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

Association of body mass index with progression from binge-eating behavior into binge-eating disorder among adolescents in the United States: A prospective analysis of pooled data

The association between body mass index (BMI) and binge-eating disorder (BED) is well-established. However, data on the extent to which BMI is associated with progression from binge-eating behavior into BED among adolescents are limited, which was the aim of this investigation. Participants were 9964 U.S. adolescents from the Adolescent Brain Cognitive Development (ABCD) Study, aged 9-13 at the time of study enrollment. A computerized parent-reported assessment was used to establish adolescents' binge-eating behaviors and BED. Cox proportional hazards models adjusting for sociodemographic covariates were used to examine prospective associations between BMI and likelihood of BED onset among a) adolescents with binge-eating behavior, and b) adolescents with no binge-eating behavior. Of 975 adolescents who met the study criteria for binge-eating behavior, 89 (9.1%) subsequently met the study criteria for BED. Of 8989 adolescents with no binge-eating behavior, 82 (0.9%) subsequently met the study criteria for BED. BMI percentile was significantly associated with the likelihood of BED onset in participants with (adjusted HR = 1.03, 95% confidence interval [CI] 1.00, 1.06) and participants without (adjusted HR = 1.05, 95% CI 1.03, 1.07) binge-eating behavior. Results were also significant when examining BMI as a dichotomous predictor (above and below 85th percentile) among those with (adjusted HR = 2.60, 95% CI 1.00, 6.68) and those without (adjusted HR = 6.01, 95% CI 3.90, 11.10) binge-eating behavior. Overall, results indicate that elevated BMI is prospectively associated with a greater risk for BED onset among U.S. adolescents with or without binge-eating behavior. Adolescents with a higher BMI may benefit from screening for binge eating, and prevention/early intervention strategies to mitigate the risk for developing BED.

Network dynamics of self-compassion, anxiety, and depression during eating disorder therapy

BACKGROUND

Recovery processes during residential treatment for eating disorders, especially in patients with a history of maltreatment, are insufficiently understood. This study aimed to explore the temporal relationships among comorbid factors, including depression, anxiety, and self-compassion, with the influence of childhood maltreatment.

METHOD

Using Dynamic Time Warp (DTW), weekly scores from the Symptom Checklist-5, Eating Disorder Examination, and Self-Compassion Scale were analysed over 12 weeks. The study generated undirected and directed networks to identify influential symptoms in a transdiagnostic sample, comparing patients with and without childhood maltreatment.

RESULTS

The study included 124 patients with eating disorders (ED) (97% women), mean age of 30.9 years (SD = 9.7, range 18-61 years). Diagnoses included anorexia nervosa (26%), bulimia nervosa (38%), and other specified feeding and eating disorders (36%). The directed DTW network showed that hopelessness, worrying, and restlessness had the highest out-strength, predicting changes in self-compassion and ED behaviour. In maltreatment cases, hopelessness and low acceptance predicted changes, while worry, restlessness, and nervousness were predictive in non-maltreatment cases.

CONCLUSION

Temporal network analyses suggest that a change in hopelessness, worrying, and restlessness drives symptom improvement in ED behaviour and the development of self-compassion during residential treatment. These processes vary between patients with and without a history of childhood maltreatment separately, indicating the need for further analyses.

US Military Veteran Perspectives on Eating Disorder Screening, Diagnosis, and Treatment: A Qualitative Study

OBJECTIVE

We aimed to explore US veteran perspectives on eating disorder screening, diagnosis, patient-provider conversations, and care in the Veterans Health Administration (VHA).

METHOD

Rapid qualitative analysis of 30-45 min phone interviews with 16 (N = 16) veterans with an electronic health record ICD-10 eating disorder diagnosis, who received care at one of two VHA healthcare systems in Connecticut or California. Topics covered included: conversations with providers about eating disorder symptoms, diagnosis, and referral to treatment; feedback about an eating disorder screener, and; reflections on eating disorders among veterans and VHA's effort to address them.

RESULTS

Most veterans reported difficulty understanding and defining the problems they were experiencing and self-diagnosed their eating disorder before discussing it with a provider. Treatment referrals were almost universally for being overweight rather than for an eating disorder, often leading veterans to feel misunderstood or marginalized. Overall, veterans were enthusiastic about the screener, preferred screening to be conducted by primary care providers, and noted that conversations needed to be non-stigmatizing. There was consensus that VHA is not doing enough to address this issue, that group support and therapy could be beneficial, and that resources needed to be centralized and accessible.

DISCUSSION

For the most part, veterans felt that, at best, eating disorders and disordered eating are overlooked, and at worst, conflated with overweight. The majority of veterans got referred for weight loss or weight management services but would welcome the opportunity to be screened for, and referred to, eating disorder treatment.

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.

Eating Disorders in Sexual and Gender Minority Adolescents

PURPOSE OF REVIEW

To consolidate recent literature addressing eating disorders and disordered eating behaviors among sexual and gender minority (SGM) adolescents, including but not limited to lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents.

RECENT FINDINGS

Sexual and gender minority adolescents are at heightened vulnerability to eating disorders and disordered eating behaviors compared to their cisgender and heterosexual peers, potentially due to minority stress, gender norms, objectification, and the influence of the media, peers, and parents. We report findings from recent literature on the epidemiology and prevalence, assessment, mental health comorbidity, quality of life and psychosocial functioning, risk and protective factors, and treatment and interventions for eating disorders in sexual and gender minority adolescents. Addressing eating disorders in sexual and gender minority adolescents requires an integrated approach consisting of screening, tailored treatment, and comprehensive support to address intersectional challenges. Gender-affirming and trauma-informed care approaches may be considered.

Attachment style to body dissatisfaction, restrained eating, and disordered eating in adolescent girls: Differential weight communication mediators

Body dissatisfaction and eating behaviors are disproportionately elevated amongst adolescent girls. Family relationships represent a context in which adolescent girls' body image issues emerge. Thus, we integrated attachment and confirmation theories to examine whether weight related supportive messages (i.e., acceptance and challenge) mediated the relationship between attachment style (i.e., anxiety and avoidance) and body image outcomes (i.e., body dissatisfaction (BD), restrained eating (RE), and disordered eating (DE)). Acceptance refers to weight related support that is characterized by warmth and accepting messages; challenge refers to weight related support that is characterized by instrumental assistance and problem-solving messages. A sample of 106 adolescent girls, ages 11 to 21, completed self-report measures on attachment (Relationship Structures Questionnaire), acceptance and challenge (weight related Parental Behavior Questionnaire), body dissatisfaction (Eating Disorders Inventory), and eating behaviors (Dutch Eating Behavior Questionnaire; Eating Disorder Diagnostic Scale). Attachment anxiety directly related to all body image outcomes, whereas attachment avoidance only directly related to RE. Attachment avoidance only related to BD and DE indirectly through perceived acceptance. Those with high anxiety endorsed lower perceived challenge, whereas avoidant individuals endorsed lower perceived acceptance and challenge. We concluded that attachment dimension characteristics to be either hyperactivated regarding relationships (i.e., anxiety), or deactivated and distant (i.e., avoidance), are associated with how individuals perceive support, and in turn, are related to body image and eating behavior outcomes. Further, we clarify the differential roles of acceptance and challenge. Although both supportive, acceptance encompasses a layer of warmth that is more meaningful in body image, particularly for avoidantly attached individuals. By integrating qualities of attachment and supportive weight communication, we reveal that potential pathways of attachment to body image and eating behaviors.

Sociodemographic correlates of parent and youth-reported eating disorder symptoms in the Adolescent Brain Cognitive Development Study

Purpose

Eating Disorders (EDs) often start in adolescence, though ED-related concerns in diverse youth samples remain understudied. We leveraged data from the Adolescent Brain Cognitive Development (ABCD) Study to identify the prevalence of parent- and youth-reported ED symptoms and their sociodemographic characteristics.

Methods

Data were drawn from baseline (ages 9-11 years, n=11,868) and 2-year follow-up (ages 11-14 years; n=10,908) from the ABCD Study. A tetrachoric factor analysis summarized clusters of ED symptoms, which were compared between parent and youth reports and across sociodemographic variables.

Results

Three factors emerged reflecting "weight distress", "weight control", and "binge eating" (prevalence range: 1.5-7.3%). Symptoms loaded onto similar factors between reporters. Rates of symptom endorsement were similar between sexes, with disproportionately higher endorsement rates for youth who self-identified as sexual minority, Hispanic, Black, or Mixed race participants, and those from a disadvantaged socioeconomic background, compared to the reference ABCD sample. Youth and parent reports at 2-year showed ~12% overlap.

Conclusions

ED-related concerns among historically understudied racial and sexual minority groups call for greater attention to the detection and treatment of these symptoms in these groups. Applying a transdiagnostic approach to ED symptoms can inform effective detection and intervention efforts.

Co-occurring psychiatric disorders in young people with eating disorders: An multi-state and real-time analysis of real-world administrative data

OBJECTIVE

We aimed to use real-world data to characterize the burden of psychiatric comorbidities in young people with eating disorders (EDs) relative to peers without EDs.

METHOD

This retrospective cohort study used a large federated multi-national network of real-time electronic health records. Our cohort consisted of 124,575 people (14,524 people receiving their index, first-ever, ED diagnosis, compared to 110,051 peers without EDs initiating antidepressants). After 1:1 propensity score matching of the two cohorts by pre-existing demographic and clinical characteristics, we used multivariable logistic regression to compute the adjusted odds ratio (aOR) of psychiatric diagnoses arising in the year following the index event (either first ED diagnosis or first antidepressant script).

RESULTS

Over 50% of people with EDs had prior psychiatric diagnoses in the year preceding the index EDs diagnosis, with mood disorders, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), specific phobia (SP), attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD) being the most common. Adjusted analyses showed higher odds for mood disorders (aOR = 1.20 [95% CI = 1.14-1.26]), GAD (aOR = 1.28 [1.21-1.35]), PTSD (aOR = 1.29 [1.18-1.40]), and SP (aOR = 1.45 [1.31-1.60]) in the EDs cohort compared to antidepressant-initiating peers without EDs, although rates of ADHD and ASD were similar in both cohorts.

CONCLUSION

This large-scale real-time analysis of administrative data illustrates a high burden of co-occurring psychiatric disorders in people with EDs.

Subclinical patterns of disordered eating behaviors in the daily life of adolescents and young adults from the general population

BACKGROUND

Disordered eating behaviors (DEBs), a risk factor for the development of eating disorders (EDs), are prevalent in young people and different DEBs frequently co-occur. Previous studies on DEB-patterns have largely used traditional retrospective questionnaires to assess DEBs. In addition, most previous studies did not specifically exclude individuals with clinical EDs, which limits current knowledge concerning purely subclinical patterns of DEBs. In the present study, we aimed to explore phenotypes and group sizes of subclinical patterns of DEBs reported in everyday life via smartphone-based ecological momentary assessment (EMA) in adolescents and young adults from the general population without lifetime EDs. In secondary analyses, we further aimed to investigate whether DEB-patterns would be associated with additional previously identified risk factors for ED-development.

METHODS

EMA was conducted in a community sample of 14-21-year-olds from Dresden, Germany, over four days for up to eight times a day and covered engagement in four DEBs: skipping eating, restrained eating, eating large amounts of food, and loss-of-control eating. Data were analyzed from N = 966 individuals without lifetime EDs with an EMA compliance rate of at least 50% (81.9% of the total sample; average compliance: 84.6%). Latent profile analyses were performed to identify subclinical patterns of DEBs, stratified by sex. Associations between symptomatic profiles and ED-risk factors were tested via regression analyses.

RESULTS

Based on theoretical deliberations, statistical indices, interpretability, and parsimony, a three-profile solution, namely no DEBs, high-mixed DEBs, and low-mixed DEBs, was selected for both sexes. Both symptomatic profiles in both sexes were associated with more unfavorable manifestations in additional ED risk factors compared to the no DEBs profile, with the highest number of associations being observed in the female high-mixed profile.

CONCLUSIONS

The present findings suggest that problematic manifestations of DEBs in young people may occur even in the absence of an ED diagnosis and that they are associated with additional risk factors for EDs, warranting increased efforts in targeted prevention, early identification and intervention in order to counteract symptom progression.

Treatment of Binge-Eating Disorder Across the Lifespan: An Updated Review of the Literature and Considerations for Future Research

PURPOSE OF REVIEW

The present review describes the recent literature on treatment for binge-eating disorder (BED) in adults and youth, with a particular focus on research gaps, emerging treatments, and future research directions.

RECENT FINDINGS

Evidence supports the efficacy of several treatment modalities in adults, including self-help treatment, clinician-led psychotherapy, and pharmacotherapy; the largest effect sizes have been found for psychotherapies, most of which were cognitive-behavioral in orientation. Adapted psychotherapies for youth also show promise but lack a robust body of evidence. Predictors, moderators, and mediators of treatment outcome remain poorly understood; individuals with BED continue to experience significant barriers to treatment; and research is needed to address suboptimal treatment response. Recent work has highlighted the potential of adaptive interventions and investigation of novel mechanisms to address these gaps. Research on BED treatment continues to grow, though critical questions must be answered to improve treatment efficacy across the lifespan.

Care pathways for longstanding eating disorders must offer paths to recovery, not managed decline

Eating disorders are historically underserved in healthcare, but are increasingly prevalent and recognised for their high costs regarding mortality, quality of life and the economy. Those with longstanding eating disorders are commonly labelled 'severe and enduring' (SEED), which has been challenged for its conceptual vagueness and potential to discourage patients. Attempts to define individuals from this cohort as having 'terminal' illness have also gained traction in recent years. This paper is grounded in lived/living experience and relevant research. It challenges the logical coherence and utility of SEED, arguing that the word 'enduring' unhelpfully situates intractability of longstanding illness within patients themselves and the nature of their illness. This risks a sense of inevitability and overlooks the important role of contextual factors such as lacking resources and insufficient evidence for withholding active treatment. Recommendations suggest approaches to dismantling unhelpful binaries between early intervention and intensive support, recovery and decline.

Preliminary evaluation of a brief worksite intervention to reduce weight stigma and weight bias internalization

Weight-based discrimination (WBD) is common and associated with reduced physical and emotional functioning. WBD is common in the workplace, yet no studies have evaluated a WBD intervention delivered in a worksite setting. This study evaluated the feasibility, acceptability, and preliminary effectiveness of a 3-hour, remote-delivered WBD intervention at a large public university. Six workshops including 94 participants (41.76 ± 9.37 y; 92.8% women) were delivered December 2020 through May 2021; 88.3% of participants enrolled in the study and 88.8% of enrolled participants completed pre- and post-intervention surveys. Participants strongly agreed the workshop contributed to a more inclusive work environment (M=4.98 ± 0.2; 1 =Strongly Disagree to 5 =Strongly Agree); and was highly needed (4.9 ± 0.3) and liked (4.8 ± 0.5). Qualitative feedback cited benefits of remote delivery in providing body size anonymity and wanting access to intervention materials and more time for discussion and action steps to reduce WBD. Participants experienced significant, medium reductions in explicit weight bias (ps < .001), significant, small reductions in weight bias internalization (p < .001), and statistically non-significant (p = .08), small-to-medium reductions in implicit bias. Targeting worksites as a delivery mechanism has the potential to reduce WBD, thereby improving the health and well-being of diverse employees and creating a more inclusive workspace.

ERP correlates of self-referential processing moderate the association between pubertal status and disordered eating in preadolescence

Preadolescence is a critical period for the onset of puberty and eating-related psychopathology. More advanced pubertal status is associated with elevated eating pathology. However, it was unclear whether this association was moderated by self-referential processing, an important, modifiable cognitive risk for various forms of psychopathology, including eating problems. Further, no study has examined the neural correlates of self-referential processing in relation to eating pathology. To address these gaps, we examined how the association between pubertal status and disordered eating was moderated by self-referential processing in a community sample of 115 nine-to-12-year-old preadolescents (66 girls; mean age/SD = 10.98/1.18 years; 87.5% White). Youths reported their pubertal status and disordered eating behaviors and completed an ERP version of the Self-Referent Encoding Task (SRET) to assess self-referential processing. A Principal Component Analysis of the ERP data identified an anterior late positive potential (LPP) in both the positive and negative SRET conditions. The LPP in the positive condition moderated the positive association between pubertal status and disordered eating behaviors, such that this association was significant for youths with a smaller LPP toward positive self-referential cues, but non-significant for those showing a larger LPP toward positive self-referential cues. These results suggest that a deeper processing of positive self-referential information, indicated by a potentiated LPP, may weaken the negative impact of pubertal status on disordered eating. Our findings also suggest that enhancing positive self-referential processing may be a useful tool in preventing the development of eating pathology in preadolescents, especially for those with more advanced pubertal status.

Are you how you eat? Aspects of self-awareness in eating disorders

Eating disorders (ED) are severe psychiatric disorders characterized by dysfunctional behaviors related to eating or weight control, with profound impacts on health, quality of life, and the financial burden of affected individuals and society at large. Given that these disorders involve disturbances in self-perception, it is crucial to comprehend the role of self-awareness in their prevalence and maintenance. This literature review presents different self-awareness processes, discussing their functioning across different levels of complexity. By deconstructing this concept, we can gain a better understanding of how each facet of self and personality relates to the symptoms of these disorders. Understanding the absence or impairment of self-awareness in ED holds significant implications for diagnosis, treatment, and overall management. By recognizing and comprehending the characteristics of self-awareness, clinicians can develop tailored interventions and evidence-based treatments for individuals with ED. Furthermore, this narrative review underscores the importance of considering temperament and personality factors in the context of ED, as temperament traits and personality characteristics may interact with self-awareness processes, influencing the development and maintenance of ED. Ultimately, the results highlight the pressing need for further research on the development of effective interventions and support strategies grounded in the aspects of self-awareness mechanisms for individuals affected by these disorders.

Perceptual Dysfunction in Eating Disorders

Eating disorders (EDs) are characterized by abnormal responses to food and weight-related stimuli and are associated with significant distress, impairment, and poor outcomes. Because many of the cardinal symptoms of EDs involve disturbances in perception of one's body or abnormal affective or cognitive reactions to food intake and how that affects one's size, there has been longstanding interest in characterizing alterations in sensory perception among differing ED diagnostic groups. Within the current review, we aimed to critically assess the existing research on exteroceptive and interoceptive perception and how sensory perception may influence ED behavior. Overall, existing research is most consistent regarding alterations in taste, visual, tactile, and gastric-specific interoceptive processing in EDs, with emerging work indicating elevated respiratory and cardiovascular sensitivity. However, this work is far from conclusive, with most studies unable to speak to the precise etiology of observed perceptual differences in these domains and disentangle these effects from affective and cognitive processes observed within EDs. Further, existing knowledge regarding perceptual disturbances in EDs is limited by heterogeneity in methodology, lack of multimodal assessment protocols, and inconsistent attention to different ED diagnoses. We propose several new avenues for improving neurobiology-informed research on sensory processing to generate actionable knowledge that can inform the development of innovative interventions for these serious disorders.

Individual differences in motivation to change in individuals with eating disorders: A systematic review

OBJECTIVE

Motivation to change has been suggested to significantly impact treatment outcomes in eating disorders (EDs). This review will investigate factors associated with motivation to change in EDs with the aim of supporting clinicians to be aware and sensitive to factors that might obstruct recovery and to inform motivation-based interventions.

METHOD

Using PRISMA guidelines, this article identified 24 studies through database searches meeting eligibility criteria. Only correlates of motivation were identified, limiting the ability of this review to identify causal relationships. Factors that changed alongside changes in motivation were identified from longitudinal studies.

RESULTS

This review identified factors such as individual characteristics, co-morbid psychopathology, lack of treatment autonomy and relationships with others to be associated with motivation to change in individuals with EDs. In addition, motivation to change significantly increased alongside self-esteem and identity re-negotiation when measured longitudinally.

DISCUSSION

Motivational interviewing can typically focus on exploring ambivalence to treatment, identifying goals and values, and increasing self-efficacy. However, this review identifies individual and relational factors to be particularly significant and may obstruct recovery from an ED. As such, evidence-based targets have been identified to inform clinicians and motivation-based interventions.

PUBLIC SIGNIFICANCE

Knowledge of factors associated with motivation to change in EDs is important to understand those who may have poorer treatment outcomes. Motivation may be improved by supporting individuals' relationship with others and tailoring interventions according to temperament and personality traits. Utilizing an individual's social support as they enter ED treatment may be effective in maximizing motivation to recover.

The United Kingdom Eating Disorders Genetics Initiative

OBJECTIVE

The United Kingdom Eating Disorders Genetics Initiative (EDGI UK), part of the National Institute for Health and Care Research (NIHR) Mental Health BioResource, aims to deepen our understanding of the environmental and genetic etiology of eating disorders. EDGI UK launched in February 2020 and is partnered with the UK eating disorders charity, Beat. Multiple EDGI branches exist worldwide. This article serves the dual function of providing an in-depth description of our study protocol and of describing our initial sample including demographics, diagnoses, and physical and psychiatric comorbidities.

METHOD

EDGI UK recruits via media and clinical services. Anyone living in England, at least 16 years old, with a lifetime probable or clinical eating disorder is eligible to sign up online: edgiuk.org. Participants complete online questionnaires, donate a saliva sample for genetic analysis, and consent to medical record linkage and recontact for future studies.

RESULTS

As of September 2022, EDGI UK recruited 7435 survey participants: 98% female, 93.1% white, 97.8% cisgender, 65.9% heterosexual, and 52.1% have a university degree. Over half (57.8%) of these participants have returned their saliva DNA kit. The most common diagnoses are anorexia nervosa (48.3%), purging disorder (37.8%), bulimia nervosa (37.5%), binge-eating disorder (15.8%), and atypical anorexia nervosa (7.8%).

CONCLUSION

EDGI UK is the largest UK eating disorders study and efforts to increase its diversity are underway. It offers a unique opportunity to accelerate eating disorder research. Researchers and participants with lived experience can collaborate on projects with unparalleled sample size.

PUBLIC SIGNIFICANCE STATEMENT

Eating disorders are debilitating and costly for society but are under-researched due to underfunding. EDGI UK is one of the largest eating disorder studies worldwide with ongoing recruitment. The collected data constitute a resource for secondary analysis. We will combine data from all international EDGI branches and the NIHR BioResource to facilitate research that improves our understanding of eating disorders and their comorbidities.

LGBTQ+ outpatients present to eating disorder treatment earlier and with more severe depressive symptoms than cisgender heterosexual peers

Community evidence indicates high eating disorder (ED) and comorbid symptom severity among LGBTQ+ compared to cisgender heterosexual (CH) individuals. Little is known about such disparities in ED treatment samples, especially in outpatient treatment. We aimed to descriptively characterize and investigate baseline group differences in symptom severity between LGBTQ+ and CH ED outpatients at treatment intake. Data from 60 (22.3%) LGBTQ+ and 209 (77.7%) CH ED outpatients were used to examine: (1) demographic and diagnostic differences; (2) differences in ED, depressive, and emotion dysregulation symptoms. Objectives were tested using Fisher-Freeman-Halton exact and independent samples t-tests, and analyses of covariance adjusted for age and diagnosis, respectively. Most LGBTQ+ outpatients were bisexual (55.2%), and 6.5% identified as transgender and non-binary. LGBTQ+ outpatients presented to treatment at younger ages (Mean Difference [MD] = -3.39, p = .016) and reported more severe depressive symptoms (MD = 5.73, p = .004) than CH patients, but endorsed similar ED symptom and emotion dysregulation severity. Groups did not differ in other demographic or diagnostic characteristics. LGBTQ+ individuals may develop more severe depression and similarly severe EDs at earlier ages but seek outpatient care sooner than CH peers. Managing depressive symptoms may be particularly important for LGBTQ+ ED patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Bibliometric Analysis of Scientific Publications on Eating Disorder Prevention in the Past Three Decades

BACKGROUND

Eating disorders (EDs) present a growing concern due to their widespread occurrence and chronic course, the low access to evidence-based treatment, and the significant burden they place on the patients and society. This picture justifies intensive focus on the prevention of EDs. The current study provides the first bibliometric analysis of research on the prevention of EDs, focusing on trends and contributions, to prompt further prevention research.

METHODS

We conducted a bibliometric analysis of publications on the prevention of EDs using the Web of Science database, from 1993 to 2023. Focusing on universal and selective prevention strategies, our study involved a rigorous selection process, narrowing down from 10,546 to 383 relevant papers through manual screening. The analysis utilized the "bibliometrix" R package (version 4.2.2) and Python (version 3.9.6) for data processing, with VOSviewer employed for mapping collaboration networks.

RESULTS

Our analysis revealed a consistent annual growth rate of 10.85% in ED prevention research publications, with significant contributions from the "International Journal of Eating Disorders" and some notable authors. The United States emerged as the dominant contributor. The analysis also highlighted key trends, including a surge in publications between 2010 and 2017, and the role of major institutions in advancing research in this field.

DISCUSSION

The increasing rate of publications on the prevention of EDs is encouraging. However, the actual number of studies on the prevention of EDs are limited, and the majority of this work is performed by a few research groups. Given the high concentration of publications within a few countries and research groups, increased funding, facilitation of prevention research on a wider scale, and engagement of more researchers and further collaboration are called for.

A cultural models approach to understanding body fatness perceptions and disordered eating in young South Korean men

OBJECTIVE

The eating disorders field has been limited by a predominant focus on White, Western women, and there is growing recognition of the need to understand cross-cultural variation in key constructs (i.e., ideal body types). A transdisciplinary, cultural models approach systematizes the incorporation of an "emic" perspective (a culture's own understandings of phenomena) into assessments of relationships between body shapes and eating disorders.

METHOD

Eighty-one young South Korean men aged 19-34 years living in Seoul participated in this research. A cultural model of body fatness was identified using cultural consensus analysis during 18 months of ethnographic, mixed-methods fieldwork. Participants also completed questionnaires assessing age, height, weight, sexual identity, university prestige, body dissatisfaction, eating disorder symptoms, and cultural consonance with the Korean cultural model of the ideal male body. Variation in these factors was analyzed using a series of chi-squares and analyses of variance with the culturally defined categories of body fatness as the independent variables.

RESULTS

Cultural consensus analysis found that young South Korean men are consistent in identifying categories of "too thin," "balanced," and "too fat." The "balanced" category contained the lowest proportion of high-prestige university attendees and the highest average cultural consonance. The "too fat" category was characterized by the highest levels of body dissatisfaction and dieting, as well as proportion of probable eating disorders.

DISCUSSION

A cultural models approach identified culturally important factors and patterns in disordered eating among young South Korean men and may be effective for understanding eating disorders in other populations not typically studied.

PUBLIC SIGNIFICANCE

This study applies a systematic, "emic" perspective to young South Korean men's body ideals. Young Korean men share a cultural model of body fatness, and this model frames how they experience risk for eating disorders. This study demonstrates a method for incorporating culture into research on eating disorder risk.

Restrained eating and alcohol use: Testing drinking to cope and impulsivity as moderators

The association between restrained eating and alcohol use remains poorly understood among undergraduates. Consistent with tension reduction theory, individuals with disordered eating may be motivated to drink alcohol to cope with negative emotionality. Perhaps what pushes them to drink despite restriction goals is impulsivity. The combined impact of drinking to cope and impulsivity on the theoretically complex link between restrained eating and alcohol outcomes has not been previously examined. The current study tested the moderating effect of drinking to cope and impulsivity on the association between restrained eating and alcohol use and problems. Undergraduates (N = 1,619) self-reported on eating disorder symptoms, alcohol use motives, impulsivity, and alcohol outcomes. A moderation model revealed that restrained eating predicted past 30-day alcohol use, but only for women high in both drinking to cope and impulsivity. These findings help characterize alcohol misuse risk among young adults who restrict their eating, thereby, results may inform interventions.

Cross-sectional and longitudinal associations between higher weight and eating disorder risk among collegiate athletes

OBJECTIVES

To examine whether higher weight status is associated with increased eating disorder risk in athletes.

DESIGN

Study 1 used cross-sectional (N = 942) and longitudinal (N = 483) data collected over a five-year period from Division I athletes at a Midwestern university. Study 2 used cross-sectional data from athletes competing at various levels at universities across the United States (N = 825).

METHODS

Weight and height were measured in Study 1 and self-reported in Study 2; higher weight was defined as body mass index ≥ 25 kg/m2. Eating disorder risk was assessed with preliminary (Study 1) and final (Study 2) versions of the Eating Disorders Screen for Athletes. Study 1 examined weight status in relation to both concurrent and one-year changes in Eating Disorder Screen for Athletes score. Study 2 examined weight status in relation to both the Eating Disorders Screen for Athletes score and elevated eating disorder risk using the established Eating Disorders Screen for Athletes cut-off. All models adjusted for gender and sport type; Study 2 additionally adjusted for race/ethnicity, age, and competition level.

RESULTS

Across studies, higher weight status was significantly associated with increased eating disorder risk among athletes. This association was observed both cross-sectionally and longitudinally, and the prevelence of elevated eating disorder risk was 43 % greater among athletes with higher weight status than among those without higher weight status.

CONCLUSIONS

Despite existing stereotypes that eating disorders tend to occur with low weight status, findings highlight the importance of screening all athletes for eating disorders, regardless of their weight status.

Parental perceptions of participation in young adult-focused eating disorder treatment

BACKGROUND

Eating disorders (ED) are serious mental illnesses affecting young adults (YA). Parent-supported treatment for this age cohort is an important consideration given the unique developmental needs and norms of familial social support, but more research is needed to understand parental perceptions of treatment involvement.

METHODS

33 parent-supports of YA with ED completed self-report assessments at admission and discharge of participation in brief, intensive, young-adult focused eating disorder treatment. Assessments measured programme satisfaction, parental self-efficacy, and parent and YA report of eating disorder-related psychopathology. Repeated measures ANOVAs were used to examine pre-post outcome differences and between group differences among parent-supports and their YA (i.e., the patients) on eating disorder psychopathology, clinical impairment, and family functioning using the EDEQ/P-EDEQ Global, P-CIA/CIA, and Family Assessment Device Family Functioning scales. Group differences across time points were examined with paired sample t-tests adjusted for multiple comparisons. Changes in parental self-efficacy were examined separately using two-tailed paired sample t-tests.

RESULTS

Parents reported high acceptability and learning, improvements in self-efficacy, and significant reductions of YA psychopathology at post-treatment. Parents reported comparable reductions in ED psychopathology post-treatment, but significantly greater reductions in clinical impairment compared to YA. Measures of family functioning did not improve for either parent or YA at post-treatment.

CONCLUSION

Results from this study suggest that parental involvement in a YA programme is feasible and acceptable from a parental perspective and improves parental self-efficacy.

Association between body composition standards and eating disorder medical claims among active-duty service women

INTRODUCTION

Eating disorders are a worldwide public health concern with the United States having a particularly high prevalence. Eating disorders are of particular concern to the Department of Defense and Military Health System (MHS) because body composition standards are in place for active-duty service members.

METHODS

We conducted a cross-sectional study of active-duty service women (ADSW) ages 18 and older in the U.S. Army, Air Force, Navy, and Marine Corps during fiscal years (FY) 2018-2019. Utilizing claims data from the MHS Data Repository (MDR), we identified ADSW with a Body Mass Index (BMI) measure during the study period and compared their BMI to Service-specific requirements and diagnosis of an eating disorder.

RESULTS

We identified a total of 161,209 ADSW from the MDR in FYs 2018-2019 with a recorded BMI, of whom 61,711 (38.3%) had a BMI exceeding the maximum BMI Service-specific standards during the study period and 0.5% had an eating disorder diagnosis. Increased risk of an eating disorder was found in ADSW with an Underweight BMI. Further, we found that there was no association of disordered eating diagnoses among ADSW who were near the maximum height/weight standard set by their Service.

CONCLUSION

There appears to be no association between body composition standards of the Services and eating disorder diagnoses in ADSW. We were not able to investigate unhealthy habits around diet or exercise directly related to body composition standards.

Economic evidence for prevention and treatment of eating disorders: An updated systematic review

OBJECTIVE

This systematic review updates an existing review examining the cost-effectiveness of interventions to prevent and treat eating disorders (EDs).

METHOD

Literature search was conducted in Academic Search Complete, MEDLINE, CINAHL, PsycINFO, EconLit, Global Health, ERIC, Health Business Elite, and Health Policy Reference Center electronic databases, capturing studies published between March 2017 to April 2023. Hand-searching was conducted as supplementary including gray literature search. Included articles were (1) full economic evaluations or return-on-investment studies, (2) in English and (3) aimed at prevention and treatment of any ED. Included studies were added and synthesized with previously reviewed studies. Screening and extraction followed PRISMA guidelines. Quality assessment was conducted using the Drummond checklist. PROSPERO registration CRD42021287464.

RESULTS

A total of 28 studies were identified, including 15 published after the previous review. There were nine prevention, seven anorexia nervosa (AN) treatment, five bulimia nervosa (BN) treatment, four binge-eating disorder (BED), and three non-specific ED treatment studies. Findings indicate value-for-money evidence supporting all interventions. Quality assessment showed studies were fair-to-good quality.

DISCUSSION

There has been significant growth in cost-effectiveness studies over the last 5 years. Findings suggest that interventions to prevent and treat ED offer value for money. Interventions such as Featback (ED prevention and non-specific ED treatment); focal psychodynamic therapy, enhanced cognitive behavioral therapy, and high-calorie refeeding (AN treatment); stepped-care with assisted self-help and internet-based cognitive behavioral therapy (BN treatment); and cognitive behavioral therapy guided self-help intervention (BED treatment) have good quality economic evidence. Further research in implementation of interventions is required.

PUBLIC SIGNIFICANCE STATEMENT

The increasing prevalence of ED globally has significant impact on healthcare systems, families, and society. This review is showcasing the value for money of interventions of eating disorders prevention and treatment. This review found that existing interventions offers positive economic benefit for the healthcare system.

Impact of the COVID-19 pandemic on care for anorexia and bulimia nervosa in US military-connected adolescents and young adults

OBJECTIVE

This study examined the impact of the COVID-19 pandemic on healthcare engagement for anorexia nervosa (AN) and bulimia nervosa (BN) in a large, geographically diverse population.

METHOD

This repeated monthly, cross-sectional study queried Military Health System records of individuals aged 10-21 before and during the pandemic (February 2019-January 2022). ICD-10 codes identified encounters for AN and BN. Monthly rates of care were modeled as the number of unique individuals with an ICD-10-identified eating disorder-related encounter per month divided by the enrolled population. Poisson regression analysis evaluated rates of care stratified by eating disorder, clinical setting, and sex.

RESULTS

In a population of 1.76 million adolescents and young adults, 1629 individuals with AN or BN received care during the pre-pandemic period; 3256 received care during the pandemic. The monthly rate of care for females with AN during the pandemic increased in inpatient settings (adjusted relative risk [aRR]: 1.31 [1.16-1.49]) and outpatient settings (aRR: 1.42 [1.37-1.47]); monthly care rates in males with AN increased in the outpatient setting (aRR: 1.46 [1.28-1.67]). Females with BN had increased engagement in outpatient settings (aRR: 1.09 [1.03-1.16]); BN care for males showed no significant monthly changes during the pandemic period in either healthcare setting.

DISCUSSION

With increased rates of AN and BN disorder-related care during the pandemic, screening for eating disorder symptomatology may allow for timely diagnosis and intervention in periods of heightened stress. Pandemic-related increases in healthcare engagement may strain limited resources, emphasizing a need to expand accessibility of clinical expertise.

PUBLIC SIGNIFICANCE

This study indicates that monthly rates of healthcare engagement during the COVID-19 pandemic for AN and BN varied based on clinical setting and sex in an adolescent and young adult population. The increased number of individuals seeking eating disorder-related care, especially outpatient care, attributed to heightened stressors necessitates accessible professionals with eating disorder clinical expertise.

Societal costs of personality disorders among treatment-seeking patients in Norway: the relative contribution of specific DSM-5 categories

Personality disorders (PDs) are associated with high levels of societal costs, regardless of whether a single PD or a broad range of PDs have been studied. However, research on the relative contribution of specific PD-types on societal costs is limited. The aim of this study was to explore the possible contributions of the individual DSM-5 categories of PDs on the level of societal costs and its components (health service costs and productivity loss), while controlling for the impact of comorbid mental health and substance use disorders on these outcomes. Participants (n = 798) were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD-treatment units within specialist mental health services. The patients were referred to treatment in the time-period 2017-2020. Costs were assessed using a structured interview covering the 6-month period prior to assessment. Diagnoses were determined by semi-structured diagnostic interviews (SCID-5-PD and M.I.N.I.). Statistics included multiple regression analyses. The main result was that no specific PD had a unique contribution to the high level of societal costs generally found among treatment-seeking patients with PDs. Borderline PD (BPD) was the only PD with significantly higher health service costs than the other PDs, while BPD, avoidant PD, and unspecified PD were independently associated with enhanced productivity loss. The differential cost-effects of specific PDs on the cost components were small. Several comorbid mental health and substance use disorders were significant contributors to costs, irrespective of PD status. The results underscore the importance of developing and implementing effective treatments for a broader range of PDs, to reduce the high levels of societal costs associated with all PDs.

Investigating the Validity of the MMPI-3 Eating Concerns (EAT) scale across Men and Women in a University Sample

Disordered eating is a major health epidemic that occurs at disproportionate rates among young adults and for which gender plays a major role in symptom presentation. Broadband psychological instruments have historically not included disordered eating as a core scale construct. The recent release of the Minnesota Multiphasic Personality Inventory-3 (MMPI-3) offers an opportunity to address this shortcoming through the newly developed Eating Concerns Scale (EAT) for which the existing literature is promising but limited. This study expands research on EAT by investigating its validity and comparing findings across gender. In 345 college students (102 men, 243 women), we examined gender differences between men and women in the EAT scale's structure, item endorsement rates, mean scores, and correlations with measures of body image and eating pathology. Differences emerged in item endorsement rate, scale score elevation rate, and correlation magnitudes. Broadly, findings further support EAT's use in detecting eating pathology and highlight ways in which the EAT scale may not effectively capture masculine expressions of eating pathology, namely binging and purging behaviors. To assess eating pathology more comprehensively, clinicians and researchers should consider including assessments of eating pathology inclusive of masculine eating patterns. Limitations and future research directions are also discussed.

[Peculiarities of the dynamics of eating disorders in the structure of depressive states]

OBJECTIVE

To determine the main trajectories of the association between eating disorders (ED) and depressive symptoms and their impact on the quality of the prognosis of the disease as a whole.

MATERIAL AND METHODS

A total sample included 59 female patients, aged 15 to 25 years (average age 16.2+0.9), who were under outpatient and inpatient observation in the department for the study of endogenous mental disorders and affective states in the clinic at the Mental Health Research Center.

RESULTS

The authors identified variants of the main trajectories of the association between ED and depression, taking into account the role and place of ED and interdependence with depressive symptoms. The following variants have been established: with a stable (44.0%, n=26), labile type of dynamics (25.0%, n=19) and dynamics according to the type of selective dissociation (22.4%, n=14).

CONCLUSION

The study allows us to assume the development of fundamentally different trajectories of the conjugation of eating behavior and depression, showing prognostic capacity and different tropism for therapeutic interventions.

Gender similarities and differences in associations between weight discrimination, shape/weight concerns, and eating disorder symptoms among post-9/11 veterans

OBJECTIVE

Weight discrimination, defined as mistreatment of people based on body weight, is associated with body image concerns and eating disorder (ED) symptoms. Military veterans are particularly vulnerable to developing ED symptoms, which may be due to experiences of weight discrimination resulting from the military's strict weight and fitness requirements. However, no previous study has examined these associations among veterans. We investigated relationships between weight discrimination during and after military service and shape/weight concerns and ED symptoms in post-9/11 veterans. Based on evidence for gender differences in weight discrimination, body image, and ED symptoms, we also examined whether gender moderated these associations.

METHOD

Participants were randomly selected from the population of post-9/11 U.S. veterans who had been discharged from the military within the previous 18 months. A total of 1494 veterans completed the Everyday Discrimination Scale, Eating Disorders Examination-Questionnaire, and the Eating Disorder Diagnostic Scale-5.

RESULT

Women were more likely to report weight discrimination and had higher levels of ED symptoms and shape/weight concerns than men. Weight discrimination in and after leaving the military were positively associated with shape/weight concerns and ED symptoms in the full sample and among men and women. Gender moderated the association between weight discrimination after leaving the military and shape/weight concerns such that the association was stronger among men.

DISCUSSION

Both male and female veterans may be vulnerable to developing ED symptoms, in part due to weight discrimination experienced during and after military service. Our findings emphasize the need to address weight discrimination and its consequences in veterans.

Oxidative stress and inflammatory pathways in female eating disorders and borderline personality disorders with emotional dysregulation as linking factors with impulsivity and trauma

BACKGROUND

Borderline personality disorder (BPD) and eating disorders (ED) are both disorders with emotional dysregulation that may share some similar biological underpinnings, leading to oxidative/inflammatory alterations. Unfortunately, to date, no studies have assessed the relationship between clinical features, inflammatory alterations and childhood trauma across these disorders. Our aim was to identify the potential common and disorder-specific inflammatory pathways and examine possible associations between these dysregulated pathways and the clinical features.

METHODS

We studied a sample of 108 women (m = 27.17 years; sd = 7.64), divided into four groups: 23 patients with a restrictive ED (ED-R), 23 patients with a bingeeating/ purging ED (ED-P) and 26 patients with BPD; whereas the control group included 23 healthy subjects. Several inflammatory/oxidative parameters: tumor necrosis factor alpha (TNFα), Thiobarbituric Acid Reactive Substances (TBARS), inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX2), p38 mitogenactivated protein kinases, ERK mitogen-activated protein kinases and c-Jun NH2- terminal kinase (JNK), and some antiinflammatory antioxidant elements: glutathione peroxidase (GPx), superoxide dismutase (SOD), catalase (CAT), Kelch-like ECHassociated protein (Keap1) were determined in plasma or peripheral blood mononuclear cells. Furthermore, clinical, impulsivity, trauma and eating behavior questionnaires were administered.

RESULTS

Three main inflammatory/oxidative components were extracted using principal component analysis (59.19 % of biomarker variance explained). Disorder-specific dysfunction in the inflammatory and oxidative pathways in patients with BPD and ED were revealed by means of relationships with specific principal components (p < .01). BPD patients showed higher levels of a component featured by elevated levels of JNK and lower of GPx and SOD. ED-R and impulsivity were associated with a component featured by the activation of ERK and negative influence of Keap1. The component featured by the suppression of catalase and COX2 was associated with both ED subtypes and trauma exposure.

CONCLUSION

Several risk factors such as trauma, impulsivity and eating disorder symptoms were transdiagnostically associated with some inflammatory alterations regardless of diagnosis. These findings suggest that the clinical profile comprising trauma exposure and an emotional dysregulation disorder might constitute a specific endophenotype highly linked with inflammatory alterations.

International consensus on patient-centred outcomes in eating disorders

The effectiveness of mental health care can be improved through coordinated and wide-scale outcome measurement. The International Consortium for Health Outcomes Measurement has produced collaborative sets of outcome measures for various mental health conditions, but no universal guideline exists for eating disorders. This Position Paper presents a set of outcomes and measures for eating disorders as determined by 24 international experts from professional and lived experience backgrounds. An adapted Delphi technique was used, and results were assessed through an open review survey. Final recommendations suggest outcomes should be tracked across four domains: eating disorder behaviours and cognitions, physical health, co-occurring mental health conditions, and quality of life and social functioning. Outcomes are collected using three to five patient-reported measures. For children aged between 6 years and 12 years, the measures include the Children's Eating Attitude Test (or, for those with avoidant restrictive food intake disorder, the Eating Disorder in Youth Questionnaire), the KIDSCREEN-10, and the Revised Children's Anxiety and Depression Screener-25. For adolescents aged between 13 years and 17 years, the measures include the Eating Disorder Examination Questionnaire (EDE-Q; or, for avoidant restrictive food intake disorder, the Nine-Item Avoidant Restrictive Food Intake Disorder Screener [NIAS]), the two-item Patient Health Questionnaire (PHQ-2), the nine-item Patient Health Questionnaire (PHQ-9), the two-item Generalised Anxiety Disorder (GAD-2), the seven-item Generalised Anxiety Disorder (GAD-7), and the KIDSCREEN-10. For adults older than 18 years, measures include the EDE-Q (or, for avoidant restrictive food intake disorder, the NIAS), the PHQ-2, the PHQ-9, the GAD-2, the GAD-7, the Clinical Impairment Assessment, and the 12-item WHO Disability Assessment Schedule 2.0. These questionnaires should be supplemented by information on patient characteristics and circumstances (ie, demographic, historical, and clinical factors). International adoption of these guidelines will allow comparison of research and clinical interventions to determine which settings and interventions work best, and for whom.

Naltrexone plus bupropion combination medication maintenance treatment for binge-eating disorder following successful acute treatments: randomized double-blind placebo-controlled trial

BACKGROUND

Certain treatments have demonstrated acute efficacy for binge-eating disorder (BED) but there is a dearth of controlled research examining pharmacotherapies as maintenance treatments for responders to initial interventions. This gap in the literature is particularly critical for pharmacotherapy for BED which is associated with relapse following discontinuation. The current study tested the efficacy of naltrexone/bupropion maintenance treatment amongst responders to acute treatments for BED.

METHODS

Prospective randomized double-blind placebo-controlled single-site trial, conducted August 2017-December 2021, tested naltrexone/bupropion as maintenance treatment for responders to acute treatments with naltrexone/bupropion and/or behavioral weight-loss therapy for BED with comorbid obesity. Sixty-six patients (84.8% women, mean age 46.9, mean BMI 34.9 kg/m2) who responded to acute treatments were re-randomized to placebo (N = 34) or naltrexone/bupropion (N = 32) for 16 weeks; 86.3% completed posttreatment assessments. Mixed models and generalized estimating equations comparing maintenance treatments (naltrexone/bupropion v. placebo) included main and interactive effects of acute treatments.

RESULTS

Intention-to-treat binge-eating remission rates following maintenance treatments were 50.0% (N = 17/34) for placebo and 68.8% (N = 22/32) for naltrexone/bupropion. Placebo following response to acute treatment with naltrexone/bupropion was associated with significantly decreased probability of binge-eating remission, increased binge-eating frequency, and no weight loss. Naltrexone/bupropion following response to acute treatment with naltrexone/bupropion was associated with good maintenance of binge-eating remission, low binge-eating frequency, and significant additional weight loss.

CONCLUSIONS

Adult patients with BED with co-occurring obesity who have good responses to acute treatment with naltrexone/bupropion should be offered maintenance treatment with naltrexone/bupropion.

Naltrexone/bupropion for binge-eating disorder: A randomized, double-blind, placebo-controlled trial

OBJECTIVE

Binge-eating disorder (BED) is a prevalent psychiatric disorder associated with obesity. Few evidence-based treatments exist for BED, particularly pharmacological options. This study tested the efficacy of naltrexone/bupropion for BED.

METHODS

A randomized, double-blind, placebo-controlled, 12-week trial tested naltrexone/bupropion for BED with and without obesity. Eighty-nine patients (70.8% women, 69.7% White, mean age 45.7 y, mean BMI 35.1 kg/m2 , 77.5% with BMI ≥ 30 kg/m2 ) were randomized to placebo (n = 46) or naltrexone/bupropion (n = 43), with randomization stratified by obesity status and gender; 92.1% completed post-treatment assessments.

RESULTS

Mixed models of binge-eating frequency revealed significant reductions that did not differ significantly between naltrexone/bupropion and placebo. Logistic regression of binge-eating remission rates revealed that naltrexone/bupropion and placebo did not differ significantly. Obesity status did not predict, or moderate, binge-eating outcomes considered either continuously or categorically. Mixed models revealed that naltrexone/bupropion was associated with significantly greater percentage weight loss than placebo. Logistic regression revealed that naltrexone/bupropion had significantly higher rates of attaining ≥5% weight loss than placebo (27.9% vs. 6.5%). Obesity status did not predict or moderate weight-loss outcomes.

CONCLUSIONS

Naltrexone/bupropion did not demonstrate effectiveness for reducing binge eating relative to placebo but showed effectiveness for weight reduction in patients with BED. Obesity status did not predict or moderate medication outcomes.

The social epidemiology of binge-eating disorder and behaviors in early adolescents

BACKGROUND

Binge-eating disorder (BED) is the most common eating disorder phenotype and is linked to several negative health outcomes. Yet, little is known about the social epidemiology of BED, particularly in early adolescence. The objective of this study was to examine the associations between sociodemographic characteristics and BED and binge-eating behaviors in a large, national cohort of 10-14-year-old adolescents in the United States (U.S.) METHODS: We conducted a cross-sectional analysis of two-year follow-up data from the Adolescent Brain Cognitive Development (ABCD) Study (2018 - 2020) that included 10,197 early adolescents (10 - 14 years, mean 12 years) in the U.S. Multivariable logistic regression models were used to assess the associations between sociodemographic characteristics and BED and binge-eating behaviors, defined based on the Kiddie Schedule for Affective Disorders and Schizophrenia.

RESULTS

In this early adolescent sample (48.8% female, 54.0% White, 19.8% Latino/Hispanic, 16.1% Black, 5.4% Asian, 3.2% Native American, 1.5% Other), the prevalence of BED and binge-eating behaviors were 1.0% and 6.3%, respectively. Identifying as gay or bisexual (compared to heterosexual; adjusted odds ratio [AOR]: 2.25, 95% CI 1.01-5.01) and having a household income of less than $75,000 (AOR: 2.05, 95% CI: 1.21-3.46) were associated with greater odds of BED. Being male (AOR: 1.28, 95% CI: 1.06-1.55), of Native American (AOR: 1.60, 95% CI: 1.01-2.55) descent, having a household income less than $75,000 (AOR: 1.34, 95% CI: 1.08-1.65), or identifying as gay or bisexual (AOR for 'Yes' Response: 1.95, 95% CI: 1.31-2.91 and AOR for 'Maybe' Response: 1.81, 95% CI: 1.19-2.76) were all associated with higher odds of binge-eating behaviors.

CONCLUSION

Several sociodemographic variables showed significant associations with binge-eating behaviors, which can inform targeted screening, prevention, and education campaigns for BED among early adolescents.

The cost-effectiveness of a virtual intervention to prevent eating disorders in young women in Sweden

OBJECTIVE

To determine the cost-effectiveness of a virtual version of the Body Project (vBP), a cognitive dissonance-based program, to prevent eating disorders (ED) among young women with a subjective sense of body dissatisfaction in the Swedish context.

METHOD

A decision tree combined with a Markov model was developed to estimate the cost-effectiveness of the vBP in a clinical trial population of 149 young women (mean age 17 years) with body image concerns. Treatment effect was modeled using data from a trial investigating the effects of vBP compared to expressive writing (EW) and a do-nothing alternative. Population characteristics and intervention costs were sourced from the trial. Other parameters, including utilities, treatment costs for ED, and mortality were sourced from the literature. The model predicted the costs and quality-adjusted life years (QALYs) related to the prevention of incidence of ED in the modeled population until they reached 25 years of age. The study used both a cost-utility and return on investment (ROI) framework.

RESULTS

In total, vBP yielded lower costs and larger QALYs than the alternatives. The ROI analysis denoted a return of US $152 for every USD invested in vBP over 8 years against the do-nothing alternative and US $105 against EW.

DISCUSSION

vBP is likely to be cost-effective compared to both EW and a do-nothing alternative. The ROI from vBP is substantial and could be attractive information for decision makers for implementation of this intervention for young females at risk of developing ED.

PUBLIC SIGNIFICANCE

This study estimates that the vBP is cost-effective for the prevention of eating disorders among young women in the Swedish setting, and thus is a good investment of public resources.

Economic evaluation of web-based guided self-help cognitive behavioral therapy-enhanced for binge-eating disorder compared to a waiting list: A randomized controlled trial

INTRODUCTION

The aim is to perform an economic evaluation alongside a randomized controlled trial comparing guided self-help cognitive behavioral therapy-enhanced (CBT-E) for binge-eating disorder (BED) to a waiting list control condition.

METHODS

BED patients (N = 212) were randomly assigned to guided self-help CBT-E or the 3-month waiting list. Measurements took place at baseline and the end-of-treatment. The cost-effectiveness analysis was performed using the number of binge-eating episodes during the last 28 days as an outcome indicator according to the eating disorder examination. A cost-utility analysis was performed using the EuroQol-5D.

RESULTS

The difference in societal costs over the 3 months of the intervention between both conditions was €679 (confidence interval [CI] 50-1330). The incremental costs associated with one incremental binge eating episode prevented in the guided self-help condition was approximately €18 (CI 1-41). From a societal perspective there was a 96% likelihood that guided self-help CBT-E led to a greater number of binge-eating episodes prevented, but at higher costs. Each additional quality-adjusted life year (QALY) gained was associated with incremental costs of €34,000 (CI 2494-154,530). With a 95% likelihood guided self-help CBT-E led to greater QALY gain at higher costs compared to waiting for treatment. Based on the National Institute for Health and Clinical Excellence willingness-to-pay threshold of €35,000 per QALY, guided self-help CBT-E can be considered cost-effective with a likelihood of 95% from a societal perspective.

DISCUSSION

Guided self-help CBT-E is likely a cost-effective treatment for BED in the short-term (3-month course of treatment). Comparison to treatment-as-usual is recommended for future research, as it enables an economic evaluation with a longer time horizon.

PUBLIC SIGNIFICANCE

Offering treatment remotely has several benefits for patients suffering from binge-eating disorders. Guided self-help CBT-E is an efficacious and likely cost-effective treatment, reducing binge eating and improving quality-of-life, albeit at higher societal costs.

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.

Economic costs for outpatient treatment of eating disorders in Japan

BACKGROUND

Few studies have examined the economic costs of outpatient care for eating disorders in Japan. This study aimed to clarify the reimbursement for outpatient treatment of eating disorders and compare the costs between the departments of Psychosomatic Medicine and Psychiatry in Japan.

METHOD

A multicenter, prospective, observational study of patients with an eating disorder was conducted in the Psychosomatic Medicine departments of three centers and the Psychiatry departments of another three centers in Japan. We analyzed medical reimbursement for an outpatient revisit, time of clinical interviews, and the treatment outcome measured by the Eating Disorder Examination Questionnaire (EDE-Q) global scores and body mass index (BMI) at 3 months. Multivariate linear regression models were performed to adjust for covariates.

RESULTS

This study included 188 patients in the Psychosomatic Medicine departments and 68 in the Psychiatry departments. The average reimbursement cost for an outpatient revisit was 4670 yen. Even after controlling for covariates, the Psychosomatic Medicine departments had lower reimbursement points per minute of interviews than the Psychiatry departments (coefficient = - 23.86; 95% confidence interval = - 32.09 to - 15.63; P < 0.001). In contrast, EDE-Q global scores and BMI at 3 months were not significantly different between these departments.

CONCLUSIONS

This study clarifies the economic costs of treating outpatients with eating disorders in Japan. The medical reimbursement points per interview minute were lower in Psychosomatic Medicine departments than in Psychiatry departments, while there were no apparent differences in the treatment outcomes. Addressing this issue is necessary to provide an adequate healthcare system for patients with eating disorders in Japan.

Direct economic burden of mental health disorders associated with polycystic ovary syndrome: Systematic review and meta-analysis

Background

Polycystic ovary syndrome (PCOS) is the most common hormone disorder affecting about one in seven reproductive-aged women worldwide and approximately 6 million women in the United States (U.S.). PCOS can be a significant burden to those affected and is associated with an increased prevalence of mental health (MH) disorders such as depression, anxiety, eating disorders, and postpartum depression. We undertook this study to determine the excess economic burden associated with MH disorders in women with PCOS in order to allow for a more accurate prioritization of the disorder as a public health priority.

Methods

Following PRISMA reporting guidelines for systematic review, we searched PubMed, Web of Science, EBSCO, Medline, Scopus, and PsycINFO through July 16, 2021, for studies on MH disorders in PCOS. Excluded were studies not in humans, without controls, without original data, or not peer reviewed. As anxiety, depression, eating disorders, and postpartum depression were by far the most common MH disorders assessed by the studies, we performed our meta-analysis on these disorders. Meta-analyses were performed using the DerSimonian-Laird random effects model to compute pooled estimates of prevalence ratios (PRs) for the associations between PCOS and these MH disorders and then calculated the excess direct costs related to these disorders in U.S. dollars (USD) for women suffering from PCOS in the U.S. alone. The quality of selected studies was assessed using the Newcastle-Ottawa Scale.

Results

We screened 78 articles by title/abstract, assessed 43 articles in full text, and included 25 articles. Pooled PRs were 1.42 (95% confidence interval [CI]: 1.32-1.52) for anxiety, 1.65 (95% CI: 1.44-1.89) for depression, 1.48 (95% CI: PR: 1.06-2.05) for eating disorders, and 1.20 (95% CI: 0.96-1.50) for postpartum depression, for PCOS relative to controls. In the U.S., the additional direct healthcare costs associated with anxiety, depression, and eating disorders in PCOS were estimated to be $1.939 billion/yr, $1.678 billion/yr, and $0.644 billion/yr in 2021 USD, respectively. Postpartum depression was excluded from the cost analyses due to the non-significant meta-analysis result. Taken together, the additional direct healthcare costs associated with anxiety, depression, and eating disorders in PCOS were estimated to be $4.261 billion/yr in 2021 USD.

Conclusions

Overall, the direct healthcare annual costs for the most common MH disorders in PCOS, namely anxiety, depression, and eating disorders, exceeds $4 billion in 2021 USD for the U.S. population alone. Taken together with our prior work, these data suggest that the healthcare-related economic burden of PCOS exceeds $15 billion yearly, considering the costs of PCOS diagnosis, and costs related to PCOS-associated MH, reproductive, vascular, and metabolic disorders. As PCOS has much the same prevalence across the world, the excess economic burden attributable to PCOS globally is enormous, mandating that the scientific and policy community increase its focus on this important disorder.

Funding

The study was supported, in part, by PCOS Challenge: The National Polycystic Ovary Syndrome Association and by the Foundation for Research and Education Excellence.

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.

Experiences of inpatient eating disorder admissions: A systematic review and meta-synthesis

OBJECTIVE

There has been a significant increase in the number of inpatient admissions for individuals with eating disorders and, with the most critical cases requiring inpatient treatment, it is essential that we continue to improve associated outcomes. The aim of the study was to synthesise the available qualitative literature on the experiences of inpatient admissions for eating disorders to understand individuals' experiences and identify areas that may require further research and/or service development.

METHOD

Searches were performed on the following online databases: PsycINFO, PsycArticles, PsycTherapy MEDLINE, Embase, CINAHL, ASSIA, Scopus and Proquest Open Access Theses. Only papers with qualitative data regarding individuals' experiences of inpatient eating disorder treatment were considered. The CASP qualitative checklist was used to assess studies and relevant data items were extracted. Thematic synthesis was used to integrate the findings in the identified studies. GRADE-CERQual was used to rate the confidence in the findings.

RESULTS

Twenty-eight studies were identified which the CASP assessment considered to be adequate. The synthesis produced 5 main themes; 'Care and control', 'Inpatient bubble', 'Being supported and understood', 'Challenges of living with others' eating disorders' and finally 'Relationship to eating disorder'. The GRADE CERQual framework rated findings with high or moderate confidence.

CONCLUSIONS

Findings reaffirmed the importance of patient-centred care and the significant impact of being separated from normal life with others also experiencing an eating disorder.

Are child maltreatment and intimate partner violence associated with adult disordered eating?

OBJECTIVE

Disordered eating is one of the most prevalent mental health concerns (Galmiche et al., 2019, Quick & Byrd-Bredbenner, 2013, Neumark-Sztainer et al., 2006). Studies show that child maltreatment increases the likelihood of disordered eating symptoms in adulthood (Caslini et al., 2016, Hazzard et al., 2019). However, these studies overlook abuse experiences later in life, such as intimate partner violence which may also be a significant contributing factor (Bundock et al., 2013). The proposed study will help identify whether childhood maltreatment and IPV are independent predictors and/or if the combination of the two are synergistic risk factors for adult disordered eating.

METHOD

We use data from 14,332 people from Wave III of the National Longitudinal Study of Adolescent to Adult Health (Add Health). Participants completed questionnaires assessing child maltreatment, intimate partner violence, and disordered eating symptoms. We will perform a series of logistic regression models to examine a) whether child maltreatment and intimate partner violence are independently associated with disordered eating and b) whether exposure to the combination of both child maltreatment and intimate partner violence is associated with worse outcomes for adult disordered eating compared to exposure to only one or none at all. We also propose a supplemental analysis to establish the robustness of these effects when accounting for the highest parental education, federal poverty percentage level, race/ethnicity, gender, and age.

PUBLIC SIGNIFICANCE

Disordered eating is a serious mental health concern, especially in an emerging adult population. Child maltreatment is consistently associated with disordered eating in adulthood. However, the independent or synergistic role of more recent abuse experiences, such as intimate partner violence, remains largely unknown. The proposed study provides insight into how both childhood abuse and intimate partner violence may be associated with disordered eating independently or in combination.

Risk of non-fatal self-harm and premature mortality in the three years following hospitalization in adolescents and young adults with an eating disorder: A nationwide population-based study

INTRODUCTION

Eating disorders (ED) are associated with high rates of suicide attempts and premature mortality. However, data in large samples of adolescents and young adults are limited. This study aims to assess the risk of self-harm and premature mortality in young people hospitalized with an ED.

METHODS

Individuals aged 12 to 25 years old hospitalized in 2013-2014 in France with anorexia nervosa and/or bulimia nervosa as a primary or associated diagnosis were identified from French national health records. They were compared to two control groups with no mental disorders, and with any other mental disorder than ED. The main outcomes were any hospitalization for deliberate self-harm and mortality in the 3 years following hospitalization. Logistic regression models were used.

RESULTS

This study included 5, 452 patients hospitalized with an ED, 14,967 controls with no mental disorder, and 14,242 controls with a mental disorder other than an ED. During the three-year follow-up, 13.0% were hospitalized for deliberate self-harm (vs. 0.2 and 22.0%, respectively) and 0.8% died (vs. 0.03 and 0.4%). After adjustment, hospitalization with an ED was associated with more self-harm hospitalizations (hazard ratio [HR] = 46.0, 95% confidence interval [32.3-65.3]) and higher all-cause mortality (HR = 12.6 [4.3-37.3]) relative to youths without any mental disorder; less self-harm hospitalizations (HR = 0.5 [0.5-0.6]) but higher mortality (HR = 1.6 [1.0-2.4]) when compared to youths with any other mental disorder.

CONCLUSION

Young patients hospitalized with an ED are at high risk of self-harm and premature mortality. It is urgent to evaluate and implement the best strategies for post-discharge care and follow-up.

PUBLIC SIGNIFICANCE

We found that the risk of being hospitalized for a suicide attempt is 46 times higher and mortality 13 times higher than the general population in adolescents and young adults during the 3 years following hospitalization with an eating disorder. Eating disorders are also associated with a 1.5 higher risk of premature mortality relative to other mental disorders. This risk is particularly high in the 6 months following hospitalization. It is therefore crucial to implement careful post-discharge follow-up in patients hospitalized for eating disorders.

Association between eating disorders and sleep duration among college students: Findings from the National Healthy Minds study

OBJECTIVES

Explore associations between eating disorders (EDs) and sleep duration and the impact of depression symptoms (DSs) in American college students.

PARTICIPANTS

College students from 2018 to 2019 Healthy Minds Study.

METHODS

Multivariate logistic regression evaluated associations between EDs (bulimia, anorexia, binge eating [BED]) and sleep duration. Stratified analyses assessed effect modification by DSs and gender.

RESULTS

Students reporting any eating disorder had no greater risk of not recommended sleep duration during weekdays compared to those with no eating disorder history (Adjusted OR = 0.99, 95% CI: 0.89-1.13). However, subjects reporting BED were at greater risk of deficient sleep during weekends compared to those with no EDs (Adjusted OR = 1.26, 95% CI: 1.01-1.58). This association was not impacted by DSs. However, all EDs were associated with not-recommended sleep duration among those who identified as other gender identity in comparison to those with no EDs.

CONCLUSION

Health educators should monitor academic performance in students with EDs for adequate sleep duration.

Exploratory graph analysis (EGA) of the dimensional structure of the eating disorder examination-questionnaire (EDE-Q) in women with eating disorders

This study examined the dimensional structure of the German Eating Disorder Examination-Questionnaire (EDE-Q) in clinical groups of women with Anorexia Nervosa (AN; N = 821), Bulimia Nervosa (BN; N = 573), and Binge-Eating Disorder (BED; N = 359) using Exploratory Graph Analyses (EGA). The EGA yielded a 12-item-four-dimension structure for the AN group (subscales "Restraint", "Body Dissatisfaction", "Preoccupation", "Importance"), a 20-item-five-dimension structure for the BN group (subscales "Restraint", "Body Dissatisfaction", "Eating Concern", "Preoccupation", "Importance"), and a 17-item-four-dimension structure for the BED group (subscales "Restraint", "Body Dissatisfaction", "Concern", "Importance"). This first investigation of the EDE-Q's dimensional structure using EGA suggests that the original factor model may be suboptimal for specific clinical ED samples and that alternative scoring should be considered when screening specific cohorts or evaluating the effects of interventions.

Obtaining long-term recovery: advances in optimizing treatment outcomes in patients with binge-eating disorder

INTRODUCTION

Binge-eating disorder (BED) is a complex and disabling eating disorder (ED) associated with considerable burden and impairments in quality of life and physical/mental health. It has been recognized as a formal ED category since 2013, however BED is still underdetected and undertreated.

AREAS COVERED

This review summarizes the advances in the understanding of the pathophysiology of BED as well as the evidence on the efficacy of the existing treatments. The authors searched Scopus, PubMed, ClinicalTrials.Gov, and ANZCTR with terms including 'assessment' OR 'treatment' OR 'diagnosis' OR 'mechanisms' AND 'binge eating' OR 'binge-eating disorder' for manuscripts published between January 2013 and April 2023.

EXPERT OPINION

Most of the trials on treatments of BED have been in people of high weight with weight loss as an outcome. Nevertheless, less is known about the treatment of this condition in people with body mass index (BMI) within the normal range where weight stabilization may be a more appropriate goal. Moreover, there is a need for an enhanced appreciation of the role of combination treatment to improve overall outcomes. Also, there are important opportunities for future research in understanding the mechanisms of action and effectiveness of BED treatments.

Design and methods of the Longitudinal Eating Disorders Assessment Project research consortium for veterans

INTRODUCTION

Military service members must maintain a certain body mass index and body fat percentage. Due to weight-loss pressures, some service members may resort to unhealthy behaviors that place them at risk for the development of an eating disorder (ED).

OBJECTIVES

To understand the scope and impact of EDs in military service members and veterans, we formed the Longitudinal Eating Disorders Assessment Project (LEAP) Consortium. LEAP aims to develop novel screening, assessment, classification, and treatment tools for veterans and military members with a focus on EDs and internalizing psychopathology.

METHODS

We recruited two independent nationally representative samples of post-9/11 veterans who were separated from service within the past year. Study 1 was a four-wave longitudinal survey and Study 2 was a mixed-methods study that included surveys, structured-clinical interviews, and qualitative interviews.

RESULTS

Recruitment samples were representative of the full population of recently separated veterans. Sample weights were created to adjust for sources of non-response bias to the baseline survey. Attrition was low relative to past studies of this population, with only (younger) age predicting attrition at 1-week follow-up.

CONCLUSIONS

We expect that the LEAP Consortium data will contribute to improved information about EDs in veterans, a serious and understudied problem.