Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders

Adaptations to family-based treatment for Medicaid-insured adolescents with anorexia nervosa

Background

Family-based treatment (FBT) is the leading intervention for adolescents with anorexia nervosa (AN); however, it is under researched in socioeconomically disadvantaged and racially diverse youth.

Methods

Semi-structured interviews were completed with ten FBT clinicians who practice in publicly-funded settings. Interview questions were focused on implementation challenges, overall acceptability and appropriateness of FBT, and naturally-occurring treatment adaptations.

Results

Content analysis revealed common themes relating to the implementation of FBT in publicly-funded, community-based settings: acceptability and appropriateness, complexity and learnability, perceived core components of FBT, cultural adaptations, socioeconomic factors, logistical considerations, organizational and systemic barriers, training acceptability, participant's self-efficacy, and telehealth accommodations.

Conclusion

The discussed themes offer insights into the implementation of FBT for settings with limited resources, aligning with prior research on clinical adaptations for multicultural patients. Recognizing these themes can guide clinical adjustments and refine the adapted treatment model in real-world settings for patients facing systemic barriers.

The moderating role of food cravings in the relationship between weight suppression and eating disorder psychopathology in college students

Weight suppression (WS), the difference between an individual's current and highest adult weight, is predictive of eating-related pathology across diagnostic categories and poor eating disorder treatment outcomes, but findings from non-clinical samples have been mixed. Cravings are strong urges for specific foods that are subjectively difficult to resist. Food cravings are now widely conceptualized as cognitive-affective states characterized by intrusive thoughts that are perceived as distressing and can interfere with adaptive functioning. Food cravings are known antecedents of binge eating, but little is known about how they interact with WS. We examined the obsessive-compulsive aspects of food cravings as potential moderators of the association between WS and eating disorder symptoms in general, and binge eating specifically in a cross-sectional study of college students. Participants (n = 144, 60.4% female) self-reported their height and current and past highest adult weight and completed the Binge Eating Scale (BES), Eating Disorder Examination-Questionnaire (EDE-Q), and Obsessive Compulsive Eating Scale (OCES). Main and interactive effects of WS and OCES scores on EDE-Q global and BES scores were examined in regression models. There were significant main effects of OCES scores on overall eating disorder symptom severity as well as binge frequency, with those endorsing more craving-related intrusive thoughts and compulsive urges engaging in maladaptive behaviors more frequently. WS alone did not consistently cross-sectionally predict eating disorder psychopathology. Findings suggest that food cravings are significantly associated with disordered eating symptoms and specifically binge eating frequency and should be accounted for in future research on WS in clinical and non-clinical samples.

Parental Binge Eating and Child Binge Eating and Weight-Control Behaviors: Cross-Sectional and Longitudinal Findings From the EAT 2010-2018 Study

OBJECTIVE

In cross-sectional and retrospective research, parental binge eating is associated with their children's eating psychopathology. The current study extended the evidence by cross-sectionally and longitudinally examining the relation between parental binge eating and binge eating and weight-control behaviors in the next generation of their adolescent children and young adult children in a population-based sample.

METHODS

Adolescents (Time 1: M = 14.5, SD = 2.0 years) (n = 2367), followed into adulthood (Time 2: M = 22.1, SD = 2.0 years), and their parents (n = 3664) were enrolled in EAT 2010-2018 and Project F-EAT 2010. The current study examined parental binge eating, and child binge eating and weight-control behaviors. Adjusted models covaried for child gender, age, and race/ethnicity.

RESULTS

Approximately 7% of adolescents at Time 1 had at least one parent who reported binge eating with no differences by child's age, gender, or race/ethnicity. Having at least one parent experiencing binge eating at Time 1 (vs. not) was associated cross-sectionally with adolescent children's use of extreme weight-control behaviors (9.6% vs. 4.8%; Risk Difference [RD] = 4.9%) and associated longitudinally with binge eating during young adulthood (21.1% vs. 11.6%; RD = 9.5%). Other associations did not reach statistical significance.

CONCLUSIONS

Children of parents with binge eating appear to have elevated risk of extreme weight-control behaviors during adolescence and binge eating in young adulthood. Clinicians should assess whether eating psychopathology extends to other family members, and offer additional support to parents with binge eating. Further research is needed to identify risk factors in the children of parents with binge eating and to assess strategies for prevention.

Weight stereotypes in eating disorder recognition

OBJECTIVE

We investigated weight stereotypes in the recognition and referral of eating disorders (EDs) by assessing if recognition, health care referral, perceived acceptability, perceived distress, and perceived prevalence of an ED differ depending on the weight of the subject in the vignette.

METHOD

Community participants (N = 180, age = 19-74) read three different vignettes describing three females with different EDs [anorexia nervosa/atypical anorexia nervosa (AN/AAN), bulimia nervosa (BN), binge eating disorder (BED)] and were randomized to three different experimental conditions concerning an individual with a different weight (overweight, normal, and underweight).

RESULTS

Across EDs, participants were more likely to recognize a problem, refer for treatment, and rate a higher perceived level of distress in the vignettes of overweight individuals than in the vignettes of normal weight individuals. For BED, a larger proportion of participants in the overweight condition classified the issue described in the vignette as a form of eating pathology compared to the normal weight condition.

DISCUSSION

These results highlight several weight stereotypes that exist in the recognition and health care referral of EDs. Future ED education and awareness programs should emphasize that EDs can occur in any individual, regardless of their weight.

Behaviourally assessed negative urgency is uniquely associated with binge-eating frequency

OBJECTIVE

Binge eating appears to be associated with impulsivity, especially in response to negative affect (i.e., negative urgency). However, negative urgency is typically assessed via self-report, which captures only some aspects of urgency and may be subject to bias. Few studies have examined impulsivity following experimental manipulations of affect in binge-eating samples.

METHOD

In the present study, individuals who engage in regular binge eating completed a behavioural impulsivity (go/no-go) task with high- and low-calorie food stimuli, once following negative affect induction and once following neutral affect induction.

RESULTS

Greater behavioural impulsivity to high-calorie food cues while in a negative (and not a neutral) affective state was associated with more frequent binge-eating behaviour. Further, this behavioural measure of negative urgency uniquely accounted for variance in binge-eating frequency when controlling for self-reported negative urgency, suggesting that behavioural measures may be a useful complement to self-report measures.

DISCUSSION

These findings provide novel and compelling evidence for the relationship between negative urgency and binge eating, highlighting negative urgency as a potentially important target for intervention.

Gender stereotypes in eating disorder recognition

PURPOSE

Eating disorder (ED) awareness is low. We assessed if ED symptom recognition, perceived need for treatment, perceived distress, perceived acceptability, and perceived prevalence differed depending on the gender of the individual with the ED.

METHODS

276 community participants were randomly assigned to one of three gender conditions (female, male, and non-binary), read three vignettes describing three different individuals with ED symptoms [anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED)], and then answered a series of questions related to participants ED symptom recognition, perceived need for treatment, perceived distress associated with having ED symptoms, perceived acceptability (e.g., the extent to which it may not be too bad to have an ED), and perceived prevalence. Mixed ANOVAs and chi-square analyses were conducted to examine differences between groups.

RESULTS

There were no significant main effects of gender condition across the outcome variables. There were main effects of ED type for problem recognition, perceived need for treatment, perceived level of distress, and perceived prevalence, with participants being more likely to recognize a problem in the AN and BN vignettes than the BED vignettes, refer for treatment and rate a higher perceived level of distress in then AN vignette than the BN and BED vignettes, and perceive a higher prevalence rate in the BN vignette than the AN vignette. There was a significant gender by condition interaction for perceived prevalence, with participants rating a higher prevalence of AN in women and non-binary individuals than men and a higher prevalence of BN in women than non-binary individuals and men.

CONCLUSION

These results highlight the importance of education on EDs and awareness that EDs can occur in any individual, regardless of their gender identification.

LEVEL OF EVIDENCE

Level I, experimental study with randomization.

Treatment of Eating Disorders: Current Status, Challenges, and Future Directions

Specific psychological treatments have demonstrated efficacy and represent the first-line approaches recommended for anorexia nervosa, bulimia nervosa, and binge-eating disorder. Unfortunately, many patients, particularly those with anorexia nervosa, do not derive sufficient benefit from existing treatments, and better or alternative treatments for eating disorders are needed. Less progress has been made in developing pharmacologic options for eating disorders. No medications approved for anorexia nervosa exist, and only one each exists for bulimia nervosa and for binge-eating disorder; available data indicate that most patients fail to benefit from available medications. Longer and combined treatments have generally not enhanced outcomes. This review presents emerging findings from more complex and clinically relevant adaptive treatment designs, as they offer some clinical guidance and may serve as models for future enhanced treatment research.

Bulimia Nervosa and Binge-Eating Disorder Across the Lifespan

This article aims to review the current evidence-based psychotherapy and psychopharmacological treatments for adults and youths with bulimia nervosa (BN) and binge-eating disorder (BED). Treatments for adults and for children and adolescents are discussed separately, including developmental considerations in the management of these disorders among youths. Although several evidence-based psychotherapy and psychopharmacological treatment options have been established for adults with BN or BED, there is much less empirical support for the management of these eating disorders among children and adolescents. This review concludes by discussing promising modalities and innovations, highlighting the potential utility of integrating technology into treatment approaches. Despite decades of treatment development and testing, a sizable proportion of individuals with BN or BED do not respond to the current evidence-based treatments, highlighting the need for continued research in these domains. Future research should focus on testing psychotherapy treatments among diverse samples in large, randomized controlled trials, as well as on treatments that can be easily scaled and implemented in community settings.

Improvements in Quality of Life and Readiness for Change After Participating in an Eating Disorder Psychoeducation Group: A Pilot Study

Psychoeducation groups are an integral part of eating disorder treatment in community programs, yet research on their efficacy remains limited. This study examines the impact of participating in a 10-week psychoeducation group on changes in quality of life and in readiness and motivation. Seventy-five adults who had eating disorders were included in the study. We administered the Eating Disorder Quality of Life Scale (EDQLS) and Readiness and Motivation Questionnaire (RMQ) before and after the group. After participation, respondents reported an 11-point increase in the EDQLS score and 9-, 8-, and 9-point increases, respectively, in the total action, confidence, and internality components of the RMQ score. In group exit evaluations, participants reported that the psychoeducation group improved their quality of life and their readiness and motivation to recover.

Practice Assessment Tool for the Care of Patients With Eating Disorders

Eating disorders are characterized by significant disturbances in eating patterns associated with negative attitudes toward one's body, weight, and shape. They are associated with an increased risk of mortality and morbidity as well as significant health, economic, and psychosocial burdens. Additionally, individuals with eating disorders often hesitate to seek treatment and symptoms may be difficult to ascertain without structured assessment. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders aims to enhance knowledge and increase the appropriate use of interventions for eating disorders, including anorexia nervosa, bulimia nervosa, and binge-eating disorder, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with eating disorders. This practice assessment activity can also be used in fulfillment of Continuing Medical Education and ABPN Continuing Certification, Improvement in Medical Practice.

Exploring Demographic and Clinical Characteristics of Racially and Ethnically Diverse Youth With Eating Disorders Using California Medicaid Claims Data

OBJECTIVE

To explore the scope of diagnosed eating disorders among Medicaid-insured youth in California, and to describe the demographic characteristics of this population in a repeated annual cross-sectional study design.

METHOD

California Medicaid claims data were extracted for youth aged 7 to 18 years between January 2014 and December 2016. Participants included all youth who received an eating disorder diagnosis at any point in the study period (N = 8,075). Additional analyses compared youth with eating disorders who were continuously enrolled across all 3 years (n = 4,500) to random subsamples of continuously enrolled youth diagnosed with a mood or anxiety disorder (n = 4,128), a disruptive behavior disorder (n = 4,599), or a psychotic disorder (n = 4,290).

RESULTS

About one-half of youth with eating disorders were Latinx (58.5%, n = 2,634) and indicated Spanish as their preferred language (48.9%, n = 2,199). About one-half (51%, n = 2,301) of eating disorder diagnoses were unspecified. Latinx ethnicity and Spanish language were significantly more frequent among youth with eating disorders than among those with other disorders (F11.97, F362.75, p values <.0005).

CONCLUSION

The first examination of publicly insured youth with eating disorders revealed a highly diverse group of individuals among whom Latinx youth were particularly prevalent. However, past-year national prevalence estimates suggest that most eating disorder cases were undiagnosed.

PLAIN LANGUAGE SUMMARY

Eating disorders affect approximately 10% of the US population and lead to serious mental health and medical problems. This study used California Medicaid claims data from 2014 to 2016 to characterize the population of youth aged 7 to 18 years with diagnosed with an eating disorder (N = 8,075). The authors found the prevalence of eating disorders among youth aged 13 to 18 years was about 0.20% across all 3 years of the study, which is far below the expected prevalence and suggests that most eating disorders in youth go undiagnosed. About half of eating disorder diagnoses provided to youth with Medicaid insurance are unspecified, which may hinder receipt of appropriate treatment. Of youth with an eating disorder, about half were Latinx and reported Spanish as their preferred language. The authors also found differences in the prevalences of eating disorder diagnoses when analyzing youth by age, sex, and ethnicity. These results suggest that more standardized screening and assessment is needed to improve eating disorders detection and diagnosis, particularly for minoritized youth.

Characterizing Medical Complications in Publicly Insured Youth With Eating Disorders

PURPOSE

The present study describes the occurrence of eating disorder (ED)-related medical diagnoses in a publicly insured sample of youth with EDs. The study also compares ED medical diagnoses with other psychiatric disorders and identifies high-risk demographic groups. Improved screening practices are needed in public mental health systems where treatment is critical for youth with EDs.

METHODS

Medicaid claims data were obtained from the state of California, including beneficiaries ages 7-18 who had at least one service episode between January 1, 2014, and December 31, 2016. From this population we extracted demographic and claims data for those youth who received an ED diagnosis during the 3-year period as a primary or secondary diagnosis (n = 8,075). Random subsamples of youth with moderate/severe mental illness were drawn for comparison: primary or secondary diagnosis of mood/anxiety disorder (N = 8,000) or psychotic disorder (n = 8,000) were also extracted. Medical diagnoses were compared within youth with EDs (across diagnostic categories) and across psychiatric diagnoses (EDs, mood/anxiety disorders, psychotic disorders). Logistic regression analyses were used to adjust for demographic characteristics.

RESULTS

Three-quarters of youth with EDs received no diagnosis of an ED-related medical complication. Bradycardia was the most prevalent diagnosis suggestive of medical instability. Odds of medical diagnosis were greater for ED than other psychiatric disorders but varied with age and gender. Across all diagnoses, Latinx youth were less likely to receive ED-related diagnoses suggesting medical instability.

DISCUSSION

Most publicly insured youth with EDs received no ED-related medical diagnosis, underscoring the structural barriers to receiving expert medical care.

Risk and resilience in eating disorders: differentiating pathways among psychosocial predictors

OBJECTIVE

Eating disorders (EDs) represent a rising global health concern. The current study takes a multivariate approach to examine psychological (i.e., perfectionism, anxiety sensitivity [AS], emotion dysregulation) and sociocultural factors (i.e., body dissatisfaction) that may relate to risk and resilience in EDs.

METHODS

Participants were 698 undergraduate students (Mage = 21, SDage = 4.02), mainly female (71%) and Hispanic (61.6%), who participated in an online survey assessing perfectionism, emotion dysregulation, AS, body dissatisfaction, and eating behaviors.

RESULTS

The results from structural equation model analyses revealed differential associations with disordered eating (DE) outcomes. Self-oriented perfectionism and dysmorphic appearance concerns were associated with increased dieting/carb restriction, desire for thinness, and binging tendencies. Specifically, emotional nonacceptance and lack of emotional awareness showed associations with elevated risk for dieting/carb restriction and purging tendencies, respectively. Conversely, lack of emotional clarity showed a protective pathway to these risk behaviors. Anxiety sensitivity cognitive concerns related to higher purging tendencies, while AS social concerns related to lower purging and binging tendencies.

DISCUSSION

Findings highlight the differential pathways of psychosocial risk and resilience for EDs. Subscales of emotional dysregulation and AS showed risk as well as resilience associations with DE outcomes. This information is key for advancing transdiagnostic prevention and intervention to reduce the rising rates of EDs.

Nutritional Strategies for Managing Iron Deficiency in Adolescents: Approaches to a Challenging but Common Problem

Iron deficiency (ID) is a common and challenging problem in adolescence. In order to prevent, recognize, and treat ID in this age range, it is critical to understand the recommended daily intake of iron in relation to an adolescent's activity, dietary habits, and basal iron losses. Adolescents following vegetarian or vegan diets exclusively rely on plant-based, nonheme iron, which has decreased bioavailability compared with heme iron and requires increased total iron intake. Individuals with disordered eating habits, excessive menstrual blood loss, and certain chronic health conditions (including inflammatory bowel disease and heart failure) are at high risk of ID and the development of symptomatic iron deficiency anemia (IDA). Adolescent athletes and those with sleep and movement disorders may also be more sensitive to changes in iron status. Iron deficiency is typically treated with oral iron supplementation. To maximize iron absorption, oral iron should be administered no more than once daily, ideally in the morning, while avoiding foods and drinks that inhibit iron absorption. Oral iron therapy should be provided for ≥3 mo in the setting of ID to reach a ferritin of 20 ng/mL before discontinuation. Intravenous iron is being increasingly used in this population and has demonstrated efficacy and safety in adolescents. It should be considered in those with persistent ID despite a course of oral iron, severe and/or symptomatic IDA, and chronic inflammatory conditions characterized by decreased gastrointestinal iron absorption.

Comparisons between atypical anorexia nervosa and anorexia nervosa: Psychological and comorbidity patterns

OBJECTIVE

Literature comparing "atypical" anorexia nervosa (atypical AN) and anorexia nervosa (AN) suggests these diagnoses share significant similarities in eating disorder (ED) pathology and psychiatric comorbidities. This study evaluated potential differences in ED pathology, psychiatric comorbidity, associated mechanisms (i.e., ED fears and perfectionism), and demographic factors (i.e., ethnicity and age) between individuals with atypical AN and AN.

METHOD

Data from seven protocols were combined for a total 464 individuals diagnosed with atypical AN (n = 215) or AN (n = 249). Between-group differences in ED severity and behaviors, psychiatric comorbidities, ED fears, perfectionism, and demographic factors were assessed using t-tests, Wilcoxon rank-sum tests, and Fisher's exact test.

RESULTS

Participants with atypical AN reported higher levels of overvaluation of weight and shape than those with AN. Participants with AN scored higher on food-related fears (anxiety about eating, food avoidance behaviors, and feared concerns) and fears of social eating, as well as obsessive-compulsive symptoms. Participants with AN were more likely to identify as Asian or Pacific Islander. No other statistically significant differences were found between groups for overall ED severity, ED behaviors, psychiatric comorbidities, general ED fears, perfectionism, or demographic factors.

DISCUSSION

Overall, results support previous literature indicating limited differences between individuals with atypical AN and AN, though individuals with atypical AN reported more overvaluation of weight and shape and those with AN reported higher food and social eating fears and obsessive-compulsive symptoms. Relatively few overall differences between atypical AN and AN highlight the importance of exploring dimensional conceptualizations of AN as an alternative to the current categorical conceptualization.

PUBLIC SIGNIFICANCE

This study assessed differences among individuals with atypical anorexia nervosa and anorexia nervosa in eating disorder severity and behaviors, comorbid psychiatric diagnoses, associated mechanisms, and demographic factors. Few differences emerged, though participants with atypical anorexia nervosa reported more overvaluation of weight and shape, while those with anorexia nervosa reported more food and social eating fears and higher obsessive-compulsive symptoms. Results support exploration of these diagnoses as a spectrum disorder.

Eating disorder psychopathology, psychiatric impairment, and symptom frequency of atypical anorexia nervosa versus anorexia nervosa: A systematic review and meta-analysis

OBJECTIVES

Restrictive eating disorders (EDs) occur across the weight spectrum, but historically more focus has been given to anorexia nervosa (AN) than atypical anorexia nervosa (atypAN). AtypAN's relegation to a diagnosis in the "other specified feeding and eating disorder" (OSFED) category and paucity of research surrounding atypAN invariably implies a less clinically severe ED. However, a growing body of research has begun to question the assumption that atypAN is less severe than AN. The current review and meta-analysis aimed to provide a comprehensive review to compare atypAN and AN on measures of eating disorder psychopathology, impairment, and symptom frequency to test whether atypAN is truly less clinically severe than AN.

METHODS

Twenty articles that reported on atypAN and AN for at least one of the variables of interest were retrieved from PsycInfo, PubMed, and ProQuest.

RESULTS

For eating-disorder psychopathology, results indicated that differences were nonsignificant for most indicators; however, atypAN was associated with significantly higher shape concern, weight concern, drive for thinness, body dissatisfaction, and overall eating-disorder psychopathology than AN. Results indicated that atypAN and AN did not significantly differ on clinical impairment or the frequency of inappropriate compensatory behaviors, whereas there was a significantly higher frequency of objective binge episodes in AN (vs. atypAN).

DISCUSSION

Overall, findings indicated that, in contrast to the current classification system, atypAN and AN were not clinically distinct. Results underscore the need for equal access to treatment and equal insurance coverage for restrictive EDs across the weight spectrum.

PUBLIC SIGNIFICANCE

The current meta-analysis found that atypAN was associated with higher drive for thinness, body dissatisfaction, shape concern, weight concern, and overall eating-disorder psychopathology than AN; whereas AN was associated with higher frequency of objective binge eating. Individuals with AN and atypAN did not differ on psychiatric impairment, quality-of-life, or frequency of compensatory behaviors, highlighting the need for equal access to care for restrictive EDs across the weight spectrum.

From disparities to equity: striving for more in our treatments for feeding and eating disorders

Adopting a framework of equity is urgently needed to reduce disparities persistent in feeding and eating disorder (FED) treatment models. This framework must emphasize the exchange of knowledge between relevant stakeholders and implementation strategies to impact practice and embrace a systemic change in the FED field.

The need for more inclusive measurement to advance equity in eating disorders prevention

Eating disorder (ED) research and practice have been shaped by prevailing stereotypes about who EDs are most likely to affect. Subsequently, the field has prioritized the needs and concerns of affluent, cisgender, heterosexual, white girls and women to the exclusion of others, especially people marginalized based on their race, ethnicity, sexual orientation, and/or gender identity. However, EDs exist across diverse groups and actually occur with elevated prevalence in several marginalized groups. Growing research points to differences in the drivers of EDs in such groups (e.g. desire to attain the curvy rather than thin ideal; dietary restraint due to food insecurity rather than weight/shape concerns), yet tools typically used for screening and intervention evaluation do not capture eating pathology driven by such factors. In this commentary, we describe gaps in existing ED assessment tools and argue these gaps likely underestimate EDs among marginalized groups, bias who is invited, participates in, and benefits from ED prevention programs, and obscure potential group differences in the efficacy of such programs. We also discuss the potential of these ramifications to exacerbate inequities in EDs. Finally, we outline recommendations to overcome existing gaps in measurement and, consequently, advance equity in the realm of ED prevention.

Examining clinicians' perceptions and experiences working with diverse families in family-based treatment: Common adaptations and considerations for treatment engagement

OBJECTIVE

Family-Based Treatment (FBT) is the leading manualized treatment for adolescent eating disorders; however, there is limited research on the adaptation of FBT for diverse families (i.e., families belonging to identity groups subject to systemic barriers and prejudices). The purpose of this qualitative study was to address: (1) adaptations made to the FBT model (if any) by clinicians working with diverse youth and families; (2) the barriers/facilitators of maintaining adherence (fidelity) to the model for these families; and, (3) the barriers/facilitators to access and engagement in FBT for diverse families.

METHOD

Forty-one FBT clinicians were recruited globally using purposive and snowball sampling, and listservs from eating disorder networks. Clinicians participated in individual interviews or focus groups, discussing their experiences delivering and adapting FBT for diverse families. Qualitative data was transcribed verbatim and analyzed using directed content analysis.

RESULTS

Some participants reported making adaptations to every phase of the FBT model, while others did not, when working with diverse families. In Phase 1, participants cited adapting the family meal, length/number of sessions provided, and addressed systemic barriers. In Phase 2, participants adapted the length of the phase and rate/level of independence given back to the adolescent. In Phase 3, participants increased or decreased the number of sessions, or eliminated this phase to address barriers to engagement in FBT.

DISCUSSION

This is the first study to qualitatively examine clinicians' experiences of implementing FBT with diverse families. Results may inform future FBT planning, clinician training, clinical decision-making tools, and opportunities for modifications to the foundational model.

PUBLIC SIGNIFICANCE

This qualitative study examined clinicians' perceptions and experiences implementing FBT with diverse families, specifically what adaptations (if any) were made to the foundational model, and the barriers and facilitators to adhering to and engaging in the model. Results show that some participants reported making adaptations to every phase of FBT, while others did not, with diverse families. Findings may inform future treatment planning, clinician training, clinical decision-making tools, and potential modifications to FBT.

The prevalence of disordered eating in outpatient general psychiatry settings in publicly insured populations: a case series

There is a dearth of research assessing the prevalence of eating disorders in publicly insured populations. While evidence shows that eating disorders affect people of all racial, ethnic, and socioeconomic backgrounds, research has neglected to focus on the rate at which they occur among those who have public health insurance. The present study indexes the prevalence of clinically significant disordered eating in a case series of 165 adults in a publicly insured sample at an outpatient general psychiatry clinic in Los Angeles, California. Results illustrate that 46 (27.8%) participants screened positive for clinically significant disordered eating with no significant differences relating to age or gender in those who screened positive versus those who did not (p > .05). This markedly elevated frequency of disordered eating presentations underscores the need for improved clinician training and education around disordered eating and eating disorder assessment as a whole. In addition, there is a critical need to study publicly insured populations so as to mitigate stereotypes about who has eating disorders and improve the likelihood of diagnosis and care.

Protocol for a scoping review to identify research reporting on eating disorders in minority ethnic populations in the UK, Canada, Australia and New Zealand

INTRODUCTION

Eating disorders (EDs) are common, severe and often life-threatening psychiatric conditions. Notwithstanding stereotypes, EDs affect individuals from all racial and ethnic backgrounds. However, despite similar and in some cases increased prevalence of disordered eating and EDs among minority ethnic groups, there appear to be disparities when it comes to ED diagnosis and treatment. To date, most of the existing literature exploring disordered eating and EDs among minority ethnic groups has been conducted in the USA. The present scoping review aims to examine the extent, range and nature of research activity into disordered eating and EDs in the UK, Canada, Australia and New Zealand providing a comprehensive overview of the existing literature. A special focus will be placed on studies exploring prevalence, access to care and treatment experiences.

METHODS AND ANALYSIS

The scoping review framework first outlined by Arksey and O'Malley and improved on by Levac et al was used to guide the development of this scoping review protocol. A detailed systematic search of relevant databases (Medline, EMBASE, PsycINFO, CINAHL and Web of Science) will be conducted. Relevant literature will also be identified from the reference lists of included studies. Two reviewers will independently screen titles and abstracts and full-texts against specified inclusion and exclusion criteria. A third reviewer will resolve disagreements if necessary. Relevant data will be extracted using a data charting form. Quantitative and qualitative summaries of extracted data will be provided.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. Findings will be of benefit to researchers, clinicians and policy-makers by highlighting areas for future research and identifying ways to making ED treatment more accessible for individuals from all backgrounds. Findings will be disseminated via conferences, presentations and peer-reviewed journals.

Eating Disorders in Men

BACKGROUND

Eating disorders are seen mainly as a problem affecting women, not just by the public at large, but also in specialized circles. Although it is true that more women than men suffer from all types of eating disorder, pertinent reviews have clearly shown that they do indeed occur in men, and that the available evidence on the matter is limited. The stigmatization of men with eating disorders makes it harder for these men, and for the relevant professionals, to recognize the symptoms and to seek or provide help.

METHODS

This review is based on publications retrieved by a selective search in PubMed on the epidemiological, diagnostic, clinical, and therapeutic aspects of eating disorders in men.

RESULTS

Current estimated lifetime prevalences in men are 0.2% for anorexia nervosa, 0.6% for bulimia nervosa, and 1% for bingeeating disorder; the corresponding figures for women are 1.4%, 1.9%, and 2.8%. Men and women may display different manifestations. Women are thought to be mainly seeking a slim figure and weight reduction; men, a muscular build. The established Germanlanguage screening and diagnostic tools, however, do not cover the types of symptoms that are more common in men. Little is known about whether treatment yields comparable results in men and women.

CONCLUSION

It is important to combat the stigmati - zation of men with eating disorders and to remove the obstacles to their appropriate diagnosis and treatment. The current methods of screening and diagnosis need to be adapted to take account of the special aspects of abnormal eating behavior in men. It remains unclear whether and how the disorderspecific treatment of these conditions in men should differ from their treatment in women.

Adaptations of an Online Cognitive-Behavioral Therapy Intervention for Binge-Purge Type Eating Disorders in Publicly-Insured and Uninsured Adults: A Pilot Study

Background Publicly-insured and uninsured individuals-many of whom are marginalized because of race/ethnicity, disability and/or sexual preferences-experience barriers to accessing evidence-based interventions for eating disorders (EDs). Additionally, EBIs have not been developed with or for diverse populations, exacerbating poor treatment uptake. Mobile technology is perfectly positioned to bridge this gap and increase access to low-cost, culturally-sensitive EBIs. Methods This study leverages a user-centered design approach to adapt an existing coached cognitive-behavioral therapy-based digital program and evaluate its usability in a sample of 11 participants with (sub)clinical binge-purge type EDs who are publicly-insured ( n  = 10) or uninsured ( n  = 1). Participants were primarily Non-Hispanic White ( n  = 8) women ( n  = 8). Two semi-structured interviews occurred with participants: one to assess treatment needs and the other to obtain app-specific feedback. Interviews were coded using inductive thematic analysis. Results Interview 1 feedback converged on three themes: Recovery Journey, Treatment Experiences, and Engagement with and Expectations for Online Programs. Participants endorsed facing barriers to healthcare, such as poor insurance coverage and a lack of trained providers, and interest in a coach to increase treatment accountability. Interview 2 feedback converged on three themes: Content Development, Participant Experiences with Mental Health, and Real-World Use. Participants liked the content but emphasized the need to improve diverse representation (e.g., gender, body size). Conclusions Overall, user feedback is critical to informing adaptations to the original EBI so that the intervention can be appropriately tailored to the needs of this underserved population, which ultimately has high potential to address critical barriers to ED treatment. Trial Registration This study was reviewed and approved by the Institutional Review Board (IRB) at the University California, San Francisco (IRB #22-35936) and the IRB at Washington University in St. Louis (IRB ID 202304167).

Intersecting gender identity and racial/ethnic inequities in eating disorder risk factors, symptoms, and diagnosis among U.S. college students: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy

INTRODUCTION

There are documented inequities in eating disorders (EDs) by gender and race/ethnicity, yet, little is known about population-level prevalence of ED risk factors, symptoms, and diagnosis at the intersection of diverse gender and racial/ethnic identities.

METHODS

Data from the Healthy Minds Study 2015-2019 (N = 251,310 U.S. university students) were used in a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). Participants were nested in 35 intersectional strata given by all combinations of 5 gender and 7 racial/ethnic categories. Multilevel logistic models with participants at level 1 and intersectional strata at level 2 were used to estimate stratum-specific predicted prevalence estimates for self-reported thin-ideal internalization, ED symptoms, and ED diagnosis. The variance partition coefficient (VPC) was calculated to quantify the contextual effect of the strata.

RESULTS

There was considerable heterogeneity in the predicted prevalence of our ED outcomes across the strata (e.g., .3%-18.3% for ED diagnoses). There were large disparities in all three outcomes, with transgender participants of color having a higher predicted prevalence than expected based on the additive effects of gender and race/ethnicity. Moderation by race/ethnicity was also apparent, such that racial/ethnic disparities were wider within the cisgender groups relative to the transgender groups. VPCs indicated that ~10% of the total variance in ED outcomes was due to intersectionality between gender and race/ethnicity, over and above variance due to individual-level differences.

CONCLUSION

Findings suggest that gender and racial/ethnic disparities in EDs are interrelated, underscoring the need to develop preventive interventions centering health equity.

PUBLIC SIGNIFICANCE

Despite evidence that sexism, racism, and cissexism (i.e., anti-transgender prejudice) can impact EDs risk, little research examines the social patterning of EDs at the intersection of diverse gender and racial/ethnic identities. Using data from a sample of 250,000 U.S. university students, this study found that gender and racial/ethnic disparities in eating disorder risk are interrelated, highlighting the need to develop health equity centered preventive interventions.

Cultural adaptation of an integrated eating disorders prevention and healthy weight management program

BACKGROUND

Both eating disorder (ED) prevention and weight management interventions often focus on the thin ideal. Yet, many Black and Latina women do not view thinness as their body ideal. This study used focus groups to investigate the influence of race, ethnicity, and culture on appearance ideals and inform the cultural adaptation and integration of two established programs addressing EDs and weight management: the Body Project, and Healthy Weight Interventions.

METHODS

White (n = 10), Black (n = 14), and Latina (n = 6) women participated in racially and ethnically homogenous focus groups.

RESULTS

Thematic analysis identified several themes, including: (1) diverse beauty standards across groups, (2) lack of acknowledgement of racialized beauty standards in prevention and cultural appropriation, (3) culturally-specific impacts of standards, (4) harm of appearance-related comments, (5) limitations of available resources, (6) stigma/minimization of mental health, (7) barriers to inclusive programming, and (8) facilitators of inclusive programming.

CONCLUSIONS

Results suggested that current programs' emphasis on thinness limit their relevance for women of color, and perpetuate the misconception that EDs primarily affect White women. Findings highlight the need for culturally responsive prevention.

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.

Migration background, eating disorder symptoms and healthcare service utilisation: findings from the Stockholm Public Health Cohort

BACKGROUND

From a global perspective, eating disorders are increasingly common, probably because of societal transformation and improved detection. However, research on the impact of migration on the development of eating disorders is scarce, and previously reported results are conflicting.

AIMS

To explore if eating disorder symptom prevalence varies according to birth region, parents' birth region and neighbourhood characteristics, and analyse if the observed patterns match the likelihood of being in specialist treatment.

METHOD

This study uses data from a large population-based health survey (N = 47 662) among adults in Stockholm, Sweden. A general linear model for complex samples, including adjustment for gender and age, was used to explore self-reported eating disorder symptoms. Odds ratios were calculated for individual symptoms.

RESULTS

Eating disorder symptoms are substantially more common in individuals born abroad, especially for migrants from a non-European country. This holds true for all surveyed symptoms, including restrictive eating (odds ratio 5.5, 95% CI 4.5-6.7), compensatory vomiting (odds ratio 6.1, 95% CI 4.6-8.0), loss-of-control eating (odds ratio 2.6, 95% CI 2.3-3.1) and preoccupation with food (odds ratio 2.3, 95% CI 1.9-2.8). Likewise, symptoms are more common in individuals with both parents born abroad and individuals living in districts with a high percentage of migrant residents. A gap exists between district-level symptom scores and the likelihood of being in specialist eating disorder treatment.

CONCLUSIONS

These findings call for oversight of current outreach strategies, and highlight the need for efforts to reduce stigma and increase eating disorder symptom recognition in broader groups.

Sex and ethnic/racial differences in disordered eating behaviors and intuitive eating among college student

Introduction

Eating behaviors encompass disordered eating behaviors (e.g., overeating, binge eating, and associated symptoms of binge eating) and intuitive eating. Certain disordered eating behaviors, including binge eating, are more prevalent among female and ethnic/racial-minority college students than male and/or non-Hispanic White college students. However, sex and ethnic/racial differences among college students with other disordered eating (e.g., associated symptoms of binge eating) and intuitive eating behaviors remain unclear.

Methods

In 2022, 887 college students (Mage = 20.9 ± 2.6 years) self-reported their sex, ethnicity/race, disordered eating behaviors (e.g., overeating, binge eating, associated symptoms of binge eating), and intuitive eating. To examine sex and ethnic/racial differences among these students, we used modified Poisson regressions for students who reported disordered eating and linear regressions for students who reported intuitive eating.

Results

Except for overeating, disordered eating behaviors were more prevalent among female [adjusted prevalence ratio (aPR) = 1.3-1.8] than male college students after adjusting for sociodemographic variables, whereas intuitive eating scores did not differ by sex. Across ethnic/racial groups, disordered eating was more prevalent among all ethnic/racial-minority college students (aPR = 1.2-2.3) than non-Hispanic White college students after adjusting for sociodemographic variables. Moreover, non-Hispanic Black or African American college students had higher intuitive eating scores than non-Hispanic White college students (adjusted β = 0.7, 95% CI = -0.2, 1.6).

Conclusion

In our sample, notable differences emerged in the prevalence of disordered eating behaviors and mean scores by sex and ethnicity/race, while differences in intuitive eating scores emerged based on ethnicity/race.

Binge-Eating Disorder Interventions: Review, Current Status, and Implications

PURPOSE OF REVIEW

Binge-eating disorder (BED) is a serious psychiatric problem associated with substantial morbidity that, unfortunately, frequently goes unrecognized and untreated. This review summarizes the current status of behavioral, psychological, pharmacological, and combined treatments for BED in adults with a particular focus on recent findings and advances.

RECENT FINDINGS

Certain specific psychological treatments, notably CBT and IPT, and to some extent DBT, have demonstrated efficacy and are associated with durable benefits after treatment. Certain specific lower-cost scalable interventions, notably CBTgsh, have demonstrated efficacy and have potential for broader uptake. An important advance is the emerging RCT data indicating that BWL, a generalist and available behavioral lifestyle intervention, has effectiveness that approximates that of CBT for reducing binge eating and eating-disorder psychopathology but with the advantage of also producing modest weight loss. There exists only one pharmacological agent (LDX) with approval by the FDA for "moderate-to-severe" BED. Research with other "off label" medications has yielded modest and mixed outcomes with a few medications statistically superior to placebo over the short-term and almost no longer-term data. Nearly all research combining medications and psychological treatments has failed to enhance outcomes (combined appears superior to pharmacotherapy-only but not to psychotherapy-only). Many people with BED suffer in silence and shame, go untreated, and rarely receive evidence-based treatments. Patients and practitioners need to recognize that research has identified several effective interventions for BED, and these can work quickly for many patients. Future research should identify treatments for those who do not derive benefit from initial interventions, identify additional pharmacological options, test agents with relevant mechanisms of action, and utilize innovative adaptative "SMART" designs to identify treatments to enhance outcomes among initial responders and to test alternative treatments to assist initial non-responders.

Racial discrimination is associated with binge-eating disorder in early adolescents: a cross-sectional analysis

BACKGROUND

Racial and ethnic discrimination are known stressors and are associated with negative psychological and physical health outcomes. Previous studies have found relationships between racial/ethnic discrimination and binge-eating disorder (BED), though they have mainly focused on adult populations. The aim of this study was to determine associations between racial/ethnic discrimination and BED in a large, national cohort study of early adolescents. We further sought to explore associations between the racial/ethnic discrimination perpetrator (students, teachers, or other adults) and BED.

METHODS

We analyzed cross-sectional data from the Adolescent Brain Cognitive Development Study (N = 11,075, 2018-2020). Logistic regression analyses examined associations between self-reported experiences of racial or ethnic discrimination and binge-eating behaviors and diagnosis, adjusting for potential confounders. Racial/ethnic discrimination measures were assessed based on the Perceived Discrimination Scale, which measures experiences of discrimination based on race/ethnicity and frequency of ethnic discrimination by teachers, adults outside of school, and students. Binge-eating behaviors and diagnosis were based on the Kiddie Schedule for Affective Disorders and Schizophrenia (KSAD-5).

RESULTS

In this racially diverse sample of adolescents (N = 11,075, age range 9-12 years), 4.7% of adolescents reported racial or ethnic discrimination and 1.1% met the criteria for BED. In the adjusted models, racial/ethnic discrimination was associated with 3 times higher odds of having BED (OR 3.31, CI 1.66-7.74). Further, experiences of ethnic discrimination by students and adults outside school were associated with significantly increased odds of BED diagnosis (OR 1.36, CI 1.10-1.68 and OR 1.42 CI 1.06-1.90, respectively)., Increased odds of binge eating behaviors were only significantly associated with ethnic discrimination perpetuated by students (OR 1.12, CI 1.02-1.23).

CONCLUSIONS

Children and adolescents who have experienced racial/ethnic discrimination, particularly when discrimination was perpetuated by other students, have higher odds of having binge-eating behaviors and diagnoses. Clinicians may consider screening for racial discrimination and providing anti-racist, trauma-informed care when evaluating and treating patients for BED.

Cognitive-behavioral therapy for binge-eating disorder for non-responders to initial acute treatments: Randomized controlled trial

OBJECTIVE

Certain treatments have demonstrated acute efficacy for binge-eating disorder (BED) but many patients who receive "evidence-based" interventions do not derive sufficient benefit. Given the dearth of controlled research examining treatments for patients who fail to respond to initial interventions, this study tested the efficacy of cognitive-behavioral therapy (CBT) for patients with BED who do not respond to initial acute treatments.

METHODS

Prospective randomized double-blind placebo-controlled single-site trial, conducted August 2017-December 2021, tested 16-weeks of therapist-led CBT for non-responders to initial treatment (naltrexone/bupropion and/or behavioral therapy) for BED with obesity. Thirty-one patients (mean age 46.3 years, 77.4% women, 80.6% White, mean BMI 38.99 kg/m2 ) who were non-responders to initial acute treatments were randomized to CBT (N = 18) or no-CBT (N = 13), in addition to continuing double-blinded pharmacotherapy. Independent assessments were performed at baseline, throughout treatment, and posttreatment; 83.9% completed posttreatment assessments.

RESULTS

Intention-to-treat remission rates were significantly higher for CBT (61.1%; N = 11/18) than no-CBT (7.7%; N = 1/13). Mixed models of binge-eating frequency (assessed using complementary methods) converged revealing a significant interaction between CBT and time and a significant main effect of CBT. Binge-eating frequency decreased significantly with CBT but did not change significantly with no-CBT. Since only four patients received behavioral treatment during the acute treatments, we performed "sensitivity-type" analyses restricted to the 27 patients who received pharmacotherapy during the acute treatment and found the same pattern of findings for CBT versus no-CBT.

CONCLUSIONS

Adult patients with BED who fail to respond to initial pharmacological treatments should be offered CBT.

PUBLIC SIGNIFICANCE

Even with leading evidence-based treatments for binge-eating disorder, many patients do not derive sufficient benefit. Almost no controlled research has examined treatments for patients who fail to respond to initial interventions. This study found that that cognitive-behavioral therapy was effective for patients with binge-eating disorder who did not respond to initial interventions, with 61% achieving abstinence.

Recruitment strategies to increase racial and ethnic diversity in anorexia nervosa clinical research

OBJECTIVE

Inclusion of underrepresented racial and ethnic groups in eating disorder (ED) research is a critical unmet need, but evidence-based recruitment strategies are lacking. We sought to determine whether methods we had implemented to increase recruitment of underrepresented racial and ethnic groups were successful in improving racial and ethnic diversity in a clinical trial in women with anorexia nervosa.

METHOD

We implemented new strategies for recruitment of underrepresented racial and ethnic groups in a clinical trial on bone health in women with anorexia nervosa, including leveraging social media, liberalizing language on advertisements to be more inclusive of women who are as yet undiagnosed with the disorder or feel stigmatized by its name, translating advertisements to Spanish, and engaging community health centers. We compared participants' race and ethnicity in this clinical trial versus two similar prior clinical trials.

RESULTS

The percent of non-White and Hispanic participants who have signed a consent form in our ongoing clinical trial (2021-2023) is higher versus two previous clinical trials on bone health in women with anorexia nervosa (2011-2019) with similar inclusion/exclusion criteria and endpoints [non-White: 11/38 (28.9%) vs. 11/188 (5.9%), Hispanic: 6/38 (15.8%) vs. 5/188 (2.7%), p ≤ 0.006]. There was no change in the percent of Black participants [0/38 (0%) vs. 1/188 (0.5%), p = 1.0].

DISCUSSION

Viewing clinical research recruitment through a diversity, equity, and inclusion lens can improve racial and ethnic diversity in ED research. Further research recruitment strategies are needed to be more inclusive of Black populations.

Socioeconomic status and eating disorder prevalence: at the intersections of gender identity, sexual orientation, and race/ethnicity

BACKGROUND

Longstanding biases have fostered the erroneous notion that only those of higher socioeconomic status (SES) experience eating disorders (EDs); however, EDs present across all SES strata. Considering the dearth of ED research among those of lower SES, this study examined (1) the overall association between SES and ED prevalence, and (2) ED prevalence in the context of four relevant social identities (i.e. SES, gender identity, sexual orientation, and race/ethnicity) from an intersectional perspective, as unique combinations of multiple social identities may differentially influence risk.

METHODS

A sample of 120 891 undergraduate/graduate students from the Healthy Minds Study self-reported family SES with a single-item question, gender identity, sexual orientation, and race/ethnicity, and were screened for ED risk.

RESULTS

Participants of lower SES had 1.27 (95% CI 1.25-1.30) times greater prevalence of a positive ED screen than those of higher SES. Substantial heterogeneity was observed across the four social identities beyond the association with SES. For example, positive ED screens were particularly common among lower SES, Latinx, sexual minority cisgender men and women, with 52% of bisexual men and 52% of lesbian women of Latinx ethnicity and lower SES screening positive.

CONCLUSIONS

Although positive ED screens were more common among undergraduate/graduate students of lower SES, the particularly high ED risk reported by certain groups of lower SES with multiple minority identities reinforces the importance of investigating multi-layered constructs of identity when identifying groups at disproportionate risk.

Racial Discrimination is Associated with Binge-Eating Disorder in Early Adolescents: A Cross-Sectional Analysis

Background Racial and ethnic discrimination are known stressors and are associated with negative psychological and physical health outcomes. Previous studies have found relationships between racial/ethnic discrimination and binge-eating disorder (BED), though they have mainly focused on adult populations. The aim of this study was to determine associations between racial/ethnic discrimination and BED in a large, national cohort study of early adolescents. We further sought to explore associations between the racial/ethnic discrimination perpetrator (students, teachers, or other adults) and BED. Methods We analyzed cross-sectional data from the Adolescent Brain Cognitive Development Study (ABCD) (N = 11,075, 2018-2020). Logistic regression analyses examined associations between self-reported racial or ethnic discrimination and binge-eating behaviors and diagnosis. Racial/ethnic discrimination measures were assessed based on the Perceived Discrimination Scale, which measures experiences of discrimination based on race/ethnicity and frequency of ethnic discrimination by teachers, adults outside of school, and students. Binge-eating behaviors and diagnosis were based on the Kiddie Schedule for Affective Disorders and Schizophrenia (KSAD-5), adjusting for age, sex, race/ethnicity, household income, parental education, and site. Results In this racially diverse sample of adolescents (N = 11,075, mean age: 11 years), 4.7% of adolescents reported racial or ethnic discrimination and 1.1% met the criteria for BED at the one-year follow-up. In the adjusted models, racial/ethnic discrimination was associated with 3 times higher odds of having BED (OR 3.31, CI 1.66-7.74); when investigating associations between the racial/ethnic discrimination perpetrator (students, teachers, or other adults) and BED, experiencing ethnic discrimination by students and adults outside school were associated with significantly increased odds of BED diagnosis (OR 1.36, CI 1.10-1.68 & OR 1.42 CI 1.06-1.90, respectively); further, increased odds of binge eating behaviors was only significantly associated with ethnic discrimination perpetuated by students (OR 1.12, CI 1.02-1.23). Conclusions Children and adolescents who have experienced racial/ethnic discrimination, particularly when discrimination was perpetuated by other students, have higher odds of having binge-eating behaviors and diagnoses. Clinicians may consider screening for racial discrimination and providing anti-racist, trauma-informed care when evaluating and treating patients for BED.

Eating Disorders in the Primary Care Setting

Eating disorders are mental health disorders with complicating medical, psychiatric, and nutritional comorbidities. Common eating disorder diagnoses include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder, and other specified feeding or eating disorder. Unspecified feeding or eating disorder is most applicable in brief acute care settings. Eating disorders occur across age, gender, racial, ethnic, and socioeconomic variables. Effective assessment, intervention, and collaborative treatment are needed to decrease risk factors and increase opportunities for recovery.

"What will people say?": Mental Health Stigmatization as a Barrier to Eating Disorder Treatment-Seeking for South Asian American Women

This study used focus group methodology to identify culturally-specific barriers to, and facilitators of, eating disorder (ED) treatment-seeking for South Asian (SA) American women. Seven focus groups were conducted with 54 participants (Mage=20.11 years, SD=2.52), all of whom had lived in the United States (US) for at least three years (63.0% of the sample was born in the US). Transcripts were independently coded by a team of researchers (n=4) and the final codebook included codes present in at least half of the transcripts. Thematic analysis identified salient themes (barriers, n=6; facilitators, n=3) for SA American women. Barriers to ED-treatment seeking were inextricable from barriers to mental health treatment, more broadly. In addition to generalized mental health stigma, participants cited social stigma (i.e., a pervasive fear of social ostracization), as a significant treatment-seeking barrier. Additional barriers were: cultural influences on the etiology and treatment of mental illness, parents' unresolved mental health concerns (usually tied to immigration), healthcare providers' biases, general lack of knowledge about EDs, and minimal SA representation within ED research/clinical care. To address these obstacles, participants recommended that clinicians facilitate intergenerational conversations about mental health and EDs, partner with SA communities to create targeted ED psychoeducational health campaigns, and train providers in culturally-sensitive practices for detecting and treating EDs. SA American women face multiple family, community, and institutional barriers to accessing mental health treatment generally, which limits their ability to access ED-specific care. Recommendations to improve ED treatment access include: (a) campaigns to destigmatize mental health more systematically, (b) collaboration with SA communities and, (c) and training providers in culturally-sensitive care.

Gender differences in individuals with obesity and binge eating disorder: A retrospective comparison of phenotypical features and treatment outcomes

OBJECTIVE

Phenotypical comparisons between individuals with obesity without binge eating disorder (OB) and individuals with obesity and comorbid binge eating disorder (OB + BED) are subject to ongoing investigations. At the same time, gender-related differences have rarely been explored, raising the question whether men and women with OB and OB + BED may require differently tailored treatments.

METHOD

We retrospectively compared pre- versus post-treatment data in a matched sample of n = 180 men and n = 180 women with OB or OB + BED who received inpatient treatment.

RESULTS

We found that men displayed higher weight loss than women independent of diagnostic group. In addition, men with OB + BED showed higher weight loss than men with OB after 7 weeks of treatment.

CONCLUSIONS

The present findings add to an emerging yet overall still sparse body of studies comparing phenotypical features and treatment outcomes in men and women with OB and OB + BED; implications for further research are discussed.

CLINICAL TRIAL REGISTRATION

The study was prospectively registered with the German Clinical Trial Register as part of application DRKS00028441.

Eating disorders and disordered eating in servicemen and women: A narrative review

OBJECTIVE

Eating disorders (EDs) are mental illnesses impacting all aspects of an individual's life. Recent research has examined EDs and disordered-eating behaviors in the military, a population subject to body composition standards, fitness requirements, and extreme stress. The purpose of this narrative review was to investigate ED and disordered-eating prevalence and their risk factors in ROTC (reserve officers' training corps), active-duty, and veteran servicemembers. The secondary purpose was to provide policy recommendations to reduce the burden of these conditions in the military.

METHODS

PubMed and PsycINFO were reviewed for relevant articles. All studies including data on EDs or disordered eating in U.S. active-duty, ROTC, or veteran populations were considered.

RESULTS

Results revealed a high burden of EDs and disordered eating with bulimic- and binge-type behaviors being the most common. Servicemembers exposed to trauma, including military sexual assault, and those with comorbidities like PTSD showed a higher prevalence. Body composition and fitness testing were also associated with a higher risk. Qualitative studies suggest these conditions serve as coping mechanisms for aspects of military life.

CONCLUSIONS

The high prevalence of EDs and disordered eating in the military points toward the importance of identification, treatment, and prevention. Policy change is necessary to protect servicemembers.

Disparities in access to eating disorders treatment for publicly-insured youth and youth of color: a retrospective cohort study

BACKGROUND

Eating disorders are associated with substantial morbidity and mortality that can be minimized by timely access to evidence-based treatment. However, disparate access to eating disorders treatment may contribute to significant health disparities amongst marginalized groups. This study examined the association between insurance type (public vs. private) and receipt of recommended mental health treatment in a sample of racially/ethnically diverse youth who presented to an adolescent medicine clinic with malnutrition secondary to disordered eating.

METHODS

A retrospective chart review was conducted for youth ages 11-25 years (N = 1060) who presented to an urban adolescent medicine specialty program between June 1, 2012 and December 31, 2019 for malnutrition secondary to disordered eating. Bivariate and logistic regression analyses examined the association between insurance type (public vs. private) and other demographic/clinical factors on receipt of recommended treatment within six months of the initial evaluation.

RESULTS

Patients with public insurance were one third as likely to receive recommended treatment as patients with private insurance (AOR = 3.23; 95% CI = 1.99, 4.52), after adjusting for demographic and clinical factors. Latinx (AOR = 0.49; 95% CI = 0.31, 0.77) and Asian (AOR = 0.55; 95% CI = 0.32, 0.94) patients were half as likely to receive recommended treatment as White patients.

CONCLUSIONS

Access to evidence-based mental health treatment is a necessary first step towards health equity for individuals with eating disorders. Additional work is needed to dismantle systemic inequities that contribute to disparities in care for youth of color and those with public insurance.

A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope

The ethical approach to treatment non-response and treatment refusal in severe-enduring anorexia nervosa (SE-AN) is the source of significant ethical debate, particularly given the risk of death by suicide or medical complications. A recent article proposed criteria to define when anorexia nervosa (AN) can be diagnosed as 'terminal' in order to facilitate euthanasia or physician-assisted suicide (EAS), otherwise known as medical assistance in dying, for individuals who wish to be relieved of suffering and accept treatment as 'futile'. This author utilises their personal lived experience to reflect on the issues raised, including: treatment refusal, iatrogenic harm, suicidality and desire to end suffering, impact of diagnosis/prognosis, schemas, alexithymia, countertransference, ambivalence, and holding on to hope. Within debates as critical as the bioethics of involuntary treatment, end-of-life and EAS in eating disorders, it is crucial that the literature includes multiple cases and perspectives of individuals with SE-AN that represent a wide range of experiences and explores the complexity of enduring AN illness, complex beliefs, communication patterns and relational dynamics that occur in SE-AN.

Associations among Intimate Partner Violence, Posttraumatic Stress Disorder Symptoms, and Disordered Eating among Women Intimate Partner Violence Survivors Residing in Shelter

Previous research has not assessed the association between intimate partner violence (IPV) and disordered eating (DE), nor the potential indirect effect through posttraumatic stress disorder (PTSD) symptoms, among residents of IPV shelters. Among 212 IPV survivors, this study examined these and the differential associations by PTSD symptom cluster and types of DE. In the current sample, 67.9% met criteria for probable PTSD, 20.3% met criteria for a probable eating disorder, and 18.4% had probable comorbid diagnoses. Consistent with escape theory, there was an indirect effect of IPV on DE through PTSD symptoms. Additionally, there was an indirect effect of IPV on weight/shape concerns and binge symptoms through PTSD symptoms. Although there was a significant total effect of IPV on compensatory behaviors, there was no indirect effect through PTSD symptoms. When PTSD symptom clusters were examined concurrently, the only indirect effect of IPV on weight/shape concerns was via the PTSD symptom cluster of negative alterations in cognition and mood. Although there was an indirect effect of IPV on binge symptoms via PTSD symptoms overall, no specific PTSD symptom cluster drove this association. Implications highlight the need for attention to DE within this population. Consistent with escape theory, survivors' DE might serve to distract from psychological distress.

A Review of Binge-Eating Disorder in Black Women: Treatment Recommendations and Implications for Healthcare Providers

PURPOSE OF REVIEW

We review relevant factors and barriers to care for binge-eating disorder (BED) in Black women. We examine evidence for the treatment of BED and provide recommendations to improve cultural relevance for assessing and treating BED in Black women.

RECENT FINDINGS

BED is the most common eating disorder among Black women. Moreover, evidence supports alternative factors that contribute to the onset of BED in Black women, including stress, trauma, and food insecurity. Furthermore, though there are evidence-based treatments for BED, disparities persist in access to care and treatment retention. Recommendations for increasing the cultural relevance of assessments and treatments are provided. Gaps in the literature remain on the use of evidence-based treatments for BED among Black women. As such, healthcare providers should include Black women as co-collaborators in their care and seek out training and consultation to aid in providing culturally affirming treatment.

Disordered eating symptoms as a function of perceived weight status and race: An intersectional examination

Disordered eating (DE) exhibited by individuals with intersecting marginalized identities may be less likely to be perceived as pathological compared to DE exhibited by individuals with non-marginalized identities. The present experiment tested the intersectional impact of weight status and race stimuli on responses to DE in a college sample. Undergraduate students (N = 193, M_age = 18.57, SD = 1.88, 71 % female) read a fictional account from a female target with DE who was described as "underweight," "average weight," or "overweight," and "White" or "Black." Participants completed an in-lab survey assessing detection of and responses to DE. Three 2 (race: Black, White) x 3 (weight status: underweight, average weight, overweight) ANCOVAs revealed a main effect of weight status. DE was more likely to be detected in "underweight" than "average" and "overweight" targets (p < .001). Participants encouraged weight loss for "average" and "overweight" targets compared to "underweight" targets (p < .001) and encouraged weight restoration for "underweight" targets compared to "average weight" and "overweight" targets (p < .001). No significant effects for target race or interaction between weight status and race emerged. These findings underscore the salience of weight status in shaping perceptions of DE.

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Update on the epidemiology and treatment of eating disorders among Hispanic/Latinx Americans in the United States

PURPOSE OF REVIEW

This review provides a 6-year update on the prevalence and treatment of eating disorders among Hispanic/Latinx Americans in the United States.

RECENT FINDINGS

Prevalence of eating disorders tends to be lower in Hispanic/Latinx American adolescents and adults relative to non-Hispanic White peers. Numerous risk factors for disordered eating symptoms have been identified, including negative body image, depression, sexual assault and culturally specific risk factors, including ethnic discrimination and acculturative stress. Hispanic/Latinx individuals seek treatment less often with the most influential barriers being cost of treatment, eating disorder stigma, eating disorder shame and mental health shame in general. Limited research on the treatment for eating disorders continue to persist. Culturally adapted cognitive behavioural therapy yielded similar outcomes to traditional cognitive behaviour therapy and had better treatment adherence and retention rates.

SUMMARY

The medical and sociopolitical climate of the United States has changed significantly since our previous review. The need for research on the effectiveness of eating disorder treatments for Hispanic/Latinx Americans remains important for one of the fastest growing populations in the U.S.

Epidemiology of eating disorders among US adults

PURPOSE OF REVIEW

Public policy efforts for prevention of and intervention upon eating disorders is severely limited in the United States due to the paucity of population-based data. This review article summarizes findings regarding eating disorders based on the National Epidemiological Studies on Alcohol and Related Conditions, Third Wave. The studies reviewed provide the most recent epidemiological indicators of anorexia nervosa, bulimia nervosa, and binge-eating disorder (BED) in the United States and demonstrate the utility of population-based data for validating the generalizability of findings from clinical samples.

RECENT FINDINGS

Anorexia nervosa, bulimia nervosa, and BED are widely distributed across sociodemographic characteristics, with substantially elevated risks for a variety of serious psychiatric, medical, and functional impairments, including heighted suicidality over the lifespan. Sexual minorities and individuals with adverse childhood experiences may be particularly vulnerable. Yet, many adults with eating disorders do not seek help, particularly professional help. National Epidemiological Studies on Alcohol and Related Conditions, Third Wave studies also validated some important clinical observations (e.g., overvaluation of shape/weight and physical inactivity in BED, more severe anorexia nervosa with onset prior to 14 years old).

SUMMARY

More rigorous population-based studies are needed to further advocate for appropriate resources and policies for eating disorders in the United States.

Navigating feminist and biomedical conceptual frameworks in educational interventions for eating disorders: Spanish educators’ understandings of the causes and treatment of eating disorders

The biomedical view of eating disorders (EDs) dominates in their classification and treatment regardless of the importance of sociocultural factors in EDs. Critical feminist approaches to EDs try to relate them to oppressive situations, disempowerment and the construction of gender. Educational interventions with people with EDs may be an alternative to biomedical approaches, giving them opportunities to tell their stories, listen to themselves and take control of their lives. This article presents a thematic analysis of semi-structured interviews with professionals who carry out educational interventions for people with EDs. Findings show that the biomedical description and treatment of EDs remain unchallenged and recognising client voice may be a problem, even in educational interventions. Also, the potential negative consequences of the rigid control of the clients’ lives seem to be ignored. Feminist approaches to EDs are acknowledged but do not seem to guide any intervention. Sociocultural critical stances that would recognise the coherence or the transitions between what is considered as healthy and sick eating also seem to be lacking.

What next for eating disorder genetics? Replacing myths with facts to sharpen our understanding

Substantial progress has been made in the understanding of anorexia nervosa (AN) and eating disorder (ED) genetics through the efforts of large-scale collaborative consortia, yielding the first genome-wide significant loci, AN-associated genes, and insights into metabo-psychiatric underpinnings of the disorders. However, the translatability, generalizability, and reach of these insights are hampered by an overly narrow focus in our research. In particular, stereotypes, myths, assumptions and misconceptions have resulted in incomplete or incorrect understandings of ED presentations and trajectories, and exclusion of certain patient groups from our studies. In this review, we aim to counteract these historical imbalances. Taking as our starting point the Academy for Eating Disorders (AED) Truth #5 "Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses", we discuss what we do and do not know about the genetic underpinnings of EDs among people in each of these groups, and suggest strategies to design more inclusive studies. In the second half of our review, we outline broad strategic goals whereby ED researchers can expand the diversity, insights, and clinical translatability of their studies.

How Physicians Can Assess and Address Dietary Behaviors to Reduce Chronic Disease Risk

With the growing burden of diet-related chronic disease impacting the public's health, nutrition counseling in a primary care setting is essential and can be accomplished through brief and creative approaches. This article reviews an example of a brief dietary assessment and counseling tool and counseling strategies focusing on dietary behavior changes that emphasize impact on health outcomes, ease of behavior change, and affordability. These, plus integrating office supports, are practical ways to start the conversation about improving diet quality with patients. Collaborative efforts in nutrition care, particularly through collaboration with registered dietitians, present a valuable opportunity to meet the nutrition care needs of patients. Additionally, this article reviews screening for eating disorders, food insecurity, and dietary supplement use.

The impact of discrimination on binge eating in a nationally representative sample of Latine individuals

OBJECTIVE

Latines have higher rates of eating disorders characterized by binge eating compared to their non-Latine white counterparts, yet culturally and socially relevant factors related to binge eating in Latines have been largely understudied. The purpose of the current study was to examine how discrimination and acculturative stress were associated with binge eating in a nationally representative sample of Latines. An additional aim was to test the extent to which family cohesion and social support could buffer against the effects of discrimination and acculturative stress on binge eating.

METHOD

Participants (56% female, N = 2550) were Latines enrolled in the National Latino and Asian American Study. Structural equation modeling using 1000 re-sampled data sets built from machine learning iterative sampling procedures was used to examine the effects of discrimination, acculturative stress, family cohesion, and social support on binge eating.

RESULTS

Results indicated that only discrimination was significantly associated with binge eating. Neither the direct effect of acculturative stress, interaction of family cohesion and acculturative stress, interaction of social cohesion and acculturative stress, nor the interaction of social support and discrimination were significantly associated with binge eating.

DISCUSSION

This study highlights the need for mental-health providers to understand and assess discrimination among Latines presenting with concerns of binge eating. Treatments that effectively provide coping strategies to manage discriminatory experiences and reduce binge eating could improve both effectiveness of treatment and retention rates for Latine individuals with binge eating.

PUBLIC SIGNIFICANCE

This study examined the association of discrimination, acculturative stress, family cohesion, and social support with binge eating in Latines. Only discrimination was significantly associated with binge eating, highlighting the importance for providers to assess discrimination among Latines with binge-eating concerns and to improve equity, inclusion, and belonging at a societal level. Modifying existing treatments to address coping with discrimination could improve the effectiveness for Latines with binge-eating concerns.