Health service utilization for eating disorders: findings from a community-based study

Who gets treated for an eating disorder? Implications for inference based on clinical populations

BACKGROUND

The minority of people with an eating disorder receive treatment. Little is known about predictors of receiving treatment.

METHODS

Using data from the Growing Up Today Study we identified correlates of receiving treatment for an eating disorder among the 1237 U.S. women who answered questions on treatment history in 2013 and reported meeting criteria for subthreshold eating disorder in ≥ 1 year between 1996 and 2013. Logistic regression models using generalized estimating equations were used to estimate the relative odds of receiving treatment.

RESULTS

Approximately 11% of the women reported receiving treatment for an eating disorder. Independent of type of eating disorder, those who had received a diagnosis of depression or anxiety were more likely (odds ratio (OR) = 3.05 95% confidence interval (CI) 1.87-4.97) to receive treatment for an eating disorder. Women with obesity were approximately 85% less likely to receive treatment (OR = 0.13, 95% CI 0.04-0.46) regardless of their type of eating disorder or history of depression of anxiety diagnosis.

CONCLUSIONS

Most women meeting criteria for an eating disorder do not receive treatment. Women with BED or obesity are the least likely to receive treatment.

Estimating additional health and social costs in eating disorder care for young people during the COVID-19 pandemic: implications for surveillance and system transformation

BACKGROUND

The impact of the COVID-19 pandemic on young people with eating disorders (EDs) and their families was profound, with surging rates of hospitalizations and referrals reported internationally. This paper provides an account of the additional health and social costs of ED care for young people living in Canada incurred during the COVID-19 pandemic, drawing attention to the available data to inform these estimates while noting gaps in data capacities to account for a full view of the ED system of care.

METHODS

Three methodologies were used to capture costs: (1) provincial administrative data holdings available at the Canadian Institute of Health Information (CIHI) were used by Deloitte Access Economics to conduct analyses on costs related to hospitalizations, emergency room visits, outpatient visits with physicians and loss of well-being from being on a waitlist. These were examined across three fiscal years (April 1 to March 31, 2019-2022) to compare costs from one year before to two years after the onset of the pandemic, (2) data collected on support-based community ED organizations and, (3) costs identified by young people, caregivers and health care professionals.

RESULTS

Estimates of additional health care costs and social costs arising from ED care waitlists were estimated to have increased by 21% across the two years after the onset of the pandemic and is likely to represent an underestimate of costs. Costs related to some standard ED care services (e.g. day treatment programs) and support-based community ED organizations that saw a 118% increase in services during this time, are some examples of costs not captured in the current cost estimate.

CONCLUSIONS

This paper provides a first account of the additional health and social ED care costs associated with the pandemic, which indicate at minimum, a 21% increase. The results invite discussion for more investments in ED services for young people in Canada, as it is unclear if needs are expected to remain elevated. We suggest a call for a national surveillance strategy to improve data holdings to aid in managing services and informing policy. A robust strategy could open the door for much-needed, data-informed, system transformation efforts that can improve ED care for youth, families and clinicians.

A systematic review and meta-synthesis of qualitative research investigating disordered eating and help-seeking in elite athletes

OBJECTIVE

Elite athletes are at elevated risk for disordered eating and eating disorders; however, little is known about risk and maintaining factors, or barriers and facilitators of help-seeking in this cohort. This systematic review synthesized qualitative findings regarding possible risk and maintaining factors for disordered eating, as well as barriers to and facilitators of help-seeking in elite athletes.

METHOD

We conducted a search for qualitative studies that included experiences with body image concerns or disordered eating in elite athletes. A systematic search of CINAHL, PsychINFO, MEDLINE, and Scopus databases identified 828 articles, with 87 retained after title and abstract screening, and 38 included in the review. Quality appraisal was conducted using the checklist for appraising qualitative research (CASP). Data were extracted from each article, including demographic information (e.g., biological sex, age, sport type, level of competition, current, or former athlete) and the text under the "results" or "findings" section. Meta-themes were identified using inductive thematic meta-synthesis.

RESULTS

The extracted data indicated that most studies sampled female athletes from the United States and UK. Eight meta-themes were identified: (1) the power imbalance; (2) hyperfocus on body, food, and exercise; (3) rigidity; (4) the athlete's balance; (5) the athlete identity; (6) overvaluation and oversimplification; (7) shame, fear, and stigma; and (8) knowledge, education, and self-identification.

DISCUSSION

These findings highlighted gaps in the demographic representation of specific groups in this research (e.g., males, para-athletes, and ethnic diversity) and propose hypotheses of how sport pressure might contribute to athletes' experiences with disordered eating.

PUBLIC SIGNIFICANCE

Disordered eating and body image concerns are prevalent and can have debilitating impacts for elite athletes; however, help-seeking is rare for this population. It remains unclear what factors contribute to disordered eating and/or inhibit help-seeking among elite athletes versus the general population. Understanding athletes' perspectives will inform the modification of prevention and treatment strategies to address athlete-specific factors.

Adapting Behavioral Treatments for Primary Care Using a Theory-Based Framework: The Case of Adolescent Eating Disorders

Evidence-based treatments have been developed for a range of pediatric mental health conditions. These interventions have proven efficacy but require trained pediatric behavioral health specialists for their administration. Unfortunately, the widespread shortage of behavioral health specialists leaves few referral options for primary care providers. As a result, primary care providers are frequently required to support young patients during their lengthy and often fruitless search for specialty treatment. One solution to this treatment-access gap is to draw from the example of integrated behavioral health and adapt brief evidence-based treatments for intra-disciplinary delivery by primary care providers in consultation with mental health providers. This solution has potential to expand access to evidence-based interventions and improve patient outcomes. We outline how an 8-step theory-based process for adapting evidence-based interventions, developed from a scoping review of the wide range of implementation science frameworks, can guide treatment development and implementation for pediatric behavioral health care delivery in the primary care setting, using an example of our innovative treatment adaptation for child and adolescent eating disorders. After reviewing the literature, obtaining input from leaders in eating disorder treatment research, and engaging community stakeholders, we adapted Family-Based Treatment for delivery in primary care. Pilot data suggest that the intervention is feasible to implement in primary care and preliminary findings suggest a large effect on adolescent weight gain. Our experience using this implementation framework provides a model for primary care providers looking to develop intra-disciplinary solutions for other areas where specialty services are insufficient to meet patient needs.

Expectations of a new eating disorder treatment and its delivery: Perspectives of patients and new therapists

BACKGROUND

A significant number of people with bulimia nervosa (BN) or binge-eating disorder (BED) do not seek professional help. Important reasons include limited knowledge of eating disorders (EDs), feelings of shame, treatment costs, and restricted access to specialized healthcare. In this study, we explored if a novel therapy delivered in a primary care setting could overcome these barriers. We investigated factors such as motivation and expectations and included the patients' and newly trained therapists' perspectives.

METHOD

We interviewed 10 women with BN (n = 2) or BED (n = 8), enrolled in the Physical Exercise and Dietary therapy (PED-t) program, in a Healthy Life Center (HLC) located in a primary healthcare facility. Interview topics discussed were motivations for and expectations of therapy, and the treatment location. In addition, 10 therapists from HLC's were interviewed on their experiences with the PED-t training program and expectations of running PED-t within their service. The semi-structured interviews were analyzed using reflexive thematic analysis.

RESULTS

Most patients had limited knowledge about EDs and first realized the need for professional help after learning about PED-t. Patients exhibited strong motivations for treatment and a positive perception of both the PED-t, the new treatment setting, and the therapists' competencies. The therapists, following a brief training program, felt confident in their abilities to treat EDs and provide PED-t. With minor operational adjustments, PED-t can seamlessly be integrated into national HLC service locations.

CONCLUSION

PED-t is an accessible therapeutic service that can be delivered in a primary care environment in a stepped-care therapy model.

PUBLIC SIGNIFICANCE

This study investigates the views and experiences of patients and newly trained therapists of PED-t (Physical Exercise and Dietary therapy), a new program-led primary care therapy for binge-eating spectrum eating disorders. The treatment and the locations for the intervention, that is, local health care centers, were found to be highly acceptable to both patients and therapists, thus PED-t could easily be integrated as a first step into a step-care delivery model.

Web-based guided self-help cognitive behavioral therapy-enhanced versus treatment as usual for binge-eating disorder: a randomized controlled trial protocol

Binge-eating disorder (BED) is a psychiatric disorder characterized by recurrent episodes of eating a large amount of food in a discrete period of time while experiencing a loss of control. Cognitive behavioral therapy-enhanced (CBT-E) is a recommended treatment for binge-eating disorder and is typically offered through 20 sessions. Although binge-eating disorder is highly responsive to CBT-E, the cost of treating these patients is high. Therefore, it is crucial to evaluate the efficacy of low-intensity and low-cost treatments for binge-eating disorder that can be offered as a first line of treatment and be widely disseminated. The proposed noninferiority randomized controlled trial aims to determine the efficacy of web-based guided self-help CBT-E compared to treatment-as-usual CBT-E. Guided self-help will be based on a self-help program to stop binge eating, will be shorter in duration and lower intensity, and will require fewer therapist hours. Patients with binge-eating disorder (N = 180) will be randomly assigned to receive guided self-help or treatment-as-usual. Assessments will take place at baseline, mid-treatment, at the end of treatment, and at 20- and 40-weeks post-treatment. Treatment efficacy will be measured by examining the reduction in binge-eating days in the previous 28 days between baseline and the end of treatment between groups, with a noninferiority margin (Δ) of 1 binge-eating day. Secondary outcomes will include full remission, body shape dissatisfaction, therapeutic alliance, clinical impairment, health-related quality of life, attrition, and an economic evaluation to assess cost-effectiveness and cost-utility. The moderators examined will be baseline scores, demographic variables, and body mass index. It is expected that guided self-help is noninferior in efficacy compared to treatment-as-usual. The proposed study will be the first to directly compare the efficacy and economically evaluate a low-intensity and low-cost binge-eating disorder treatment compared to treatment-as-usual. If guided self-help is noninferior to treatment-as-usual in efficacy, it can be widely disseminated and used as a first line of treatment for patients with binge-eating disorder. The Dutch trial register number is R21.016. The study has been approved by the Medical Research Ethics Committees United on May 25th, 2021, case number NL76368.100.21.

Undetected eating disorders among adolescent psychiatric inpatients

AIM

The aim of this study was to identify the prevalence of undetected eating disorders (EDs) among adolescent psychiatric inpatients and to investigate the association between clinical, psychiatric, and sociocultural factors and EDs.

METHODS

Between January and December 2018, patients aged 12-18 years, hospitalized for inpatient-level treatment were given the self-assessment questionnaires of the Eating Attitudes Test-26 (EAT-26), the Contour Drawing Figure Rating Scale (CDFRS), the Child Behaviour Check List, and Sociocultural Attitudes Toward Appearance Questionnaire-4 after their routine unstructured clinical diagnostic assessment on admission by a psychiatrist. Patients were reassessed after reviewing the psychometric assessment results.

RESULTS

The prevalence of EDs among 117 psychiatric inpatients was 9.4%, all were female and all diagnosed with unspecified feeding and eating disorder. We showed that 63.6% of patients with EDs was diagnosed after the screening and not with the routine clinical interview. EAT-26 scores were weakly correlated with affective (r = 0.314, p = .001), anxious (r = 0.231, p = .012), somatic (r = 0.258, p = .005), and impulsive maladaptive behaviours (r = 0.272, p = .003). A formal ED diagnosis was positively associated with media pressure, (OR:1.660, 95% CI: 1.105-2.495) and oppositional defiance (OR: 1.391, 95% CI: 1.005-1.926), and negatively with conduct problems (OR: 0.695, 95% CI: 0.500-0.964). The CDFRS results were not different between the ED and non-ED groups.

CONCLUSIONS

Our study suggests EDs remain a prevalent yet often overlooked diagnosis in adolescent psychiatric inpatients. Health care providers should screen for EDs in inpatient psychiatric settings as a part of routine assessment to improve the identification of disordered eating behaviours that often begin during adolescence.

Assessing the factor structure of the Eating Attitude Test-26 among undergraduate students in Malaysia

The objective of this study was to assess the factor structure of the 26-item Eating Attitude Test (EAT-26) through confirmatory factor analysis (CFA) among 1,084 undergraduate students in Malaysia. The initial findings indicated a lack of support for the proposed three-factor structure. Model modifications were made due to the inadequate initial fit. The fit of the model was significantly improved by excluding items with factor loadings below 0.40 and integrating residual covariances. In conclusion, it is necessary to make contextual modifications to the EAT-26 in order to effectively utilize it among Malaysian undergraduates. This highlights the significance of cultural adaptations in psychological instruments.

Evaluation of an online modular eating disorders training (PreparED) to prepare healthcare trainees: a survey study

BACKGROUND

Eating disorders (EDs) are serious, complex disorders for which broad-based clinical training is lacking. This study aimed to evaluate the efficacy of a free, brief, web-based curriculum, PreparED, in increasing comfort and confidence with, and knowledge about EDs in healthcare trainees, and to obtain program feedback from key stakeholders (i.e., learners).

METHODS

This programmatic evaluation study was designed as a quantitative, repeated measures (i.e., pre- and post-test intervention) investigation. A convenience sample of two groups of healthcare trainees across geographically diverse training sites completed an anonymous survey pre- and post- engagement with PreparED. The survey included items to assess prior exposure to EDs, as well as program feasibility. The main educational outcomes included (1) Confidence and Comfort with EDs and (2) Knowledge of EDs. User experience variables of interest were likeability, usability, and engagement with the training modules. Mixed effects linear regression was used to assess the association between PreparED and educational outcome variables.

RESULTS

Participants (N = 67) included 41 nutrition graduate students and 26 nurse practitioner students recruited from Teacher's College/Columbia University in New York, NY, USA, Columbia University School of Nursing in New York, NY, USA and North Dakota State University School of Nursing in Fargo, ND, USA. Confidence/Comfort scores and Knowledge scores significantly improved following engagement with PreparED (β = for effect of intervention = 1.23, p < 0.001, and 1.69, p < 0.001, respectively). Neither training group nor prior exposure to EDs moderated the effect on outcomes. All learners agreed the program was easy to follow; the overwhelming majority (89.4%) felt the length of the modules was "just right." All participants perceived that PreparED had increased their knowledge of EDs, and the majority (94.0%) reported greater confidence in and comfort with caring for people with these disorders, including assessment of symptoms, awareness of associated medical complications, and likelihood of future screening.

CONCLUSIONS

Findings suggest that brief, user-friendly, online courses can improve knowledge and attitudes about EDs, filling a critical gap in healthcare training.

A diagnostic subgroup comparison of health care utilization patterns in individuals with eating disorders diagnosed in childhood and/or adolescence

OBJECTIVE

This study examined a 2-year period after diagnosis of an eating disorder to compare health care utilization in diagnostic subgroups including: anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), and other specified eating disorders (Other).

METHOD

We conducted a retrospective study of children diagnosed with AN (n = 674), BN (n = 230), BED (n = 59), ARFID (n = 171), and Other (n = 315). We used a general population cohort for comparison, matched 5:1 to the diagnostic subgroups on sex and birth date. We then conducted a separate analysis using the ARFID subgroup as a reference group compared to the other subgroups. Outcomes were determined using data linkage with health administrative databases and included hospitalizations, emergency department, general practitioner, psychiatry, and pediatrician visits. Odds ratios (dichotomous outcomes) and rate ratios (continuous outcome) were calculated.

RESULTS

Mental health care utilization was higher for all subgroups compared to the general population. When the subgroups were compared to the ARFID subgroup, those with ARFID appeared to have similar health care utilization to the other subgroups, except when compared to those with AN. The AN subgroup had higher odds of a mental health related hospitalization (OR 1.62, 95% CI 1.04-2.5) higher rates of mental health related pediatrician visits (RR 1.76, 95% CI 1.26-2.46) and psychiatry visits (RR 1.69, 95% CI 1.07-2.68).

CONCLUSIONS

Those with ARFID have similar utilization as other subtypes of eating disorders, except when compared to those with AN who have higher health care utilization.

PUBLIC SIGNIFICANCE

Our study found that the health service needs of young people with all types of eating disorders are substantially higher than the general population, and it appears that Avoidant/Restrictive Food Intake Disorder (ARFID) has similar health care utilization to other eating disorders.

Guided Internet-Based Cognitive Behavioral Therapy for Women With Bulimia Nervosa: Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

Individual face-to-face cognitive behavioral therapy is known to be effective for bulimia nervosa (BN). Since foods vary considerably between regions and cultures in which patients live, cultural adaptation of the treatment program is particularly important in cognitive behavioral therapy for BN. Recently, an internet-based cognitive behavioral therapy (ICBT) program was developed for Japanese women with BN, adapted to the Japanese food culture. However, no previous randomized controlled trial has examined the effectiveness of ICBT.

OBJECTIVE

This paper presents a research protocol for strategies to examine the effects of guided ICBT.

METHODS

This study is designed as a multicenter, prospective, assessor-blinded randomized controlled trial. The treatment groups will be divided into treatment as usual (TAU) alone as the control group and ICBT combined with TAU as the intervention group. The primary outcome is the total of binge eating and purging behaviors assessed before and after treatment by an independent assessor. Secondary outcomes will include measures of eating disorder severity, depression, anxiety, quality of life, treatment satisfaction, and working alliances. Treatment satisfaction and working alliances will be measured post assessment only. Other measures will be assessed at baseline, post intervention, and follow-up, and the outcomes will be analyzed on an intention-to-treat basis.

RESULTS

This study will be conducted at 7 different medical institutions in Japan from August 2022 to October 2026. Recruitment of participants began on August 19, 2022, and recruitment is scheduled to continue until July 2024. The first participants were registered on September 8, 2022.

CONCLUSIONS

This is the first multicenter randomized controlled trial in Japan comparing the effectiveness of ICBT and TAU in patients with BN.

TRIAL REGISTRATION

University Hospital Medical Information Network UMIN000048732; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000055522.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49828.

Sociodemographic and clinical characteristics of treated and untreated adults with bulimia nervosa or binge-eating disorder recruited for a large-scale research study

BACKGROUND

Eating disorders affect millions of people worldwide, but most never receive treatment. The majority of clinical research on eating disorders has focused on individuals recruited from treatment settings, which may not represent the broader population of people with eating disorders. This study aimed to identify potential differences in the characteristics of individuals with eating disorders based on whether they self-reported accessing treatment or not, in order to contribute to a better understanding of their diverse needs and experiences.

METHODS

The study population included 762 community-recruited individuals (85% female, M ± SD age = 30 ± 7 years) with bulimia nervosa or binge-eating disorder (BN/BED) enrolled in the Binge Eating Genetics Initiative (BEGIN) United States study arm. Participants completed self-report surveys on demographics, treatment history, past and current eating disorder symptoms, weight history, and their current mental health and gastrointestinal symptoms. Untreated participants (n = 291, 38%) were compared with treated participants (n = 471, 62%) who self-reported accessing BN/BED treatment at some point in their lives.

RESULTS

Untreated participants disproportionately self-identified as male and as a racial or ethnic minority compared with treated participants. Treated participants reported a more severe illness history, specifically, an earlier age at onset, more longstanding and frequent eating disorder symptoms over their lifetime, and greater body dissatisfaction and comorbid mental health symptoms (i.e., depression, anxiety, ADHD) at the time of the study. A history of anorexia nervosa was positively associated with treatment engagement. Individuals self-reporting a history of inpatient or residential treatment exhibited the most severe illness history, those with outpatient treatment had a less severe illness history, and untreated individuals had the mildest illness history.

CONCLUSIONS

Historically overlooked and marginalized populations self-reported lower treatment access rates, while those who accessed treatment reported more severe eating disorder and comorbid mental health symptoms, which may have motivated them to seek treatment. Clinic-based recruitment samples may not represent individuals with milder symptoms or racial and ethnic diversity, and males. Community-based recruitment is crucial for improving the ability to apply research findings to broader populations and reducing disparities in medical research. Trial Registration ClinicalTrials.gov NCT04162574 ( https://clinicaltrials.gov/ct2/show/NCT04162574 ).

Qualitative exploration of factors influencing women veterans' disordered eating symptoms and treatment preferences in VHA primary care

INTRODUCTION

Disordered eating symptoms (DES) are common among women veterans. While integrated primary care (IPC) may be an important venue to treat DES, little is known on patients' treatment preferences. The purpose of this study was to gather patient feedback on factors that may influence women veterans' DES and preferences for IPC services.

METHOD

We conducted semistructured interviews with purposefully sampled women who reported DES using the Eating Disorder Examination Questionnaire (EDE-Q). Twelve veterans (Mage = 54.0, SD = 8.38 years, 83.3% Caucasian, MEDE-Q Total = 3.87, SD = .77) enrolled in Veterans Health Administration primary care participated. Interviews gathered opinions on weight, appearance, and eating behaviors; experiences and preferences in addressing DES; and opinions on ways to improve their health care experience. Responses were analyzed via a directed content analysis that utilized a priori codes pertaining to health care utilization and compensatory health beliefs.

RESULTS

Results revealed longstanding DES of various types, including those consistent with restriction, binge eating, and bulimia. However, past experiences with symptom management primarily involved self-management vs. clinical management. Participants also endorsed multiple perceived treatment facilitators and barriers. Among facilitators were strong provider relationships, patient-centered communications, personalized goal setting, and skill-focused whole-person care. Barriers included feeling judged by others (including providers), amotivation, and financial and time limitations.

DISCUSSION

While IPC may be an important venue to identify and treat DES, multiple factors are likely to influence patients' use of these services. Future work should explore the potential for multidisciplinary IPC teams to address DES. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sociodemographic and Clinical Characteristics of Treated and Untreated Adults with Bulimia Nervosa and/or Binge-eating Disorder Recruited for a Large-Scale Research Study

Background: Eating disorders affect millions of people worldwide, but most never receive treatment. The majority of clinical research on eating disorders has focused on individuals recruited from treatment settings, which may not represent the broader population of people with eating disorders. This study compared the characteristics of individuals with eating disorders based on whether they self-reported accessing treatment or not, to identify potential differences and contribute to a better understanding of the diverse needs and experiences of individuals with eating disorders. Methods: The study population included 762 community-recruited individuals (85% female, M ± SD age = 30 ± 7 y) with bulimia nervosa and/or binge eating disorder (BN/BED) enrolled in the Binge-Eating Genetics Initiative (BEGIN) United States study arm. Participants completed self-report surveys on demographics, treatment history, past and current eating disorder symptoms, weight history, and current mental health and gastrointestinal comorbidity. Untreated participants ( n = 291, 38%) were compared with treated participants ( n = 471, 62%) who self-reported accessing BN/BED treatment at some point in their lives. Results: Untreated participants disproportionately self-identified as male and as a racial or ethnic minority compared with treated participants. Treated participants reported a more severe illness history, specifically, an earlier age at onset, more longstanding and frequent ED symptoms over their lifetime, and higher body dissatisfaction and comorbid mental health symptoms (i.e., depression, anxiety, ADHD) at the time of the study. Those who reported a history of inpatient or residential treatment displayed the most severe illness history, whereas those who reported outpatient treatment had a less severe illness history, and untreated individuals had the mildest illness history. Conclusions: Individuals from historically overlooked or marginalized populations were less likely to access treatment. Those who accessed treatment had more severe ED and comorbid symptoms, which may have motivated them to seek treatment. Clinic-based recruitment samples may not accurately represent all individuals with EDs, particularly those with milder symptoms and those with gender or racial/ethnic diversity. The results of this study indicate that community-based recruitment is crucial for improving the ability to apply research findings to broader populations and to reduce disparities in medical research. Trial Registration : ClinicalTrials.gov NCT04162574 (https://clinicaltrials.gov/ct2/show/NCT04162574).

Community Women’s Lifestyle and Eating Disorders in the Era of COVID-19 Pandemic: A 15-Year Follow-Up Study

Most studies suggest that COVID-19 has adversely affected the quality of life and mental health, including eating disorders. However, studies have yet to examine longitudinally the impact of COVID-19 on eating disorder symptomatic individuals. This study aims to examine longitudinally the impact of the COVID-19 pandemic on the lifestyle and eating disorder symptoms of a symptomatic group of community-dwelling women. These women (n = 171) were enrolled in a longitudinal study, completed a COVID-19 modular self-report (post or Qualtrics, 2020/21), and participated in the current study. This study examined a 15th year follow-up. In 2020, 40% were tested for COVID-19. Of these, 87% had negative results; 5.3% self-isolated at home; 20.5% stopped working/studying in person; 28% continued online work/study; and 28% stopped work/studying in person. The pandemic affected sporting activities, music, and club activities (32.7% discontinued); 38% socialized in person; 16% socialized online; and 10% completely stopped socializing. Preliminary findings showed that the respondents showed no significant changes in levels of psychological distress (K10: 21.4 ± 9.8 vs. 19.0 ± 7.1, p < 0.171), and impaired quality of life (SF12: 50.9 ± 8.0 vs. 48.3 ± 9.5, p < 0.055) at 15-year follow-up. Eating disorder symptoms increased over time (EDE-Q global: 2.1 ± 1.4 vs. 2.9 ± 1.4, p < 0.013). Observed worsening of eating disorder-related symptoms during the COVID-19 pandemic may be due to interrupted eating patterns, exercise restrictions and the absence of social support. Provision and access to interventions to support those affected by eating disorders are a high priority, especially during these times. Further analyses with data imputation may find or further establish direct implications of COVID-19 in eating disorders.

Prevalence of Disordered Eating and Its Associated Factors From a Socioecological Approach Among a Sample of Spanish Adolescents: The EHDLA Study

Objectives: The aim of this study was twofold: a) to establish the prevalence of adolescents with disordered eating and b) to determine the factors associated with this prevalence in a sample of Spanish adolescents from the Valle de Ricote (Region of Murcia, Spain).

Methods: This cross-sectional study analyzed data from 730 adolescents (56.2% girls) from the EHDLA study. To determine the prevalence of disordered eating, the Sick, Control, One stone, Fat, Food (SCOFF) questionnaire was used. A socioecological approach was used to identify individual-, interpersonal-, or organizational-level factors associated with disordered eating.

Results: The prevalence of disordered eating was 30.1%. This condition was associated with female sex (odds ratio [OR] = 2.60; 95% confidence interval [CI], 1.81–3.73), immigrant status (OR = 2.22; 95% CI, 1.51–3.25), or excess weight (OR = 2.74; 95% CI, 1.93–3.89). Furthermore, for each additional hour slept, lower odds of having disordered eating were found (OR = 0.81; 95% CI, 0.67–0.98).

Discussion: Almost one-third of the sample of Spanish adolescents analyzed reported disordered eating. Female sex, immigrant status and excess weight are individual aspects that seem to be related to disordered eating among Spanish adolescents.

Eating Disorder Screening and Treatment in a Medically Underserved Southern State: Data Collected by a Legislative Eating Disorder Council and Implications for Statewide Assessment

Healthcare providers play a key role in early identification of eating disorders (EDs), especially in underserved states where ED treatment resources are lacking. Currently, there is little known about ED screening and treatment practices in underserved states. The current study assessed current ED screening and treatment practices among healthcare providers in an underserved state using data collected by a government-formed state ED council. Healthcare providers (N = 242; n = 209 behavioral health providers; n = 33 medical providers) practicing in Kentucky completed a brief, anonymous survey on ED screening and treatment practices, comfort with screening for EDs, and interest in continued education. Over half of healthcare providers indicated screening for EDs, with the majority using a clinical interview. After identification of ED symptoms, providers reported a combination of treating in-house, referring out, or seeking consultation. In bivariate analyses, medical providers were significantly more likely than behavioral health providers to use a screening tool specifically designed for EDs. The majority of medical providers indicated that they received education about EDs and feel knowledgeable about ED screening tools, though most reported infrequent use of these screening tools in their practice. Nearly all behavioral health and medical providers expressed interest in continuing education on ED screening and treatment. These findings indicate a need for, and interest in, education on evidence-based ED screening and treatment resources in underserved states and demonstrate the utility of a state ED council to collect these data to inform future education and treatment strategies.

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders

OBJECTIVE

Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group - anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder.

METHOD

Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13-60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis).

RESULTS

Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group.

CONCLUSION

Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.

Ethnic and racial comparisons of weight-loss treatment utilization history and outcomes in patients with obesity and binge-eating disorder

BACKGROUND

This study examined ethnic/racial differences in reported utilization of weight-loss methods/treatments and weight loss among adults with binge-eating disorder (BED) with co-existing obesity.

METHODS

Participants were 400 adults (non-Hispanic Black: n = 99, Hispanic: n = 38, non-Hispanic White: n = 263) seeking treatment for BED in Connecticut from 2007 to 2012. Participants were asked about prior weight-loss methods/treatments and resulting weight losses.

RESULTS

Overall, self-help diets were utilized most; mental-health services were utilized least. While non-significant differences for most methods/treatments were observed by ethnicity/race, significant differences emerged for self-help diets and supervised programs with non-Hispanic Whites, in general, utilizing these diets more frequently and losing more weight on these types of diets.

CONCLUSIONS

Among treatment-seeking patients with BED and obesity, non-Hispanic White patients reported histories of greater weight-loss treatment utilization and weight loss than non-White patients for supervised and self-help diets. Findings highlight the need for greater understanding of treatment utilization and outcomes among minority patients with obesity and BED.

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.

Overeaters Anonymous: An Overlooked Intervention for Binge Eating Disorder

The purpose of this communication is to provide an overview as well as the strengths and weaknesses of Overeaters Anonymous (OA) as an intervention for binge eating disorder treatment. Binge eating disorder is associated with low remission rates, high relapse rates, treatment dissatisfaction, and high rates of failure to receive treatment attributed to stigma, misconceptions, lack of diagnosis, access to care, and inadequate insurance coverage. New interventions are needed that can overcome these barriers. OA is a twelve-step program and established fellowship for individuals who self-identify as having problematic relationships with food or eating. OA can be referred clinically or sought out by an individual confidentially, without a diagnosis, and free of charge. OA’s Nine Tools, Twelve Steps, and Twelve Traditions can provide structure, social support, and open, anonymous sharing that fosters a sense of connection and belonging. This may provide benefit to individuals who value structure and social support in their recovery. The tradition of anonymity may also create some challenges for conducting research and may explain the shortage of empirical support. This commentary reviews existing research findings on the effectiveness of twelve-step interventions and OA. Common misunderstandings about and within OA are also addressed and OA’s limitations are discussed. Overall, OA provides a promising option for binge eating disorder treatment that warrants clinical research on its feasibility and efficacy in a way that respects and protects its tradition of anonymity.

Can adolescents with eating disorders be treated in primary care? A retrospective clinical cohort study

BACKGROUND

Family-Based Treatment (FBT) is considered the first-line intervention for adolescent anorexia nervosa. However, access to this treatment is limited. Treatment programs for other pediatric mental health conditions have successfully overcome barriers to accessing evidence-based intervention by integrating mental health services into primary care. This study evaluated the proof-of-concept of a novel modification of FBT, Family-Based Treatment for Primary Care (FBT-PC) for adolescent restrictive eating disorders designed for delivery by primary care providers in their practices.

METHODS

This retrospective clinical cohort study evaluated 15 adolescents with restrictive eating disorders receiving FBT-PC and 15 adolescents receiving standard FBT. We examined improvement in BMI percentile, reduction in weight suppression, and clinical benchmarks of eating disorder recovery including weight restoration to > 95% of expected body weight (EBW) and resolution of DSM-5 criteria for eating disorders.

RESULTS

In both groups, effect sizes for increased BMI percentile exceeded Cohen's convention for a large effect (FBT-PC: d = .94; standard FBT: d = 1.15) as did effect sizes for reduction in weight suppression (FBT-PC: d = 1.83; standard FBT: d = 1.21). At the end of treatment, 80% of the FBT-PC cohort and 87% in the standard FBT group achieved > 95%EBW and 67% in the FBT-PC group and 60% in the standard FBT group no longer met DSM-5 criteria for an eating disorder. There were no cohort differences in the number of treatment drop-outs or referrals to a more intensive level of eating disorder treatment.

CONCLUSIONS

Findings suggest that primary care providers have potential to improve weight and clinical status in adolescents with restrictive eating disorders. Based on these results, more rigorous testing of the FBT-PC model is warranted.

Self-recognition of trauma-related psychopathology and help-seeking among resettled Iraqi refugees in Australia

The current study sought to examine resettled Iraqi refugees' recognition of trauma-related psychopathology and the association between recognition and help-seeking. Participants were 66 men and women aged 18 to 70 years with clinically significant symptoms of posttraumatic stress disorder (PTSD) recruited from a larger, community-based sample in Western Sydney, Australia. Participants were presented with a vignette of a fictional character who had been exposed to trauma prior to leaving Iraq and who was suffering from symptoms of PTSD. Participants were then asked if they believed that they might currently have a problem such as the one described in the vignette. Approximately half (50.8%) of participants believed that they might currently have a problem such as the one described in the vignette and one third (33.3%) of participants had ever sought help for such a problem. Participants who believed that they might currently have a problem like the one described were 13 times more likely to have sought help for such a problem, controlling for demographic characteristics, trauma-related symptomatology, and levels of general psychological distress. Poor self-recognition level of trauma-related psychopathology among resettled Iraqi refugees may be a barrier to help-seeking and may therefore be an important target for health promotion and early intervention initiatives.

Paths to the first-time diagnoses of anorexia nervosa and bulimia nervosa in Taiwan

OBJECTIVE

This study aimed to examine the characteristics of psychiatrists and the hospital settings in relation to the first-time diagnoses of anorexia nervosa (AN) and bulimia nervosa (BN) and depict medical utilization and the detection rate before diagnosis of patients with AN and BN.

METHOD

We extracted data of individuals with AN or BN, as defined by the International Classification of Diseases, Ninth Revision, Clinical Modification, from a national health insurance database. Individuals with AN (n = 1,893) or BN (n = 10,542) who were first-time diagnosed by psychiatrists from 2002 to 2013 were included. Individuals with schizophrenia were selected as control groups that were matched with the incident AN and BN cases for sex, age stratum, and year of diagnosis.

RESULTS

AN was more likely to be diagnosed by female psychiatrists. Patients with AN were more frequently diagnosed in medical centers while patients with BN were mostly diagnosed in primary care clinics. Nearly all patients with AN and BN had sought treatment for physical problems but less than half had sought help for mental health problems in the year preceding the diagnosis. Individuals with AN, BN, and schizophrenia were all under-detected by nonpsychiatric medical professionals. Notably, BN was least likely to be recognized by both psychiatrists and other medical professionals.

DISCUSSION

Our findings underscore the importance of educational programs that are designed to improve the detection and management of eating disorders by medical professionals in Taiwan. Advanced educational programs that target differential diagnosis and the tailored management of different eating disorders should be highlighted among psychiatrists.

Help-seeking for body image problems among adolescents with eating disorders: findings from the EveryBODY study

PURPOSE

Little is known regarding correlates of help-seeking for a body image problem in adolescents with an eating disorder. This study provides the first population-based investigation of help-seeking correlates among adolescents with an eating disorder.

METHODS

Australian adolescents (N = 1002, 75.5% female, mean age = 15.14, SD = 1.40) who met operational diagnostic criteria for an eating disorder completed a survey assessing help-seeking, and potential correlates of help-seeking (sex, age, body mass index, socio-economic status, migrant status, sexuality, eating disorder diagnosis, psychological distress, and quality of life).

RESULTS

Only 10.1% of participants reported having sought help. Bivariate analyses revealed that increased likelihood of help-seeking was associated with female sex, sexual minority status, being born outside Australia, older age, having a major eating disorder (compared to having an unspecified or other specified feeding or other eating disorder diagnosis), higher psychological distress, and reduced psychological and social functioning. Older age, being born outside of Australia, and having a major eating disorder were significant independent correlates of help-seeking.

CONCLUSIONS

Very few adolescents with an eating disorder seek help for a body image problem. Promoting early, appropriate help-seeking among those who are younger and/or those with less well-known disorders may be particularly important.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Dispositional optimism is associated with weight status, eating behavior, and eating disorders in a general population-based study

OBJECTIVE

The objective of this cross-sectional study was to assess whether optimism is associated with body mass index (BMI), eating behavior and eating disorders (EDs) in a population-based study.

METHOD

In 2016, a total of 32,805 participants aged ≥18 years from the NutriNet-Santé cohort completed the Life Orientation Test-Revised, assessing dispositional optimism. Height and weight were self-reported. Eating behavior was assessed with the revised 21-item Three-Factor Eating Questionnaire. Risk of EDs was evaluated with the Sick-Control-One-Fat-Food Questionnaire. Linear and Logistic regression was used to analyze the association between optimism, BMI categories, eating behavior and ED risk, controlling for sociodemographic, lifestyle and depressive symptom characteristics.

RESULTS

Our sample was composed of 73.5% women, and the mean age was 55.39 ± 13.70 years. More optimistic participants were less likely to be underweight (OR = 0.82; 95% CI: 0.75, 0.89), or obese, particularly class III obese (BMI ≥40 kg/m² ) (OR = 0.69; 95% CI: 0.56, 0.84) compared with less optimistic individuals. Optimism was negatively associated with cognitive restraint (β = -.07; 95%CI: -0.08; -0.06), emotional eating (β = -.17; 95% CI: -0.19, -0.16) and uncontrolled eating (β = -.10; 95% CI: -0.11, -0.09). In addition, more optimistic participants had a lower risk of EDs (OR = 0.60; 95% CI: 0.56, 0.64).

DISCUSSION

Our findings showed that optimism was associated with weight status, eating behavior and risk of EDs in both women and men. The causal structure of the underlying observed association remains unclear and should be further investigated.

Help-Seeking for Eating Pathology Among Collegiate Athletes: Examining Stigma and Perfectionism as Moderating and Mediating Mechanisms

Despite elevated risk of eating pathology (EP) among athletes, utilization of EP-treatment among athletes is low. Factors that may inhibit EP-help-seeking among athletes include perceived social stigma, self-stigma, and perfectionism. Heightened stigma associated with EP and sport climates may be exacerbated by negative perfectionism characteristic of athletes and decrease intentions to seek help for EP. We tested the following moderated-mediation model among a sample of collegiate athletes (N = 201) via online questionnaires: EP indirectly relates to EP help-seeking intentions through perceived and self-stigma and these relations are conditional on negative perfectionism. EP help-seeking intentions were negatively associated with EP severity, stigma, and negative perfectionism. EP was related to eating-specific help-seeking intentions through perceived social stigma, influencing self-stigma, but this was not moderated by negative perfectionism. Targeting mental-health treatment stigma among athletes may reduce risk of untreated EP among collegiate athletes.

Effects associated with the use of healthcare for eating disorders by women in the community: a longitudinal cohort study

OBJECTIVES

This study examined formal and informal healthcare use (HCU) in community women with disordered eating, and associations of HCU with mental health-related quality of life (MHRQoL), psychological distress, mental health literacy (MHL) and eating disorder (ED) symptoms over time.

HYPOTHESIS

We hypothesised that HCU would lead to improvement in ED symptom severity, MHRQoL, MHL and psychological distress.

DESIGN, SETTING, PARTICIPANTS

Data were from years 2, 4 and 9 of a longitudinal cohort of 443 community women (mean age 30.6, SE 0.4 years) with a range of ED symptoms, randomly recruited from the Australian Capital Territory electoral role or via convenience sampling from tertiary education centres. Data were collected using posted/emailed self-report questionnaires; inclusion criteria were completion of the HCU questionnaire at time point of 2 years (baseline for this study). HCU was measured using a multiple-choice question on help seeking for an eating problem. To test the effect of HCU over time on MHRQoL (Short Form-12 score), psychological distress (Kessler Psychological Distress Scale score), ED symptom severity (Eating Disorder Examination Questionnaire score) and ED-MHL, linear or logistic mixed-effects regression analyses were used.

RESULTS

20% of participants sought ED-specific help at baseline; more than half of participants sought help that was not evidence based. HCU at baseline was significantly associated with improved MHRQoL and ED symptom severity and decreased psychological distress over time (Cohen's d all >0.3, ie, small). HCU was not significantly associated with MHL over time. The predictive ability of the fitted models ranged from 32.18% to 42.42% for psychological distress and MHL treatment, respectively.

CONCLUSIONS

Formal and informal HCU were associated with small improvements in ED symptoms, MHRQoL and psychological distress but not with improved MHL. Informal services in ED management should be investigated further along with efforts to improve ED-MHL.

Benefits of yoga in the treatment of eating disorders: Results of a randomized controlled trial

Yoga has begun to be incorporated into the treatment of eating disorders despite limited empirical support for this practice. The purpose of this study was to investigate the efficacy of incorporating Yoga into the treatment of eating disorders. This preliminary randomized controlled trial investigated the benefits of participating in an eight-week Kripalu Yoga program for 53 women with symptoms of bulimia nervosa and binge eating disorder. Compared to waitlist controls, Yoga participants experienced decreases in binge eating frequency, emotional regulation difficulties and self-criticism, and increases in self-compassion. Yoga participants also experienced increases in state mindfulness skills across the eight weeks of the Yoga program. While these results are encouraging and suggest Yoga may have a valuable role to play in the treatment of eating disorders, it is important to stress their tentative nature. Further research, adopting a more rigorous design, is needed to address the limitations of the present study and expand on these findings.

A model of post-traumatic stress symptoms on binge eating through emotion regulation difficulties and emotional eating

Individuals who struggle with binge eating often report a history of trauma and post-traumatic stress symptoms (PTSS), but there is still a paucity of studies on the relationship between PTSS (as opposed to trauma exposure) and binge eating specifically. The current study aimed to contribute to a small body of literature surrounding the link between PTSS and binge eating. Binge eating may be a behavioral coping mechanism against negative affect; however, it has been proposed that additional psychological mechanisms (e.g. emotion regulation difficulties and emotional eating) may explain the link between PTSS and binge eating. It was hypothesized that increased PTSS severity would predict greater emotion regulation difficulties, leading to greater emotional eating, and ultimately predict more severe binge eating in a trauma-exposed sample. Cross-sectional data were collected from 360 U.S. based MTurk workers (i.e. convenience sample) who reported trauma-exposure. Demographic and relevant covariates were included in the hypothesized serial mediation model and the results suggest a significant effect of PTSS severity on binge eating problems through emotion regulation difficulties and emotional eating. When both mediators were included in the model, the direct effect of PTSS on binge eating severity was no longer significant; thus, the association between PTSS and binge eating was partly explained by emotion regulation difficulties and emotional eating. This study expands the understanding of the mechanisms underlying PTSS and binge eating and provides support for complementing therapy approaches for PTSS with methods that target emotion regulation and acceptance.

Gender and help-seeking for an eating disorder: findings from a general population sample

PURPOSE

This study aimed to compare gender differences in eating disorder (ED) features and to examine the role of gender as a predictor of ED help-seeking controlling for other putative determinants, namely weight/shape overvaluation, age, BMI, and impairment in role functioning.

METHODS

Demographic, ED symptoms, and related data were collected during household interviews of individuals aged ≥ 15 years. One hundred and forty-eight participants (164 after data were weighted) with an ED syndrome were identified.

RESULTS

Compared to women, men with an ED were younger and had lower levels of purging and overvaluation. However, men and women with an ED had similar levels of functional impairment, binge eating and strict dieting. In univariate analyses, males in general, but not males with an ED, were significantly less likely than females to seek help for an ED. In multivariate analysis of people with an ED, only BMI was significantly associated with treatment-seeking.

CONCLUSION

Functional health impairment and common ED behaviours were similar for men and women with EDs. Gender may not be a primary reason to be more or less likely to seek help for an ED. Rather, other features, most notably, a higher BMI, appear to be stronger predictors of ED-specific help-seeking.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

General practitioner and mental healthcare use in a community sample of people with diagnostic threshold symptoms of bulimia nervosa, binge-eating disorder, and other eating disorders

OBJECTIVE

Lengthy delays in receiving treatment have been reported for people with bulimia nervosa (BN) and binge-eating disorder (BED). This study aimed to investigate healthcare use and predictors of mental health specialist healthcare use in a community sample of individuals with diagnostic threshold symptoms of BN, BED-Broad, or another eating disorder (Other ED).

METHOD

In 2017, 2,977 individuals aged ≥15 years were interviewed in a general population survey. Participants were asked questions relating to sociodemographic, ED symptoms, other clinical features, and healthcare use data. Assessment of ED symptoms was based on diagnostic questions derived from the eating disorder examination.

RESULTS

Thirty-six participants with symptoms of BN, 33 participants with BED-Broad, and 369 with an Other ED were identified. Fewer people with symptoms of BN/BED-Broad (23%) or an Other ED (6%) had treatment from a mental health specialist than from a general practitioner (GP; 80%, 71.6%). Healthcare use differed significantly across type of ED only for treatment from a mental health specialist. In multivariate analyses, being asked about a person's mental health by a GP was the best explanatory variable for receiving treatment from a mental health specialist.

DISCUSSION

A large treatment gap exists in healthcare for people with EDs. Inquiry about an individual's mental health by a GP was associated with higher rates of treatment from mental health specialists. However, a similar diet/eating inquiry did not have this association. Future research should consider the use of this patient and practitioner consultation in targeting improved detection of EDs.

Healthcare utilisation for eating disorders among patients with depression: a cross-sectional study in Taiwan

OBJECTIVES

Although depressed patients may have a comorbid eating disorder (ED), to date, no study has focused on healthcare utilisation among this population. This study was designed to investigate the characteristics of healthcare service utilisation among depressed patients with ED.

DESIGN

A cross-sectional study.

SETTING

This population-based study used claims data from Taiwan's National Health Insurance Research database between 2001 and 2012.

PARTICIPANTS

The study involved 1270 participants. These included 254 depressed individuals with ED and 1016 propensity score-matched depressed individuals without ED.

OUTCOME MEASURES

We tracked each patient for a 1 year period to evaluate their healthcare service utilisation, including outpatient visits, inpatient days, and costs for psychiatry and non-psychiatry services. We performed a Mann-Whitney U test to compare outcome variables in healthcare service utilisation between the two groups.

RESULTS

Patients with both depression and ED had significantly more outpatient visits (32.2 vs 28.9, p=0.023), outpatient costs (US$1089 vs US$877, p<0.001) and total costs (US$1356 vs US$1296, p<0.001) than comparison patients. For psychiatric services, patients with depression and ED had more outpatient visits (11.0 vs 6.8, p<0.001), outpatient costs (US$584 vs US$320, p<0.001) and total costs (US$657 vs US$568, p<0.001) than those without ED. For non-psychiatric services, there was no significant difference for all utilisation. This indicates that the total costs were about 1.0-fold greater for depression patient with ED than those without ED.

CONCLUSION

Depression patients with ED had more outpatient visits, outpatient costs and total costs of healthcare services than those without ED.

Screening four broad categories of eating disorders: suitability of a clinical algorithm adapted from the SCOFF questionnaire

BACKGROUND

We evaluated the performance of a clinical algorithm (Expali™), combining two or more positive answers to SCOFF questionnaire with Body Mass Index (BMI), to identify four Broad Categories of eating disorders (ED) derived from DSM-5.

METHODS

The clinical algorithm (Expali™) was developed from 104 combinations of BMI levels and answers to five SCOFF questions with at least two positive answers. Two senior ED physicians allocated each combination to one of the four Broad Categories of ED derived from DSM-5: restrictive disorder, bulimic disorder, hyperphagic disorder and other unspecified ED diagnosed by ED clinicians. The performance of Expali™ was evaluated on data from 206 patients with ED. Sensitivity, specificity values and Youden index were calculated for each category.

RESULTS

The 206 patients were diagnosed as follows: 31.5% restrictive disorder, 18.9% bulimic disorder, 40.8% hyperphagic disorder and 8.8% other ED. The sensitivity of Expali™ for restrictive, bulimic, hyperphagic and other unspecified ED were respectively: 76.9, 69.2, 79.7 and 16.7%. The Youden index was respectively 0.73, 0.57, 0.67 and 0.07.

CONCLUSIONS

In a SCOFF-positive ED population (at least two positive answers), the clinical algorithm Expali™ demonstrated good suitability by correctly classifying three of the four Broad Categories of eating disorders (restrictive, bulimic and hyperphagic disorder). It could be useful both to healthcare professionals and the general population to enable earlier detection and treatment of ED and to improve patient outcomes.

Predictors of professional help-seeking for emotional problems in Afghan and Iraqi refugees in Australia: findings from the Building a New Life in Australia Database

BACKGROUND

Refugees are particularly vulnerable to poor mental health outcomes due to exposure to pre migration trauma and post migration stressors. Research has demonstrated evidence to suggest that the professional help-seeking among refugee groups is low or problematic. This study seeks to examine help-seeking for emotional problems in two large samples of Iraqi and Afghan refugees in Australia.

METHODS

This study uses data from two waves of the Building a New Life in Australia, the longitudinal study of Humanitarian migrants. The data was collected face-to-face between 2013 and 2016, among humanitarian migrants. All participants held a permanent protection visa and had arrived in Australia or been granted their visa between period of May to December 2013. The study sample included 1288 participants born in Iraq and Afghanistan (aged 15 and over). In the Wave 3 interview (2015-2016) participants reported on professional help received to deal with emotional problems.

RESULTS

Approximately 36 and 37% of the Iraqi and Afghan groups respectively, reported seeking help for emotional problems. Within the Iraqi group, associations between mental health status, namely general psychological distress and PTSD and help-seeking were found but this was not present in the Afghan group, where age seemed to play a role in help-seeking. Frequency of help received was low with approximately 47% of the Iraqi and 57% of the Afghan groups reporting having received help 5 times or less in the last 12 months.

CONCLUSIONS

Findings from this study provide clear directions on areas where culturally tailored mental health promotion programs should target in these two refugee communities. Further, the differences in help-seeking behaviour of these communities should be noted by both clinicians and policy makers as efforts to provide culturally responsive mental health services.

Identifying Risk Factors for Disordered Eating among Female Youth in Primary Care

Eating disorders are a serious, life-threating condition impacting adolescents and young adults. Providers in primary care settings have an important role in identifying disordered eating (DE) symptoms. Unfortunately, symptoms go undetected in 50% of patients in medical settings. Using the behavioral health screen, this study identified DE risk profiles in a sample of 3620 female adolescents and young adults (ages 14-24), presenting in primary care. A latent class analysis with twenty psychosocial factors identified three DE risk groups. The group at highest risk for DE was characterized by endorsement of internalizing symptoms and a history of trauma. The next risk group consisted of those with externalizing symptoms, particularly substance use. The group at lowest risk for DE reported more time spent with friends compared to their peers. Primary care providers and psychiatric teams can benefit from knowing the psychosocial risk patterns affiliated with DE, and using brief, comprehensive screening tools to identify these symptoms.

The perceived knowledge, skill and clinical practice of psychologists, naturopaths and fitness instructors when working with eating disorders

AIMS

When it comes to working with eating disorders (EDs), few studies have explored: the clinical practice; service provision barriers; and self-perceptions of knowledge/skill and the ability to detect EDs in practice against measured ability to do so, of common health providers including psychologists, naturopaths and fitness instructors.

METHODS

Of the 115 participants, 90.4% were female with a mean age of 40.77 years (SD = 10.80 years) and comprised: 35 psychologists, 50 naturopathic and 30 fitness practitioners. Participants completed a 23-item survey measuring clinical practice behaviours including assessment and early intervention services, practitioner service barriers, perceived ED knowledge and skill.

RESULTS

Only 1 in 20 indicated using standardized surveys to screen for EDs, with 72% indicating reluctance to universally screen clients, with a key barrier being that ED symptoms were typically not the presenting issue. For practitioners who missed detecting EDs in practice, 53.6% indicated this was because weight fell within the normal range or because the client did not present with an ED so they did not think to screen for one (39.29%). In terms of interventions, most (79%) were providing services to clients with EDs, with over one-third providing weight-loss advice, potentially contributing to a harmful weight-centric/dieting treatment approach. Despite most practitioners delivering services, 85.7% felt unable to treat some clients appropriately, primarily due to a lack of skill (52.6%).

CONCLUSIONS

Further training is imperative to improve universal screening and evidence-based early intervention practices, which may be particularly helpful for naturopaths and fitness instructors who more commonly perceived their knowledge to be low.

Overlaps and Disjunctures: A Cultural Case Study of a British Indian Young Woman's Experiences of Bulimia Nervosa

Eating disorder diagnoses are characterised by a pattern of disordered eating behaviour alongside symptoms such as body dissatisfaction and preoccupation with food, weight or shape (APA in Diagnostic and statistical manual of mental disorders, DSM-5, APA, Washington, DC, 2013). Incidence rates for eating disorders have increased during the last 50 years. However, epidemiological studies have suggested that such trends may not be a true representation of the occurrence of these illnesses in the general population, with figures underestimated due to reduced help seeking and poor access to care, particularly amongst ethnic minorities. This case study explores the experiences of a young British Indian woman with bulimia nervosa. Arising from an in-depth semi-structured interview, analysed with interpretative phenomenological analysis, her narrative offers a critical lens onto how diverse fragments of cultural practices and meanings come together to produce the clinical category of 'bulimia.' It thereby offers an alternative portrait of relationships between eating disorders and 'culture,' one that goes beyond a framing of these illnesses as culture inscribed on the body. Interrogating relationships between culture and the development, expression and maintenance of bulimia is suggested to be key to forging culturally-sensitive understandings of this illness; this paper begins to provide the evidence base for the design and development of appropriate support services, thereby aiming to contribute to a reduction in health inequalities and barriers to treatment.

Weighty decisions: How symptom severity and weight impact perceptions of bulimia nervosa

OBJECTIVE

The current study examined whether variations in patient weight and eating-disorder behavior frequency influenced the recognition of bulimia nervosa (BN) and the perception that it is a serious mental health concern.

METHOD

Participants (N = 320) were randomly assigned to one of six conditions in which they read a vignette describing a young woman with BN. Each vignette was identical except for the variables of interest: weight status (underweight, healthy-weight, and overweight), and symptom frequency (daily or weekly binge-eating episodes and purging).

RESULTS

Participants were more likely to have negative attitudes toward and blame the patient with overweight. Participants were less likely to believe that the patient with overweight was experiencing mental illness and that her problems were too serious to handle on her own. There were no significant differences by symptom frequency.

DISCUSSION

Findings suggest the presence of weight stigma and that overweight might impede the recognition of eating disorders.

Cost-Effectiveness of Internet-Based Cognitive-Behavioral Treatment for Bulimia Nervosa: Results of a Randomized Controlled Trial

OBJECTIVE

To evaluate the cost-effectiveness of Internet-based cognitive-behavioral therapy for bulimia nervosa (CBT-BN) compared to face-to-face delivery of CBT-BN.

METHODS

This study is a planned secondary analysis of data from a randomized clinical trial. Participants were 179 adults (98% female, mean age = 28 years) meeting DSM-IV criteria for bulimia nervosa who were randomized to group face-to-face or group Internet-based CBT-BN for 16 sessions during 20 weeks. The cost-effectiveness analysis was conducted from a third-party payor perspective, and a partial societal perspective analysis was conducted to investigate cost-utility (ie, cost per gain in quality-adjusted life-years) and patient out-of-pocket travel-related costs. Net health care costs were calculated from protocol and nonprotocol health care services using third-party payor cost estimates. The primary outcome measure in the clinical trial was abstinence from binge eating and purging, and the trial start and end dates were 2008 and 2016.

RESULTS

The mean cost per abstinent patient at posttreatment was $7,757 (95% confidence limit [CL], $4,515, $13,361) for face-to-face and $11,870 (95% CL, $6,486, $22,188) for Internet-based CBT-BN, and at 1-year follow-up was $16,777 (95% CL, $10,298, $27,042) for face-to-face and $14,561 (95% CL, $10,165, $21,028) for Internet-based CBT-BN. There were no statistically significant differences between treatment arms in cost-effectiveness or cost-utility at posttreatment or 1-year follow-up. Out-of-pocket patient costs were significantly higher for face-to-face (mean [95% CL] = $178 [$127, $140]) than Internet-based ($50 [$50, $50]) therapy.

CONCLUSIONS

Third-party payor cost-effectiveness of Internet-based CBT-BN is comparable with that of an accepted standard. Internet-based dissemination of CBT-BN may be a viable alternative for patients geographically distant from specialist eating disorder services who have an unmet need for treatment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00877786​.

Clinician-Delivered Teletherapy for Eating Disorders

The delivery of teletherapy is an important advancement in clinical care for the treatment of eating disorders (EDs). Specifically, it seems to improve access to highly specialized ED treatment. Research on the application of videoconferencing-based psychotherapy services for EDs is minimal; however, results suggest that this treatment format leads to significant improvements in clinical symptoms and is well accepted by patients. General telemedicine guidelines and administrative and clinical recommendations specific to the treatment of ED patients have been identified. With careful planning and thoughtful application, Internet-based therapy seems to be a valuable resource for practitioners seeking to disseminate specialized ED treatments.

Barriers to seeking treatment for eating disorders: The role of self-recognition in understanding gender disparities in who seeks help

OBJECTIVE

Previous research suggests that men with eating disorders are less likely to seek treatment than are women. Given stereotypes linked to eating disorders, men may be less likely to recognize when they have an eating disorder, which could act as a barrier to treatment-seeking.

METHOD

The current study examined differences in self-recognition and treatment-seeking behavior by gender, controlling for other covariates, in participants with probable DSM-5 eating disorders drawn from a larger community-based sample.

RESULTS

Being female and self-recognition were both associated with increased likelihood of treatment-seeking while accounting for other potential covariates, including race/ethnicity, age, BMI, and comorbid disorders.

DISCUSSION

Results indicate that self-recognition is a barrier to seeking treatment for both genders and does not account for help-seeking differences between women and men. Findings have implications for interventions to address barriers to treatment-seeking for eating disorders.

A Tertiary-Care/Primary-Care Partnership Aimed at Improving Care for People with Eating Disorders

We describe the implementation and impact of a province-wide program of knowledge exchange (KE), aimed at developing capacity for the treatment of people with eating disorders (EDs). The program is designed to equip clinicians working in nonspecialized health-care installations with skills to evaluate and treat people with EDs. Trainings were conducted at 21 institutions. The majority of clinicians reported satisfaction with the KE program and indicated that the trainings enhanced their confidence and ability to treat patients with EDs. A subset of clinicians received case supervision with a specialist ED therapist and followed patients with EDs (n = 119). Treated patients showed significant improvements on eating and depressive symptoms, and reported satisfaction with the treatments they received.

Associations between healthcare use and disordered eating among female veterans

OBJECTIVE

Individuals with eating disorders (EDs) have considerable medical and psychiatric comorbidity as well as increased healthcare use and associated costs. However, EDs remain largely undetected and understudied among veteran populations, and EDs are not routinely screened for or treated in Veterans Affairs (VA) medical settings. Research elucidating the links between disordered eating and VA and non-VA healthcare use is needed to inform policy and practice for ED screening and treatment.

METHOD

Data regarding probable EDs and VA and non-VA healthcare use was obtained through a mail survey of 198 female veterans receiving care from VA.

RESULTS

A total of 21 participants (10.6%) met probable criteria for subthreshold anorexia nervosa, bulimia nervosa, or binge-eating disorder. Negative binomial regression models revealed that female veterans with EDs reported higher frequency of VA mental healthcare use and substance use disorder treatment, above and beyond the association of comorbid PTSD and depression symptoms.

DISCUSSION

These findings confirm the high probability that female veterans with EDs are utilizing significant VA mental health resources. Screening for EDs may be particularly important in VA medical and mental health settings.

Rates and correlates of disordered eating among women veterans in primary care

Rates of disordered eating may be higher among women veterans than civilians, and are associated with co-occurring mental health (MH) conditions, such as depression, post-traumatic stress disorder (PTSD), and alcohol misuse. Although evidence suggests that these conditions are common in primary care settings, limited research has examined symptoms of disordered eating among women veterans in primary care. This study used a cross-sectional design to examine rates and MH correlates of disordered eating among women veterans treated in a primary care setting. Participants (N = 176) completed self-report measures of disordered eating attitudes and behaviors, depression, anxiety, PTSD, alcohol misuse, and military sexual trauma. Results indicated that women veterans were likely to report objective (35.8%) and subjective binge episodes (29.5%), as well as shape and weight concerns (36.4% and 23.3%, respectively). While, anxiety and PTSD were strongly associated with disordered eating, restraint, eating concerns, weight concerns, and shape concerns, military sexual trauma was often unrelated to these outcomes. Further study is needed to improve the detection of disordered eating behaviors among women veterans, as well as to identify effective management strategies in primary care. Overall, these findings suggest that integrated primary care (IPC) may be a useful setting to improve the detection and treatment of eating disorders, particularly by targeting binge eating and body dissatisfaction among women veterans within these settings.

Health and Well-Being of International University Students, and Comparison with Domestic Students, in Tasmania, Australia

International students comprise an increasingly larger proportion of higher education students globally. Empirical evidence about the health and well-being of these students is, however, limited. We sought to examine the health and well-being of international students, primarily from Asian countries, attending the University of Tasmania, Australia, using domestic students as a comparison group. Ethics approval was given to invite (via email) all currently enrolled students to participate in the study by completing a pilot-tested, online survey. The survey was completed by 382 international students (response rate = 8.9%) and 1013 domestic students (9.2%). Independent samples t-tests, analysis of variance (ANOVA) and chi-square tests were used for bivariate comparisons between international and domestic students, and between subgroups of international students. Regression models were used to examine the associations between student status (international vs. domestic) and health outcomes, controlling for demographic and enrolment variables. International students, particularly male students, were found to be at increased risk of several adverse health outcomes while also being less likely to seek help for mental health and related problems. The findings indicate the need for accessible, targeted, culturally-sensitive health promotion and early intervention programs.

A register-based case-control study of health care utilization and costs in binge-eating disorder

OBJECTIVE

Capturing trends in healthcare utilization may help to improve efficiencies in the detection and diagnosis of illness, to plan service delivery, and to forecast future health expenditures. For binge-eating disorder (BED), issues include lengthy delays in detection and diagnosis, missed opportunities for recognition and treatment, and morbidity. The study objective was to compare healthcare utilization and expenditure in people with and without BED.

METHODS

A case-control design and nationwide registers were used. All individuals diagnosed with BED at eating disorder clinics in Sweden between 2005 and 2009 were included (N = 319, 97% female, M age = 22 years). Ten controls (N = 3190) were matched to each case on age-, sex-, and location of birth. Inpatient, hospital-based outpatient, and prescription medication utilization and expenditure were analyzed up to eight years before and four years after the index date (i.e., date of diagnosis of the BED case).

RESULTS

Cases had significantly higher inpatient, hospital-based outpatient, and prescription medication utilization and expenditure compared with controls many years prior to and after diagnosis of BED. Utilization and expenditure for controls was relatively stable over time, but for cases followed an inverted U-shape and peaked at the index year. Care for somatic conditions normalized after the index year, but care for psychiatric conditions remained significantly higher.

CONCLUSION

Individuals with BED had substantially higher healthcare utilization and costs in the years prior to and after diagnosis of BED. Since previous research shows a delay in diagnosis, findings indicate clear opportunities for earlier detection and clinical management. Training of providers in detection, diagnosis, and management may help curtail morbidity. A reduction in healthcare utilization was observed after BED diagnosis. This suggests that earlier diagnosis and treatment could improve long-term health outcomes and reduce the economic burden associated with BED.

Media Smart-Targeted: Diagnostic outcomes from a two-country pragmatic online eating disorder risk reduction trial for young adults

BACKGROUND

Diagnostic outcomes in eating disorder (ED) risk reduction trials are important but rarely reported.

METHODS

An online pragmatic randomized-controlled trial was conducted with young-adult women in Australia and New Zealand seeking to improve their body image. Media Smart-Targeted (MS-T) was a 9-module program released weekly while control participants received tips for positive body image. Eating Disorder Examination-Questionnaire (EDE-Q) scores from baseline and 12-month follow-up were used to investigate two outcomes: ED onset in those who were asymptomatic at baseline (prevention effects); and, ED remission in those who met diagnosis at baseline (treatment effects).

RESULTS

MS-T participants were 66% less likely than controls to develop an ED by 12-month follow-up (nonsignificant). MS-T participants who met ED criteria at baseline were 75% less likely than controls to still meet diagnostic criteria at follow-up. This effect was significant and remained so for both those who did and who did not access external face-to-face ED treatment during the trial.

CONCLUSIONS

While further investigations are necessary, MS-T has fully automated procedures, low implementation costs, the potential to be delivered at-scale to assist those assist those where face-to-face services are limited or not available (e.g., remote areas).

Economic evaluation of cognitive behavioral therapy and Internet-based guided self-help for binge-eating disorder

OBJECTIVE

To determine the cost-effectiveness of individual face-to-face cognitive behavioral therapy (CBT) compared to therapist guided Internet-based self-help (GSH-I) in overweight or obese adults with binge-eating disorder (BED).

METHOD

Analysis was conducted alongside the multicenter randomized controlled INTERBED trial. CBT (n = 76) consisted of up to 20 individual therapy sessions over 4 months. GSH-I (n = 71) consisted of 11 modules combining behavioral interventions, exercises including a self-monitoring food diary, psychoeducation, and 2 face-to-face coaching sessions over 4 months. Assessments at baseline, after 4 months (post-treatment), as well as 6 and 18 months after the end of treatment included health care utilization and sick leave days to calculate direct and indirect costs. Binge-free days (BFD) were calculated as effect measure based on the German version of the Eating Disorder Examination. The incremental cost-effectiveness ratio (ICER) was determined, and net benefit regressions, adjusted for comorbidities and baseline differences, were used to derive cost-effectiveness acceptability curves.

RESULTS

After controlling for baseline differences, CBT was associated with non-significantly more costs (+€2,539) and BFDs (+40.1) compared with GSH-I during the 22-month observation period, resulting in an adjusted ICER of €63 per additional BFD. CBTs probability of being cost-effective increased above 80% only if societal willingness to pay (WTP) was ≥€250 per BFD.

DISCUSSION

We did not find clear evidence for one of the treatments being more cost-effective. CBT tends to be more effective but also more costly. If the societal WTP for an additional BFD is low, then our results suggest that GSH-I should rather be adopted.