Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

'In an otherwise limitless world, I was sure of my limit.'† Experiencing Anorexia Nervosa: A phenomenological metasynthesis

Anorexia Nervosa (AN) has the highest mortality rate of the mental disorders, with still less than 50% of affected individuals achieving recovery. Recent calls to bring innovative, empirical research strategies to the understanding of illness and its core psychopathological features highlight the need to address significant paucity of efficacious treatment. The current study brings a phenomenological approach to this challenge, synthesizing lived experience phenomena as described by qualitative literature. Fifty-three studies published between the years 1998 and 2021 comprising a total of 1557 participants aged 12-66 suffering from AN or sub-threshold AN are included. Reciprocal and refutational analysis generated six key third-order constructs: "emotion experienced as overwhelming," "identity," "AN as a tool," "internal conflict relating to Anorexia," "interpersonal communication difficulties" and "corporeality." Twenty-six sub-themes were identified, the most common being fear, avoidance, AN as guardian/protector, and AN as intertwined with identity. Some themes associated with current treatment models such as low self-esteem, need for social approval and feelings of fatness were less common. We highlight the significant role of intense and confusing emotion in AN, which is both rooted in and engenders amplified fear and anxiety. Restrictive eating functions to numb these feelings and withdraw an individual from a chaotic and threatening world whilst providing a sense of self around which to build an illness identity. Results have implications for therapeutic practice and overly protective weight and shape focused medical treatment models, which may serve to reinforce the disease.

Recognising and managing eating disorders in the emergency department

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

Beyond Refeeding: The Effect of Including a Dietitian in Eating Disorder Treatment. A Systematic Review

Eating disorders are potentially life-threatening mental health disorders that require management by a multidisciplinary team including medical, psychological and dietetic specialties. This review systematically evaluated the available literature to determine the effect of including a dietitian in outpatient eating disorder (ED) treatment, and to contribute to the understanding of a dietitian’s role in ED treatment. Six databases and Google Scholar were searched for articles that compared treatment outcomes for individuals receiving specialist dietetic treatment with outcomes for those receiving any comparative treatment. Studies needed to be controlled trials where outcomes were measured by a validated instrument (PROSPERO CRD42021224126). The searches returned 16,327 articles, of which 11 articles reporting on 10 studies were included. Two studies found that dietetic intervention significantly improved ED psychopathology, and three found that it did not. Three studies reported that dietetic input improved other psychopathological markers, and three reported that it did not. One consistent finding was that dietetic input improved body mass index/weight and nutritional intake, although only two and three studies reported on each outcome, respectively. A variety of instruments were used to measure each outcome type, making direct comparisons between studies difficult. Furthermore, there was no consistent definition of the dietetic components included, with many containing psychological components. Most studies included were also published over 20 years ago and are now out of date. Further research is needed to develop consistent dietetic guidelines and outcome measures; this would help to clearly define the role of each member of the multidisciplinary team, and particularly the role of dietitians, in ED treatment.

Impact of patient characteristics on clinicians' decisions to involve dietitians in eating disorder treatment

BACKGROUND & AIMS

Dietetic involvement in eating disorder (ED) treatment is often initiated by other members of a patient's treating team. This study aimed to examine the impact of patient characteristics on clinicians' decisions to involve a dietitian in a patient's ED treatment, as well as the influence of clinician characteristics on their decision-making.

METHODS

ED clinicians were recruited to complete an online survey, which used case vignettes to assess their likelihood of referring patients to a dietitian or consulting with a dietitian for guidance. Questions were also included measuring clinician anxiety, beliefs about the therapy they deliver, beliefs about dietitians and views on evidence-based practice, to determine if these were related to their responses to case vignettes.

RESULTS

Fifty-seven clinicians completed the survey, with the largest group being clinical psychologists (n=22, 39%). ED diagnosis, weight status, medical co-morbidities and progress in treatment were all shown to be influential on whether clinicians involved dietitians in ED treatment. Clinician characteristics and their beliefs about dietitians were generally not correlated with the likelihood of seeking dietetic input.

CONCLUSIONS

This study indicates that clinicians' decisions to involve dietitians in ED treatment are systematic rather than random decisions influenced by individual clinician characteristics. Clinicians require further education on the potential for malnutrition regardless of patients'ED diagnosis or weight status, and the dietitian's role in addressing this. This article is protected by copyright. All rights reserved.

A standard enteral formula versus an iso-caloric lower carbohydrate/high fat enteral formula in the hospital management of adolescent and young adults admitted with anorexia nervosa: a randomised controlled trial

BACKGROUND

The nutritional rehabilitation of malnourished patients hospitalised with anorexia nervosa is essential. The provision of adequate nutrition must occur, while simultaneously, minimising the risk of refeeding complications, such as electrolyte, metabolic, and organ dysfunction. The aim of this study was to compare the efficacy and safety of an iso-caloric lower carbohydrate/high fat enteral formula (28% carbohydrate, 56% fat) against a standard enteral formula (54% carbohydrate, 29% fat).

METHODS

Patients (aged 15-25 years) hospitalised with anorexia nervosa were recruited into this double blinded randomised controlled trial. An interim analysis was completed at midpoint, when 24 participants, mean age 17.5 years (± 1.1), had been randomly allocated to lower carbohydrate/high fat (n = 14) or standard (n = 10) feeds.

RESULTS

At baseline, there was no significant difference in degree of malnutrition, medical instability, history of purging or serum phosphate levels between the two treatment arms. A significantly lower rate of hypophosphatemia developed in patients who received the lower carbohydrate/high fat formula compared to standard formula (5/14 vs 9/10, p = 0.013). The serum phosphate level decreased in both feeds, however it decreased to a larger extent in the standard feed compared to the lower carbohydrate/high fat feed (standard feed 1.11 ± 0.13 mmol/L at baseline vs 0.88 ± 0.12 mmol/L at week 1; lower carbohydrate/high fat feed 1.18 ± 0.19 mmol/L at baseline vs 1.06 ± 0.15 mmol/L at week 1). Overall, serum phosphate levels were significantly higher in the lower carbohydrate/high fat feed compared with standard feed treatment arm at Week 1 (1.06 ± 0.15 mmol/L vs 0.88 ± 0.12 mmol/L, p < 0.001). There was no significant difference in weight gain, number of days to reach medical stability, incidence of hypoglycaemia, or hospital length of stay.

CONCLUSIONS

The results of this study indicate that enteral nutrition provided to hospitalised malnourished young people with anorexia nervosa using a lower carbohydrate/high fat formula (28% carbohydrate, 56% fat) seems to provide protection from hypophosphatemia in the first week compared to when using a standard enteral formula. Further research may be required to confirm this finding in other malnourished populations.

TRIAL REGISTRATION

ANZCTR, ACTRN12617000342314. Registered 3 March 2017, http://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000342314.

Exploring occupation in recovery from bulimia nervosa: An interpretative phenomenological analysis

Introduction

Recovering from bulimia nervosa challenges a person to learn, revise, and do occupations that contribute to rather than detract from health. This study utilized Interpretative Phenomenological Analysis to (a) explore the recovery experiences of six adult women with histories of bulimia nervosa and (b) interpret how their accounts reflected the assumptions and characteristics of occupation.

Methods

Data were collected via audio-recorded, semi-structured interviews. Data analysis within and between cases identified six superordinate themes, which included interpretation in terms of criteria of occupation.

Findings

Superordinate themes reflect (1) occupation emerged in recovering from bulimia nervosa through committed action, not doing what fueled bulimia nervosa, adopting new ways of living, prioritizing self-care, connecting with others, and creating supportive environments and (2) recovery from bulimia nervosa can be construed as an occupation.

Conclusion

This study provides insight into nuances of recovery from bulimia nervosa. Results offer novel implications distinct to an occupational therapy lens, for example, consideration of self-care beyond eating and meal preparation; modification of the home, work, and social environment; and setting goals associated with not doing versus doing. Further, the interpretative finding of recovery as occupation holds implications for the evolving philosophical considerations within occupational science and therapy.

Discrepancies between Australian eating disorder clinicians and consumers regarding essential components of dietetic treatment

BACKGROUND

A recent Delphi study indicated that compared to eating disorder (ED) consumers and carers, ED specialists were less likely to endorse involvement of a dietitian as a standard component of treatment. Additionally, there was disagreement between these groups regarding the inclusion of a number of components of dietetic treatment.

OBJECTIVE

This study aimed to further investigate this data to identify areas of disagreement between ED specialist dietitians, ED specialist non-dietetic clinicians, consumers and carers with regards to outpatient dietetic treatment.

DESIGN AND PARTICIPANTS/SETTING

The ED specialists panel from a previous Delphi study was re-coded into two panels: ED specialist dietitians (n=31) and ED specialist non-dietetic clinicians (n=48) to compare responses of these panels to responses from consumers (n=32) and carers (n=23).

MAIN OUTCOME MEASURES

Statements under seven categories relating to referral to dietitian, essential components of outpatient dietetic treatment regarding four ED patient populations, strategies to promote multi-disciplinary collaboration and skills dietitians should possess if treating patients with an ED were rated on a five point Likert scale.

STATISTICAL ANALYSIS PERFORMED

One-way ANOVA were conducted with post-hoc multiple comparisons to compare mean statement ratings.

RESULTS

Thirty-seven statements (30%) showed statistically significant differences (p<0.05) in responses between panels. Discrepancies were primarily observed for statements regarding how and when dietetics is included in treatment and essential components of dietetic treatment, particularly the use of behavioural tasks such meal plans and self-monitoring. Results also highlighted deficits in participants' understanding of core responsibilities of dietitians in ED treatment and dietitians 'drifting' from delivering evidence-based components of dietetic treatment.

CONCLUSIONS

Results of this study show discrepancies amongst ED dietitians, clinicians, consumers and carers regarding what dietetic treatment for people with EDs should encompass. It also indicates the need for further research into optimising dietetic treatment for EDs which is conducted in collaboration with individuals with lived experience.

Widening the reach of family-based interventions for Anorexia Nervosa: autism-adaptations for children and adolescents

Family-based interventions are widely recommended as a first line treatment for children and young people with Anorexia Nervosa. There is clear evidence that model-adherent delivery of specific eating disorder focused family interventions has the potential to help adolescents with Anorexia Nervosa, who have typically engaged in extreme dietary restriction and lost a significant amount of weight over a relatively short period of time. Nevertheless, there remains a significant number of young people with restrictive eating disorders for whom family-based interventions for Anorexia Nervosa prove less effective, suggesting adaptations may be indicated for some. In this paper we provide a rationale and structure for considering a number of possible adaptations to the delivery of family-based therapy for anorexia nervosa specifically intended to enhance its relevance and potential effectiveness for children and adolescents on the autism spectrum; a subgroup known to represent a significant minority in eating disorder populations who have been identified as having relatively poor outcomes. Past research has shown that certain family-based treatments are effective for many children and adolescents who develop Anorexia Nervosa. At the same time this type of treatment approach in its current form does not work for everyone. Recent research has highlighted the overlap between anorexia and autism and the need for the development of adaptations to existing treatments to better meet the requirements of people on the autism spectrum who develop anorexia. With this in mind we propose a number of autism-related adaptations that could be made to family-based treatments for anorexia. We hope that these might be formally tested in the future to see if these adaptations improve outcomes for this group of individuals.

Multi-family therapy for eating disorders: A systematic scoping review of the quantitative and qualitative findings

OBJECTIVE

This study reviewed the quantitative and qualitative evidence-base for multi-family therapy (MFT) for eating disorders regarding change in physical and psychological symptoms, broader individual and family factors, and the experience of treatment.

METHOD

A systematic scoping review was conducted. Four databases (PsycInfo, Medline, Embase, CENTRAL) and five grey literature databases were searched on 24th June 2021 for relevant peer-reviewed journal articles, book chapters, and dissertations. No beginning time-point was specified. Only papers that presented quantitative or qualitative data were included. No restrictions on age or diagnosis were imposed. Studies were first mapped by study design, participant age, and treatment setting, then narratively synthesized.

RESULTS

Outcomes for 714 people who received MFT across 27 studies (one mixed-method, 17 quantitative and nine qualitative) were synthesized. MFT is associated with improvements in eating disorder symptomatology and weight gain for those who are underweight. It is also associated with improvements in other individual and family factors including comorbidities, self-esteem, quality of life, and some aspects of the experience of caregiving, although these findings are more mixed. MFT is generally experienced as both helpful and challenging due to the content addressed and intensive group process.

DISCUSSION

MFT is associated with significant improvements in eating disorder symptoms across the lifespan and improvement in broader individual and family factors. The evidence base is small and studies are generally underpowered. Larger, higher-quality studies are needed, as is research investigating the unique contribution of MFT on outcomes, given it is typically an adjunctive treatment.

Predictors of improvement in a family-based partial hospitalization/intensive outpatient program for eating disorders

The efficacy of family-based treatment (FBT) in outpatient settings has led to efforts to incorporate FBT principles into higher levels of care. The present study examined predictors of improvement in an FBT-based partial hospitalization program/intensive outpatient program (PHP/IOP) as measured by the Eating Disorder Examination-Questionnaire. Participants were 113 patients with anorexia nervosa (AN) or eating disorder not otherwise specified (EDNOS) consecutively participating in an FBT-based PHP/IOP. Multilevel modeling was used to investigate predictors for adolescents and young adults separately. Predictors considered included illness duration, previous hospitalization, hospitalization immediately prior to treatment, previous outpatient therapy, hospitalization during treatment, diagnosis, gaining 4 pounds in 4 weeks, and family status as time-invariant variables. Time-varying variables considered included depression symptoms and mothers'/fathers' ratings of parental self-efficacy and expressed emotion. For adolescents, depression by time and diagnosis by time interactions were statistically significant. At all levels of depression, adolescent patients with AN demonstrated greater reductions in eating disorder symptoms compared to patients with EDNOS. For young adults, depression and gaining 4 pounds in 4 weeks were significant predictors. The relationships for young adults were curvilinear such that, while lower eating disorder symptoms were found during treatment, these gains were not maintained at follow up.

What role can accredited exercise physiologists play in the treatment of eating disorders? A descriptive study

Including exercise alongside other therapeutic approaches may help to address dysfunctional exercise use and improve eating disorder treatment outcomes. However, traditional treatment teams often lack the expertise needed to safely prescribe exercise. The aims of this study were to explore the perceptions and experiences of Accredited Exercise Physiologists (AEPs) relating to working with clients diagnosed with eating disorders to identify the role they play in the treatment of eating disorders and identify future training needs. Individual semi-structured telephone interviews were conducted with 12 (n = 9 females) AEPs working in the eating disorders field. Thematic analysis was conducted to extract major themes from the interview transcripts. Five major themes were identified: (1) The role of AEPs in the treatment of individuals with eating disorders is comprehensive; (2) Treatment is more effective when all components are addressed; (3) The absence of therapeutic exercise within standard treatment protocols reflects limitations of traditional scope of practice and knowledge about the role of AEPs; (4) Methods of acquiring further knowledge are insufficient for those in current practice; and (5) Accredited comprehensive training is currently unavailable but needed. This qualitative study showed that AEPs believe they can play a major role in the treatment of eating disorders and that treatment outcomes for individuals are likely to be greatly enhanced when dysfunctional exercise is addressed. Multidisciplinary training is needed.

[Diversity of hospital care for anorexia nervosa in psychiatry in France]

BACKGROUND

Hospitalization is rare in anorexia nervosa (AN) and local application of indications is heterogeneous. However, no study has evaluated the effect of these different treatment modalities on the mean length of stay. Our objective was to describe the context and modalities of a wide range of hospital care programs offered to patients with anorexia nervosa in eleven specialized French psychiatric centers for patients from childhood to adulthood. This work was carried out within the framework of the EVHAN (Evaluation of Hospitalization for AN, Eudract number: 2007-A01110-53, registered in Clinical trials) research program. The EVHAN program comprises five main lines: weight objectives at discharge, the practice or not of a separation period, the use of clear nutritional dietary objectives (cognitive/behavioral), the intensity of family involvement in treatment, and the existence or absence of a stabilization phase before ending inpatient treatment. These main lines will make it possible to study the impact of treatment modalities on the future of patients in the short and medium term (at discharge and at 1-year follow-up).

METHODS

The eleven centers are located in France (Bordeaux, Nantes, Paris and Ile-de-France, Rouen and Saint-Étienne). Various staff members (psychiatrists, somatic doctors, nurses, dieticians, psychologists) from each center were interviewed using a semi-structured questionnaire. Data on operating modalities and context of care were collected and analyzed.

RESULTS

Four of the eleven centers were exclusively child/adolescent centers, and seven of 11 were adolescent (from 11, 13 or 16 years) and young adult centers. All centers offered a graduated approach from outpatient to full hospitalization. The majority had a number of beds allocated for patients with eating disorders. The criteria for hospitalization were homogeneous with respect to somatic and/or psychic severity prefiguring the consensus criteria defined by the French Health Authority (HAS) in 2010. Child/adolescent units used the weight curve to set weight objectives at discharge (between the 10th and 50th percentiles). Most adult units used weight objectives at discharge corresponding to a body mass index between 17 and 20kg/m². Nine centers used a written or oral care contract. One unit did not separate the patient from her/his usual environment, the others had a practice gradient of partial separation and total separation times. These were either short, lasting a maximum of 3 weeks, or long, lasting more than 3 weeks. Conversely, patients were not isolated within the unit, and benefited from a rich social life, depending on her/his physical condition. The patient's family was in contact with the team and fully supported. The longest periods of separation involved adolescents and adults. Nutritional support varied from a group approach (meals in the dining room, standardized meals of the care center) to very individualized approaches within a specific framework. All the units reported meeting with families at least once during the hospitalization; with the patient's parents for child/adolescent patients and/or unmarried patients and with the husband/wife for married patients. The majority of the centers requested a phase of weight stabilization, whatever the age before hospital discharge.

CONCLUSION

There is international and national consensus regarding the indications for hospitalization, and the main lines of multidisciplinary care to be developed within this framework. However, local application of these indications was heterogeneous resulting in diverse modalities of hospital care for anorexia nervosa in France. Specialized teams have developed management strategies arising from their "team culture". The complexity of the anorexic pathology, due to the psyche-soma intrication and the diversity of age groups, highlights the complexity of care available. The impact of this diversity of hospital care on patient outcomes will be studied as a result of this work.

An evaluation of family-based treatment for restrictive-type eating disorders, delivered as standard care in a public mental health service

BACKGROUND

Family-based treatment (FBT) has demonstrated efficacy for anorexia nervosa (AN) in youth in randomized, controlled trials. It is important to assess if it shows a similar effectiveness when implemented in standard care.

AIM

To evaluate outcomes of FBT for restrictive-type eating disorders, delivered as standard care in a public mental health service. Outcomes are remission, frequency of hospital admissions and day-patient treatment, and frequency of other adaptations within 12 months from commencement of treatment. Second, to compare the collaborative clinical decisions of successful treatment in standard care made by family therapist at the end of treatment, with more objective definitions of recovery.

METHODS

The design is a prospective, uncontrolled study of a consecutive series of patients with restrictive-type eating disorders, treated with FBT in a specialty unit at the Child and Adolescent Mental Health Centre in the Capital Region of Denmark.

RESULTS

FBT was successfully completed within 12 months by 57% of participants, and 47% completed with 20 sessions or fewer. Weight restoration was achieved by 75% within 12 months, and 46% achieved both normalisation of body weight and behavioural symptoms of AN within 12 months. A total of 20% needed intensified treatment. All aspects of remission were often not present simultaneously, and the collaborative clinical decisions of successful treatment only partly aligned with other parameters of remission.

CONCLUSION

FBT showed good results when implemented as standard care, and it can be adapted to the specifics of local service organisation without compromising effectiveness.

Treatment of eating disorders in older people: a systematic review

BACKGROUND

Historically, eating disorders were not identified in older populations and it is only in more recent times that there is greater recognition of the existence of eating disorders among the elderly. This is despite the high level of morbidity and mortality associated with these disorders. Current guidelines focus on treatment of eating disorders within the adolescent and general adult age groups, without apparent concessions made for the older age group. The aim of this study was to review existing literature on the demographics and treatment of eating disorders in older people.

METHODS/DESIGN

A systematic review of the literature was conducted using CINAHL, MEDLINE, EMBASE, PsycInfo, Scopus, and Web of Science to identify publications focusing on treatment of eating disorders in people over the age of 65 years, age of diagnosis, gender distribution, treatment setting, and treatment outcomes.

RESULTS

A total of 35 articles (reporting on 39 cases) were relevant to our study, with 33 of the 35 articles being either case studies or case series. The mean age of participants was 73.2 years (range 66-94 years) with the majority (84.6%) being female. Most cases (84.6%) were diagnosed with anorexia nervosa, and 56.4% of all cases were reported as late onset (i.e., after age 40 years). The vast majority (94.8%) received treatment, of which 51.5% was hospital-based treatment. In case descriptions where improvement was reported, the majority described a multidimensional approach that included a combination of hospital admission, therapy and pharmacotherapy. Overall, 79.5% of cases who underwent treatment for an eating disorder improved, while 20.5% relapsed or died as a result of the complications from their eating disorder. There were significant inconsistencies and omissions in the way cases were described, thereby impacting on the interpretation of the results and potential conclusions.

CONCLUSIONS

The information available on the treatment of eating disorders in people over the age of 65 years is limited. The quality of case reports to date makes it difficult to suggest specific assessment or treatment guidelines for this population.

Prophylactic supplementation of phosphate, magnesium, and potassium for the prevention of refeeding syndrome in hospitalized individuals with anorexia nervosa

Medical stabilization, nutrition rehabilitation, and weight restoration, while minimizing risk for the potentially fatal complication of refeeding syndrome, are the primary goals for the treatment of hospitalized individuals with anorexia nervosa and other restrictive-type eating disorders. The purpose of this review was to examine the literature exploring the prophylactic supplementation of phosphate, magnesium, and potassium, in addition to routine thiamin and multivitamin supplementation, for the prevention of refeeding syndrome in adolescents and adults with anorexia nervosa. Through evaluation of outcomes (including serum electrolyte levels and clinical signs and symptoms such as respiratory failure, cardiac failure, peripheral edema, rhabdomyolysis, and encephalopathy), three studies found that prophylactic supplementation of potassium, magnesium, and/or phosphate were effective in preventing refeeding syndrome or refeeding hypophosphatemia (a characteristic of refeeding syndrome). Although all studies found that prophylactic supplementation was effective in preventing refeeding syndrome, refeeding approaches (including the method, amount, and duration of nutrient delivery) as well as the populations studied varied considerably, making it difficult to arrive at specific recommendations for practice. Randomized controlled trials are needed to further examine the safety and effectiveness of prophylactic supplementation of phosphate, magnesium, and potassium on the prevention of refeeding syndrome, utilizing similar feeding and supplementation protocols.

Supported online cognitive behavioural therapy for bulimia nervosa: a study protocol of a randomised controlled trial

BACKGROUND

Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions.

METHODS

A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness.

DISCUSSION

There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145 .

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations

OF RECOMMENDATIONS AND LEVELS OF EVIDENCE

Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity-frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient's needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the "teach-back" technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A).

SUMMARY OF KEY RECOMMENDATIONS AND LEVELS OF EVIDENCE

Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).

Life is different now - impacts of eating disorders on Carers in New Zealand: a qualitative study

BACKGROUND

Eating disorders are widely recognized as serious illnesses, with complex psychological and physiological comorbidities. Affected individuals face a protracted and challenging treatment journey which, particularly for children and adolescents, requires significant input from family members as carers. This study investigated the perspectives and experiences of those caring for family members with an eating disorder diagnosis.

METHOD

Participants were carers of affected individuals with an eating disorder, and were recruited from an online survey, subsequently consenting to a semi-structured qualitative interview. Inductive thematic analysis was undertaken to identify themes.

RESULTS

Most participants in the sample were parents of affected individuals. Significant and ongoing psychological and emotional impacts were identified across the sample. The diagnosis, treatment journey and overall impact of the carer role created a situation captured by the over-arching theme 'life is different now'. Impacts profoundly influenced relationships and were felt across all aspects of life by carers, affected individuals and other family members. Heightened worry and vigilance experienced by carers continued beyond improvement or recovery.

CONCLUSIONS

This research highlighted challenging and often exhausting impacts felt by carers due to their pivotal role in eating disorder treatment. Inadequate support for most carers in this sample has clear implications for families as well as service and funding providers. Further research should more fully investigate carer experience with different eating disorders to explore the type of support necessary to build capacity and resilience to reduce carer burden.

A systematic review of enteral feeding by nasogastric tube in young people with eating disorders

BACKGROUND

Adolescents with severe restrictive eating disorders often require enteral feeding to provide lifesaving treatment. Nasogastric feeding (NG) is a method of enteral nutrition often used in inpatient settings to treat medical instability, to supplement poor oral intake or to increase nutritional intake. This systematic review sets out to describe current practice of NG in young people with eating disorders.

METHODS

A systematic review following PRISMA guidelines was conducted by searching AMED, EMBASE and MEDLINE databases from 2000 to 2020. Inclusion terms were: enteral feeding by nasogastric tube, under 18 years, eating disorders, and primary research. Exclusion terms: psychiatric disorders other than eating disorders; non-primary research; no outcomes specific to NG feeding and participants over 18 years. Titles and abstracts were screened by all authors before reviewing full length articles. Quality assessment, including risk of bias, was conducted by all authors.

RESULTS

Twenty-nine studies met the full criteria. 86% of studies were deemed high or medium risk of bias due to the type of study: 34.4% retrospective cohort and 10.3% RCT; 17.2% were qualitative. Studies identified 1) a wide range of refeeding regimes depending on country, settings, and the reason for initiation; 2) standard practice is to introduce Nasogastric feeds (NG) if medically unstable or oral intake alone is inadequate; 3) NG may enable greater initial weight gain due to increased caloric intake; 4) there are 3 main types of feeding regime: continuous, nocturnal and bolus; 5) complications included nasal irritation, epistaxis, electrolyte disturbance, distress and tube removal; 6) where NG is routinely implemented to increase total calorie intake, length of stay in hospital may be reduced; however where NG is implemented in correlation to severity of symptoms, it may be increased; 7) both medical and psychiatric wards most commonly report using NG in addition to oral intake.

CONCLUSIONS

NG feeding is a safe and efficacious method of increasing total calorie intake by either supplementing oral intake or continuously. There are currently no direct comparisons between continuous, nocturnal or bolus regimes, which may be used to direct future treatment for YP with ED.

Low carbohydrate diets in eating disorders and type 1 diabetes

Dietary intake requires attention in the treatment of both eating disorders and type 1 diabetes (T1D) to achieve optimal outcomes. Nutritional management of both conditions involves encouraging a wide variety of healthful foods in the context of usual cultural and family traditions. In recent times, low carbohydrate diets have seen a rise in popularity, both in T1D and in the general population. Low carbohydrate diets involve dietary restriction, although the extent depends on the level of carbohydrate prescription. Although dietary restriction is a known risk factor for eating disorders, there is limited literature on the impact of following a low carbohydrate diet on the development and maintenance of eating disorders in T1D. The aim of this review is to discuss the impact of dietary restriction on the development and treatment of eating disorders and propose considerations to enable optimum health outcomes in individuals with T1D, an at risk group. In order to achieve this, clarity regarding strategies that allow both flexibility in dietary intake and facilitate healthy eating behaviours, whilst achieving glycaemic targets, are required.

Clinical and cost-effectiveness of two ways of delivering guided self-help for people with an eating disorder: A multi-arm randomized controlled trial

OBJECTIVE

Increasing the availability and accessibility of evidence-based treatments for eating disorders is an important goal. This study investigated the effectiveness and cost-effectiveness of guided self-help via face-to-face meetings (fGSH) and a more scalable method, providing support via email (eGSH).

METHOD

A pragmatic, randomized controlled trial was conducted at three sites. Adults with binge-eating disorders were randomized to fGSH, eGSH, or a waiting list condition, each lasting 12 weeks. The primary outcome variable for clinical effectiveness was overall severity of eating psychopathology and, for cost-effectiveness, binge-free days, with explorative analyses using symptom abstinence. Costs were estimated from both a partial societal and healthcare provider perspective.

RESULTS

Sixty participants were included in each condition. Both forms of GSH were superior to the control condition in reducing eating psychopathology (IRR = -1.32 [95% CI -1.77, -0.87], p < .0001; IRR = -1.62 [95% CI -2.25, -1.00], p < .0001) and binge eating. Attrition was higher in eGSH. Probabilities that fGSH and eGSH were cost-effective compared with WL were 93% (99%) and 51% (79%), respectively, for a willingness to pay of £100 (£150) per additional binge-free day.

DISCUSSION

Both forms of GSH were associated with clinical improvement and were likely to be cost-effective compared with a waiting list condition. Provision of support via email is likely to be more convenient for many patients although the risk of non-completion is greater.

Implementing evidence-based individual psychotherapies for adults with eating disorders in a real world clinical setting

OBJECTIVE

This study aimed to evaluate the effectiveness of evidenced-based psychological treatments (specifically, Cognitive-Behaviour Therapy for Eating Disorders [CBT-ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology.

METHOD

Three hundred and seventy-nine participants meeting criteria for DSM-5 anorexia nervosa, bulimia nervosa, binge-eating disorder or other specified feeding or eating disorder completed pre- and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging.

RESULTS

Ninety seven percent of participants received treatment in line with evidence-based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m² over treatment, with similar outcomes for MANTRA and CBT-ED.

DISCUSSION

These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence-based psychotherapies to real-world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders.

Inpatients with severe-enduring anorexia nervosa: Understanding the "enduringness" specifier

BACKGROUND

Despite the need for a common definition of severe and enduring anorexia nervosa (SE-AN) with the overarching goal to optimize treatments, this definition still is being debated. Therefore, in this study we conducted an in-depth investigation of the history of AN and its clinical outcomes on inpatients with AN to ascertain the eventual "profiles" for individuals with varying durations of the illness (DOI).

METHODS

We recruited 169 inpatients with AN, grouping them according to DOI: <3 years (short duration, SD-AN); 3-6.99 years (medium duration, MD-AN); and ≥7 years (long duration, LD-AN). We then performed a self-report and interview-based investigation of AN history, clinical data, eating, and general psychopathology, including personality, premorbid traits, stage of change, and quality of life. We measured the clinical outcomes for hospitalization as well.

RESULTS

The majority of the measures did not differ across groups. Those with LD-AN were older and diagnosed mostly with the binge-purging AN subtype, failed more previous AN-related treatments, reported a lower lifetime body mass index, and trended toward a younger age at onset when compared to the other groups. All patients responded equally well to hospitalization, but patients with SD-AN improved less in drive for thinness and body-related concerns.

CONCLUSIONS

We did not find the "enduringness" of AN to be a specifier of severity. Hospitalization was effective for those with LD-AN and MD-AN, while interventions for the core cognitive aspects of over-evaluation of body shape should be offered to patients with SD-AN.

What role do dietitians have in providing nutrition care for eating disorder treatment? An integrative review

BACKGROUND

Dietitians are recognised as experts in nutrition care and essential members of multidisciplinary healthcare teams. However, the role of dietitians in caring for people with eating disorders is not well understood. The present review aimed to identify, critically appraise and synthesise the current evidence exploring the views and experiences of dietitians, other health professionals, patients and carers regarding the role of dietitians in the treatment of eating disorders.

METHODS

CINAHL, MEDLINE, Embase, Scopus and PsycINFO were searched in April 2020 and again in February 2021. Studies were included if they were original research; explored views and experiences of the role of dietitians in the treatment of eating disorders, including perceptions of patients, carers and other health professionals regarding nutrition care for eating disorders; and the full-text article was available in English. Title and abstract screening, full-text screening, quality assessment and data extraction were completed in duplicate. Quality assessment was conducted using the Mixed Methods Assessment Tool. Thematic synthesis was used for data analysis.

RESULTS

Fourteen studies met the inclusion criteria. Quantitative, qualitative and mixed-methods study designs were included. Four themes emerged inductively from the data: (i) dietitians as collaborators, educators and counsellors; (ii) dietitians individualising care and desiring a holistic approach; (iii) opportunities for dietitians to gain confidence; and (iv) experiencing nutrition care as a patient or carer.

CONCLUSIONS

This review suggests that dietitians have a varied role in eating disorder treatment but desire further training. Understanding the training needs of dietitians can identify practice gaps and opportunities to enhance clinician confidence.

Rationale and development of a manualised dietetic intervention for adults undergoing psychological treatment for an eating disorder

PURPOSE

Due to the current dearth of literature regarding dietetic treatment for patients with an eating disorder (ED), no manualised dietetic interventions exist to enable the testing of dietetic treatments in this population. This paper aims to: (1) describe the rationale and development of a manualised dietetic intervention for adults undergoing concurrent psychological treatment for an ED; and (2) provide an overview of the feasibility testing of this intervention.

METHODS

Current best evidence to date for dietetic treatment in EDs was utilised to develop a manualised dietetic intervention for feasibility testing alongside outpatient psychological 'treatment as usual'.

RESULTS

The developed intervention consists of five, dietitian-delivered outpatient sessions: (1) getting started; (2) mechanical eating and dietary rules; (3) estimating portion sizes and social eating; (4) maximising your meal plan and meal preparation; and (5) review and treatment planning as well as pre- and post-intervention assessments.

CONCLUSION

This paper is intended as a resource for clinicians and researchers in the conduct of future studies examining dietetic treatment for patients with an ED.

LEVEL OF EVIDENCE

Level V, description of a new manualised, reproducible dietetic intervention.

Gastrointestinal symptoms following treatment for anorexia nervosa: A systematic literature review

OBJECTIVE

Gastrointestinal (GI) disturbances are a frequent and burdensome experience for patients with anorexia nervosa (AN). How GI symptoms respond to current interventions is not well characterized, yet is critical to facilitate treatment success, and to inform the development of new treatments for AN. Therefore, the aim of this systematic review was to identify which treatments are effective in improving GI symptoms in patients with AN.

METHOD

A systematic search for studies of AN treatments measuring GI symptoms pre- and post-treatment was conducted in May 2020 (PROSPERO ID: CRD42020181328). After removal of duplicates, title and abstracts of 3,370 studies were screened. Methodological quality was assessed using National Institute of Health Quality Assessment Tool.

RESULTS

Following full-text screening, 13 studies (12 observational studies and 1 randomized double-blind placebo-controlled trial) with 401 participants met eligibility criteria and were included. All observational studies included a component of nutritional rehabilitation, with half (n = 6) involving concurrent psychological treatment. The randomized controlled trial reported a drug therapy. Eleven studies reported an improvement in all (n = 6) or at least one (n = 5) patient-reported GI symptom following treatment. Two studies reported no change. Methodological quality was fair or poor across all studies.

DISCUSSION

This is the first systematic review to synthesize available evidence on the trajectory of patient-reported GI symptoms from commencement to end of treatment for AN. The results suggest that most studies showed improvement in one or more GI symptom in response to current treatments. Future therapeutic approaches should consider GI symptoms within their design for optimal treatment adherence and outcomes.

Cognitive Remediation Therapy Does Not Enhance Treatment Effect in Obsessive-Compulsive Disorder and Anorexia Nervosa: A Randomized Controlled Trial

BACKGROUND

Guideline-recommended therapies are moderately successful in the treatment of obsessive-compulsive disorder (OCD) and anorexia nervosa (AN), leaving room for improvement. Cognitive inflexibility, a common trait in both disorders, is likely to prevent patients from engaging in treatment and from fully benefiting from existing therapies. Cognitive remediation therapy (CRT) is a practical augmentation intervention aimed at ameliorating this impairing cognitive style prior to disorder-specific therapy.

OBJECTIVE

To compare the effectiveness of CRT and a control treatment that was not aimed at enhancing flexibility, named specialized attention therapy (SAT), as add-ons to treatment as usual (TAU).

METHODS

In a randomized controlled multicenter clinical trial, 71 adult patients with OCD and 61 with AN were randomized to ten twice-weekly sessions with either CRT or SAT, followed by TAU. Patients were evaluated at baseline, post-CRT/SAT, and after 6 and 12 months, with outcomes being quantified using the Yale-Brown Obsessive Compulsive Scale for OCD and the Eating Disorder Examination Questionnaire for AN.

RESULTS

Across study groups, most importantly CRT+TAU was not superior to control treatment (SAT)+TAU in reducing OCD and AN pathology. Contrary to expectations, SAT+TAU may have been more effective than CRT+TAU in patients being treated for OCD.

CONCLUSIONS

CRT did not enhance the effect of TAU for OCD and AN more than SAT. Unexpectedly, SAT, the control condition, may have had an augmentation effect on TAU in OCD patients. Although this latter finding may have been due to chance, the effect of SAT delivered as a pretreatment add-on intervention for adults with OCD and AN merits future efforts at replication.

Mixture Modeling to Characterize Anorexia Nervosa: Integrating Personality and Eating Disorder Psychopathology

BACKGROUND: Efforts to examine alternative classifications (e.g., personality) of anorexia nervosa (AN) using empirical techniques are crucial to elucidate diverse symptom presentations, personality traits, and psychiatric comorbidities. AIMS: The purpose of this study was to use an empirical approach (mixture modeling) to test an alternative classification of AN as categorical, dimensional, or hybrid categorical-dimensional construct based on the co-occurrence of personality psychopathology and eating disorder clinical presentation. METHODS: Patients with AN (N = 194) completed interviews and questionnaires at treatment admission and 3-month follow-up. Mixture modeling was used to test whether indicators best classified AN as categorical, dimensional, or hybrid. RESULTS: A four-latent class, one-latent dimension mixture model that was variant across groups provided the best fit to the data. Results suggest that all classes were characterized by low self-esteem and self-harming and suicidality tendencies. Individuals assigned to Latent Class 2 (LC2; n = 21) had a greater tendency toward being impulsive and easily angered and having difficulties controlling anger compared with those in LC1 (n = 84) and LC3 (n = 66). Moreover, individuals assigned to LC1 and LC3 were more likely to have a poor outcome from intensive treatment compared with those in LC4 (n = 21). Findings indicate that the dimensional aspect within each class measured frequency of specific eating disorder behaviors but did not predict treatment outcomes. CONCLUSIONS: These results emphasize the complexity of AN and the importance of considering how facets of clinical presentation beyond eating disorder behaviors may have different treatment and prognostic implications.

Compulsory treatments in eating disorders: a systematic review and meta-analysis

INTRODUCTION

The aims of this systematic review and meta-analysis are to provide a summary of the current literature concerning compulsory treatments in patients with eating disorders (ED) and to understand whether compulsorily and involuntarily treated patients differ in terms of baseline characteristics and treatment outcomes.

METHODS

Relevant articles were identified following the PRISMA guidelines by searching the following terms: "treatment refusal", "forced feeding", "compulsory/coercive/involuntary/forced treatment/admission", "eating disorders", "feeding and eating disorders", "anorexia nervosa", "bulimia nervosa". Research was restricted to articles concerning humans and published between 1975 and 2020 in English.

RESULTS

Out of 905 articles retrieved, nine were included for the analyses allowing the comparisons between 242 compulsorily and 738 voluntarily treated patients. Mean body mass index (BMI) was slightly lower in patients compelled to treatments. Mean illness duration, BMI at discharge and BMI variation showed no significant differences between the two groups. Average length of hospitalization was 3 weeks longer among compulsory-treated patients, but this did not result in a higher increase in BMI. No significant risk difference on mortality was estimated (three studies).

CONCLUSIONS

Compulsory treatments are usually intended for patients having worse baseline conditions than voluntary ones. Those patients are unlikely to engage in treatments without being compelled but, after the treatments, albeit with longer hospitalisations, they do achieve similar outcomes. Therefore, we can conclude that forcing patients to treatment is a conceivable option.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

Lower leptin level at discharge in acute anorexia nervosa is associated with early weight-loss

OBJECTIVE

Predictive values of acute phase metabolic abnormalities of anorexia nervosa (AN) have seldom been studied. As early postrestoration weight loss is associated with poor outcome, discharge biologic parameters were assessed to detect an association with 2-month follow-up weight loss as a proxy to poor outcome.

METHOD

Fasting plasma levels of leptin, acyl-ghrelin, obestatin, PYY, oxytocin and BDNF were measured in 26 inpatients, at inclusion, at discharge and 2 months later. A body mass index less than 18 2-month postdischarge was considered a poor outcome.

RESULTS

Nineteen patients (73%) had a fair outcome and seven (27%) had a poor one with a mean loss of 0.69 versus 4.54 kg, respectively. Only discharge leptin levels were significantly higher in fair versus poor outcome patients (14.1 vs. 7.0 ng/ml, p = 0.006). The logistic regression model using discharge leptin, acyl-ghrelin, obestatin, oxytocin, PYY and BDNF levels as predictors of outcome disclosed a nearly significant effect of leptin (p < 0.10). Receiver operating characteristic analysis showed 11.9 ng/ml was the best value of threshold. Neither clinical variables differed according to outcome.

CONCLUSION

Leptin level may be a biomarker of early weight relapse after acute inpatient treatment of AN. Its clinical usefulness in monitoring care in AN should further be determined.

Possible use of fermented foods in rehabilitation of anorexia nervosa: the gut microbiota as a modulator

Anorexia nervosa is a serious psychiatric disorder with high morbidity and mortality rate. Evidence for the optimal psychopharmacological approach to managing the disorder remains limited, with nutritional treatment, focused on weight restoration through the consumption of high energy diet, regarded as one of the fundamental steps in treatment. The human gut microbiome is increasingly recognised for its proposed role in gastrointestinal, metabolic, immune and mental health, all of which may be compromised in individuals with anorexia nervosa. Dietary intake plays an important role in shaping gut microbiota composition, whilst the use of fermented foods, foods with potential psychobiotic properties that deliver live bacteria, bacterial metabolites, prebiotics and energy, have been discussed to a lesser extent. However, fermented foods are of increasing interest due to their potential capacity to affect gut microbiota composition, provide beneficial bacterial metabolites, and confer beneficial outcomes to host health. This review provides an overview of the role of the gut microbiota in relation to the disease pathology in anorexia nervosa and especially focuses on the therapeutic potential of fermented foods, proposed here as a recommended addition to the current nutritional treatment protocols warranting further investigation.

Intensive Treatments in Adolescent Anorexia Nervosa

Approximately one-fifth to one-third of patients with adolescent anorexia nervosa (AN) need intensive care in the course of their illness. This article provides an update and discussion on different levels of intensive care (inpatient treatment (IP), day patient treatment (DP) and home treatment (HoT)) in different health care systems based on recently published literature. Important issues discussed in this article are new recommendations for the refeeding process and the definition of target weight as well as principles of medical stabilization and psychotherapeutic approaches. The pros and cons of longer or shorter hospitalization times are discussed, and the advantages of stepped care and day patient treatment are described. A new promising intensive treatment method involving the patient, their caregivers and the direct home environment is introduced. Parents and caregivers should be included in treatment research to foster collaborative work with the attending clinicians. There is an urgent need to evaluate the mid- to long-term outcomes of various intensive treatment programs to compare their effectiveness and costs across different health care systems. This could help policy makers and other stakeholders, such as public and private insurances, to enhance the quality of eating disorder care.

Practitioner eating disorder detection: The influence of health mindset, thin-ideal internalization, orthorexia and gender role

AIMS

The current study sought to determine what factors inhibited psychologists, naturopaths and fitness instructors from detecting an eating disorder (ED), and the discipline differences across these factors.

METHODS

Participants of the online study were 115 health practitioners who consisted of 35 psychologists, 50 naturopathic and 30 fitness practitioners. A vignette describing a female experiencing a sub-threshold bulimic variant without purging was presented alongside ED mental health literacy items such as assessing one's ability to detect a problem. Additional items examined factors that may inhibit detection, including practitioners' level of: thin-ideal internalization, orthorexia, health or fitness mindset (a newly developed scale measuring health and fitness obsessiveness) and gender role identity.

RESULTS

A significant number of naturopaths and fitness instructors (20% and 33.3%, respectively) were found to have elevated orthorexia scores. Similarly, psychologists had the greatest tendency to internalize the thin-ideal (M = 3.60), which was comparable to levels seen in recent research for 20- to 21-year-old females with EDs. The two largest factors inhibiting ED detection were the strength of a health mindset and gender role identity. Practitioners who had higher health mindset scores or who associated with gender identities higher in masculinity traits (ie, either androgynous or masculine gender roles) were more likely to miss detecting an ED.

CONCLUSIONS

While many present ED studies focus upon assessing and changing client cognitions, this study emphasizes the need for further research regarding training interventions to address practitioner cognitions and gender role biases, which may in turn improve ED detection.

Comparative efficacy and acceptability of psychological interventions for the treatment of adult outpatients with anorexia nervosa: a systematic review and network meta-analysis

BACKGROUND

No consistent first-option psychological interventions for adult outpatients with anorexia nervosa emerges from guidelines. We aimed to compare stand-alone psychological interventions for adult outpatients with anorexia nervosa with a specific focus on body-mass index, eating disorder symptoms, and all-cause dropout rate.

METHODS

In this systematic review and network meta-analysis, we assessed randomised controlled trials about stand-alone pharmacological or non-pharmacological treatments of adult outpatients with anorexia nervosa, defined according to standardised criteria, with data for at least two timepoints relating to either body-mass index or global eating disorder psychopathology. We searched Cochrane CENTRAL, CINAHL, MEDLINE, and PsychINFO for published and unpublished literature from inception until March 20, 2020. The primary outcomes were the change in body mass index and clinical symptoms, and the secondary outcome was all-cause dropout rate, which were all assessed for treatment as usual, cognitive behavioural therapy (CBT), Maudsley anorexia treatment for adults, family-based treatment, psychodynamic-oriented psychotherapies, a form of CBT targeting compulsive exercise, and cognitive remediation therapy followed by CBT. Global and local inconsistencies for the network meta-analysis were measured, and CINeMA was used to assess the confidence in evidence for primary outcomes. The protocol is registered in PROSPERO (CRD42017064429).

FINDINGS

Of 14 003 studies assessed for their title and abstract, 16 (0·1%) randomised controlled trials for psychological treatments were included in the systematic review, of which 13 (0·1%) contributed to the network meta-analysis, with 1047 patients in total (of whom 1020 [97·4%] were female). None of the interventions outperformed treatment as usual in our primary outcomes, but the all-cause dropout rate was lower for CBT than for psychodynamic-oriented psychotherapies (OR 0·54, 95% CI 0·31-0·93). Heterogeneity or inconsistency emerged only for a few comparisons. Confidence in the evidence was low to very low.

INTERPRETATION

Compared with treatment as usual, specific psychological treatments for adult outpatients with anorexia nervosa can be associated with modest improvements in terms of clinical course and quality of life, but no reliable evidence supports clear superiority or inferiority of the specific treatments that are recommended by clinical guidelines internationally. Our analysis is based on the best data from existing clinical studies, but these findings should not be seen as definitive or universally applicable. There is an urgent need to fund new research to develop and improve therapies for adults with anorexia nervosa. Meanwhile, to better understand the effects of available treatments, participant-level data should be made freely accessible to researchers to eventually identify whether specific subgroups of patients are more likely to respond to specific treatments.

FUNDING

Flinders University, National Institute for Health Research Oxford Health Biomedical Research Centre.

How are families included in the treatment of adults affected by eating disorders? A scoping review

OBJECTIVE

The involvement of families in the treatment of adults with eating disorders is recommended as a core component of comprehensive care, yet little is known about the optimal way to implement or routinely facilitate this. This article evaluates the recent evidence on the inclusion of families in treatment programs for adults with eating disorders.

METHOD

A systematic literature search was conducted to identify evidence of family inclusive treatment approaches for adults with eating disorders. A scoping review framework was applied to assess and synthesize findings.

RESULTS

Sixty-eight studies were identified. Substantial conceptual research contributing to the theoretical basis of current practice with families of adults with eating disorders and clinical applications in current use were identified. Most research used uncontrolled studies with few experimental designs, reflecting the standing of the extant literature. Common elements of existing approaches have been distinguished and shared core components of interventions identified.

DISCUSSION

Results confirmed that family members of adults were willing to be involved with eating disorder treatment services and appeared to respond to interventions of varying intensity and duration. The impact on individual patients, and effect on treatment outcomes, are yet to be established. The localized settings of existing studies, the homogenous nature of interventions used, and the limited diversity in research subjects, make it difficult to generalize from the results to the wide range of adult eating disorder presentations seen in practice. Suggestions for future research and further clinical developments are discussed.

Can you find the right support for children, adolescents and young adults with anorexia nervosa: Access to age-appropriate care systems in various healthcare systems

OBJECTIVE

Anorexia nervosa (AN) often has its onset in childhood or adolescence. However, there is insufficient knowledge regarding access to and utilisation of age-specific clinical diagnostics and treatment.

METHODS

A literature review covering the last 10 years was conducted to provide a narrative review of the current state of research on the detection and treatment of young patients with AN in primary and secondary care.

RESULTS

Most articles were of Western European or US origin. Timely diagnosis of the eating disorder (ED) and treatment options more often depend on the structure and quality of the national health care system than on scientific evidence. Regular paediatric health check-ups and age-appropriate eating disorder services appear to facilitate early diagnosis. Age-specific treatment that also involves the carers is often associated with a higher continuity of care and a better outcome. Although many adolescents require an extension of treatment into young adulthood, individual and health care system-related obstacles in many countries prevent a smooth transition.

CONCLUSION

To improve outcomes in childhood and adolescent AN, age-specific and timely diagnostic and therapeutic procedures are urgently needed.

Understanding training needs in eating disorders of graduating and new graduate dietitians in Australia: an online survey

BACKGROUND

Following recent reforms by the Australian Government to the Medicare Benefits Schedule, people living with a diagnosed eating disorder (ED) in Australia have greater access to dietetic services. However, new graduate dietitians anecdotally lack confidence to provide appropriate interventions to support patients with an ED. Therefore, this cross-sectional study aims to explore the perceived confidence, and educational and professional development needs of student dietitians and new graduate dietitians in the area of EDs.

METHODS

An online survey with 17 questions was designed, consisting of a combination of discrete (yes/no) questions, free text, ordered scales and 5-point Likert scales. Student dietitians, and first- and second- year graduates (n = 1456) were approached via email as potential participants, from the professional organisation Dietitians Australia member list. Survey data was analysed using descriptive statistics and odds ratios.

RESULTS

In total, 150 surveys were completed, with a response rate of 10.3%. Respondents reported a lack of confidence in managing patients with an ED and implementing ED treatment approaches (81 and 95%, respectively). However, participants previously exposed to patients with an ED, such as anorexia nervosa, were 4.7 times (95% CI 1.72, 12.97) more likely to be confident compared to those not exposed to patients with an ED. The majority of respondents (37%) stated they would seek assistance from other dietitians, and develop their skills via online webinars (27%) and workshops (25%).

CONCLUSIONS

This survey identified that final year dietetics students and new graduate dietitians perceive lower levels of confidence to practice in the area of EDs. The desire for further ED-specific training and education was reported.

Metacognition and emotion regulation as treatment targets in binge eating disorder: a network analysis study

BACKGROUND

This study aims to examine the underlying associations between eating, affective and metacognitive symptoms in patients with binge eating disorder (BED) through network analysis (NA) in order to identify key variables that may be considered the target for psychotherapeutic interventions.

METHODS

A total of 155 patients with BED completed measures of eating psychopathology, affective symptoms, emotion regulation and metacognition. A cross-sectional network was inferred by means of Gaussian Markov random field estimation using graphical LASSO and the extended Bayesian information criterion (EBIC-LASSO), and central symptoms of BED were identified by means of the strength centrality index.

RESULTS

Impaired self-monitoring metacognition and difficulties in impulse control emerged as the symptoms with the highest centrality. Conversely, eating and affective features were less central. The centrality stability coefficient of strength was above the recommended cut-off, thus indicating the stability of the network.

CONCLUSIONS

According to the present NA findings, impaired self-monitoring metacognition and difficulties in impulse control are the central nodes in the psychopathological network of BED whereas eating symptoms appear marginal. If further studies with larger samples replicate these results, metacognition and impulse control could represent new targets of psychotherapeutic interventions in the treatment of BED. In light of this, metacognitive interpersonal therapy could be a promising aid in clinical practice to develop an effective treatment for BED.

Treatment of compulsive exercise in eating disorders and muscle dysmorphia: protocol for a systematic review

BACKGROUND

Compulsive exercise is a core feature of both eating disorders and muscle dysmorphia. Earlier models of treatment recommended complete abstinence from exercise in eating disorder populations, but recent guidelines advocate for the gradual inclusion of healthier forms of exercise into an overall treatment plan where appropriate. Given the association between problematic exercise behaviour and poorer prognosis, there has been a recent upsurge in the number of treatment interventions for compulsive exercise in eating disorders. However, no systematic review has been published summarising this existing treatment literature. The aim of this review is to determine the efficacy of existing treatments for compulsive exercise in eating disorders and muscle dysmorphia.

METHODS

A systematic review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five electronic databases (PsycInfo, MEDLINE, Embase, Web of Science, and Scopus) will be searched from database inception until November 2020. We will include studies that: (a) sampled adolescents and/or adults with either an eating disorder or muscle dysmorphia; (b) assessed changes in compulsive exercise from pre- to post-intervention; and (c) used a standardised instrument to measure compulsive exercise or related constructs. We will include studies with a comparison group (e.g., randomised controlled trials) and without a comparison group (e.g., pilot studies and case studies) to provide a comprehensive overview of the literature. One reviewer will screen all titles and abstracts against eligibility criteria, with 20% of excluded articles cross-referenced by another reviewer. Full texts will be obtained for articles deemed relevant or where inclusion was uncertain, and will be screened by both reviewers. We will also evaluate the quality of the included studies using a modified Downs and Black (J Epidemiol Community Health 52:377-384, 1998) assessment checklist.

DISCUSSION

Results from this review will help to determine the most efficacious treatment components for compulsive exercise in eating disorders and muscle dysmorphia. We hope that our results will help inform clinical practice guidelines in recommending targeted interventions for the treatment of compulsive exercise.

Dietetic intervention for adult outpatients with an eating disorder: a systematic review and assessment of evidence quality

CONTEXT

Eating disorders (EDs) are complex mental illnesses that require medical, psychological, and dietetic intervention to assist patients achieve recovery.

OBJECTIVE

Available evidence was reviewed regarding dietetic intervention for adult outpatients with an ED and the quality of this evidence was assessed.

DATA SOURCES

Systematic literature searches were conducted using 5 databases (MEDLINE, PreMEDLINE, EMBASE, CINAHL, PsycINFO) for studies comparing adults with an ED receiving a dietetic intervention with those receiving a psychological intervention alone, those receiving a combined dietetic and psychological intervention, or a control group.

DATA EXTRACTION

Literature searches returned 3078 results, with 10 articles reporting on 9 randomized controlled trials meeting the inclusion criteria. The quality of evidence was assessed using the Cochrane Risk-of-Bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

DATA ANALYSIS

GRADE assessments for studies involving individuals with anorexia nervosa indicated very low quality of evidence for outcomes including weight, ED psychopathology and ED behaviors , and no studies measured nutritional changes. For studies conducted with participants with bulimia nervosa or binge eating disorder, only 1 study included a group receiving combined evidence-based psychological and dietetic intervention. A combined intervention produced moderate-quality evidence for lower attrition, greater abstinence from ED behaviors, and more meals eaten per week in comparison with a stand-alone psychological or dietetic intervention.

CONCLUSIONS

There is currently limited evidence to sufficiently assess the impact of incorporating dietetic interventions into outpatient treatment for adults with an ED; however, available evidence supports clinical practice guidelines that dietetic intervention should not be delivered as a stand-alone treatment. Additional methodologically sound studies in larger samples are required to fully inform dietetic treatment in EDs and incorporation of such interventions as part of a multidisciplinary treatment approach.

Integrated weight loss and cognitive behavioural therapy (CBT) for the treatment of recurrent binge eating and high body mass index: a randomized controlled trial

PURPOSE

The association between binge eating and obesity is increasing. Treatments for disorders of recurrent binge eating comorbid with obesity reduce eating disorder (ED) symptoms, but not weight. This study investigated the efficacy and safety of introducing a weight loss intervention to the treatment of people with disorders of recurrent binge eating and a high body mass index (BMI).

METHODS

A single-blind randomized controlled trial selected adults with binge eating disorder or bulimia nervosa and BMI ≥ 27 to < 40 kg/m². The primary outcome was sustained weight loss at 12-month follow-up. Secondary outcomes included ED symptoms. Mixed effects models analyses were conducted using multiple imputed datasets in the presence of missing data.

RESULTS

Ninety-eight participants were randomized to the Health Approach to Weight Management and Food in Eating Disorders (HAPIFED) or to the Cognitive Behavioural Therapy-Enhanced (CBT-E). No between-group differences were found for percentage of participants achieving weight loss or secondary outcomes, except for reduction of purging behaviour, which was greater with HAPIFED (p = 0.016). Binge remission rates specifically at 12-month follow-up favoured HAPIFED (34.0% vs 16.7%; p = 0.049). Overall, significant improvements in the reduction of ED symptoms were seen in both groups and these were sustained at the 12-month follow-up.

CONCLUSION

HAPIFED was not superior to CBT-E in promoting clinically significant weight loss and was not significantly different in reducing most ED symptoms. No harm was observed with HAPIFED, in that no worsening of ED symptoms was observed. Further studies should test approaches that target both the management of ED symptoms and the high BMI.

LEVEL OF EVIDENCE

Level I, randomized controlled trial TRIAL REGISTRATION: US National Institutes of Health clinical trial registration number NCT02464345, date of registration 1 June 2015.

A review of treatment manuals for adults with an eating disorder: nutrition content and consistency with current dietetic evidence

PURPOSE

This study aimed to summarise the nutrition and food-related content of treatment manuals for adults with eating disorders (EDs) and assess the degree to which this information conforms with current guidelines and literature.

METHODS

Treatment manuals for adults with an ED were identified by conducting an online search of Internet book dealer Amazon and University of Sydney library catalogue as per methods used in previous reviews of self-help patient resources. The nutrition and food-related content of these manuals was extracted and reviewed independently by two reviewers using a criteria based on current best evidence to date regarding dietetic treatment for EDs.

RESULTS

Twenty-two manuals met inclusion criteria, 20 (91%) of which contained some degree of nutrition and food-related content. Two manuals (9%) included content written by a dietitian, six (27%) included citation of dietetic literature to support the recommendations made and eight (36%) recommended a dietitian be consulted as part of a multidisciplinary approach to treatment. Thirteen manuals (60%) contained nutrition and food-related information not substantiated by current evidence.

CONCLUSION

It is common for treatment manuals for EDs to contain nutrition and food-related content. However, most of the authors of the 22 manuals identified did not appear to collaborate with a dietitian in writing this content or cite peer-reviewed literature to substantiate dietary advice given. Consistent with current clinical practice guidelines, greater collaboration between dietitians and clinicians is required to develop, evaluate and disseminate evidence-based approaches to dietetic management.

LEVEL OF EVIDENCE

Level V, narrative review.

Assessing Family Functioning Before and After an Integrated Multidisciplinary Family Treatment for Adolescents With Restrictive Eating Disorders

The present study presents an investigation of family functioning in the families of adolescents with severe restrictive eating disorders (REDs) assessed before and 6 months after a multidisciplinary family treatment program that combined psychodynamic psychotherapy, parental role intervention, and triadic or family-centered interventions. Nutritional counseling and neuropsychiatric monitoring of the overall treatment and care process were also provided. Family functioning was assessed using the clinical version of the Lausanne Trilogue Play (LTPc), a semi-structured procedure for observing family dynamics, previously validated for this patient population. The LTPc is divided into four phases. In phase 1, the mother interacts with the patient while the father assumes the role of observer. In phase 2, the father plans an activity with the patient while the mother observes. In phase 3, all the family members interact. Finally, in phase 4, the parents talk while the adolescent observes. A significant change emerged in family functioning after the treatment, but only for the interactive phase 2, when the father is required to interact with the daughter while the mother silently observes. The results of this study suggest that a relatively brief multidisciplinary treatment program may significantly improve family functioning in the families of patients diagnosed with severe REDs. Although appropriate clinical trials are needed to further test the efficacy of this treatment, the results also reinforce the concept that treatment programs targeting the individual patient and both the parents should be a first-line approach in adolescents with severe REDs.

Rehospitalization and "Revolving Door" in Anorexia Nervosa: Are There Any Predictors of Time to Readmission?

Objective: Anorexia nervosa (AN) is a severe psychiatric illness with multifactorial etiology and unsatisfactory treatment outcomes. Hospitalization is required for a substantial number of patients, and readmission (RA) commonly occurs. Some individuals need multiple hospitalizations sometimes over a short amount of time, thus, delineating the "revolving door" (RD) phenomenon. However, very little is known about readmissions and their frequency in AN. Therefore, we aimed to longitudinally investigate readmissions in AN in order to: (a) characterize patients with AN who need readmission (i.e., RA-AN), sometimes rapidly (RD-AN); (b) ascertain differences between RA-AN and non-RA-AN groups during baseline hospitalization; (c) investigate as to whether clinical or psychometric parameters worsened on RA; and (d) analyze predictors of time-to-readmission in AN. Methods: A total of 170 inpatients with AN were enrolled at their baseline hospitalization; all their subsequent rehospitalizations were recorded with a longitudinal design by which each patient has been observed for 3 years. Patients were classified as RD-AN if requiring a readmission <12 months since last discharge. Clinical characteristics were measured upon admission and discharge for each hospitalization, and at all time points, patients completed questionnaires assessing eating and general psychopathology, and body shape concerns. Results: Sixty-seven patients (39.4%) needed at least one readmission and 62 (92.5% of RA-AN) reported RD. Compared with non-RA-AN, those with RA-AN were younger, reported a shorter duration of illness, and were more frequently diagnosed with AN-BP. Also, greater severity of anxious and depressive symptoms and body shape concerns emerged in the RA-AN group. The outcome of baseline hospitalization did not differ between groups, and only depressive symptoms worsened at readmission. Shorter duration of AN and low weight gain during baseline hospitalization predicted early readmission but did not survive statistical control. In contrast, high scores on drive for thinness upon baseline hospital entry robustly predicted a shorter time to readmission even after statistical control. Discussion: Individuals with AN who require readmission do so over a short period notwithstanding a positive treatment outcome during their baseline hospitalization. Shorter time-to-readmission can be predicted mostly in case of marked drive for thinness and poor weight gain at baseline hospital admission.