Healthcare costs and resource utilization of patients with binge-eating disorder and eating disorder not otherwise specified in the Department of Veterans Affairs

Behavioral weight loss treatment for adults with binge-eating disorder: A qualitative analysis of patients' perspectives and experiences

OBJECTIVE

Understanding the perspectives of behavioral weight loss (BWL) participants could inform whether, how, and for whom BWL should be offered.

METHOD

All 126 participants in a clinical trial of BWL for adults with binge-eating disorder (BED) and overweight/obesity were contacted about a qualitative study. 45 participants, 11 of whom had dropped out of the parent study, completed qualitative interviews. The interview guide was developed using data from a survey of providers who offer Health at Every Size and other weight-neutral lifestyle interventions. Questions were phrased to invite even the most negative responses. Questions focused on participants' experiences of weight stigma during treatment, perceptions of BWL's calorie and WL goals, and opinions of BWL and weight-neutral interventions.

RESULTS

We identified four themes using thematic analysis: (1) BWL did not perpetuate weight stigma. (2) Calorie and WL goals did not exacerbate participants' binge eating. (3) Patients should have the right to pursue any treatment that aligns with their personal goals. (4) BWL can improve participants' overall health.

DISCUSSION

BWL participants with BED and overweight/obesity want others to have access to a program that can reduce both weight and binge eating. Participants emphasized that no treatment works for everyone, and they all agreed that BWL had not perpetuated weight stigma. Fewer than 20% of participants considered the program's calorie and WL goals to be harmful; most participants viewed those goals as achievable and helpful, and many asserted that their participation in BWL had improved their overall health.

PUBLIC SIGNIFICANCE

We interviewed adults with binge-eating disorder and overweight/obesity who had participated in a behavioral weight loss (BWL) program. Our participants wanted others in their position to have access to BWL because it aims to reduce both weight and binge-eating frequency. Efforts should be made to provide patients, clinicians, and policymakers with the knowledge that supervised, evidence-based BWL is an effective and desired treatment choice for this population.

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.

Efficacy, safety, and tolerability of nivasorexant in adults with binge-eating disorder: A randomized, Phase II proof of concept trial

OBJECTIVE

This Phase II, placebo-controlled, double-blind study investigated the efficacy, safety, and tolerability of nivasorexant in the treatment of adults with moderate to severe binge-eating disorder (BED).

METHODS

Adults meeting the DSM-5 BED criteria were randomized 1:1 to placebo or nivasorexant (100 mg b.i.d.). The primary endpoint was the change from baseline to Week 12 in the number of binge eating (BE) days per week. Exploratory efficacy endpoints included cessation of BE in the last 4 weeks of treatment; and change from baseline to Week 12 in the number of BE episodes/week, the clinician global impression (CGI) of change, the Yale-Brown Obsessive-Compulsive Scale modified for BE, and the Hamilton rating scale for depression (HAMD-17). Key safety outcomes included treatment-emergent adverse events (TEAEs) and adverse events of special interest (i.e., somnolence and fatigue).

RESULTS

Sixty-eight participants were randomized to each treatment arm. The change from baseline to Week 12 in the number of BE days/week was the same for placebo (least squares mean [LSM]: -2.93) and nivasorexant (LSM: -2.93), with no difference between the treatment groups (LSM difference = .000 [95% confidence interval (CI): -.69, .69], p = .9992). Furthermore, no differences between treatment groups were observed in the exploratory efficacy endpoints. Nivasorexant was well tolerated; the overall incidence of TEAEs was balanced between treatment groups, and the frequency of somnolence and fatigue in the nivasorexant group were similar to placebo.

DISCUSSION

In this proof-of-concept study, 100 mg b.i.d. nivasorexant did not improve BE in adults with moderate to severe BED.

PUBLIC SIGNIFICANCE

The results of this Phase II study indicate that nivasorexant was well tolerated in adults with BED, but did not improve binge eating behavior over placebo. Further research is needed to improve our understanding of the role of the orexin-1 receptor in BED.

Health service utilization among women veterans who report eating disorder symptoms

OBJECTIVE

Describe health service utilization in women veterans with eating disorder symptoms and characterize the nature of mental health services received.

METHOD

Women veterans (N = 191) in a northeastern Veterans Health Administration region completed the Eating Disorders Examination Questionnaire. Health service utilization was then observed for 5 years across multiple domains (i.e., mental health, primary care, telephone consultations, emergency services); negative binomial or zero-inflated negative binomial regression models (mental health) estimated the relative impact of reported eating disorder symptoms on health service utilization.

RESULTS

After adjusting for the effects of age and body mass index, higher eating disorder symptoms were associated with higher primary care, mental health services, and telephone consultations. Eating disorder diagnoses were infrequent across the sample.

DISCUSSION

Women veterans with higher self-reported eating disorder symptoms evidence higher health service utilization across common healthcare domains. Encounter data suggest that eating disorder symptoms are rarely identified or clinically addressed by providers. Existing mental health visits may represent an opportunity for selective screening for eating disorder symptoms, particularly among women who evidence known risk factors.

PUBLIC SIGNIFICANCE

This study reveals that women veterans with higher levels of eating disorder symptoms (e.g., dietary restriction, poor body image) use more primary care, mental health, and telephone consultations than others, but may not receive services that target disordered eating. Opportunities may exist to better identify eating disorder symptoms in the context of existing mental health visits, or potentially to combine treatment for eating disorder symptoms into their mental health care.

Eating Disorders in U.S. Active Duty Military Members and Veterans: A Systematic Review

INTRODUCTION

Feeding and eating disorders can be difficult to treat and frequently co-occur with other mental health conditions. The last systematic review of eating disorders in a military and veteran population was published in 2015. An updated review is warranted to re-examine the current literature on eating disorders in the active duty and veteran populations.

MATERIALS AND METHODS

A systematic review that described the prevalence, co-occurrence of other disorders and/or events, and health care utilization of U.S. active duty members and veterans was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Databases and Medical Subject Headings (MeSH) terms used are listed in Appendix A. Each category of the literature was extracted and graded using the Oxford Centre for Evidence-Based Medicine Levels of Evidence.

RESULTS

Twenty-one studies revealed prevalence estimates with varying rates based on demographic information. Trauma exposure is consistently associated with eating disorder development. Individuals diagnosed with eating disorders had greater health care utilization.

CONCLUSIONS

Research on eating disorders in the military and veteran populations has expanded in recent years. Limitations of the evidence included in this review stem from the use of self-reported questionnaires, changes to medical record systems, and limited generalizability to the overall population of patients with eating disorders. Further research should investigate the impact of demographic factors and trauma exposure on the development of an eating disorder within the military and veteran populations.

Treatment characteristics among patients with binge-eating disorder: an electronic health records analysis

OBJECTIVES

Treatment for adults diagnosed with binge-eating disorder (BED) includes psychotherapy and/or pharmacotherapy and aims to reduce the frequency of binge-eating episodes and disordered eating, improve metabolic-related issues and reduce weight, and address mood symptoms. Data describing real-world treatment patterns are lacking; therefore, this study aims to characterize real-world treatment patterns among patients with BED.

METHODS

This retrospective study identified adult patients with BED using natural language processing of clinical notes from the Optum electronic health record database from 2009 to 2015. Treatment patterns were examined during the 12 months preceding the BED recognition date and during a follow-up period after BED recognition (1-3 years for most patients).

RESULTS

Among 1042 patients, 384 were categorized as the BED cohort and 658, who met less stringent criteria, were categorized as probable BED. In the BED cohort, mean ± SD age was 45.2 ± 13.4 years and 81.8% were women (probable BED, 45.9 ± 12.8 years, 80.2%). A greater percentage of patients in the BED cohort were prescribed pharmacotherapy (70.6% [probable BED, 66.9%]) than received/discussed psychotherapy (53.1% [probable BED, 39.2%]) at baseline. In the BED cohort, 54.4% of patients were prescribed antidepressants (probable BED, 52.4%), 25.3% stimulants (probable BED, 20.1%), and 34.4% nonspecific psychotherapy (probable BED, 24.6%) at baseline, with no substantive differences observed during follow-up. Low percentages of patients in the BED cohort received/discussed cognitive behavioral therapy at baseline (12.5% [probable BED, 9.0%) or during follow-up (13.0% [probable BED, 8.8%). Among patients with ≥1 psychotherapy visit, the mean ± SD number of visits in the BED cohort was 1.2 ± 5.9 at baseline (probable BED, 1.7 ± 7.3) and 2.2 ± 7.7 during follow-up (probable BED, 2.6 ± 7.7).

CONCLUSION

This cohort of patients with BED was treated more frequently with pharmacotherapy than psychotherapy. These data may help inform strategies for reducing differences between real-world treatment patterns and evidence-based recommendations.

Associations between probable eating disorders and healthcare use among post-9/11 veteran men and women

OBJECTIVE

Healthcare use is elevated among individuals with eating disorders (EDs); however, most people with EDs do not receive ED-specific care, likely due to factors such as the cost and availability of treatment as well as stigma. U.S. military veterans historically have been understudied in ED research. We investigated healthcare use and barriers to care among recently separated veteran men and women.

METHOD

In this cross-sectional study, 1494 participants completed an online or paper survey assessing ED symptoms, healthcare use, and logistical and attitudinal barriers to care. We estimated logistic regression models to investigate the association of ED status with healthcare use variables and examined gender similarities and differences in barriers to care.

RESULTS

Men and women with probable EDs reported low rates of ED treatment but greater healthcare use, during military service and since separating from service, compared to veterans without probable EDs (odds ratios = 1.57-7.05). Large proportions of participants reported that they did not know where to get help for EDs and that treatment is too costly. There were few gender differences in barriers to care (Cramer's V = 0.02-0.32).

CONCLUSION

Veterans reported high healthcare use but low rates of ED treatment. Findings underscore the need to increase the reach and accessibility of ED treatment in potentially vulnerable groups.

Cost-of-illness for non-underweight binge-eating disorders

PURPOSE

This study examined economic costs associated with untreated eating disorders (EDs) characterised by regular binge eating in the absence of low weight. Both direct and indirect costs were assessed, reporting a limited societal perspective of economic impact as some costs were not included.

METHODS

One hundred and twenty six adults seeking treatment for recurrent binge eating were asked to report impairment associated with an ED. Costs were calculated using 2017 prices, including an examination of variables associated with costs.

RESULTS

Estimated societal costs for the year preceding assessment were £3268.47 (€3758.54) per person. In multivariate analyses, no reliable baseline associates of cost were identified.

CONCLUSION

The economic burden of EDs characterised by regular binge eating is significant, and underscores the need for efficacious and cost-effective treatments. Individuals with binge-eating disorders report work impairment and healthcare use that may cost the United Kingdom economy upwards of £3.5 billion (€4bn) per annum. Further studies should consider academic impairment and the economic impact of EDs on families.

LEVEL OF EVIDENCE

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

Eating disorders in the U.S. Medicare population

OBJECTIVE

The social and economic burden of eating disorders is significant and often financially devastating. Medicare is the largest public insurer in the United States and provides coverage for older adults and some disabled individuals. This study explores prevalence, sociodemographic and clinical characteristics, and health care spending for Medicare enrollees with eating disorders.

METHOD

A cross-sectional study was conducted with the nationally representative 20% sample of 2016 Medicare inpatient, outpatient, carrier, and home health fee-for-service claims and Medicare Advantage encounter records. Sociodemographic characteristics and comorbid somatic conditions were compared between individuals with versus without an eating disorder diagnosis. Mean spending was compared overall and separately for inpatient, outpatient, home health, and pharmacy claims.

RESULTS

The sample included 11,962,287 Medicare enrollees of whom 0.15% had an eating disorder diagnosis. Compared to those without a 2016 eating disorder diagnosis, a greater proportion of individuals with an eating disorder were female (73.8% vs. 54.3%), under age 65 (41.6% vs. 15.5%), and dually eligible for Medicaid due to disability or low-income qualification (48.0% vs. 19.6%). Individuals with eating disorders had higher rates of comorbid conditions, with the greatest differences in cardiac arrythmias (35.3% vs. 19.9%), arthritis (40.1% vs. 26.6%), and thyroid conditions (32.2% vs. 19.4%). Spending was higher for enrollees with eating disorders compared to those without overall ($29,456 vs. $7,418) and across settings.

DISCUSSION

The findings establish that eating disorders occur in the Medicare population, and that enrollees with these illnesses have risk factors associated with significant healthcare spending and adverse health outcomes.

Extracting social determinants of health from electronic health records using natural language processing: a systematic review

OBJECTIVE

Social determinants of health (SDoH) are nonclinical dispositions that impact patient health risks and clinical outcomes. Leveraging SDoH in clinical decision-making can potentially improve diagnosis, treatment planning, and patient outcomes. Despite increased interest in capturing SDoH in electronic health records (EHRs), such information is typically locked in unstructured clinical notes. Natural language processing (NLP) is the key technology to extract SDoH information from clinical text and expand its utility in patient care and research. This article presents a systematic review of the state-of-the-art NLP approaches and tools that focus on identifying and extracting SDoH data from unstructured clinical text in EHRs.

MATERIALS AND METHODS

A broad literature search was conducted in February 2021 using 3 scholarly databases (ACL Anthology, PubMed, and Scopus) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 6402 publications were initially identified, and after applying the study inclusion criteria, 82 publications were selected for the final review.

RESULTS

Smoking status (n = 27), substance use (n = 21), homelessness (n = 20), and alcohol use (n = 15) are the most frequently studied SDoH categories. Homelessness (n = 7) and other less-studied SDoH (eg, education, financial problems, social isolation and support, family problems) are mostly identified using rule-based approaches. In contrast, machine learning approaches are popular for identifying smoking status (n = 13), substance use (n = 9), and alcohol use (n = 9).

CONCLUSION

NLP offers significant potential to extract SDoH data from narrative clinical notes, which in turn can aid in the development of screening tools, risk prediction models, and clinical decision support systems.

Study protocol and rationale for a randomized, placebo-controlled trial of solriamfetol to treat binge eating disorder

INTRODUCTION

Binge eating disorder (BED) is an important public health problem associated with severe psychosocial and medical consequences for which treatment options are limited. The objective of this study is to evaluate the efficacy and tolerability of the novel dopamine and norepinephrine reuptake inhibitor (DNRI) solriamfetol in the treatment of BED.

METHODS

This study is a 12-week, randomized (1:1 ratio), placebo-controlled, double-blind, parallel-group, 2-arm clinical trial of solriamfetol in 64 outpatients with BED. The primary outcome is binge-eating day frequency as assessed by take-home patient-completed binge eating diaries. Secondary outcomes include binge-eating episode frequency and scores on The Yale-Brown Obsessive Compulsive Scale for Binge Eating (YBOCS-BE) and Clinical Global Severity (CGIS) scale.

DISCUSSION

To our knowledge this is the first randomized, double-blind protocol investigating the safety and efficacy of solriamfetol in BED. We highlight the background and rationale for this study, including a discussion on using DNRIs in BED.

TRIAL REGISTRATION

This study was registered on ClinicalTrials.gov, identifier NCT04602936, on Oct 26, 2020 https://www.clinicaltrials.gov/ct2/show/NCT04602936.

Suicidality risk among adults with binge-eating disorder

OBJECTIVE

To estimate relative suicidality risk associated with binge-eating disorder (BED).

METHODS

Retrospective study of patients identified as having BED (N = 1042) and a matched general population cohort (N = 10,420) from the Optum electronic health record database between January 2009 and September 2015. Patients had ≥1 outpatient encounter with a provider who recognized BED during the 12-month baseline preceding entry date. Incidence and relative risk of suicidality were assessed.

RESULTS

Incidence per 1000 person-years (95% CI) of suicidal ideation and suicide attempts, respectively, was 31.1 (23.1, 41.0) and 12.7 (7.9, 19.4) in the BED cohort and 5.8 (4.7, 7.1) and 1.4 (0.9, 2.2) in the comparator cohort. Risk of suicidal ideation and suicide attempts was greater in the BED cohort (HR [95% CIs], 6.43 [4.42, 9.37]) than in the comparator cohort (HR [95% CI], 9.47 [4.99, 17.98]) during follow-up. After adjusting for psychiatric comorbidities, associations of suicidal ideation and suicide attempts with BED remained elevated in patients with BED having histories of suicidality.

CONCLUSIONS

Findings suggest that history of suicidality may result in an increased risk of suicidal ideation and suicide attempts in patients with BED relative to the general population. Psychiatric comorbidity burden may explain the elevated risk of these conditions in BED.

DSM-5 eating disorder prevalence, gender differences, and mental health associations in United States military veterans

OBJECTIVE

Little is known about prevalence estimates of new and revised DSM-5 eating disorders diagnoses in general, and especially among high-risk, underserved and diverse eating disorder populations. The aim of the current study was to determine prevalence, gender differences and correlates of DSM-5 eating disorders in veterans.

METHOD

Iraq and Afghanistan war era veterans (N = 1,121, 51.2% women) completed the Eating Disorder Diagnostic Scale-5 and validated measures of eating pathology and mental health between July 2014 and September 2019.

RESULTS

Overall more women than men (32.8% vs. 18.8%, p < .001) reported symptoms consistent with a DSM-5 eating disorder. Prevalence estimates (women vs. men) for the specific diagnoses were: Anorexia Nervosa (AN; 0.0% vs. 0.0%), Bulimia Nervosa (BN; 6.1% vs. 3.5%), Binge-Eating Disorder (BED; 4.4% vs. 2.9%), Atypical AN (AAN; 13.6% vs. 4.9%), Subclinical BN (0.0% vs. 0.2%), Subclinical BED (1.4% vs. 0.6%), Purging Disorder (2.1% vs. 0.7%), and Night Eating Syndrome (NES; 5.2% vs. 6.0%). Women were more likely to have BN or AAN, and there was no difference for BED or NES among genders. The eating disorder group had a higher mean BMI, and significantly greater eating pathology and mental health symptoms than the non-eating disorder group.

DISCUSSION

Approximately one-third of women, and one-fifth of men, reported symptoms consistent with a DSM-5 eating disorder diagnosis. These high prevalence estimates across genders, and associated mental health concerns, suggest an urgent need to better understand and address eating disorders in military and veteran populations.

The economic cost of bulimia nervosa and binge eating disorder: a population-based study

BACKGROUND

The most common eating disorders (EDs) are bulimia nervosa (BN) and binge eating disorder (BED), serious psychiatric illnesses that have devastating effects on the physical and psychological wellbeing of sufferers. EDs range in complexity and severity but can be life-threatening without appropriate treatment. Although it is well-known that quality of life impacts is high for ED sufferers, research regarding fiscal and related costs is severely limited. The aim of this study was to understand economic and other costs of EDs at the community level.

METHOD

Data were derived from 2017 household community representative structured interview of 2977 people aged ⩾ 15 years in South Australia. ED diagnoses, health systems, productivity, transaction, out-of-pocket expenses and other related costs of BN and BED were used to estimate the economic burden of EDs in South Australia.

RESULTS

The annual total economic cost of EDs in 2018 was estimated at $84 billion for South Australia. This included $81 billion from the burden of disease as the result of years lived with disability (YLD) ($62 billion) and years of life lost ($19 billion). The health system costs, productivity and tax revenue loss to the Australian economy were estimated at $1 billion, $1.6 billion and $0.6 billion, respectively.

CONCLUSIONS

The YLD average cost in 2018 in South Australia was $296 649 per person. This is two-thirds of the costs borne by individuals and the wider economy. Prevention and management initiatives for EDs need to take into account these costs when assessing their potential benefits.

A retrospective chart review study of symptom onset, diagnosis, comorbidities, and treatment in patients with binge eating disorder in Canadian clinical practice

PURPOSE

In the Canadian healthcare setting, there is limited understanding of the pathways to diagnosis and treatment for patients with binge eating disorder (BED).

METHODS

This retrospective chart review examined the clinical characteristics, diagnostic pathways, and treatment history of adult patients diagnosed with BED.

RESULTS

Overall, 202 charts from 57 healthcare providers (HCPs) were reviewed. Most patients were women (69%) and white (78%). Mean ± SD patient age was 37 ± 12.1 years. Comorbidities identified in > 20% of patients included obesity (50%), anxiety (49%), depression and/or major depressive disorder (46%), and dyslipidemia (26%). Discussions regarding a diagnosis of BED were typically initiated more often by HCPs than patients. Most patients (64%) received a diagnosis of BED ≥ 3 years after symptom onset. A numerically greater percentage of patients received (past or current) nonpharmacotherapy than pharmacotherapy (84% vs. 67%). The mean ± SD number of binge eating episodes/week numerically decreased from pretreatment to follow-up with lisdexamfetamine (5.4 ± 2.8 vs. 1.7 ± 1.2), off-label pharmacotherapy (4.7 ± 3.9 vs. 2.0 ± 1.13), and nonpharmacotherapy (6.3 ± 4.8 vs. 3.5 ±  6.0) Across pharmacotherapies and nonpharmacotherapies, most patients reported improvement in symptoms of BED (84-97%) and in overall well-being (80-96%).

CONCLUSIONS

These findings highlight the importance of timely diagnosis and treatment of BED. Although HCPs are initiating discussions about BED, earlier identification of BED symptoms is required. Furthermore, these data indicate that pharmacologic and nonpharmacologic treatment for BED is associated with decreased binge eating and improvements in overall well-being.

LEVEL OF EVIDENCE

IV, chart review.

Social and economic cost of eating disorders in the United States: Evidence to inform policy action

OBJECTIVE

To estimate one-year costs of eating disorders in the United States (U.S.) from a societal perspective, including the costs to the U.S. health system, individual and family productivity costs, lost wellbeing, and other societal economic costs, by setting and payer. Findings will inform needed policy action to mitigate the impact of eating disorders in the U.S.

METHOD

Costs of eating disorders were estimated using a bottom-up cost-of-illness methodology, based on the estimated one-year prevalence of eating disorders. Intangible costs of reduced wellbeing were also estimated using disability-adjusted life years.

RESULTS

Total economic costs associated with eating disorders were estimated to be $64.7 billion (95% CI: $63.5-$66.0 billion) in fiscal year 2018-2019, equivalent to $11,808 per affected person (95% CI: $11,754-$11,863 per affected person). Otherwise Specified Feeding or Eating Disorder accounted for 35% of total economic costs, followed by Binge Eating Disorder (30%), Bulimia Nervosa (18%) and Anorexia Nervosa (17%). The substantial reduction in wellbeing associated with eating disorders was further valued at $326.5 billion (95% CI: $316.8-$336.2 billion).

DISCUSSION

The impact of eating disorders in the U.S. is substantial when considering both economic costs and reduced wellbeing (nearly $400 billion in fiscal year 2018-2019). Study findings underscore the urgency of identifying effective policy actions to reduce the impact of eating disorders, such as through primary prevention and screening to identify people with emerging or early eating disorders in primary care, schools, and workplaces and ensuring access to early evidence-based treatment.

Healthcare use and costs of adults with anorexia nervosa and bulimia nervosa in Taiwan

OBJECTIVE

This study aimed to examine the health service use and healthcare costs of adults with anorexia nervosa (AN) and bulimia nervosa (BN) in Taiwan.

METHOD

AN and BN cases between 2002-2013 were extracted from a national health insurance database. For each AN and BN case, we randomly selected 10 controls with no eating disorder, matched for sex, age, urbanization of residence, and year of medical visit. The percentage and frequency of health services use and costs in the year preceding and after the diagnosis of AN/BN were compared between groups. We used generalized linear models with gamma distribution and log link function to determine the effects of age, sex, and psychiatric comorbidities on the total cost adjusting for physical comorbidities and to calculate the mean cost difference between groups by using marginal and incremental effects.

RESULTS

Both individuals with AN and BN had significantly elevated healthcare utilization and costs compared to controls during the baseline and one-year period after diagnosis. Patients with AN had more than three times higher total costs (US $792) and patients with BN had two times higher total costs (US $320) than individuals without eating disorders. Comorbidity of depressive disorder and older age significantly increased healthcare costs among both individuals with AN and BN.

DISCUSSION

There are high medical and economic burdens of care for individuals with AN and BN. Early diagnosis and integrated care for eating disorders are important tasks to reduce disease burden in Taiwan.

The Utility of Clinical Notes for Sexual Minority Health Research

INTRODUCTION

Despite improvements in electronic medical record capability to collect data on sexual orientation, not all healthcare systems have adopted this practice. This can limit the usability of systemwide electronic medical record data for sexual minority research. One viable resource might be the documentation of sexual orientation within clinical notes. The authors developed an approach to identify sexual orientation documentation and subsequently derived a cohort of sexual minority patients using clinical notes from the Veterans Health Administration electronic medical record.

METHODS

A hybrid natural language processing approach was developed and used to identify and categorize instances of terms and phrases related to sexual orientation in Veterans Health Administration clinical notes from 2000 to 2019. System performance was assessed with positive predictive value and sensitivity. Data were analyzed in 2019.

RESULTS

A total of 2,413,584 sexual minority terms/phrases were found within clinical notes, of which 439,039 (18%) were found to be related to patient sexual orientation with a positive predictive value of 85.9%. Documentation of sexual orientation was found for 115,312 patients. When compared with 2,262 patients with a record of administrative coding for homosexuality, the system found mentions of sexual orientation for 1,808 patients (79.9% sensitivity).

CONCLUSIONS

When systemwide structured data are unavailable or inconsistent, deriving a cohort of sexual minority patients in electronic medical records for research is possible and permits longitudinal analysis across multiple clinical domains. Although limitations and challenges to the approach were identified, this study makes an important step forward for the Veterans Health Administration sexual minority research, and the methodology can be applied in other healthcare organizations.

Eating Disorders and Overweight/Obesity in Veterans: Prevalence, Risk Factors, and Treatment Considerations

PURPOSE OF REVIEW

Eating disorders (EDs) and overweight/obesity (OW/OB) have a significant impact on veterans. This review highlights current research on EDs and OW/OB in this population.

RECENT FINDINGS

Prevalence estimates for both EDs and OW/OB among veterans remain consistent with and possibly higher than those in the general population. Both diagnoses share multiple risk factors, including trauma history, and mental health comorbidities. Although weight loss treatments have been fairly well studied among veteran samples, there are no published investigations on psychotherapies for EDs in this population. The Veterans Healthcare Administration is working to train providers in ED treatments. VHA treatments for OW/OB show some benefits and areas for improvement. Areas for future research include structured assessments for EDs and disordered eating behaviors in veterans to clarify prevalence estimates. There is a need for interventions that consider common mechanisms for ED and OW/OB, and there is a need for more research on the associations between different types of trauma and ED/OW/OB in veterans.

Developing an Acceptance-Based Behavioral Weight Loss Treatment for Individuals With Binge Eating Pathology: A Preliminary Proof of Concept Study and Clinical Case Series

Binge eating (BE; i.e., the consumption of a large amount of food in a discrete time period, accompanied by a sense of loss of control) is highly comorbid with overweight or obesity and is the primary symptom of binge eating disorder (BED). Current gold-standard treatment for BED (i.e., CBT) does not produce meaningful weight loss, thus failing to address a critical treatment target. This article describes the development of a novel acceptance-based behavioral treatment (ABBT) for individuals with clinically significant BE desiring to reduce BE symptoms and achieve concurrent weight loss. We discuss the development and structure of the novel treatment approach, and describe the test of a proof of concept version of the treatment in a clinical case series of four individuals. In the context of each clinical case description, we present initial acceptability of the treatment and challenges faced in treatment development and delivery. Finally, we discuss future research directions for the treatment, which could improve BE symptoms and weight loss outcomes for individuals with BE pathology.

"Making weight" during military service is related to binge eating and eating pathology for veterans later in life

PURPOSE

"Making weight" behaviors are unhealthy weight control strategies intended to reduce weight in an effort to meet weight requirements. This study aimed to examine a brief measure of making weight and to investigate the relationship between making weight and weight, binge eating, and eating pathology later in life.

METHODS

Participants were veterans [N = 120, mean age 61.7, mean body mass index (BMI) 38.0, 89.2% male, 74.2% Caucasian] who were overweight/obese and seeking weight management treatment. Participants completed the making weight inventory (MWI), a measure of making weight behaviors engaged in during military service, and validated measures of eating behavior. Analyses compared participants who engaged in at least one making weight behavior (MWI+) versus those who did not (MWI-).

RESULTS

The MWI had good internal consistency. One-third of participants were MWI+ and two-thirds were MWI-. The most frequently reported behavior was excessive exercise, reported in one-quarter of the sample, followed by fasting/skipping meals, sauna/rubber suit, laxatives, diuretics, and vomiting. MWI+ participants were significantly more likely to be in a younger cohort of veterans, to be an ethnic/racial minority, and to engage in current maladaptive eating behaviors, including binge eating, vomiting, emotional eating, food addiction, and night eating, compared to the MWI- group. Groups did not differ on BMI.

CONCLUSIONS

One-third of veterans who were overweight/obese screened positive for engaging in making weight behaviors during military service. Findings provide evidence that efforts to "make weight" are related to binge eating and eating pathology later in life. Future research and clinical efforts should address how to best eliminate unhealthy weight control strategies in military service while also supporting healthy weight management efforts.

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.

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.

Reducing the burden of suffering from eating disorders: Unmet treatment needs, cost of illness, and the quest for cost-effectiveness

Eating disorders are serious mental disorders as reflected in significant impairments in health and psychosocial functioning and excess mortality. Despite the clear evidence of clinical significance and despite availability of evidence-based, effective treatments, research has shown a paradox of elevated health services use and, yet, infrequent treatment specifically targeting the eating disorder (i.e., high unmet treatment need). This review paper summarizes key studies conducted in collaboration with G. Terence Wilson and offers an update of the research literature published since 2011 in three research areas that undergirded our collaborative research project: unmet treatment needs, cost of illness, and cost-effectiveness of treatments. In regards to unmet treatment needs, epidemiological studies find that the number of individuals with an eating disorder who do not receive disorder-specific treatment continues to remain high. Cost-of-illness show that eating disorders are associated with substantial financial burdens for individuals, their family, and society, yet comprehensive examination of costs across public sectors is lacking. Cost measures vary widely, making it difficult to draw firm conclusions. Hospitalization is a major driver of medical costs incurred by individuals with an eating disorder. Only a handful of cost-effectiveness studies have been conducted, leaving policy makers with little information on which to base decisions about allocation of resources to help reduce the burden of suffering attributable to eating disorders.

Direct and indirect costs among patients with binge-eating disorder in the United States

OBJECTIVE

To quantify the economic burden of binge-eating disorder (BED) in terms of work productivity loss, healthcare resource utilization, and healthcare costs.

METHODS

Respondents of the US National Health and Wellness Survey 2013 were invited to participate in a follow-up internet survey to identify adults with BED using DSM-5 criteria. Work productivity loss, healthcare resource utilization, and direct and indirect costs were assessed for BED respondents and matched non-BED respondents using generalized linear models or two-part models as appropriate.

RESULTS

A total of 1,720 people were included in our analysis (N = 344 with BED; N= 1,376 without BED). BED respondents had higher levels of activity impairment than non-BED respondents (41.29% vs. 23.18%, p < .001). Employed BED respondents (N = 178) had a greater level of work impairment than employed non-BED respondents (N = 686) (36.83% vs. 14.41%, p = .009). Higher healthcare resource utilization in the past 6 months among BED respondents was reported than matched non-BED respondents: numbers of surgeries (0.23 vs. 0.13, p = .021), ER visits (0.26 vs. 0.15, p = .016), and physician visits (6.09 vs. 4.56, p = .002). BED respondents reported higher total direct costs than matched non-BED respondents ($20,194 vs. $14,465, p = .005). The indirect costs among employed BED respondents were also higher than those without BED ($19,327 vs. $9,032, p < .001).

DISCUSSION

Individuals with BED reported significantly greater economic burden with respect to work productivity loss, level of healthcare resource utilization, and costs compared to non-BED respondents. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:523-532).

Medical comorbidity of binge eating disorder

PURPOSE

To gain further understanding of the general medical comorbidity of binge eating disorder (BED) beyond its association with obesity.

METHOD

We reviewed studies of general medical comorbidity in people with BED or clinically significant binge eating behavior beyond obesity. We also reviewed studies of BED in specific medical conditions.

RESULTS

Three broad study categories of medical comorbidity in BED were found: cross-sectional studies of medical conditions in BED; prospective studies of medical conditions in BED; and studies of BED in specific medical conditions. Cross-sectional epidemiologic data suggest that BED is associated with medical conditions related to obesity, including diabetes, hypertension, dyslipidemias, sleep problems/disorders, and pain conditions, and that BED may be related to these conditions independent of obesity and co-occurring psychiatric disorders. Prospective data suggest that BED may be associated with type 2 diabetes and metabolic syndrome. BED or binge eating behavior is also associated with asthma and gastrointestinal symptoms and disorders, and among women, menstrual dysfunction, pregnancy complications, intracranial hypertension, and polycystic ovary syndrome.

CONCLUSIONS

BED is associated with substantial medical comorbidity beyond obesity. Further study of the general medical comorbidity of BED and its relationship to obesity and co-occurring psychiatric disorders is greatly needed.

Characteristics and use of treatment modalities of patients with binge-eating disorder in the Department of Veterans Affairs

OBJECTIVE

In 2013 binge-eating disorder (BED) was recognized as a formal diagnosis, but was historically included under the diagnosis code for eating disorder not otherwise specified (EDNOS). This study compared the characteristics and use of treatment modalities in BED patients to those with EDNOS without BED (EDNOS-only) and to matched-patients with no eating disorders (NED).

METHODS

Patients were identified for this study from electronic health records in the Department of Veterans Affairs from 2000 to 2011. Patients with BED were identified using natural language processing and patients with EDNOS-only were identified by ICD-9 code (307.50). First diagnosis defined index date for these groups. NED patients were frequency matched to BED patients up to 4:1, as available, on age, sex, BMI, depression, and index month encounter. Baseline characteristics and use of treatment modalities during the post-index year were compared using t-tests or chi-square tests.

RESULTS

There were 593 BED, 1354 EDNOS-only, and 1895 matched-NED patients identified. Only 68 patients with BED had an EDNOS diagnosis. BED patients were younger (48.7 vs. 49.8years, p=0.04), more were male (72.2% vs. 62.8%, p<0.001) and obese (BMI 40.2 vs. 37.0, p<0.001) than EDNOS-only patients. In the follow-up period fewer BED (68.0%) than EDNOS-only patients (87.6%, p<0.001), but more BED than NED patients (51.9%, p<0.001) used at least one treatment modality.

DISCUSSION

The characteristics of BED patients were different from those with EDNOS-only and NED as was their use of treatment modalities. These differences highlight the need for a separate identifier of BED.