-informed online intervention for people with eating disorders

OBJECTIVES

Eating disorders (EDs) have a worldwide prevalence of 7.8%, with towering mortality rates and high healthcare costs. The current recommended treatment for EDs principally works by directly targeting ED thoughts and behaviours, but recovery rates are low. A multifaceted link between difficulties with emotions and EDs is now widely established, and newer third-wave therapies that aim to address these underlying emotion difficulties are promising. The current study piloted an online emotion self-help intervention which was co-developed with clinicians and people with lived experienced of EDs. The intervention aimed to specifically address difficulties with emotion identification and regulation, as well as unhelpful beliefs about emotions, which are believed to give rise to and maintain ED thoughts and behaviours.

METHOD

We recruited 39 people with self-reported EDs to test this intervention over a one-week period. Our participants were asked to complete a series of questionnaires measuring emotion processes and psychopathology on Day 1 (T1) before being given access to the intervention. Participants were then asked to practice the newly acquired skills for seven days, before taking the same questionnaires on Day 9 (T2). We also asked participants to qualitatively report on their experience of the intervention.

RESULTS

We found significant improvements in ED psychopathology (ED-15), depression (PHQ-9), and anxiety (GAD-7) pre- to post-intervention, with medium to large effect sizes. All our emotion variables namely alexithymia (TAS-20), difficulties regulating emotions (DERS-SF), and unhelpful beliefs about emotions (EBQ) also showed significant changes post-intervention with medium to large effect sizes. Most importantly, changes in emotion regulation processes were linked to improved eating psychopathology. The qualitative analysis corroborated this finding, highlighting how the intervention helped them form new beliefs about emotions, which helped them reduce ED behaviours.

DISCUSSION

Significant improvements in emotion processing and regulations, as well as psychopathology, along with positive qualitative feedback, suggest that the intervention effectively met its aims of increasing awareness of the link between emotions and eating psychopathology, providing help to identify and regulate emotions, and normalising emotional experiences. While our results are promising, further research is required to assess its effectiveness longer term and in clinical settings.

Longitudinal associations between community violence exposure, posttraumatic stress symptoms, and eating disorder symptoms

BACKGROUND

Eating disorder (ED) symptoms have been associated with different types of traumatic events, such as exposure to sexual and physical violence, and emotional abuse. However, the relation between ED symptoms and community violence exposure (CVE) is underexplored, despite the latter's adverse effects on many aspects of adolescent functioning. The primary aim of this study was to evaluate the relation between CVE and ED symptoms in adolescents, while also investigating the potential mediating and moderating roles of posttraumatic stress (PTS) symptoms, gender, and ethnicity.

METHODS

Data were collected longitudinally over two consecutive years in the city of New Haven, CT, in the United States. Participants were 2612 adolescent students from the public school system (1397 girls and 1215 boys) with an average age of 12.8 years (SD = 1.29). The students were comprised of several different ethnic groups, including Caucasians, African Americans and Hispanic Americans. Associations between CVE (no exposure, witnessing, and victimization) and PTS symptoms at year one, and ED symptoms (thoughts and compensatory behaviors) at year two, were assessed with self-rating instruments. Moderation and mediation analyses were conducted using a variant of linear regression (Hayes PROCESS macro).

RESULTS

ED symptoms at year two were significantly associated with both witnessing and being a victim of community violence at year one, with most or all of the relations being explained by PTS symptoms. Overall, neither gender nor ethnicity had a meaningful moderating effect in the observed relations.

CONCLUSIONS

The findings support the notion that assessing and addressing PTS symptoms might be beneficial when treating individuals with ED symptoms who have experienced community violence, irrespective of gender or ethnicity.

The importance of factors early in life for development of eating disorders in young people, with some focus on type 1 diabetes

AIM

Eating disorders have a serious impact on quality of life, especially when combined with Type 1 diabetes. We investigated eating disorders in relation to factors early in life with some focus on Type 1 diabetes.

METHODS

Out of 21,700 children born 1st of Oct 1997-1st of Oct 1999 17,055 (78.6%) were included in ABIS (All Babies in southeast Sweden) and 16,415 had adequate questionnaires. ICD-10 diagnosis from The National Patient Register was merged with the ABIS data.

RESULTS

In total 247 individuals, 19 boys (7.7%) and 219 girls (92.3%) out of 16,415 (1.5%) developed eating disorders (EDs), 167 (1.0%) Type 1 diabetes of whom 7 (4.2%) also got eating disorders (ED) (OR 3.25 (1.47-7.28); p = 0.04), all of them years after diagnosis of Type 1 diabetes. EDs was associated with high parental education especially in fathers (OR 1.65 (1.09-2.50); p = 0.02) and to at birth anxiety, and depression among mothers. There was no association with the duration of breastfeeding.

CONCLUSIONS

Eating disorders are common in girls, with increased risk in high-educated but psychologically vulnerable families. Prevalence is increased in type 1 diabetes. Even modern diabetes treatment needs to be completed with psychological support.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Eating disorder hospitalizations among children and youth in Canada from 2010 to 2022: a population-based surveillance study using administrative data

BACKGROUND

Eating disorders (EDs) are severe mental illnesses associated with significant morbidity and mortality. EDs are more prevalent among females and adolescents. Limited research has investigated Canadian trends of ED hospitalizations prior to the COVID-19 pandemic, however during the pandemic, rates of ED hospitalizations have increased. This study examined rates of ED hospitalizations among children and youth in Canada from 2010 to 2022, by sex, age, province/territory, length of stay, discharge disposition and ED diagnosis.

METHODS

Cases of ED hospitalizations among children and youth, ages 5 to 17 years, were identified using available ICD-10 codes in the Discharge Abstract Database from the 2010/11 to 2022/23 fiscal years. The EDs examined in this study were anorexia nervosa (F50.0), atypical anorexia nervosa (F50.1), bulimia nervosa (F50.2), other EDs (F50.3, F50.8) and unspecified EDs (F50.9). Both cases of total and first-time ED hospitalizations were examined. Descriptive statistics and trend analyses were performed.

RESULTS

Between 2010/11 and 2022/23, 18,740 children and youth were hospitalized for an ED, 65.9% of which were first-time hospitalizations. The most frequent diagnosis was anorexia nervosa (51.3%). Females had significantly higher rates of ED hospitalization compared to males (66.7/100,000 vs. 5.9/100,000). Youth had significantly higher rates compared to children. The average age of ED hospitalization was 14.7 years. Rates of ED hospitalizations were relatively stable pre-pandemic, however during the pandemic (2020-2021), rates increased.

INTERPRETATION

Rates of pediatric ED hospitalizations in Canada increased significantly during the pandemic, suggesting that there may have been limited access to alternative care for EDs or that ED cases became more severe and required hospitalization. This emphasizes the need for continued surveillance to monitor how rates of ED hospitalizations evolve post-pandemic.

Role of Endogenous Opioids in the Pathophysiology of Obesity and Eating Disorders

This second chapter in our trilogy reviews and critically appraises the scientific evidence for the role of endogenous opioid system (EOS) activity in the onset and progression of both obesity and eating disorders. Defining features of normative eating and maladaptive eating behaviors are discussed as a foundation. We review the scientific literature pertaining to the predisposing risk factors and pathophysiology for obesity and eating disorders. Research targeting the association between obesity, disordered eating, and psychiatric comorbidities is reviewed. We conclude by discussing the involvement of endogenous opioids in neurobiological and behavior traits, and the clinical evidence for the role of the EOS in obesity and eating disorders.