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Silverstein S, Hellner M, Menzel J. Development of a gender-affirming care protocol in eating disorder treatment settings. Eat Disord 2024:1-17. [PMID: 38922313 DOI: 10.1080/10640266.2024.2371250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Transgender and gender-expansive (TGE) individuals suffer from eating disorders (EDs) at disproportionate rates relative to their gender-conforming counterparts. While literature on EDs in TGE populations is growing and evolving, best practice guidelines are scant. A framework for providing gender-affirming care (GAC) in an ED treatment setting was developed by integrating findings from a focused literature review and insights from leading experts. Following synchronous and asynchronous training, the protocol was implemented in a virtual ED treatment setting with a national reach serving patients ages 6-24 years. This paper offers a summary of best practices and approaches for providing GAC in ED treatment settings. The use of GAC practices has the potential to address underlying issues and inequities in treatment delivery and outcomes. We encourage ED treatment providers to consider the adoption/adaptation of GAC best practices to more effectively meet the needs of TGE patients. More research is needed to better understand the influence of individual and collective GAC practices on specific ED treatment outcomes.
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Affiliation(s)
| | | | - Jessie Menzel
- Program Development, Equip Health, San Diego, California, USA
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Hellner M, Steinberg D, Baker J, Cai K, Freestone D. Dietary interventions in family-based treatment for eating disorders: results of a randomized comparative effectiveness study. Eat Disord 2024:1-21. [PMID: 38592961 DOI: 10.1080/10640266.2024.2336278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Family-based treatment (FBT) is a first-line treatment for adolescents with eating disorders (ED's) for which weight gain early in treatment and caregiver empowerment are predictive of success. A variety of dietary interventions are used in practice, but little is known about their effectiveness. We compared clinical outcomes of patients (N = 100) undergoing eating disorder treatment, and user experience across two virtually delivered interventions: (1) Daily calorie target and (2) Plate-by-Plate™ approach. The calorie group gained more weight on average, though the difference was small (β = 1.62 [-0.02, 3.26]). Participants in both groups improve their eating disorder symptoms at roughly the same rate (β = 0.09 [-0.83, 1.04]). Caregivers in the Plate-by-Plate group increased confidence at a slower rate (β = 0.05 [-0.002, 0.09]). Caregivers rated the daily calorie target as more effective (β = 2.18 [0.94, 3.6]), and rated the two approaches equally for ease of use (β = -0.73 [-1.92, 0.48]). The daily calorie target approach was rated as more effective and was preferred overall by caregivers and dietitians. Findings challenge long-standing assumptions underlying FBT and suggest that clinicians should consider using a calorie framework with caregivers to guide renourishment efforts.
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Affiliation(s)
- Megan Hellner
- Research Department, Equip Health, Carlsbad, California, USA
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Johnson-Munguia S, Bottera AR, Vanzhula I, Forbush KT, Gould SR, Negi S, Thomeczek ML, L’Insalata AM, Like EE, Sharma AR, Morgan RW, Rasheed S. Understanding community provider practices in diagnosing and treating atypical anorexia nervosa: A mixed methods study. Int J Eat Disord 2024; 57:892-902. [PMID: 38239071 PMCID: PMC11018496 DOI: 10.1002/eat.24125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 02/07/2024]
Abstract
OBJECTIVE There is a lack of consensus in defining "significant weight loss" when diagnosing atypical anorexia nervosa (atypical AN) and no guidelines exist for setting target weight (TW). The current study aimed to identify community providers' practices related to the diagnosis of atypical AN and the determination of TW. A secondary aim was to evaluate whether professional discipline impacted "significant weight loss" definitions. METHOD A variety of providers (N = 141; 96.4% female) completed an online survey pertaining to diagnostic and treatment practices with atypical AN. Descriptive statistics were computed to characterize provider-based practices and Fisher's exact tests were used to test for differences in diagnostic practices by professional discipline. Thematic analysis was used to examine open-ended questions. RESULTS Most (63.97%) providers diagnosed atypical AN in the absence of any weight loss if other AN criteria were met, but doctoral-level psychologists and medical professionals were less likely to do so compared to nutritional or other mental health professionals. Most providers found weight gain was only sometimes necessary for atypical AN recovery. Qualitative responses revealed providers found atypical AN to be a stigmatizing label that was not taken seriously. Providers preferred to use an individualized approach focused on behaviors, rather than weight when diagnosing and treating atypical AN. DISCUSSION Lack of diagnostic clarity and concrete treatment guidelines for atypical AN may result in substantial deviations from the DSM-5-TR criteria in real-world practice. Clinically useful diagnostic definitions for restrictive eating disorders and evidence-based treatment guidelines for TW and/or other relevant recovery metrics are needed. PUBLIC SIGNIFICANCE The current study found variability in how community providers diagnose and determine target recovery weight for atypical anorexia nervosa (atypical AN). Many providers viewed the diagnosis of atypical AN as stigmatizing and preferred to focus on behaviors, rather than weight. This study underscores the importance of creating a clinically useful diagnostic definition and guidelines for recovery for atypical AN backed by empirical evidence that providers may implement in practice.
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Perry TR, Cai K, Freestone D, Steinberg DM, Bohon C, Menzel JE, Baker JH. Early weight gain as a predictor of weight restoration in avoidant/restrictive food intake disorder. J Eat Disord 2024; 12:27. [PMID: 38360833 PMCID: PMC10870495 DOI: 10.1186/s40337-024-00977-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/21/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Previous research has demonstrated that early weight gain in family-based treatment (FBT) is predictive of remission for adolescents with anorexia nervosa (AN). However, no published data has addressed if early weight gain is also predictive of reaching weight restoration (i.e., 95% EBW) in patients with avoidant/restrictive food intake disorder (ARFID). Furthermore, no studies have evaluated the performance of the statistical models used to predict weight restoration at the end of treatment. This study sought to examine whether early weight gain in ARFID is predictive of weight restoration at 20 weeks using ROC analysis. Additionally, this study assessed how accurately the model classified patients and what types of misclassifications occurred. METHODS Participants (n = 130, 57.7% cisgender female 70.0% white) received virtual outpatient FBT. Receiver operating characteristics (ROC) were used to predict successful weight restoration at end of treatment, using early weight gain as the predictor. Twenty weeks was considered as the end of treatment, to align with the definition of end of treatment in FBT clinical trials. ROC analyses demonstrated that gaining at least 6.2 pounds by week 5 of treatment was the strongest predictor of achieving 95% EBW at 20 weeks (AUC = 0.72 [0.63, 0.81]). ROC analyses misclassified 35% of patients; the most common misclassification was predicting that a patient would not achieve 95% EBW when they actually did (61.6%). A logistical regression model, which included the patients' %EBW at admission in addition to early weight gain as a predictor, outperformed the ROC analyses (AUC = 0.90 [0.85, 0.95]) and provided additional context by showing the probability that a patient would succeed. CONCLUSION Taken together, research demonstrates that early weight gain is a useful predictor of 95% EBW at 20 weeks of treatment for patients with ARFID who require weight restoration. Furthermore, results suggest that statistical models need to take into account additional information, such as %EBW at admission, along with early weight gain in order to more accurately predict which patients will reach weight restoration at week 20.
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Affiliation(s)
- Taylor R Perry
- Equip Health, Inc, 2659 State Street Suite 100 #1012, Carlsbad, CA, 92008, USA.
- State University of New York at Albany, Albany, NY, USA.
| | - Kelly Cai
- Equip Health, Inc, 2659 State Street Suite 100 #1012, Carlsbad, CA, 92008, USA
| | - David Freestone
- Equip Health, Inc, 2659 State Street Suite 100 #1012, Carlsbad, CA, 92008, USA
| | - Dori M Steinberg
- Equip Health, Inc, 2659 State Street Suite 100 #1012, Carlsbad, CA, 92008, USA
- Duke University, Durham, NC, USA
| | - Cara Bohon
- Equip Health, Inc, 2659 State Street Suite 100 #1012, Carlsbad, CA, 92008, USA
- Stanford University, Stanford, CA, USA
| | - Jessie E Menzel
- Equip Health, Inc, 2659 State Street Suite 100 #1012, Carlsbad, CA, 92008, USA
| | - Jessica H Baker
- Equip Health, Inc, 2659 State Street Suite 100 #1012, Carlsbad, CA, 92008, USA
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Huffman LG, Lawrence-Sidebottom D, Beam AB, Parikh A, Guerra R, Roots M, Huberty J. Improvements in Adolescents' Disordered Eating Behaviors in a Collaborative Care Digital Mental Health Intervention: Retrospective Observational Study. JMIR Form Res 2024; 8:e54253. [PMID: 38294855 PMCID: PMC10867747 DOI: 10.2196/54253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/14/2023] [Accepted: 12/28/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Young people today are exhibiting increasing rates of disordered eating behaviors, as well as eating disorders (EDs), alongside other mental and behavioral problems such as anxiety and depression. However, limited access to mental health care means that EDs, disordered eating behaviors, and comorbid mental health problems are often underdiagnosed and undertreated. Digital mental health interventions (DMHIs) offer accessible and scalable alternatives to traditional treatment modalities, but their effectiveness has not been well established among adolescents with EDs and disordered eating behaviors. OBJECTIVE This study uses data from a collaborative care pediatric DMHI to determine whether participation in a DMHI is associated with a reduction in adolescents' disordered eating behaviors. METHODS Adolescent members in care with Bend Health Inc completed the SCOFF questionnaire at baseline (before the start of care) and approximately every month during care to assess disordered eating behaviors. They also completed assessments of mental health symptoms at baseline. Member characteristics, mental health symptoms, and disordered eating behaviors of adolescents with elevated SCOFF scores at baseline (before the start of care) were compared to those of adolescents with nonelevated SCOFF scores at baseline. Members participated in web-based coaching or therapy sessions throughout the duration of mental health care. RESULTS Compared to adolescents with nonelevated SCOFF scores (n=520), adolescents with elevated SCOFF scores (n=169) were predominantly female and exhibited higher rates of elevated anxiety and depressive symptoms. SCOFF scores decreased over time in care with the DMHI for 61.4% (n=70) of adolescents with elevated SCOFF scores, and each additional month of participation was associated with greater improvements in disordered eating behaviors (F1,233=72.82; P<.001). CONCLUSIONS Our findings offer promising preliminary evidence that participation in mental health care with a collaborative care DMHI may be beneficial in the reduction of disordered eating symptoms in adolescents, including those who are experiencing comorbid anxiety and depressive symptoms.
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Affiliation(s)
| | | | | | | | | | | | - Jennifer Huberty
- Bend Health Inc, Madison, WI, United States
- FitMinded Inc LLC, Phoenix, AZ, United States
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Cooper M, Mears C, Heckert K, Orloff N, Peebles R, Timko CA. The buffet challenge: a behavioral assessment of eating behavior in adolescents with an eating disorder. J Eat Disord 2024; 12:8. [PMID: 38238787 PMCID: PMC10797715 DOI: 10.1186/s40337-024-00968-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVE Eating disorders are characterized by disturbances in nutritional intake and abnormal mealtime behaviors. Laboratory eating paradigms offer a unique opportunity to accurately measure dietary intake and eating behaviors, however, these studies have predominantly occurred in adults. This paper describes the development and preliminary psychometric examination of the Buffet Challenge, a laboratory-based meal task for youths with an eating disorder. METHOD We recruited and assessed 56 participants as part of a randomized controlled trial of Family-Based Treatment for adolescents with anorexia nervosa. Adolescents completed the Buffet Challenge at baseline, midway through treatment (~ week 16 of a 6 months course), and end of treatment. Participants and their parents also reported eating disorder symptomatology and treatment related variables of interest were recorded. RESULTS All adolescents were willing to complete the Buffet Challenge at all time points, although one refused to give up their cellphone, and there were no significant adverse events recorded. Preliminary results are presented. CONCLUSIONS Our initial pilot of this task in adolescents with anorexia nervosa demonstrates its acceptability, although investigation of our hypotheses was hindered by significant missing data due to COVID-related research shutdowns. Future studies should replicate procedures in a larger sample to ensure analyses are adequately powered.
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Affiliation(s)
- Marita Cooper
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Connor Mears
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Psychology, West Chester University, West Chester, PA, USA
| | - Kerri Heckert
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalia Orloff
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Equip Health, Philadelphia, USA
| | - Rebecka Peebles
- The Craig Dalsimer Division of Adolescent Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Monte Nido & Affiliates, Philadelphia, USA
| | - C Alix Timko
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA, 19146, USA.
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Vanzhula IA, Wang E, Martinelli MK, Schreyer C, Guarda AS. Inpatient hospital course and self-reported symptomatology in underweight adults with ARFID compared to age- and sex-matched controls with anorexia nervosa. J Eat Disord 2023; 11:206. [PMID: 37986115 PMCID: PMC10658840 DOI: 10.1186/s40337-023-00912-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/12/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE Avoidant restrictive food intake disorder (ARFID) has similar prevalence to anorexia nervosa (AN) in adults, but research in this population is lacking. Although inpatient or residential treatment involving nutritional rehabilitation is increasingly recommended for malnourished individuals with ARFID, best practices remain poorly defined. Existing studies on self-reported symptomatology and treatment course and outcome are primarily in child and adolescent cohorts and demonstrate inconsistent findings. This study aimed to compare hospital course and self-reported symptomatology of underweight adult inpatients with ARFID and sex- and age-matched patients with AN. METHOD Underweight adult patients with ARFID or AN admitted to a specialized, hospital-based behavioral treatment program completed measures of body dissatisfaction, drive for thinness, bulimic symptoms, anxiety, depression, and personality traits. Demographic and treatment course data were abstracted from electronic medical records. Patients with ARFID (n = 69) were matched to those with AN (n = 69) based on sex and age. RESULTS Adults with ARFID were closer to target weight at admission, but gained weight at a slower rate, were discharged at lower BMI, and were less likely to reach target weight by discharge than adults with AN. Patients with ARFID reported less weight and shape-related eating disorder, state anxiety, and depression symptoms and lower neuroticism. DISCUSSION Adults with ARFID progress through treatment more slowly and achieve less favorable weight outcomes by hospital discharge than patients with AN, but long-term outcomes are unclear. Describing clinical presentations and course of illness of adult ARFID may help inform treatment protocols.
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Affiliation(s)
- Irina A Vanzhula
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
| | - Erin Wang
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Mary K Martinelli
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Colleen Schreyer
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Angela S Guarda
- Johns Hopkins University School of Medicine, Meyer 101, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
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