Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors

Patient perspectives on premature termination of eating disorder treatment: a systematic review and qualitative synthesis

BACKGROUND

High rates of premature treatment termination are a well-reported issue in eating disorder treatment, and present a significant barrier for treatment effectiveness and longer term health outcomes of patients with eating disorders. Understanding patient perspectives on this phenomenon is essential in improving treatment completion rates and informing research and intervention development. The aim of this review is to synthesise qualitative literature on patient perspectives of premature termination of eating disorder treatment and to summarise the key issues leading to discontinuation of treatment.

METHODS

A systematic review of 1222 articles was conducted to identify studies using qualitative methods to investigate patient experiences of prematurely terminating eating disorder treatment. Ten articles were included in the review, with thematic synthesis used to analyse the primary research and develop overarching analytical themes.

RESULTS

Conflict around enmeshment of eating disorder with identity, and lack of support with reconstructing a sense of self without the eating disorder; challenges of managing pressures of social and clinical relationships while feeling unheard and misunderstood by both; expectations and disappointments around treatment; and dissatisfaction with progress were key themes behind premature termination of treatment.

CONCLUSIONS

The findings of this review demonstrate the key issues influencing the decision to end treatment early, highlighting the contribution of individual, environmental, and service-level factors. Implications of these factors are discussed and suggestions raised for future research and service development.

Factors associated with disordered feeding among high school students in Kerman City, Iran

BACKGROUND

Mental health problems and disordered eating, are more common in adolescents. This study investigated relationship between mental health and disordered eating in high school girls in southeast Iran.

METHODS

This cross-sectional descriptive correlational study accomplished in high school girls of Kerman at the southeast of Iran in 2019. Using three parts demographic, Standard General Health Questionnaire (GHQ-28) and Eating Attitudes questionnaire, (Eat-26) with three subscales: eating habits, desire to eat and oral control. We investigated high school girl's mental health and relationship with disordered eating with cluster sampling method (600 high school girl). Multivariate logistic regression was used to determine the association between significant variables and the risk of General Health (Yes/No) and Eating attitude (Yes/No). Spearman correlation test, Mann-Witheny U test and Kruskal-Wallis test were used, and Significant level was considered at P < 0.05.

RESULTS

A direct and significant relationship between mental health and disordered eating (r = 0/19, P < 0.001). In other words, the higher the mental health disorder score, the higher the disordered eating score, and the higher disordered eating score, the higher mental problems. There was a direct and significant relationship between mental health and all aspects of disordered eating including eating habits (r = 0/12, P < 0.05), desire to eat (r = 0/1, P < 0.05) and oral control (r = 0/14, P < 0.001).

CONCLUSIONS

It seems that the disordered eating and mental health have a determinant role in relationship with each other. Therefore, prevention and health promotion programs should be implemented to improve female adolescent mental health and reduce disordered eating.

Adaptation and validation of the Caregiver Burden Inventory in eating disorders

BACKGROUND

Living with people diagnosed with a mental disorder is known to increase the risk of developing high levels of so-called "caregiver burden" in informal caregivers. In-depth analysis of this phenomenon and specific assessment tools for caregivers of patients diagnosed with Eating Disorders (EDs) are lacking. In this study, we aimed to evaluate the psychometric properties of the Caregiver Burden Inventory in EDs and employ this adapted tool in this category of caregivers.

METHODS

A cross-sectional study was conducted in the Eating Disorders outpatient unit of an Italian University hospital. Face and content validity were investigated by calculating standard Content Validity Indices (CVI-I and CVI-S) after administering the Inventory to 6 expert nurses with at least 5 years of experience in mental health services assisting people diagnosed with Eating Disorders. Internal consistency was evaluated with Cronbach's α coefficient for the overall scale and subscales. An exploratory factor analysis (EFA) was performed to explore latent constructs. The adapted CBI was then administered to 62 informal caregivers of ED patients.

RESULTS

The EFA yielded a 5-factor structure. The CVI-S was 97.2%; the Cronbach α coefficient was 0,90 (> 0.74 in each subscale). The median burden level in the experimental population was 40.0 [range = 21 to 54], in a theoretical range from 0 (no burden) to 96 (highest level of burden).

CONCLUSION

The Caregiver Burden Inventory appears to be a valid and reliable instrument to assess caregiver burden in individuals diagnosed with Eating Disorders. Further research is needed to evaluate this tool's efficiency in improving individually tailored interventions on families.

The relationship between the risk of eating disorder and meal patterns in University students

PURPOSE

This study was carried out to evaluate the relation between meal patterns and the risk of eating disorders in university students.

METHODS

The study was conducted on a total of 331 volunteer students with a mean age of 22.08 ± 1.80 years, 56.5% female. Participants' sociodemographic characteristics, health information and eating habits like meal skipping and dieting were questioned. Sick, Control, One stone, Fat, Food (SCOFF) Eating Disorders Scale and Eating Disorder Examination Questionnaire (EDE-Q) were used to determine eating behavior disorders, with face to face interviews by the researches.

RESULTS

A significant correlation was found between dieting and skipping meals and the risk of eating disorders in both genders (p < 0.05). In addition, when the reasons for skipping meals were questioned, a significant relationship was detected between skipping meals and eating behaviour disorders by 3.285 times (p = 0.000). Also, every unit of increase in body mass index (BMI) values of individuals who participated to the study led to an increase in eating disorders by a factor of 1.262 (p = 0.000).

CONCLUSIONS

Our findings support concerns about the negative health effects of increasing overweight among university students in accordance with the data that the increase in BMI values led to an increase in eating disorders. Notably a significant correlation was found between dieting, skipping meals and the risk of eating disorders in both genders it is highlighting the need for monitoring and early diagnosis of eating disorders in youth with simple scales like SCOFF.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

The Florence Emotional Eating Drive (FEED): a validation study of a self-report questionnaire for emotional eating

PURPOSE

Emotional eating is a trans-diagnostic dimension in eating disorders and is present in many other conditions that could affect eating attitudes. At present, there is no instrument that measures emotional eating evaluating both the intensity and the frequency of emotion-induced desire to eat. The aim of the study was the validation of the Florence Emotional Eating Drive (FEED).

METHODS

A sample of healthy volunteers was initially enrolled to explore internal consistency and test-retest reliability. The Emotional Eating Scale (EES), Eating Disorders Evaluation-Questionnaire (EDE-Q), Binge Eating Scale (BES) and Symptom Checklist-90 (SCL-90-R), together with the final version of FEED, were administered to a clinical sample composed by patients with eating disorders, obesity, and type 2 diabetes, to explore the underlying structure of the questionnaire and verify its validity.

RESULTS

FEED showed excellent internal consistency (Cronbach's alpha = 0.96) and test-retest reliability (r = 0.93). FEED scores were higher in patients with BN and BED than in AN patients, negatively correlated with age and positively with BES and EES. Multiple regression analysis showed that FEED, but not EES, was independently associated with SCL-90-R and EDE-Q scores.

CONCLUSION

FEED internal consistency and test-retest reliability were excellent. The addition of specific questions on the frequency of behaviours led to a better component structure and robustness compared to EES. A tool that reliably and specifically assesses eating behaviours driven by emotional states may be extremely useful in clinical settings.

LEVEL OF EVIDENCE

Level V, cross-sectional study.

Ameliorating cognitive control in patients with binge eating disorder by electrical brain stimulation: study protocol of the randomized controlled ACCElect pilot trial

BACKGROUND

The current first-line treatment for binge eating disorder (BED), which is psychotherapy, is moderately effective in terms of abstinence from binge-eating. Neurobiological evidence suggests that people affected by BED show difficulties along the spectrum of impulsivity, including inhibitory control impairments and highlights the potential of novel treatment approaches directly targeting inhibitory control, including cognitive training approaches and non-invasive brain stimulation.

METHODS

ACCElect is a prospective, randomized controlled pilot trial investigating a novel, food-related inhibitory control training combined with transcranial direct current stimulation (tDCS). 40 patients with BED will be randomly assigned to receive the training either combined with verum or with sham stimulation (control condition). The inhibitory control training is based on principles of the antisaccade paradigm and comprises six training sessions over two weeks. Core aims are the investigation of feasibility and clinically relevant effects of a tDCS-enhanced inhibitory control training in BED patients and the establishment of a data basis for a larger efficacy trial. The primary clinical endpoint is binge-eating (BE) frequency in terms of changes in BE episodes four weeks after treatment termination as compared to baseline. Key secondary outcomes comprise ED pathology and general psychopathology, inhibitory control capacities, quality of life as well as acceptability and satisfaction with the intervention.

DISCUSSION

The results of the present trial will contribute to the development of novel neurobiologically informed treatment approaches for patients suffering from BED. Trial registration The ACCElect trial was prospectively registered on October 1, 2020, under the registration number NCT04572087 at ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT04572087 ).

The Negative Impact of Night Shifts on Diet in Emergency Healthcare Workers

Despite the consequences of night-shift work, the diet of night-shift workers has not been widely studied. To date, there are no studies related to food intake among emergency healthcare workers (HCWs). We performed a prospective observational study to assess the influence of night work on the diet of emergency HCWs. We monitored 24-h food intake during a day shift and the consecutive night, and during night work and the daytime beforehand. We analyzed 184 emergency HCWs' food intakes. Emergency HCWs had 14.7% lower (-206 kcal) of their 24-h energy intake during night shifts compared to their day-shift colleagues (1606.7 ± 748.2 vs. 1400.4 ± 708.3 kcal, p = 0.049) and a 16.7% decrease in water consumption (1451.4 ± 496.8 vs. 1208.3 ± 513.9 mL/day, p = 0.010). Compared to day shifts, night-shift had 8.7% lower carbohydrates, 17.6% proteins, and 18.7% lipids. During the night shift the proportion of emergency HCWs who did not drink for 4 h, 8 h and 12 h increased by 20.5%, 17.5%, and 9.1%, respectively. For those who did not eat for 4 h, 8 h and 12 h increased by 46.8%, 27.7%, and 17.7%, respectively. A night shift has a huge negative impact on both the amount and quality of nutrients consumed by emergency healthcare workers.

The prevalance of binge eating disorder and associated psychiatric and substance use disorders in a student population in Kenya - towards a public health approach

INTRODUCTION

Kenya in particular and Africa in general lack data on Binge Eating Disorder (BED). The overarching objective of this study is to fill that gap. Kenyans may not be aware that BED exists when a "very good" appetite is considered a sign of good health, especially if food is available either at home, in fast food shops or when communally eating together, a very common cultural practice. On the other hand where there is relatively insufficient food, it is not expected that one could be having a problem of eating too much.

METHOD

We administered the following tools and measurements to 9742 participants (high school, college and university students): 1) Researcher designed socio-demographic and economic indicator questionnaire; 2) An instrument documenting DSM-IV diagnostic criteria for BED and its various symptoms; 3) An instrument to determine DSM-IV psychiatric disorders and substance abuse;4) An instrument measuring high risk for psychosis ,affectivity and stress; 5) A WHO designed instrument measuring the severity of substance abuse for specific substances. We used descriptive and inferential analysis to determine the prevalence and association of the different variables. Independent predictors of BED were generated from a generalized linear model (p<0.05).

RESULTS

We found a prevalence of 3.2% of BED and a wide range of prevalence for BED and BED related symptoms (8.1% to 19%). The least prevalent was "To prevent weight gain from eating binge did you force yourself to vomit, or used laxatives?". The most common was "Did you often go on eating binges (eating a very large amount of food very quickly over a short period of time)." Major depression, obsessive compulsive disorder, panic disorder, agoraphobia, generalized anxiety disorder ,a positive stress screen and drug abuse were independent predictors of BED (p<0.05).

CONCLUSION

Our findings on the prevalence of BED and significant associations with various psychiatric disorders and substance use disorders are similar to those obtained in High Income Countries (HIC) using similar large-scale samples in non-clinical populations. Our findings suggest the need fora public health approach to enhance awareness of BED and to promote health-seeking behaviour towards management of BED.

Feasibility of guided internet-based cognitive behavioral therapy for patients with anorexia nervosa

OBJECTIVE

The objective of the present study was to investigate the feasibility of guided internet cognitive behavioral therapy (ICBT) for anorexia nervosa.

METHODS

We conducted a prospective single-arm study between January 2020 and March 2021. The intervention was built using videos, web programs, and chat tools. The intervention program was largely based on metacognitive training. Participants performed the self-help program once a week for 12 consecutive weeks. The primary outcome was the global Eating Disorder Examination Questionnaire (EDE-Q) score. Secondary outcomes included clinical symptoms of eating disorders, metacognitive function, body mass index, depression, and generalized anxiety. The main statistical analysis examined whether the EDE-Q score and other outcomes at the end of the intervention differed from the baseline.

RESULTS

Fourteen participants underwent the trial treatment, and 13 completed the intervention. There was a significant reduction in the global EDE-Q score from 3.48 (SD = 1.4) to 2.54 (SD = 1.5, p = 0.02, Cohen's d = 0.75) from baseline to post-intervention. Some EDE-Q subscales and body checking questionnaire scale demonstrated statistically significant improvements, with moderate to large effect sizes. Although there was no significant improvement in body mass index, metacognitive function, or depressive symptoms, there was a significant improvement in the severity of generalized anxiety (M = -4.0, p = 0.01, Cohen's d = 0.95). No adverse events were observed.

DISCUSSION

Our findings suggest that guided ICBT for anorexia nervosa is well accepted by female patients and practical as a telemedicine approach that improves symptoms. In the future, tightly controlled randomized controlled trials should be conducted for efficacy verification.

Body-related shame or guilt? Dominant factors in maladaptive eating behaviors among Hungarian and Norwegian university students

The main purpose of our study was to examine the psychometric properties of Conradts' Weight- and Body-Related Shame and Guilt Scale (WEB-SG) and associations of body shame and guilt with maladaptive eating behaviors and general chronic shame among Hungarian and Norwegian university students. Therefore, we collected data from 561 university students from both nations in a cross-sectional questionnaire study. Participants completed the following standardized self-report questionnaires in this online survey: WEB-SG, Eating Attitude Test-26 (EAT-26) and Experience of Shame Scale (ESS). We tested the measurement model of the WEB-SG with confirmatory factor analysis (CFA), and we performed CFA with covariates analysis to examine the association between WEB-guilt (WEB-G) and WEB-shame (WEB-S) and predictors. Our empirical model of WEB-SG has adequate fit with Conradts’ theoretical model among both samples. The body-related guilt positively associated with dieting and negatively related to oral control in both groups. We found a significant positive relationship between WEB-S and BMI in Hungarian sample. According to our results, WEB-SG is an adequate questionnaire for assessing weight and body-related shame and guilt in Hungarian and Norwegian non-clinical samples. Maladaptive weight and body-related guilt could be a relevant factor in proneness to anorexia. Our results highlight WEB-G and WEB-S as two critical factors in the assessment and treatment of eating difficulties.

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The two-factor model of WEB-SG was confirmed in Hungary and Norway.

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WEB-guilt is associated with dieting as a restrictive eating attitude.

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WEB-shame is associated with higher BMI and chronic body shame.

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WEB-guilt and WEB-shame may be two important factors in eating disorders.

Bulimia Symptoms in Russian Youth: Prevalence and Association With Internalizing Problems

BACKGROUND

There has been limited research on bulimia symptoms in adolescents from the general population outside the United States. This study aimed to evaluate the prevalence of bulimia symptoms in Russian youth and explore the associations between a clinical level of self-reported probable bulimia nervosa (BN) and internalizing problems, binge drinking and functional impairment by gender.

METHODS

Data were collected from a representative sample of school students (N = 2,515, 59.5% female) from Northern Russia [age M (SD) = 14.89 ± 1.13 years]. Probable BN and internalizing psychopathology were assessed using self-report scales. Chi-square and independent sample t-tests were used to compare respondents' demographic characteristics and disordered eating behaviors. GLM multivariate analysis of covariance was used to assess the associations between probable BN, functional impairment and mental health problems (MHP) by gender.

RESULTS

Analyses showed that the 3-month prevalence of probable BN was higher in girls (3.9%) than in boys (1.2%). Probable BN was associated with depressive and anxiety symptoms, somatic anxiety, somatic complaints, binge drinking and functional impairment. Boys reported a higher level of problem scores in relation to probable BN.

CONCLUSIONS

Our findings suggest that bulimia symptoms are prevalent in Russian adolescents and are associated with MHP and functional impairment. Timely recognition of bulimia symptoms and associated MHP is important for early prevention and intervention strategies.

Psychopathological and Neurobiological Overlap Between Anorexia Nervosa and Self-Injurious Behavior: A Narrative Review and Conceptual Hypotheses

Empirical evidence and clinical observations suggest a strong -yet under acknowledged-link between anorexia nervosa (AN) and non-suicidal self-injurious behavior (NSSI). By reviewing the literature on the psychopathology and neurobiology of AN and NSSI, we shed light on their relationship. Both AN and NSSI are characterized by disturbances in affect regulation, dysregulation of the reward circuitry and the opioid system. By formulating a reward-centered hypothesis, we explain the overlap between AN and NSSI. We propose three approaches understanding the relationship between AN and NSSI, which integrate psychopathology and neurobiology from the perspective of self-destructiveness: (1) a nosographical approach, (2) a research domain (RDoC) approach and (3) a network analysis approach. These approaches will enhance our knowledge of the underlying neurobiological substrates and may provide groundwork for the development of new treatment options for disorders of self-destructiveness, like AN and NSSI. In conclusion, we hypothesize that self-destructiveness is a new, DSM-5-transcending concept or psychopathological entity that is reward-driven, and that both AN and NSSI could be conceptualized as disorders of self-destructiveness.

Gender-related differences in health-care and economic costs for eating disorders: A comparative cost-development analysis for anorexia and bulimia nervosa based on anonymized claims data

OBJECTIVE

Anorexia nervosa (AN) and bulimia nervosa (BN) impose a significant financial burden and immense sufferings on affected individuals. Yet little is known about the differences between how each disorder affects males and females, respectively.

METHOD

We performed a retrospective cost-development analysis of anonymized claims data from the German statutory health-insurance system. Insured persons who suffered from an onset of AN (F50.0; N = 1,242 females and 71 males) or BN (F50.2; N = 1,104 females and 64 males) were analyzed for cost-of-illness over a 5-year period, beginning 2 years before the index diagnosis.

RESULTS

In total, all groups incurred similar distributions of total costs over the 5-year observation period, with roughly 14,000-20,000 EUR median costs. About two-thirds of the total costs for females and males with AN are associated with mental illness, whereas for females and males with BN, this applies to approximately half the total costs. Analyses revealed differences between disorders and genders for single outcomes. AN is associated with a stronger increase in costs within a short period following onset and higher inpatient treatment costs, whereas BN entails more instances of incapacity to work before and after onset. Compared to females, males incurred lower costs in outpatient treatments.

DISCUSSION

Our study adds evidence as to the disparities in health-care utilizations and costs over the course of illness, in outcome ratios, and between genders, for both AN and BN.

A population-based study of macronutrient intake according to mental health status with a focus on pure and comorbid anxiety and eating disorders

PURPOSE

Eating disorders (ED) and anxiety impact food choices. In addition, comorbid anxiety seems to increase ED symptoms and severity. However, the association between such comorbidity and dietary intake is unknown. This population-based, cross-sectional study aimed to assess macronutrient intake according to mental health status (i.e., no disorder, pure and comorbid anxiety and ED).

METHODS

The study included N = 24,771 participants (74% female, mean age = 53.2 ± 13.7 years) in the NutriNet-Santé cohort, who completed once the trait subscale of the State-Trait Anxiety Inventory (STAI-T; high anxiety: ≥ 40 points) between 2013 and 2016 and the SCOFF questionnaire screening for ED in 2014. The Expali algorithm was applied to categorize ED (no ED; restrictive: RS; bulimic: BL; hyperphagic: HP; other ED). Participants were divided into ten groups by crossing their anxiety status (two groups: low or high) and their ED status (five groups). Macronutrient intakes were evaluated from ≥ 3 24-h dietary records. Analyses of covariance (ANCOVA) and Dunnett-Hsu tests (reference = no disorder) were performed.

RESULTS

Significant differences in macronutrient intake were seen between the pure and comorbid forms, especially for RS and HP. Compared to the "no disorder" group, a significantly higher percentage of energy from carbohydrates, higher intakes of total carbohydrates, simple sugars, and plant-based protein, lower intakes of total fat, saturated and monounsaturated fatty acids, and cholesterol were observed in the comorbid anxiety + RS group, but not in the pure RS group. In contrast, significantly lower intakes of added sugar and plant-based protein, and a higher intake of cholesterol were observed in the pure HP group, but not in the comorbid anxiety + HP group. For BL and other ED, similar results were observed between the pure and comorbid forms.

CONCLUSION

This large epidemiological study provided some support for differences in macronutrient intake between individuals with pure or comorbid anxiety and ED. Differences in intake were largely dependent on ED type. Future prospective studies and studies using clinically defined anxiety and ED are needed to elucidate causality as well as potential effect modification of the observed associations.

The light and the dark side of social media use: Depression, anxiety, and eating attitudes among adolescents

In the current study, we explored the links between social networking activity, eating attitudes (EA), anxiety, and depression among adolescents. We used a cross-sectional design. Our sample consisted of 532 males and females, aged 12 to 15 (M = 13.55, SD = 0.90), from the Eastern side of Romania. We analyzed our data using three different pathways to explore these relationships on the overall sample, as well as the at-risk for eating disorders (ED) group (n = 134), and the non-ED-risk (n = 398) samples. The results suggested that depressive and anxiety symptoms partially mediated the relationship between social networking and eating attitudes in the overall group and in the not-at-risk for ED group, but not in the at-risk for ED sample. When controlling for gender, social networking use partially mediated the relationship between anxiety and depressive symptoms and eating attitudes in the overall group and the not-at-risk for ED group, and a total mediating effect within this relationship in the at-risk ED sample was also found. In adolescents with symptoms of potential ED, social networking use seemed to have a protective role compared to the not-at-risk sample. The present study suggested that social networking use might increase the chances of developing unhealthy eating attitudes in adolescents who are not-at risk to develop an eating disorder, but, at the same time, it might play a protective role (instead of a harmful one) for adolescents who already developed such symptoms. Results are discussed concerning their clinical and practical implication for adolescents? physical and mental health, especially during the COVID?19 pandemic, and the potential protective role of social media use for adolescents with ED symptoms.

An analysis of patient motivation for seeking online treatment for binge eating disorder-A mixed methods study combining systematic text condensation with sentiment analysis

OBJECTIVE

Online treatment for binge eating disorder (BED) is an easily available option for treatment compared to most standard treatment procedures. However, little is known about how motivation types characterize this population and how these impact treatment adherence and effect in an online setting. Therefore, we aimed to investigate a sample of written motivation statements from BED patients, to learn more about how treatment and online treatment in particular, presents in this population.

METHODS

Using self-determination theory in a mixed methods context, we investigated which types of motivation were prevalent in our sample, how this was connected with patient sentiment, and how these constructs influence treatment and adherence.

RESULTS

Contrary to what most current literature suggests, we found that in our sample (n = 148), motivation type was not connected with treatment outcome. We did find a strong association between sentiment scores and motivation types, indicating the model is apt at detecting effects. We found that when comparing an adult and young adult population, they did not differ in motivation type and the treatment was equally effective in young adults and adults. In the sentiment scores there was a difference between sentiment score and adherence in the young adult group, as the more positive the young adults were, the less likely they were to complete the program.

DISCUSSION

Because motivation type does not influence online treatment to the same degree as it would in face-to-face treatment it indicates that the typical barriers to treatment may be less crucial in an online setting. This should be considered during intake; as less motivated patients may be able to adhere better to online treatment, because the latter imposes fewer barriers of the kind that only strong motivation can overcome. The fact that motivation type and sentiment score of the written texts are strongly associated, indicate a potential for automated models to detect motivation based on sentiment.

The prevalence of substance use disorders and substance use in anorexia nervosa: a systematic review and meta-analysis

AIM

Individuals with anorexia nervosa (AN) often present with substance use and substance use disorders (SUDs). However, the prevalence of substance use and SUDs in AN has not been studied in-depth, especially the differences in the prevalence of SUDs between AN types [e.g., AN-R (restrictive type) and AN-BP (binge-eating/purge type]. Therefore, this systematic review and meta-analysis aimed to assess the prevalence of SUDs and substance use in AN samples.

METHOD

Systematic database searches of the peer-reviewed literature were conducted in the following online databases: MEDLINE, PsycINFO, Embase, and CINAHL from inception to January 2021. We restricted review eligibility to peer-reviewed research studies reporting the prevalence for either SUDs or substance use in individuals with AN. Random-effects meta-analyses using Freeman-Tukey double arcsine transformations were performed on eligible studies to estimate pooled proportions and 95% confidence intervals (CIs).

RESULTS

Fifty-two studies met the inclusion criteria, including 14,695 individuals identified as having AN (mean age: 22.82 years). Random pooled estimates showed that substance use disorders had a 16% prevalence in those with AN (AN-BP = 18% vs. AN-R = 7%). Drug abuse/dependence disorders had a prevalence of 7% in AN (AN-BP = 9% vs. AN-R = 5%). In studies that looked at specific abuse/dependence disorders, there was a 10% prevalence of alcohol abuse/dependence in AN (AN-BP = 15% vs. AN-R = 3%) and a 6% prevalence of cannabis abuse/dependence (AN-BP = 4% vs. AN-R = 0%). In addition, in terms of substance use, there was a 37% prevalence for caffeine use, 29% prevalence for alcohol use, 25% for tobacco use, and 14% for cannabis use in individuals with AN.

CONCLUSION

This is the most comprehensive meta-analysis on the comorbid prevalence of SUDs and substance use in persons with AN, with an overall pooled prevalence of 16%. Comorbid SUDs, including drugs, alcohol, and cannabis, were all more common in AN-BP compared to AN-R throughout. Therefore, clinicians should be aware of the high prevalence of SUD comorbidity and substance use in individuals with AN. Finally, clinicians should consider screening for SUDs and integrating treatments that target SUDs in individuals with AN. Individuals with anorexia nervosa (AN) may also present with substance use or have a substance use disorder (SUDs). Thus, we conducted a systematic review and meta-analysis to determine the prevalence of substance use and substance use disorders in individuals with AN. We examined published studies that reported the prevalence of either substance use or SUDs in individuals with AN. We found that substance use disorders had a 16% prevalence and that drug abuse/dependence disorders had a prevalence of 7% in those with AN. These rates were much higher in individuals with binge-eating/purging type compared to the restrictive AN. However, many specific substance use disorders and substance use types were low in individuals with AN. Nonetheless, clinicians should be aware of the high prevalence of SUD comorbidity and substance use in individuals with AN.

Gender compatibility and drive for muscularity among adolescent boys: Examining the indirect effect of emotion regulation difficulties

The drive for muscularity continues to be a prominent concern among adolescent boys. However, it is unknown how gender compatibility (gender typicality and gender contentedness) relates to this pursuit. The present study sought to examine the link between gender compatibility and drive for muscularity among male adolescents, and whether this is partially accounted for by emotion regulation difficulties. Participants were 903 male adolescents, aged 11-19 years, who completed self-report measures as part of the EveryBODY study. Using path analysis, a proposed mediation model was assessed, testing an indirect pathway of gender compatibility and drive for muscularity through emotion regulation difficulties. Findings showed an indirect pathway between gender compatibility and drive for muscularity through emotion regulation difficulties. That is, boys who were more content with their male gender and believed they were typical of their gender reported fewer emotion regulation difficulties and, in turn, exhibited a lower drive for muscularity. Findings support theoretical perspectives integrating masculinity and muscularity in boys, in that those who feel less compatible with their masculinity could be susceptible to developing a greater drive for muscularity to regulate distress deriving from perceptions of not being sufficiently masculine. This study sets the groundwork for future longitudinal studies.

Relationship between Negative Running Addiction and Eating Disorder Patterns in Runners

Current studies show an increase in the risk of eating disorders in runners. Since it is known that abusive exercise can be both a cause and a consequence of such developments, the main objective of the present study was to examine the risk and possible relationships between negative running addiction (NRA), as measured by the reduced and validated SAS-40 scale, and the tendency to be a compulsive eater (measured by YFAS 2.0), anorexia nervosa (AN), and/or bulimia nervosa (BN) (measured by EAT-40). This study highlights the novelty of researching the level of influence of NRA on each defined eating disorder.

METHOD

A total of 167 Spanish-speaking federated runners in cross-country and track running (42% women and 58% men), with an average age of 24 years and an average BMI of 21 kg/m2, responded to an online questionnaire that asked about sociodemographic data and the Spanish versions of the SAS-40, YFAS 2, YFAS 3, and YFAS 4. Through a quantitative methodology using logistic regressions-the coefficient of determination and Pearson's correlation coefficient-we created a sample analysis that related the significant items of the DSM-V to the results of the questionnaires administered, as well as their relationship with the practice of the sport in question and various variables of the environment.

RESULTS

The rates of CE, AN, and BN were 65, 11.4, and 16.2%, respectively. The tendency towards CE increased with a lower weight (r = 0.156, p < 0.05), not having been overweight in childhood (r = 0.151, p < 0.05), and being a long-distance runner (r = 0.123 p < 0.05). The risk of AN increased with the absence of menstruation for more than 3 months (r = 0.271 p < 0.01), having suffered from childhood obesity (r = 0.213 p < 0.05), and being underweight (r = 0.064 p < 0.05). The risk of BN increased with having suffered from childhood obesity (r = 0.194 p < 0.05), having a higher weight (r = 0.140, p < 0.05), and practicing athletics, especially the relay modality (r = 0.044 p < 0.05).

CONCLUSIONS

A considerable number of runners are at risk of suffering from some type of eating disorder. A significant relationship was observed between long-distance runners and the risk of eating disorders (AN, BN, and CE), and the association is stronger for CE than for AN and BN. Lastly, childhood experiences (such as being obese/a healthy weight) were notorious for increasing the risk of eating disorders. Further studies are needed to research each particular parameter and the relationships between the possible levels of dependence on exercise.

LEVEL OF EVIDENCE

Level III, cohort analytic study.

Food Allergy, Eating Disorders and Body Image

Background/Introduction

Food allergy (FA) management involves avoiding allergenic foods to prevent an adverse reaction. Affected individuals spend substantial amounts of time thinking about food and the impact it has on their bodies. As such, we posit sustained awareness of food choices may contribute to distorted body image and disordered eating. We performed a narrative review to glean insight into associations between FA, body image and eating disorders.

Methods

A literature search of Scopus, PsycINFO, PubMed and Google Scholar was conducted connecting terms for "food allergy" with terms for "body image" and "eating disorders". Title and abstract screening were independently performed by two reviewers, with relevant abstracts carried forward to full text screening.

Results

159 articles were eligible for full text screening and a total of 12 publications were ultimately included in this narrative review, and 1 article from the grey literature. Adolescents and adults both reported feeling as though their bodies were "defective" and were found to have integrated their FA as a stable facet of their identities. In addition, FA was overwhelmingly associated with prevalence of eating disorders and eating disorder-like symptoms. Disturbed body image was found to be a mediating variable for the development of disordered patterns of eating in food allergic individuals.

Limitations

Few studies appeared to consider comorbidities as confounders. Also, many studies employed convenience sampling, which does limit generalizability of conclusions.

Discussion/Conclusion

Based on a small body of literature, there appears to be a potential association between FA and distorted body image and disordered eating.

A study protocol for a preliminary randomised controlled trial assessing the acceptability and effectiveness of two eating disorders prevention interventions in Switzerland: The HEIDI BP-HW project

Because of the serious consequences of eating disorders on young women’s lives and because of the lack of specialised care facilities, assessing and implementing evidence-based prevention interventions is necessary. Switzerland, like other Western countries, has high prevalence rates of eating disorders. However, no prevention interventions have been evaluated in this country so far. This paper presents the protocol of a preliminary study with the aim to evaluate the acceptability and effectiveness of two interventions, the Body Project (BP) and the Healthy Weight Program (HW), for female students from French-speaking Switzerland. These two interventions were chosen because they have been widely evaluated and they proved to be effective in various countries. They take place in groups and include four weekly sessions over one month. Because of the pandemic situation, the group sessions will take place online on an collaborative platform. The design is a three-arm randomised controlled study. Ninety female students aged 18–25 and presenting with at least moderate body dissatisfaction will be randomised into three groups: (1) one-month BP intervention, (2) one-month HW intervention, and (3) one-month waiting-list control group followed by the BP intervention. Assessments of body dissatisfaction, thin-ideal internalisation, dietary restraint, negative affect, and eating disorder psychopathology will be conducted before and after the interventions or waiting list and after a one-month follow-up. ANCOVA and ANOVA with repeated measures will be used to assess group differences and follow-up stability. Acceptability will be assessed with a questionnaire on participants’ satisfaction with the interventions, group discussion at the end of the intervention, and with participants’ rate of attendance to the group sessions. The study results will provide additional data on these two eating disorders prevention interventions and will suggest ways for their dissemination and further evaluation in Switzerland.

Shame and eating disorders symptoms: A meta-analysis

OBJECTIVE

Numerous empirical studies and theoretical models posit that shame is a common experience among individuals across the eating disorder spectrum. In this study we aim to investigate the association between shame and eating disorders symptoms using a meta-analytical approach.

METHOD

In this meta-analysis, we synthesized findings from 195 studies to examine the proposed association between shame and eating disorders symptoms. We looked at the associations with both general eating disorders symptoms and with specific eating disorders symptoms (i.e., anorexic, bulimic, and binge-eating symptoms). Moderation analyses testing for the effect of type of shame, type of eating symptoms, clinical status, quality of the study, age, and gender were conducted.

RESULTS

Shame was significantly associated with a medium to large effect size with all types of eating disorders symptoms (rs between .40 and .52). Body shame (r = .55) and shame around eating (r = .59) were more strongly related with eating disorders pathology. Type of eating disorders symptoms did not moderate the relationship between shame and disturbed eating.

DISCUSSION

Overall, the magnitude of the effect size of the association between shame and eating disorders symptoms is a medium to large one. Body shame and shame around eating seem to be the types of shame most closely tied with eating disorders symptoms, suggesting that directly targeting them in interventions might be highly beneficial. Findings highlight current gaps in the literature (e.g., mostly correlational studies, low quality studies) with implications for future research.

Prevalence and management of people with eating disorders presenting to primary care: A national study

OBJECTIVE

Primary care practitioners are well placed to support diagnosis and appropriate treatment of eating disorders as they are often the first point of contact with the health care system. However, little is known about management of eating disorders in primary care. We aimed to estimate the prevalence of management of eating disorders in primary care and identify how these disorders are managed.

METHODS

This study used data from the Bettering the Evaluation of Care of Health programme, which annually surveys 1000 randomly sampled general practitioners in Australia who each record details of 100 successive patient encounters. In total, data were utilised from 1,568,100 primary care encounters between 2000/2001 and 2015/2016.

RESULTS

Eating disorders were managed in less than 1% of primary care encounters between 2000/2001 and 2015/2016. When extrapolated to the Australian population, up to 0.32% of the population were managed in primary care for a primary or probable eating disorder. In the majority of encounters where an eating disorder was managed (58.5%), the encounter was initiated for reasons other than the eating disorder itself. Of a group of patients identified with a clinically significant low body mass index (N = 5917), a small number (n = 118) had either no other diagnosis or a related condition that may be indicative of an eating disorder. In encounters where an eating disorder was managed, referrals to a mental health specialist/service, medical specialist and nutritionist/dietician were provided in 20%, 8% and 6% of encounters, respectively. Mental health treatment plans, which provide subsidised access to mental health services, were ascribed in approximately 7.7% of encounters where an eating disorder was managed.

CONCLUSION

Primary care provides an opportunity to improve detection and management of eating disorders, particularly when patients present for 'other' issues or with unexplained low body mass index and one or more symptoms related to an eating disorder.

A Pilot Event-Related Potentials Study on Mechanisms Underlying a tDCS-Enhanced Food-Specific Response Inhibition Task for Patients With Binge Eating Disorder

Behavioural studies demonstrate alterations in cognitive functioning, particularly impaired response inhibition and increased attentional bias towards food in binge eating disorder (BED). This pilot study aimed to investigate the neurophysiological processing of a food-specific inhibition training combined with anodal transcranial direct current stimulation (tDCS) of the right dorsolateral prefrontal cortex (DLPFC) in 16 patients with BED (mean age = 38.6, mean BMI = 33.7 kg/m²). Patients performed a food-specific antisaccade task at baseline (T0) and in a cross-over design with verum vs. sham stimulation at T1 and T2. We investigated (i) event-related potentials (ERPs; N2, ERN and P3 amplitudes) while executing the task at baseline, (ii) whether baseline ERPs would predict task performance at T1 and T2 and (iii) associations between ERPs, eating disorder pathology and impulsivity at baseline. The mean amplitude of N2 was less pronounced in erroneous saccades (ES) than correct saccades (CS), whereas ERN and P3 mean amplitudes were more pronounced in ES. Moreover, the P3 mean amplitude of ES predicted the percentage of ES at both follow up-measurements irrespective of the applied stimulation (sham vs. verum). N2 in trials with correct saccades were negatively correlated with nonplanning trait impulsivity, while P3 in erroneous antisaccade trials was negatively correlated with food-related impulsivity. Overall, the findings of reduced ERN, enhanced P3 and N2 amplitude might be interpreted as difficulties in response inhibition towards food in individuals with BED. In particular, P3 predicts task outcome at follow-up and might represent a potential marker for inhibitory control processes.

[Factors associated with the risk of developing eating disorders among medical students in Casablanca, Morocco]

Introduction

les troubles du comportement alimentaire (TCA) sont particulièrement fréquents chez les jeunes adultes, y compris les étudiants. Les objectifs de cette étude sont de déterminer la prévalence d'éventuels troubles du comportement alimentaire chez les étudiants en médecine de Casablanca et d´évaluer le risque de TCA selon les facteurs associés, notamment les facteurs socioéconomiques, cliniques, l´anxiété et la dépression.

Méthodes

nous avons mené une étude transversale descriptive et analytique au niveau du Centre Hospiatlier Universiatire Ibn Rochd de Casablanca et à la faculté de médecine et de pharmacie de Casablanca Maroc, durant l´année universitaire 2016-2017. L´enquête a porté sur un échantillon de 506 étudiants. Nous avons utilisé le questionnaire SCOFF-F (Sick, Control, One stone, Fat, Food; version française), un outil validé pour le dépistage des troubles du comportement alimentaire et l´échelle HAD (Hospital anxiety and depression) pour dépister les troubles anxieux et dépressifs.

Résultats

le questionnaire SCOFF a détecté 127 personnes (soit 25,09%) sur 506 susceptibles de souffrir de troubles du comportement alimentaire. L´âge, le niveau d´études, l´utilisation des moyens de contrôle du poids, l´anxiété et la dépression sont des facteurs associés de façon significative au risque de présenter un trouble du comportement alimentaire chez les étudiants.

Conclusion

nos résultats sont en accord avec les données de la littérature concernant la fréquence des troubles du comportement alimentaire en population étudiante et plus spécifiquement les étudiants en médecine. Mener d´autres études sur une population plus variée pourraient également être envisagées afin d´avoir une vision plus globale de la situation au Maroc.

Prevalence and early risk factors for bulimia nervosa symptoms in inner-city youth: gender and ethnicity perspectives

BACKGROUND

Research on risk factors associated with bulimia nervosa symptoms (BN) in ethnic minorities has been limited. This study adds to the existing literature by providing the ethnicity- and gender-specific prevalence of BN in US inner-city youth and by exploring the longitudinal associations between a clinical level of BN and early risk factors assessed one year previously.

METHODS

The study was conducted on a representative sample of predominantly ethnic minority youth (N = 2794; 54.1% female; age 11-16 years old (M(SD) = 12.77(1.29)); 60.0% African-American, 26.1% Hispanic American, 13.9% White). Self-reported information was obtained on BN and early risk factors (e.g., depressive and anxiety symptoms, posttraumatic stress, somatic complaints). Multivariate analysis of covariance was used to examine the longitudinal associations.

RESULTS

The 3-month BN prevalence was higher in girls (5.1%) than in boys (2.3%) (ratio 2.22:1). Significant differences in BN rates were found between White and African American students (higher in Whites), whereas Hispanic-Americans did not differ significantly from either group. Individuals with BN had significantly higher levels of early risk factors one year prior.

CONCLUSIONS

Timely recognition of BN and associated early risk factors is important for early prevention and intervention strategies.

BDNF levels in adolescent patients with anorexia nervosa increase continuously to supranormal levels 2.5 years after first hospitalization

BACKGROUND

Brain-derived neurotrophic factor (BDNF) influences brain plasticity and feeding behaviour, and it has been linked to anorexia nervosa in numerous studies. Findings in mostly adult patients point to reduced serum BDNF levels in the acute stage of anorexia nervosa and rising levels with weight recovery. However, it is unclear whether this increase leads to normalization or supranormal levels, a difference that is potentially important for the etiology of anorexia nervosa and relapse.

METHODS

We measured serum BDNF at admission (n = 149), discharge (n = 130), 1-year follow-up (n = 116) and 2.5-year follow-up (n = 76) in adolescent female patients with anorexia nervosa hospitalized for the first time, and in healthy controls (n = 79). We analyzed associations with body mass index, eating disorder psychopathology and comorbidities.

RESULTS

Serum BDNF was only nominally lower at admission in patients with anorexia nervosa compared to healthy controls, but it increased continuously and reached supranormal levels at 2.5-year follow-up. BDNF was inversely associated with eating disorder psychopathology at discharge and positively associated with previous weight gain at 1-year follow-up.

LIMITATIONS

We compensated for attrition and batch effects using statistical measures.

CONCLUSION

In this largest longitudinal study to date, we found only nonsignificant reductions in BDNF in the acute stage of anorexia nervosa, possibly because of a shorter illness duration in adolescent patients. Supranormal levels of BDNF at 2.5-year follow-up could represent a pre-existing trait or a consequence of the illness. Because of the anorexigenic effect of BDNF, it might play an important predisposing role for relapse and should be explored further in studies that test causality.

Emotional reactivity to binge food and erotic cues in women with bulimia nervosa symptoms

BACKGROUND

Studies on food cue reactivity have documented that altered responses to high-calorie food are associated with bulimic symptomatology, however, alterations in sexual motivations and behaviors are also associated clinical features in this population, which justify their inclusion as a research target. Here, we study responses to erotic cues-alongside food, neutral and aversive cues-to gain an understanding of specificity to food versus a generalized sensitivity to primary reinforcers.

METHODS

We recorded peripheral psychophysiological indices -the startle reflex, zygomaticus, and corrugator responses-and self-reported emotional responses (valence, arousal, and dominance) in 75 women completing the Bulimia Test-Revised (BULIT-R). Multiple regression analysis tested whether BULIT-R symptoms were predicted by self-reported and psychophysiological responses to food versus neutral and erotic versus neutral images.

RESULTS

The results showed that individuals with higher bulimic symptoms were characterized by potentiated eye blink startle response during binge food (vs. neutral images) and more positive valence ratings during erotic (vs. neutral) cues.

CONCLUSIONS

The results highlight the negative emotional reactivity of individuals with elevated bulimic symptoms toward food cues, which could be related to the risk of progression to full bulimia nervosa and thereby addressed in prevention efforts. Results also point to the potential role of reactivity to erotic content, at least on a subjective level. Theoretical models of eating disorders should widen their conceptual scope to consider reactivity to a broader spectrum of primary reinforcers, which would have implications for cue exposure-based treatments. We examined appetitive and aversive cue responses in college women to investigate how bulimic symptoms relate to primary reinforcers such as food and erotic images. We recorded peripheral psychophysiological indices (the startle reflex, zygomaticus, and corrugator responses) and self-reported emotional responses (valence, arousal, and dominance) in 75 college women that were presented with the Spanish version of the Bulimia Test-Revised. The results showed that bulimic symptoms increase both psychophysiological defensiveness toward food cues and subjective pleasure toward erotic cues. The findings suggest a generalized sensitivity to primary reinforcers in the presence of bulimic symptoms, and emphasize the relevance of adopting a wider framework in research and treatment on bulimia nervosa.

Clinicians as a critical link: Understanding health professionals' beliefs and attitudes toward anorexia nervosa, bulimia nervosa, and binge eating disorder

Understanding the perspectives of health professionals remains an understudied issue, yet may help bridge research-practice gaps and pinpoint important areas for education, training, and research. This study investigated attitudes toward anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) among Nordic health professionals specialized within the eating disorder (ED) field. Participants (n = 144) completed a modified ED-version of the Illness Perception Questionnaire which assessed attitudes and beliefs toward perceived symptom controllability, severity, treatment effectiveness, and views on the prognosis of AN, BN, and BED. Personal enjoyment and level of comfort working with AN, BN, and BED were also assessed. The majority agreed or strongly agreed that patients with AN, BN, and BED were not responsible for their illness, and viewed the illnesses as psychological rather than medical in etiology. AN was viewed as the most severe and enduring, followed by BN, then BED. Treatment for BN was viewed as being more highly effective than treatments for either AN or BED. Professionals rated significantly less enjoyment and less confidence working with BED. To conclude, both commonalities and differences in attitudes toward AN, BN and BED were found in terms of perceived symptom controllability, views on severity, treatment effectiveness, and anticipated prognosis. In particular, findings emphasized the need for additional training in the management of BED among Nordic healthcare professionals.

Relationship between eating disorders and internalized problems in chilean adolescents

BACKGROUND

Eating disorders (ED) are associated with internalized problems (INTP), such as depression and anxiety. Evidence shows that ED and INTP are associated with comorbidities. The relationship between these variables has not been the focus of studies on young people from Northern Chile. Children and adolescents are considered as an at-risk group, since they have been found to experience greater vulnerability to psychological problems than other age groups within the population and given the scarcity of studies in Chile, it is necessary to study the relationship between these variables.

METHODS

This study analyzed the relationship between ED and INTP in Chilean high school students aged 12 to 18 years using Pearson's correlation. This is a non-experimental and transactional correlational study. We included 2277 students belonging to the public, government-subsidized, and private educational establishments in Northern Chile. The Child and Adolescent Evaluation System [Sistema de Evaluación de Niños y Adolescentes (SENA)] was used to detect a range of INTP, as well as ED. The Brief Self-Control Scale was used in this study.

RESULTS

A strong and direct correlation of the eating disorder variable with depression and anxiety was found. Additionally, significant differences were observed with sex, highlighting females with a higher presence of INTP and ED.

CONCLUSIONS

There is a need to establish strategies in the school setting for detecting frequent symptomatology in adolescents with INTP and ED to achieve a timely and accessible intervention. Since the symptomatology of ED is more prevalent in adolescents, this research evaluated relationships between ED and INTP in young people from Northern Chile. This research is relevant because the evidence on this topic in Chile is scarce and the relationships found could be the first research on the subject and serve to design an intervention plan at the school level in the medium and long terms. It is a non-experimental and transactional correlational study because all variables were measured at a single moment, and it sought to establish relationships between variables without assuming causality. The sample of secondary school students consisted of 2277 students, belonging to the public, subsidized, and private schools. Strong relationships were observed between INTP and ED, the strongest correlations being with the variables depression and anxiety. In addition, female participants presented greater problems in ED and INTP.

Effects of Dog-Assisted Therapy in Adolescents with Eating Disorders: A Study Protocol for a Pilot Controlled Trial

BACKGROUND

Eating disorders are characterized by a persistent disturbance that alters food intake and it is often accompanied by anxiety, depression, low self-esteem, or reduced functional capacity and quality of life. Animal-assisted therapies (AAT) have shown benefits in these variables in children and adult populations. Thus, the present pilot study will aim to evaluate the effects of a dog-assisted therapy on the eating disorders symptoms, mental, psychosocial, and physical health, quality of life, and handgrip strength of adolescents suffering from eating disorders.

METHODS

The current pilot study will involve 32 patients, who will be assigned to a control or an experimental group. Intervention will be conducted once a week for seven weeks. Neither the experimental nor the control group will discontinue their usual care. The main outcome measures will be the eating disorder symptoms and the health-related quality of life measured with standardized questionnaires, while the secondary variables will be anxiety, depression, character, behavior, strength, and body mass.

CONCLUSIONS

This pilot-controlled trial will be the first to evaluate the effects of dog-assisted therapy on the physical and mental health of adolescents with eating disorders. Significant improvements, in the primary and secondary outcomes, may be expected based on the known benefits of AAT on self-esteem, stress, and self-control in different populations. Finally, although the program is focused on the improvement of adolescents' health, animal welfare will be a priority in this study.

Compulsive exercise and mental health challenges in fitness instructors; presence and interactions

BACKGROUND

Some physically active people exercise compulsively, which can be associated with several mental health challenges. Fitness instructors are considered important role models for an active, healthy lifestyle; yet little is known about their exercise motives and mental health. The aim of this study was to examine the presence of compulsive exercise and mental health challenges, and their interaction, in fitness instructors.

METHODS

A total of 270 fitness instructors from Norwegian fitness clubs were recruited for this cross-sectional study. Inclusion criteria were operating as instructors within the current year and understanding Norwegian language. Data were collected by an electronic questionnaire and included demographic information, hours of classes instructed and of personal physical activity, Compulsive Exercise Test (CET), Symptom Check List - 10 (SCL-10), Beck Depression Inventory (BDI), and Eating Disorder Examination Questionnaire (EDE-Q)).

RESULTS

Females had higher CET scores than males, and 9% of all respondents had CET score above clinical cutoff. Respondents with clinical CET score had higher SCL-10, BDI and EDE-Q global- and subscale scores compared with their counterparts. Although CET was positively and significantly associated with BDI, SCL-10, and EDE-Q, only the latter explained the CET score (ß = 1.23, 99% CI = 0.87, 1.59).

CONCLUSION

About one out of eleven instructors were above clinical CET cut-off, revealing symptoms of compulsive exercise. EDE-Q significantly contributed in a model explaining 43% of the variation of compulsive exercise.

Bone mineral density at extremely low weight in patients with anorexia nervosa

OBJECTIVE

Low bone mineral density (BMD) is a frequent and invalidating consequence of chronic undernourishment in patients with anorexia nervosa (AN). The aim of this study was to assess prevalence and clinic-biological correlates of low BMD and fractures in extremely undernourished inpatients with AN.

DESIGN

Retrospective cohort study.

PATIENTS AND MEASUREMENTS

This study included 97 extremely malnourished female inpatients with AN consecutively admitted over 2 years. Clinical-biological variables, history of fractures and BMD by dual-energy X-ray absorptiometry (DXA) were examined to find predictors of low BMD and fractures.

RESULTS

The prevalence of low BMD was of 51% for lumbar spine and 38% for femoral neck. Z-scores were lower at lumbar spine (-2.2 ± 1.2 SD) than at femoral neck (-1.9 ± 0.9 SD) (P<.01). Fragility fractures were reported by 10% of patients. BMD was mainly predicted by FFM, illness duration, age at onset and restricting AN (P<.05). Fractures were predicted by sodium concentrations, femoral neck Z-score and illness duration (P<.03).

CONCLUSION

Extremely severe patients with AN have high prevalence of low BMD, predicted by severity and chronicity of malnutrition.

Mixture Modeling of Nonsuicidal Self-Injury and Binge Eating: Behaviors and Motives

Nonsuicidal self-injury (NSSI) and binge eating frequently co-occur. These behaviors are often used to alleviate distress. Previous studies examining this co-occurrence have used a variable-centered approach. The current study used a person-centered approach (mixture modeling) to examine how individuals cluster in groups based on their past-month NSSI, past-month objective and subjective binge episodes (OBEs and SBEs, respectively), and endorsement of coping motives for NSSI and eating in two large samples of emerging adults. Validators included self-report measures of emotion regulation, impulsivity, and negative affect. In Study 1, additional validators included lifetime history of mental health treatment and suicide attempts. In Study 2, additional validators included child abuse history. In both Study 1 and Study 2, a three-class solution provided the most interpretable fit with classes characterized as (a) low psychopathology; (b) the presence of OBEs and NSSI, and endorsement of NSSI coping motives; and (c) the presence of SBEs and NSSI, and endorsement of high levels of NSSI coping motives. In both studies, eating motives were equivalent in Classes 2 and 3, but NSSI motives were most strongly endorsed by Class 3. In Study 1, Class 2 endorsed higher rates of lifetime suicide attempts than Class 3. In Study 2, both Class 2 and Class 3 endorsed higher rates of child abuse than Class 1, although they did not differ from each other. The class structure and validator analysis were consistent across samples and measures. Results suggest that binge eating and NSSI tend to cluster together in otherwise healthy emerging adults.

Excess mortality associated with eating disorders: population-based cohort study

BACKGROUND

Individuals with eating disorders have a high mortality risk. Few population-based studies have estimated this risk in eating disorders other than anorexia nervosa.

AIMS

To investigate all-cause mortality in a population-based cohort of individuals who received hospital-based care for an eating disorder (anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified) in Ontario, Canada.

METHOD

We conducted a retrospective cohort study of 19 041 individuals with an eating disorder from 1 January 1990 to 31 December 2013 using administrative healthcare data. The outcome of interest was death. Excess mortality was assessed using standardised mortality ratios (SMRs) and potential years of life lost (PYLL). Cox proportional hazards regression models were used to examine sociodemographic and medical comorbidities associated with greater mortality risk.

RESULTS

The cohort had 17 108 females (89.9%) and 1933 males (10.1%). The all-cause mortality for the entire cohort was five times higher than expected compared with the Ontario population (SMR = 5.06; 95% CI 4.82-5.30). SMRs were higher for males (SMR = 7.24; 95% CI 6.58-7.96) relative to females (SMR = 4.59; 95% CI 4.34-4.85) overall, and in all age groups in the cohort. For both genders, the cohort PYLL was more than six times higher than the expected PYLL in the Ontario population.

CONCLUSIONS

Patients with eating disorders diagnosed in hospital settings experience five to seven times higher mortality rates compared with the overall population. There is an urgent need to understand the mortality risk factors to improve health outcomes among individuals with eating disorders.

Mindfulness in persons with anorexia nervosa and the relationships between eating disorder symptomology, anxiety and pain

Mindfulness is useful for some psychiatric illnesses, but limited research exists among persons with anorexia nervosa (AN). This study aimed to determine the relationship between mindfulness, eating disorder symptomology and indicators of health in women with AN (n = 59) entering residential treatment. Participants completed a self-administered survey, including the Cognitive Affective Mindfulness Scale and other measures. Additional data from medical records were collected. Greater mindfulness was associated with less eating disorder symptoms (p = .049). This relationship was most profound in individuals with AN, including restrictive and binge-purge subtypes compared to individuals with atypical AN (interaction p-value = 0.044). Greater mindfulness was significantly associated with less shape (p = .023) and weight concern (p = .047). Expectedly, anxiety was inversely associated with eating disorder symptoms (p = .001). Greater pain was associated with less eating disorder symptoms (p = .024). Overall, mindfulness may be a protective factor against some eating disorder symptomology.

Comorbid mental disorders during long-term course in a nationwide cohort of patients with anorexia nervosa

OBJECTIVE

Comorbid mental disorders in anorexia nervosa during long-term course require detailed studies.

METHOD

This matched cohort study was based on nationwide Danish register data of all patients born 1961-2008 with a first-time ICD-10 diagnosis of anorexia nervosa (AN) between 1994 and 2018 at age 8-32 and matched controls taken from all individuals without an eating disorder (ED). For nine categories of non-eating mental disorders, time from date of first AN-diagnosis (inclusion date) to time of first diagnosis, accounting for censoring, was studied by use of time-stratified Cox models.

RESULTS

A total of 9,985 patients with AN (93.5% females) and 49,351 matched controls were followed for a median (IQR) of 9.0 (4.4-15.7) years. For patients, there was about 25% and 55% risk of receiving any non-ED disorder during the first 2 years and two decades after inclusion, respectively. A hazard ratio (HR) of seven for any non-ED was found for the first 12 months after inclusion, a ratio that reduced to two at five or more years after inclusion. During the first years, large HRs ranging in 6-9 were found for affective, autism spectrum, personality, and obsessive-compulsive disorders with the latter displaying the highest continuous increased risk. The HR at 12 months after inclusion was highest for any non-ED disorder and affective disorders in patients aged 8-13 at diagnosis.

DISCUSSION

Comorbid mental disorders in AN are most frequently diagnosed in the first years after diagnosis of AN and on longer terms imply a double immediate risk.

BED-online: Acceptance and efficacy of an internet-based treatment for binge-eating disorder: A randomized clinical trial including waitlist conditions

Objective

Internet‐based guided self‐help (GSH) programs increase accessibility and utilization of evidence‐based treatments in binge‐eating disorder (BED). We evaluated acceptance and short as well as long‐term efficacy of our 8‐session internet‐based GSH program in a randomized clinical trial with an immediate treatment group, and two waitlist control groups, which differed with respect to whether patients received positive expectation induction during waiting or not.

Method

Sixty‐three patients (87% female, mean age 37.2 years) followed the eight‐session guided cognitive‐behavioural internet‐based program and three booster sessions in a randomized clinical trial design including an immediate treatment and two waitlist control conditions. Outcomes were treatment acceptance, number of weekly binge‐eating episodes, eating disorder pathology, depressiveness, and level of psychosocial functioning.

Results

Treatment satisfaction was high, even though 27% of all patients dropped out during the active treatment and 9.5% during the follow‐up period of 6 months. The treatment, in contrast to the waiting conditions, led to a significant reduction of weekly binge‐eating episodes from 3.4 to 1.7 with no apparent rebound effect during follow‐up. All other outcomes improved as well during active treatment. Email‐based positive expectation induction during waiting period prior to the treatment did not have an additional beneficial effect on the temporal course and thus treatment success, of binge episodes in this study.

Conclusion

This short internet‐based program was clearly accepted and highly effective regarding core features of BED. Dropout rates were higher in the active and lower in the follow‐up period. Positive expectations did not have an impact on treatment effects.

The present internet‐based guided self‐help program adds to the existing research regarding online treatment of binge‐eating disorder and is currently one of the two existing validated programs available in German language. It is based on an established cognitive‐behavioural treatment approach, shows high acceptance by patients and high efficacy after eight guided online sessions, thereby representing the shortest duration of currently evaluated treatments

During the internet‐based therapy, the number of weekly binge‐eating episodes, depressive symptoms, eating disorder pathology as well as impairments in psychosocial functioning all significantly decreased. These positive effects were maintained during follow‐up (6 months). Abstainer rate (no binge‐eating during last month) continued to increase during follow‐up with booster sessions

An email‐based pre‐treatment positive expectation induction did not alter the temporal course and thus treatment success, of binge episodes

Parental practices, body dissatisfaction and weight control practices in female adolescents from public schools in southern Brazil

The objective was to verify the association between body dissatisfaction (BD) - constituted by the desire to lose weight - with family and personal aspects related to the shape of the body and weight control practices in female adolescents. A cross-sectional, observational epidemiological study with adolescents aged 12-19 years, enrolled in classes of the 8th and 9th years of public schools belonging to the urban area of the city of Caxias do Sul/Rio Grande do Sul, Brazil, was conducted. A self-applicable questionnaire was used. BD was assessed using a silhouette scale. Multivariate regression was performed using Poisson regression with robust variation, hierarchically using a pre-established conceptual model, using the prevalence ratio (PR) adjusted with 95 % CI as a measure of effect. A significance level of 5 % (P ≤ 0·05) was considered. Among the 685 female students, 77·2 % had BD. The father's incentive to diet sometimes (PR 1·19; 95 % CI 1·07, 1·32; P ≤ 0·001) and always (PR 1·15; 95 % CI 1·03, 1·28; P ≤ 0·001), trying to lose weight (PR 1·63; 95 % CI 1·33, 1·99; P ≤ 0·001), dieting five times or more (PR 1·22; 95 % CI 1·09, 1·36; P ≤ 0·001) and skipping meals less than once a week (PR 1·16; 95 % CI 1·04, 1·29; P = 0·026) increased the chances of having BD. In conclusion, among the investigated parents' behaviours, only the father's incentive to go on a diet was associated with BD. Adolescent weight control practices increased the chances of having BD. Thus, it facilitates the identification of this condition at an early stage, enabling adequate treatment and prevention of health complications.

A mixed-method systematic review of text-based telehealth interventions in eating disorder management

Purpose

Eating disorders (EDs) is a major health condition affecting 9% of the global population and 10% of those with EDs lost their lives as a result. Text-based telehealth interventions (TTIs) seem to provide a low-cost and convenient treatment option; however, the evidence is scarce. This study aimed to synthesize evidence relating to the use of TTIs for the management of EDs.

Design/methodology/approach

Five databases were searched published between January 2020 and May 2019. The authors used keywords relating to telehealth and EDs. The authors used Joanna Briggs Institute's (JBI's) critical appraisal instrument to assess the methodology quality of included studies.

Findings

Fifteen studies were included in this mix-method systematic review and assessed for methodology quality. Email, web-based texting, text-messaging and online chat room were used as mode for deliver healthcare for patients with EDs. In the treatment phase, all studies (nine studies; n = 860 participants) showed effectiveness (for RCTs) and usefulness (for non-RCT studies). In the aftercare phase (six studies; n = 364 participants), the results regarding the effectiveness of TTIs were mixed. Two studies showed effectiveness whilst four studies did not find statistically significant change of ED outcomes.

Research limitations/implications

The qualities of these studies varied; firstly, 66% (n = 10) of the studies were non-randomized studies (e.g. single-arm trial, case report) with small samples. Moreover, one-fourth (n = 4) of the studies did not use validated instruments or indicate the instrument. Also, half (n = 7) of the studies used TTIs as adjunct to face-to-face treatment or bigger online treatment, it is hard to make conclusion that the changes were due to TTIs' effect. In addition, follow-up rate is not satisfactory, thus results should be interpreted cautiously.

Practical implications

TTIs seem to be promising for management of EDs, particularly in the treatment phase. This provides an important treatment option for health practitioners and people with EDs as an alternative or in adjunct with face-to-face services.

Originality/value

This is the first review to synthesis the use of TTIs for ED management.

Food for Thought: A Dissonance Between Healthcare Utilization Costs and Research Funding for Eating Disorders in Canada

In this commentary, we present the premise that, in Canada, mental illness research specific to eating disorders is underfunded, and many Canadians are suffering the consequences of this underinvestment. We highlight three critical aspects of eating disorders: 1) the increasingly common yet potentially life-threatening nature of eating disorders, with an onset usually during adolescence; 2) the challenges and costs to treating eating disorders, with a discussion of current hospital-related costs across Canada; and 3) the glaring discrepancy between the money spent on eating disorder diagnoses/treatment and the funding dollars granted for eating disorder research in Canada (i.e. only $0.70 per affected Canadian in 2018). Research funding per affected individual for other psychiatric and neurodevelopmental conditions are used as comparisons (e.g. $50.17 per affected Canadian with schizophrenia). We suggest that it is time to revolutionize treatment for individuals with eating disorders and use our resources in a more efficient and effective manner, using current neuroimaging and neuromodulation methods as promising examples. We conclude by emphasizing the need for increased research funding in the field of eating disorders in Canada, as the current research-related investments hinder progress in developing neuroscientifically-sound treatments for these populations.

Perinatal stress and epigenetics

Animal and humans exposed to stress early in life are more likely to suffer from long-term behavioral, mental health, metabolic, immune, and cardiovascular health consequences. The hypothalamus plays a nodal role in programming, controlling, and regulating stress responses throughout the life course. Epigenetic reprogramming in the hippocampus and the hypothalamus play an important role in adapting genome function to experiences and exposures during the perinatal and early life periods and setting up stable phenotypic outcomes. Epigenetic programming during development enables one genome to express multiple cell type identities. The most proximal epigenetic mark to DNA is a covalent modification of the DNA itself by enzymatic addition of methyl moieties. Cell-type-specific DNA methylation profiles are generated during gestational development and define cell and tissue specific phenotypes. Programming of neuronal phenotypes and sex differences in the hypothalamus is achieved by developmentally timed rearrangement of DNA methylation profiles. Similarly, other stations in the life trajectory such as puberty and aging involve predictable and scheduled reorganization of DNA methylation profiles. DNA methylation and other epigenetic marks are critical for maintaining cell-type identity in the brain, across the body, and throughout life. Data that have emerged in the last 15 years suggest that like its role in defining cell-specific phenotype during development, DNA methylation might be involved in defining experiential identities, programming similar genes to perform differently in response to diverse experiential histories. Early life stress impact on lifelong phenotypes is proposed to be mediated by DNA methylation and other epigenetic marks. Epigenetic marks, as opposed to genetic mutations, are reversible by either pharmacological or behavioral strategies and therefore offer the potential for reversing or preventing disease including behavioral and mental health disorders. This chapter discusses data testing the hypothesis that DNA methylation modulations of the HPA axis mediate the impact of early life stress on lifelong behavioral and physical phenotypes.

"Putting your own oxygen mask on first": a qualitative study of siblings of adults with anorexia or bulimia

BACKGROUND

In families where one of the siblings has an eating disorder (ED), research indicates that the siblings without eating disorders (EDs) experience insufficient care and negative changes in family life. The illness then takes up a great deal of space within the family. Support from the siblings without EDs is considered to be important for the recovery of the sibling with ED. A key issue is how to involve siblings without EDs in treatment and establish what kind of support they themselves need. A majority of the research on EDs and family has focused on children and adolescents with EDs. The aim of this study is to expand knowledge about the experiences and coping strategies of sisters and brothers of adult women with anorexia nervosa or bulimia nervosa.

METHODS

This qualitative study used a constructivist grounded theory approach. Individual semi-structured interviews were conducted with 10 sisters and brothers (aged 20-31 years). They were recruited from eating disorders and general psychiatrics units and from user organisations for patients with eating disorders within Norway. An iterative process of data collection, coding and analysis was employed in order to generate a theory about these participants' experiences and strategies.

RESULTS

The core category is "put your own oxygen mask on first". It indicates that the siblings realize that they need to take care of themselves first, in order to be able to stay involved with their sister with the ED. The three subcategories; "taking a new role", "distancing" and "adapted care" describe how the siblings handle their situation as the relatives of adult sisters with an ED. The siblings without ED became more responsible and independent and assumed a caregiving role. They downplayed their own needs to reduce their parents' burden. This new role became difficult to fulfil and the siblings experienced that over time they needed more distance. Eventually, they developed a more manageable way of caring for their sister.

CONCLUSIONS

The findings suggest that the ED challenged the boundaries within the family. The siblings without ED assumed a caregiver role, gradually leading to exhaustion and the need to distance from the sister with the ED, to take care of themselves.