Validating the eating disorder inventory (EDI-2) in two danish samples: A comparison between female eating disorder patients and females from the general population

A naturalistic study of plasma lipid alterations in female patients with anorexia nervosa before and after weight restoration treatment

BACKGROUND

Plasma lipid concentrations in patients with anorexia nervosa (AN) seem to be altered.

METHODS

We conducted a naturalistic study with 75 adult female patients with AN and 26 healthy female controls (HC). We measured plasma lipid profile, sex hormones and used self-report questionnaires at admission and discharge.

RESULTS

Total cholesterol (median (IQR): 4.9 (1.2)) and triglycerides (TG) (1.2 (0.8)) were elevated in AN at admission (BMI 15.3 (3.4)) compared with HC (4.3 (0.7), p = 0.003 and 0.9 (0.3), p = 0.006) and remained elevated at discharge (BMI 18.9 (2.9)) after weight restoration treatment. Estradiol (0.05 (0.1)) and testosterone (0.5 (0.7)) were lower in AN compared with HC (0.3 (0.3), p =  < 0.001 and 0.8 (0.5), p = 0.03) and remained low at discharge. There was no change in eating disorder symptoms. Depression symptoms decreased (33 (17) to 30.5 (19), (p = 0.007)). Regression analyses showed that illness duration was a predictor of TG, age was a predictor of total cholesterol and LDL, while educational attainment predicted LDL and TG.

CONCLUSION

Lipid concentrations remained elevated following weight restoration treatment, suggesting an underlying, premorbid dysregulation in the lipid metabolism in AN that persists following weight restoration. Elevated lipid concentrations may be present prior to illness onset in AN.

LEVEL OF EVIDENCE

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

Impulsivity and reward and punishment sensitivity among patients admitted to a specialized inpatient eating disorder treatment program

Introduction

Eating disorders (EDs) are conceptualized as disorders of under- and over-control, with impulsivity reflecting under-control. Extant research indicates that impulsivity and related factors such as reward sensitivity and punishment sensitivity may serve as trait-level transdiagnostic risk and/or maintenance factors in EDs. Findings on impulsivity and reward and punishment sensitivity by diagnosis are mixed and research on the relationship between these factors and ED symptoms, hospital course, and treatment outcomes is limited.

Methods

Participants (N = 228) were patients admitted to a specialized inpatient behavioral treatment program for EDs who agreed to participate in a longitudinal study and completed self-report measures of impulsivity, reward sensitivity, and punishment sensitivity at admission. Weight and ED symptomatology were measured at admission and discharge. Hospital course variables included length of stay and premature treatment dropout.

Results

Impulsivity was lower in individuals with anorexia nervosa (AN) restricting type compared to those with AN binge/purge type or bulimia nervosa; no other group differences were observed. Higher impulsivity was associated with greater bulimic symptoms on the Eating Disorder Inventory 2 (EDI-2) at admission. Impulsivity was not related to ED symptoms, weight outcomes, length of hospital stay, or treatment dropout at program discharge.

Conclusion

Impulsivity may help distinguish restrictive versus binge/purge EDs, but does not necessarily relate to discharge outcomes in an intensive inpatient ED program. Findings from this study provide novel contributions to the literature on personality traits in EDs and have important clinical implications. Results suggest that patients with higher levels of impulsivity or reward and punishment sensitivity can be expected to respond to inpatient treatment. Suggestions for future research are discussed.

Identity Functioning in Patients with an Eating Disorder: Developmental Trajectories throughout Treatment

Increasing research has indicated a strong association between identity functioning and eating disorder (ED) symptomatology. However, a detailed investigation of identity throughout ED treatment is lacking. The present longitudinal study examined identity in inpatients with an ED and explored its simultaneous change with ED symptomatology throughout treatment. A total of 225 female patients completed questionnaires at admission. From these 225 patients participating at admission (Wave 1), 110 also participated in at least one additional measurement wave, with 43.64% (n = 48) participating at admission and during treatment, 16.36% (n = 18) participating at admission and at discharge, and 40% (n = 44) participating at admission, during treatment and at discharge. Questionnaires on identity synthesis, identity confusion, identity processes, and ED symptomatology were completed. Latent growth curve modeling was used to address the research questions. Throughout treatment, a decrease in identity confusion and an increase in identity synthesis and adaptive identity processes were found. Accordingly, increases in identity synthesis and identification with commitment were related to general decreases in the drive for thinness and body dissatisfaction. Similarly, such decreases in ED symptoms were related to general decreases in identity confusion and ruminative exploration. The present study points to an increase in identity functioning throughout treatment, and longitudinal associations between identity functioning and ED symptomatology were found. Helping patients to decrease their ruminative exploration and to increase their identification with previously made life commitments and treating body/weight concerns could both be helpful in ED treatment.

Childhood trauma and outcome trajectories in patients with longstanding eating disorders across 17 years

BACKGROUND

A large proportion of patients with eating disorders (ED) report experiences of childhood trauma. Latent trajectory analysis in ED samples reveals the complexities in course and outcome and can explore the long-term impact of adverse experiences in childhood.

METHOD

A total of 84 patients with longstanding ED were included. ED symptoms were assessed by the Eating Disorder Examination interview at discharge from inpatient treatment, and at 1-, 2-, 5-, and 17-year follow-up, respectively. Change over time was examined using growth mixture modeling, allowing the number of trajectories to emerge through the data. Prevalence of childhood trauma was assessed, and its relation to class membership was tested.

RESULTS

We identified four distinct classes: patients with (a) a continuous improvement in the entire follow-up period, and scores within normal range at the end, "continuous improvement" (54.8%); (b) a high symptom level at baseline and moderate decrease over time, "high and declining" (22.6%); (c) initial ED scores below clinical cut-off and stable symptoms throughout the course, "consistently low" (14.3%); and (d) with high scores initially, and a significant increase in symptoms over time, "high and increasing" (8.3%). A history of childhood sexual abuse (CSA) was overrepresented in classes with persistently high symptom levels and poor long-term outcome DISCUSSION: Patients with longstanding ED displayed considerable diversity in trajectories of symptom change across 17 years. To improve long-term outcome, enhanced treatment of sequelae from CSA seems essential.

PUBLIC SIGNIFICANCE

Patients with longstanding eating disorders displayed four different trajectories of change in a 17-year follow-up study. Although there were significant changes over time, the majority of patients remained within similar symptom levels as they presented with at discharge from inpatient treatment. Exposure to childhood maltreatment was common within the sample. Childhood sexual abuse predicted poor long-term outcome, which highlights the importance of trauma informed care.

Elevated lipid class concentrations in females with anorexia nervosa before and after intensive weight restoration treatment-A lipidomics study

OBJECTIVE

To study the plasma lipidome of patients with anorexia nervosa (AN) before and after weight restoration treatment and report associations with AN subtypes and oral contraceptive pill (OCP) usage.

METHODS

Quantitative shotgun lipidomics analysis was used to study plasma lipids of 50 female patients with AN before and after weight restoration treatment and 50 healthy female controls (HC). The AN group was assessed with blood samples and questionnaires before and after weight restoration.

RESULTS

In total we quantified 260 lipid species representing 26 lipid classes of which 13 lipid class concentrations were elevated in patients with AN at admission compared with HC. Lipid classes remained elevated after weight restoration treatment of 84 days (median; interquartile range 28), and only the concentration of the ceramide lipid class increased between pre- and post-treatment (p = .03), whereas lysophosphatidylcholine (LPC, p = .02), ether-linked Phosphatidylcholine (LPCO, p = .02), and lysophosphatidylethanolamine (LPE, p = .009) decreased.

CONCLUSION

In AN, 13 out of 26 lipid class concentrations were elevated at admission and remained elevated post-treatment. Ceramides increased further between pre- and post-weight restoration treatment, which could be related to the rapid weight gain during re-nutrition. Further research is needed to elucidate the effects of weight restoration treatment on short- and long-term lipid profiles in individuals with AN.

PUBLIC SIGNIFICANCE STATEMENT

Lipidomics research can increase the understanding of AN, a complex and potentially life-threatening eating disorder. By analyzing lipids, or fats, in the body, we can identify biological markers that may inform diagnosis and develop more effective treatments. This research can also shed light on the underlying mechanisms of the disorder, leading to a better understanding of the processes involved in eating behavior.

Influence of eating disorder psychopathology and general psychopathology on the risk of involuntary treatment in anorexia nervosa

PURPOSE

We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment.

METHODS

This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)).

RESULTS

Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment.

CONCLUSIONS

Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment.

LEVEL OF EVIDENCE

Level III, cohort study.

Factors of body dissatisfaction among lebanese adolescents: the indirect effect of self-esteem between mental health and body dissatisfaction

Background

Body dissatisfaction (BD) rates are alarmingly high, especially among adolescents, thus. Having a better understanding of correlates associated with BD seems to be an important issue in this developmental context. Furthermore, as adolescence is an essential time in the development of self-perception and self-esteem the current study assesses factors associated with BD among Lebanese adolescents and evaluates the indirect effect of self-esteem between depression/anxiety/stress and BD.

Methods

This is a cross-sectional study among 555 Lebanese adolescents, ages 15–18, who completed an online survey incorporating BD, socioeconomic status, weight and height, physical activity index, Rosenberg Self Esteem Scale, Beirut Distress Scale, Hamilton Anxiety Rating Scale, Patient Health Questionnaire-9, Pittsburgh Sleep Quality Index and Global Physical Activity Questionnaire.

Results

The results of a stepwise linear regression, taking the body dissatisfaction score as the dependent variable, showed that higher BMI (B = 0.47), feeling pressured by media/TV to lose weight (Beta = 2.80), higher depression (Beta = 0.39), exercising to lose weight (Beta = 1.84) and following a diet to lose weight (Beta = 1.58) were significantly associated with more body dissatisfaction, whereas higher self-esteem (Beta=-0.11) and more psychological distress (Beta=-0.21) were significantly associated with less body dissatisfaction. Self-esteem played an indirect role in the associations between anxiety and body dissatisfaction and stress and body dissatisfaction.

Conclusions

BD is common among young Lebanese adolescents. Treating adolescents with low self-esteem and psychological issues is crucial in preventing anticipated BD and future eating disorders.

Psychometric Properties of the Eating Disorder Inventory-3 (EDI-3) in Chilean Youth

The aim of this study was to analyze the psychometric properties of the Eating Disorder Inventory (EDI)-3 test to evaluate eating disorders in young Chilean population. Methods: The sample consisted of 1,091 Chilean adolescents and young people (i.e., 476 men and 615 women) between 15 and 28 years old, from the metropolitan region, and four regions from the coast and south-central zone of the country. The reliability and factorial structure of the instrument were analyzed, replicating the confirmatory factor analyses of Brookings et al. (2020), evaluating four additional models that included bifactor exploratory structural equation modeling (ESEM), bifactor, and two-bifactor. Results: A majority of the subscales presented alphas and omegas equal to or greater than 0.70, with the exception of asceticism (α = 0.543, ω = 0.552) and interpersonal alienation (α = 0.684, ω = 0.695) scales, which are consistent with the values of the Spanish and Mexican non-clinical samples. The best fit indices were obtained by the ESEM two-bifactor model, with twelve specific factors corresponding to the EDI-3 subscales and two general orthogonal factors (i.e., risk subscales and psychological subscales), consistently with the theoretical basis.

Cortisol, Depression, and Anxiety Levels Before and After Short-Term Intensive Nutritional Stabilization in Patients With Severe Anorexia Nervosa

INTRODUCTION

Depression and anxiety are well-known comorbid conditions in patients with anorexia nervosa (AN). Hypercortisolemia in patients with AN may be pathogenic and contribute to depression and anxiety symptomatology.

OBJECTIVE

The aim of this study was to investigate short-term changes in cortisol levels and depression and anxiety symptomatology following intensive re-nutrition in patients with severe AN and hospitalized in a specialized unit. Furthermore, we investigated the potential association between cortisol levels and psychometric parameters.

METHODS

A total of 36 patients with AN were enrolled in the study. Nine dropped out before follow-up. Patients underwent paraclinical and psychometric examinations at admission and discharge. Measurements included plasma cortisol, cortisol binding globulin (CBG), 24-h urine cortisol, and self-report questionnaires regarding eating disorder, depression, anxiety, and stress symptoms. Patients were hospitalized in the unit for somatic stabilization and intensive re-nutrition. Mean admission length was 41 days. The study was registered at ClinicalTrials.gov (NCT02502617).

RESULTS

Cortisol levels in blood and urine did not change from admission to discharge in patients with severe AN. Symptoms of depression, anxiety, stress, and eating disorder remained elevated at discharge. There were no associations between changes in cortisol levels and changes in psychometrics.

DISCUSSION

Our results suggest that short-term intensive re-nutrition did not alter hypothalamic-pituitary-adrenal axis activity or mental health in patients with severe AN. Long-term stabilization and longer follow-up after hospital discharge may be needed to detect changes in cortisol levels and whether these changes are associated with depression and anxiety symptomatology. Greater knowledge about cortisol levels and mental health in patients with severe AN may help in the development of new treatment choices for the chronically ill patients. Future studies could investigate whether cortisol-lowering drugs have a therapeutic effect on mental health in AN.

Disordered eating measures validated in pregnancy samples: a systematic review

Although disordered eating in pregnancy has been linked to numerous negative consequences, there is currently no published instrument specifically devised to identify or measure such symptoms in pregnancy. As such, this study systematically reviewed the literature to evaluate the performance of general measures of disordered eating in pregnancy samples. A systematic search of the following electronic databases was undertaken from inception to April 2019: Scopus, Medline, PsycINFO, Embase, ProQuest Dissertations and Theses, and the Cumulative Index to Nursing and Allied Health Literature. From 1724 citations, eight publications met the inclusion criteria and were included in the review. Most of the included studies (6/8) were of reasonable quality. Overall, three self-report inventories (EDE-Q, EDI-2, and DEBS) and one semi-structured clinical interview (EDE) had some form of psychometric information available. Most studies reported reliability, with only two reporting validity. No studies assessed screening accuracy. Other than the EDE-Q, which had preliminary evidence to suggest possible utility in pregnancy, the findings of this review revealed little to no evidence to support the use of general measures of disordered eating in pregnancy. A strong need for research exploring the validity of existing measures in pregnancy samples, including the EDE-Q, was also evident.

Increased plasma asprosin levels in patients with drug-naive anorexia nervosa

PURPOSE

Asprosin is a centrally acting appetite-promoting hormone and promotes glucose production in the liver. This study is the first to investigate the difference in asprosin in the plasma between anorexia nervosa (AN) and healthy controls, and to explore the relationship between asprosin changes and plasma glucose levels and AN symptoms.

METHODS

Plasma asprosin and glucose concentrations were detected in AN patients (n = 46) and healthy control subjects (n = 47). Eating Disorder Inventory-2 (EDI-2) was used to assess subjects' eating disorder symptoms and related personality traits. The patient's concomitant levels of depression and anxiety were also measured using the beck depression inventory and beck anxiety inventory, respectively.

RESULTS

Results indicate that AN patients had a higher asprosin concentration in their plasma compared to healthy controls (p = 0.033). Among AN patients, plasma asprosin levels correlated positively with EDI-2 interoceptive awareness subscale score (p = 0.030) and negatively with duration of illness (p = 0.036). Multiple linear regression analyses showed that increases in asprosin levels (p = 0.029), glucose levels (p = 0.024) and body mass index (p = 0.003) were associated with an increase of the score of EDI-2 bulimia subscale.

CONCLUSIONS

Our findings suggest that the increase in plasma asprosin concentration in patients with AN may be a compensation for the body's energy shortage, and asprosin may be involved in the development of bulimia and lack of interoceptive awareness in AN patients.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

The outcome at follow-up after inpatient eating disorder treatment: a naturalistic study

BACKGROUND

Patients with eating disorders may experience a severe and enduring course of illness. Treatment outcome for patients provided with inpatient treatment is reported as poor. Research to date has not provided consistent results for predictors of treatment outcome. The aims of the study were to investigate rates of remission at follow-up after inpatient treatment, symptom change from admission to follow-up, and predictors of treatment outcome.

METHODS

The follow-up sample consisted of 150 female adult former patients (69.4% of all eligible female patients) with eating disorders. Mean age at admission was 21.7 (SD = 4.9) years. Diagnostic distribution: 66% (n = 99) anorexia nervosa, 21.3% (n = 32) bulimia nervosa and 12.7% (n = 19) other specified feeding or eating disorder, including binge eating. Data were collected at admission, discharge and follow-up (mean 2.7 (SD = 1.9) years). Definition of remission was based on the EDE-Q Global score, body mass index and binge/purge behavior. Paired T-tests were performed to investigate change over time. Univariate and multivariate logistic regressions were estimated to investigate predictors of remission.

RESULTS

At follow-up, 35.2% of the participants were classified as in remission. Significant symptom reduction (in all patients) (p <  0.001) and significant increase in body mass index (BMI) (in underweight participants at admission) (p <  0.001) was found. Increased BMI (p <  0.05), the level of core eating disorder symptoms at admission (p <  0.01) and reduced core eating disorder symptoms (p <  0.01) during inpatient treatment were found significant predictors of outcome in the multivariate model.

CONCLUSIONS

All participants had an eating disorder requiring inpatient treatment. Approximately one-third of all participants could be classified as in remission at follow-up. However, most participants experienced significant symptom improvement during inpatient treatment and the improvements were sustained at follow-up. Increased probability of remission at follow-up was indicated by lower core ED symptoms at admission for all patients, raised BMI during admission for patients with AN, and reduced core ED symptoms during inpatient treatment for all patients. This finding contributes important information and highlights the importance of targeting these core symptoms in transdiagnostic treatment programs.

Prolonged constipation and diarrhea in childhood and disordered eating in adolescence

OBJECTIVES

Gastrointestinal problems are common in all eating disorders; however, the extent to which these problems predate the onset of eating disorders is not clear. We explored longitudinal associations between childhood gastrointestinal problems and adolescent disordered eating, and assessed whether observed associations are potentially causal or due to familial confounding factors.

METHODS

Data from a population-based Swedish twin sample were used to investigate associations between parent- and self-reported protracted constipation and diarrhea in childhood and adolescence, and later disordered eating, measured by the Eating Disorders Inventory-2 (EDI). Linear regression models were used to investigate the associations. Possible familial confounding was explored by using a within-twin pair analysis.

RESULTS

We found that those who reported a history of constipation at age 15 scored 5.55 and 5.04 points higher, respectively, on the EDI total score at age 15 and 18, compared with those without constipation. Those reporting a history of diarrhea at age 15 scored 5.15 points higher, and the group reporting both problems scored 9.52 points higher on the EDI total score at age 15 than those reporting no problems. We observed that the association between constipation and disordered eating was attenuated in the within-twin pair analysis, but remained positive.

CONCLUSIONS

Gastrointestinal problems in childhood and adolescence are significantly associated with disordered eating. Associations were partly due to familial confounding, but might also be consistent with a causal interpretation. Clinicians should be aware of the increased risk of disordered eating when following children and adolescents who present with gastrointestinal problems.

Associations Between Attention-Deficit/Hyperactivity Disorder and Various Eating Disorders: A Swedish Nationwide Population Study Using Multiple Genetically Informative Approaches

BACKGROUND

Although attention-deficit/hyperactivity disorder (ADHD) and eating disorders (EDs) frequently co-occur, little is known about the shared etiology. In this study, we comprehensively investigated the genetic association between ADHD and various EDs, including anorexia nervosa (AN) and other EDs such as bulimia nervosa.

METHODS

We applied different genetically informative designs to register-based information of a Swedish nationwide population (N = 3,550,118). We first examined the familial coaggregation of clinically diagnosed ADHD and EDs across multiple types of relatives. We then applied quantitative genetic modeling in full-sisters and maternal half-sisters to estimate the genetic correlations between ADHD and EDs. We further tested the associations between ADHD polygenic risk scores and ED symptoms, and between AN polygenic risk scores and ADHD symptoms, in a genotyped population-based sample (N = 13,472).

RESULTS

Increased risk of all types of EDs was found in individuals with ADHD (any ED: odds ratio [OR] = 3.97, 95% confidence interval [CI] = 3.81, 4.14; AN: OR = 2.68, 95% CI = 2.15, 2.86; other EDs: OR = 4.66, 95% CI = 4.47, 4.87; bulimia nervosa: OR = 5.01, 95% CI = 4.63, 5.41) and their relatives compared with individuals without ADHD and their relatives. The magnitude of the associations decreased as the degree of relatedness decreased, suggesting shared familial liability between ADHD and EDs. Quantitative genetic models revealed stronger genetic correlation of ADHD with other EDs (.37, 95% CI = .31, .42) than with AN (.14, 95% CI = .05, .22). ADHD polygenic risk scores correlated positively with ED symptom measures overall and with the subscales Drive for Thinness and Body Dissatisfaction despite small effect sizes.

CONCLUSIONS

We observed stronger genetic association with ADHD for non-AN EDs than for AN, highlighting specific genetic correlation beyond a general genetic factor across psychiatric disorders.

The self and eating disorders

In our review, we focus on self-related constructs in the context of eating disorders with four aims. First, we examine a variety of self-related constructs that have been theoretically and empirically linked to the development and course of eating disorders. In addition to the more well-researched constructs of self-esteem and self-efficacy, we also report on findings related to selflessness, contingent self-worth, self-objectification, ego-syntonicity, self-concept clarity, self-compassion, social comparison, self-oriented perfectionism/self-criticism, and narcissism. Second, we discuss self-related constructs that may be especially relevant to comorbidities common among those with eating disorders. Third, we review intervention and prevention programs where self-related constructs play a prominent role. Lastly, we share future research directions regarding self-related constructs and eating disorders that we believe will advance a deeper understanding of the role of the self in the eating disorders.

Are adolescent elite athletes less psychologically distressed than controls? A cross-sectional study of 966 Norwegian adolescents

Introduction

Psychological distress is increasing among adolescents and clusters with other mental health problems such as eating problems. The aim of this study was to investigate the prevalence of psychological distress among young elite athletes and age-matched controls and whether prevalence figures may be attributed to perfectionism and eating problems.

Methods

First-year athletes from all Norwegian elite sport high schools (n=711) and 500 students from randomly selected ordinary high schools were eligible for this cross-sectional study. In total, 611 athletes and 355 student controls provided self-report data about psychological distress, perfectionism, and eating problems (ie, body dissatisfaction and a drive for thinness), as well as their physical training/activity.

Results

A significantly higher proportion of controls scored above the cutoff point for marked psychological distress. Physical activity above the recommended levels for this age group predicted psychological distress among the controls, while the opposite was found in the student elite athlete sample. In both samples, perfectionistic concerns, ie, concern over mistakes, predicted overall psychological distress. However, among elite athletes, perfectionistic concerns were particularly associated with clinically significant psychological distress. Moreover, the impact of eating problems was negligible.

Conclusion

Results from this study highlight the need to target the maladaptive perfectionistic concerns to prevent psychological distress among young athletes as well as among their age-matched nonathlete counterparts.

Effect of Yoga in the Treatment of Eating Disorders: A Single-blinded Randomized Controlled Trial with 6-Months Follow-up

Aim of the Study

The aim of this study is to examine the effect of yoga treatment of eating disorders (EDs).

Methods

Adult females meeting the Diagnostic and Statistical Manual-IV criteria for bulimia nervosa or ED not otherwise specified (n = 30) were randomized to 11-week yoga intervention group (2 × 90 min/week) or a control group. Outcome measures, the Eating Disorder Examination (EDE)-Interview and Eating Disorders Inventory-2 (EDI-2) scores, were administered at baseline, posttest, and at 6-month follow-up. There was a dropout rate of 30% (posttest) and 37% (6-month follow-up).

Results

The intervention group showed reductions in EDE global score (P < 0.01), the EDE subscale restraint (P < 0.05), and eating concern (P < 0.01) compared to the control group. The differences between the groups increased at 6-month follow-up. There were no differences between the groups in the EDI-2 score.

Conclusion

The results indicate that yoga could be effective in the treatment of ED.

Use of doping agents and symptoms of eating disorders among male and female patients in drug addiction treatment

Aims

This study investigates the prevalence of use of doping agents and symptoms of eating disorders among patients in drug addiction treatment. The aim is also to look for characteristics of the groups reporting the use of doping agents or symptoms of eating disorders.

Design

A survey including questions on exercise, the use of doping agents and Eating Disorder Inventory-2 was administered in a Norwegian drug addiction facility. The study included 109 patients in residential drug treatment, 30 females and 79 males (ranging from 17 to 50 years old).

Results

–Symptoms of eating disorders were reported by 33 percent of the females and 7.6 percent of the males. Previous use of doping agents (anabolic-androgenic steroids in particular) was reported by 40.5 percent of the men and 20 percent of the women. The results are discussed in light of the theory on emotion regulation, gender and cultural expectations, drug treatment as a liminal phase and similarities to drug addiction.

Conclusions

The symptoms of eating disorders and the use of doping agents are prevalent in this sample of male and female drug addicts in treatment. Drug treatment facilities should be aware of this and take the appropriate actions regarding attention, screening and treatment.

Patient- and clinician- reported outcome in eating disorders

Patient-reported outcome is increasingly applied in health sciences. Patients with eating disorders (EDs) characteristically have a different opinion of their needs to that of the health professionals, which can lead to ambivalence towards treatment and immense compliance difficulties. This cross-sectional study compared data assessed by the clinician to patient-reported measures in patients with a history of EDs. We included data from a cohort of patients with EDs (n=544) referred to a specialized ED unit in Denmark. Patient-reported measures included the Eating Disorder Inventory-2 (EDI-2) and the Short Form 36 (SF-36), and clinical data included remission status and body mass index (BMI). We found a positive association between BMI and EDI-2 scores for anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS), reflecting increasing ED symptomatology with increasing BMI. This association was not observed in bulimia nervosa (BN). We did not find a correlation between SF-36 scores and BMI in any of the diagnostic groups.

Impact of female adult eating disorder inpatients' attitudes to compulsive exercise on outcome at discharge and follow-up

BACKGROUND

The link between compulsive exercise and eating disorders is well known, but research with clinical samples has been limited. The purpose of the study was to investigate changes in attitudes towards compulsive exercise and its impact on outcome at follow-up in female adult hospitalised patients with eating disorders.

METHODS

The sample consisted of 78 patients: Diagnostic distribution: anorexia nervosa 59 % (n = 46), approximately 22 % (n = 16) in bulimia nervosa, and Eating Disorder not Otherwise Specified respectively. The average follow-up period was 26 months (SD =15 months). Compulsive exercise was measured by the Exercise and Eating Disorder (EED) questionnaire. Other measures were the Eating Disorder Inventory (EDI-2), Body Attitude Test (BAT), Symptom Checklist (SCL-90), Inventory of Interpersonal Problems (IIP 64), Beck Depression Inventory (BDI), and body mass index (BMI). Outcome measures were EDI-2 and BMI (patients with admission BMI ≤ 18.5). Paired sample t-tests and mixed model regression analysis were conducted to investigate changes in compulsive exercise and predictors of outcome respectively.

RESULTS

All measures revealed significant improvements (p < .01 - p < .001) from admission to follow-up. EED scores significantly predicted changes in EDI-2 scores and BMI (p < .01 and p < .001 respectively). Other significant predictors were BAT, SCL-90, IIP-64, BMI (p < .01-.001) (EDI-2 as outcome measure), and BAT and BDI (p < .001) (BMI as outcome measure).

CONCLUSIONS

The results demonstrated significant improvements in attitudes towards compulsive exercise during treatment and follow-up. The change in compulsive exercise scores predicted the longer-term course of eating disorder symptoms and BMI.

Exercise addiction in men is associated with lower fat-adjusted leptin levels

OBJECTIVE

To test a hypothesized association between resting leptin levels (adjusted for body fat percentage) and symptoms of primary exercise addiction.

DESIGN

Cross-sectional design.

SETTING

Habitual amateur exercisers participating in running, fitness, weight training, and biking.

PARTICIPANTS

Twenty men with exercise addiction as defined by the Exercise Addiction Inventory (EAI scores 24-30) and 20 men in an exercise control group (EAI scores 6-16) matched on body mass index.

MAIN OUTCOME MEASURES

Plasma leptin and sex hormones were measured in blood samples collected under fasting and resting conditions. Body composition was assessed by dual-energy x-ray absorptiometry. Eating disorder symptoms were identified by the Eating Disorder Inventory 2.

RESULTS

The exercise addiction group had significantly (P < 0.001) lower leptin levels (1.1 μg/L, SD = 1.3) than controls (4.3 μg/L, SD = 2.9). Even when adjusted for body fat percentage, the addiction group had significantly (P < 0.001) lower leptin levels (0.1 μg/L, SD = 0.1) than the controls (0.2 μg/L, SD = 0.1). Body fat-adjusted leptin correlated with free bioavailable testosterone, but it was only significant in nonaddictive exercisers. None of the exercisers seemed to suffer from an eating disorder.

CONCLUSIONS

This is the first study showing that excessive training in exercise addiction is associated with low levels of body fat-adjusted leptin levels.

CLINICAL RELEVANCE

Hypoleptinemia could be involved in the pathogenesis of exercise addiction. However, further studies are needed to explore the potential causal relationship.

Effect of dronabinol therapy on physical activity in anorexia nervosa: a randomised, controlled trial

PURPOSE

The level of physical activity is inappropriately high in up to 80% of the patients suffering of anorexia nervosa (AN), as a result of conscious efforts to lose weight, affect regulation and biological adaptive changes to starvation induced by hypothermia and neuroendocrine mechanisms. The purposes of this paper were to (1) assess the effect of dronabinol-a synthetic cannabinoid agonist-on physical activity in patients with chronic and stable AN, and to (2) unravel the role of leptin and cortisol in this process.

METHODS

This prospective, randomised, double-blind, crossover study was conducted at a specialised care centre for eating disorders. Twenty-four adult women with AN of at least 5-year duration received either the dronabinol-placebo or placebo-dronabinol sequence. Physical activity was monitored during the fourth week of each intervention. Body weight, leptin and urinary free cortisol excretion were measured repeatedly during the trial. Changes in behavioural dimensions related to AN were assessed by Eating Disorder Inventory-2.

RESULTS

The total duration of physical activity did not change, while its average intensity increased by 20% (P = 0.01) during dronabinol therapy, resulting in an increased energy expenditure with 68.2 kcal/day (P = 0.01) above placebo.

CONCLUSIONS

This randomised, double-blind study revealed that cannabinoid agonist treatment was associated with a modest increase in physical activity in adult women with severe and longstanding AN. Additionally, we detected a strong relationship between the circulating levels of leptin and physical activity in these chronically undernourished patients.

Eating Disorder Inventory-3, validation in Swedish patients with eating disorders, psychiatric outpatients and a normal control sample

BACKGROUND

The Eating Disorder Inventory-3 (EDI-3) is designed to assess eating disorder psychopathology and the associated psychological symptoms. The instrument has been revised and has not yet been validated for Swedish conditions in its current form.

AIMS

The aim of this study was to investigate the validity and reliability of this inventory and present national norms for Swedish females.

METHODS

Data from patients with eating disorders (n = 292), psychiatric outpatients (n = 140) and normal controls (n = 648), all females, were used to study the internal consistency, the discriminative ability, and the sensitivity and specificity of the inventory using preliminary cut-offs for each subscale and diagnosis separately. Swedish norms were compared with those from Denmark, USA, Canada, Europe and Australian samples.

RESULTS

The reliability was acceptable for all subscales except Asceticism among normal controls. Analysis of variance showed that the EDI-3 discriminates significantly between eating disorders and normal controls. Anorexia nervosa was significantly discriminated from bulimia nervosa and eating disorder not otherwise specified on the Eating Disorder Risk Scales. Swedish patients scored significantly lower than patients from other countries on the majority of the subscales. Drive for Thinness is the second best predictor for an eating disorder. The best predictor for anorexia nervosa was Interoceptive Deficits and Bulimia for the other diagnoses. Conclusions/clinical implications: The EDI-3 is valid for use with Swedish patients as a clinical assessment tool for the treatment planning and evaluation of patients with eating-related problems. However, it still exist some uncertainty regarding its use as a screening tool.

Disordered eating behavior among group fitness instructors: a health-threatening secret?

BACKGROUND

The present study aimed to examine disordered eating behavior (DE) and self-reported eating disorders (ED) among Norwegian group fitness instructors.

METHODS

Group fitness instructors from Norway (n = 685 females and 152 males, response rate: 57 %) completed an online survey. The survey included the instruments Eating Disorders Inventory (EDI) and the Exercise Dependence Scale (EDS).

RESULTS

A total of 22 % of the male and 59 % of the female respondents were classified with DE. The respondents classified with DE had higher BMI, more weight loss attempts, and higher total EDI score compared to the respondents with no DE. A correlation between EDI total score and EDS total score was found among both male and female group fitness instructors. No males and four percent of the females reported having a current ED. The instructors with self-reported current ED had higher weekly volume of instructing classes compared to the other instructors. None of the respondents with self-reported ED had informed their center manager about it.

CONCLUSION

The high prevalence of DE behavior calls for concern. The reported secrecy regarding self-reported ED might decrease the possibility for early recognition and intervention. The findings reveal implications for the instructors' physical and mental health, for their reputation and impact as important healthy role models and health/fitness authorities, and for the importance of prevention, identification and management of such behavior in fitness center settings.

Exercise addiction: a study of eating disorder symptoms, quality of life, personality traits and attachment styles

Exercise addiction is characterized by excessive exercise patterns with potential negative consequences such as overuse injuries. The aim of this study was to compare eating disorder symptoms, quality of life, personality traits and attachments styles in exercisers with and without indications of exercise addiction. A case-control study with 121 exercisers was conducted. The exercisers were categorized into an addiction group (n=41) or a control group (n=80) on the basis of their responses to the Exercise Addiction Inventory. The participants completed the Eating Disorder Inventory 2, the Short-Form 36, the NEO Personality Inventory Revised and the Adult Attachment Scale. The addiction group scored higher on eating disorder symptoms, especially on perfectionism but not as high as eating disorder populations. The characteristic personality traits in the addiction group were high levels of excitement-seeking and achievement striving whereas scores on straightforwardness and compliance were lower than in the exercise control group. The addiction group reported more bodily pain and injuries. This study supports the hypothesis that exercise addiction is separate to an eating disorder, but shares some of the concerns of body and performance. It is driven by a striving for high goals and excitement which results in pain and injuries from overuse.

Attachment insecurities, maladaptive perfectionism, and eating disorder symptoms: a latent mediated and moderated structural equation modeling analysis across diagnostic groups

Although 96-100% of individuals with eating disorders (EDs) report insecure attachment, the specific mechanisms by which adult insecure attachment dimensions affect ED symptomatology remain to date largely unknown. This study examined maladaptive perfectionism as both a mediator and a moderator of the relationship between insecure attachment (anxiety and avoidance) and ED symptomatology in a clinical, treatment seeking, sample. Insecure anxious and avoidant attachment, maladaptive perfectionism, and ED symptomatology were assessed in 403 participants from three medium size specialized care centres for EDs in Italy. Structural equation modeling indicated that maladaptive perfectionism served as mediator between both insecure attachment patterns and ED symptomatology. It also interacted with insecure attachment to predict higher levels of ED symptoms - highlighting the importance of both insecure attachment patterns and maladaptive aspects of perfectionism as treatment targets. Multiple-group comparison analysis did not reveal differences across diagnostic groups (AN, BN, EDNOS) in mediating, main and interaction effects of perfectionism. These findings are consistent with recent discussions on the classification and treatment of EDs that have highlighted similarities between ED diagnostic groups and could be viewed through the lens of the Trans-theoretical Model of EDs. Implications for future research and intervention are discussed.

Dronabinol in severe, enduring anorexia nervosa: a randomized controlled trial

OBJECTIVE

The evidence for pharmacological treatment of severe, longstanding anorexia nervosa (AN) is sparse and the few controlled pharmacologic studies have focused on a narrow range of drugs. The aim of the present study was to investigate the effects of treatment with a synthetic cannabinoid agonist on body weight and eating disorder-related psychopathological personality traits in women with severe, enduring AN.

METHOD

This add-on, prospective, randomized, double blind, controlled crossover study was conducted between 2008 and 2011 at a specialized care center for eating disorders. Twenty-five women over 18 years with AN of at least 5 years duration were randomized to treatment with either dronabinol-placebo or placebo-dronabinol. In addition to the standardized baseline therapeutic regime, the participants received dronabinol, 2.5 mg twice daily for 4 weeks and matching placebo for 4 weeks, separated by a 4-week wash-out period. Primary outcome was the mean change in body weight. Secondary outcome was score changes on the Eating Disorder Inventory-2 (EDI-2). Data were analyzed for the 24 patients who completed the trial.

RESULTS

During dronabinol treatment, participants gained 0.73 kg (t = 2.86, df = 22, p < 0.01) above placebo without significant psychotropic adverse events. Dronabinol significantly predicted weight gain in a multiple linear regression including EDI-2 body dissatisfaction score and leptin. EDI-2 subscale scores showed no significant changes over time.

DISCUSSION

Dronabinol therapy was well tolerated. During four weeks of exposure it induced a small but significant weight gain in the absence of severe adverse events.

Attitudes toward life and death and suicidality among inpatient female adolescents with eating disorders

This study investigated whether attitudes about life and death are associated with suicidal behavior in eating disorders (EDs). We examined 43 nonsuicidal inpatients with EDs, 32 inpatients with EDs who attempted suicide, and 21 control participants with scales assessing attitudes to life and death, body-related attitudes, core ED symptoms, depression, and anxiety. Both ED groups showed less attraction to life and more repulsion from life than did the control participants. The suicide attempters showed greater attraction to death, less repulsion from death, and more negative attitudes toward their body than did the nonsuicidal ED and control participants. Fear of life was associated with elevated depression, body-related problems, and childhood sexual abuse. Pathological attitudes toward death were associated with greater depression and body-related problems. Suicide attempts were found in the inpatients with EDs showing binge/purge ED pathology and maladaptive attitudes toward death. This study suggests that whereas fear of life is a core feature of an ED, maladaptive attitudes toward death appear only in ED patients who have attempted suicide.

The impact of age and BMI on impairment due to disordered eating in a large female community sample

The impact of age and BMI on functional impairment in eating disorders was assessed by the Clinical Impairment Assessment (CIA) scale in a representative community sample. The CIA was administered to 1080 women aged 16-50 years (M=36.2, SD=9.5) with a range of BMI from 13.5 to 55.0 (M=24.6, SD=4.9) randomly selected from the Norwegian National Population Register. The average global CIA score was 5.3 (SD=8.5). Impairment tended to decrease with age (r(s)=-.20, p<.01), yet increased with greater BMI (r(s)=.31, p<.01). Approximately 30% of the participants with obesity scored in the clinical range compared to 7% of the underweight and normal-weight participants. Data supported the utility and feasibility of the CIA as a measure of functional impairment secondary to weight, shape, and eating concerns. It is recommended that age and BMI be considered during the interpretation of CIA data.

Psychological characteristics and associations with weight outcomes two years after gastric bypass surgery: Postoperative eating disorder symptoms are associated with weight loss outcomes

This study investigated symptoms of eating disorder, depression, and anxiety among Roux-en-Y gastric bypass patients two years after surgery, and the relationship between these characteristics and weight loss. Respondents completed assessment questionnaires including Eating Disorder Inventory-2 (EDI-2), Harvard Anxiety and Depression Scale (HADS), and questions related specifically to binge eating. Forty-five patients (8 men, 37 women) out of 65 (67%) responded. Scores were significant higher on impulse regulation, interoceptive awareness, ineffectiveness, maturity fears and interpersonal distrust in comparison with a Danish norm group (p≤0.05). The weight losses obtained after surgery varied from 12 to 60% of the starting weights. Binge eating and ineffectiveness were found to significantly correlate with weight loss variations after surgery (p≤0.05). The results of this study indicate that knowledge of the potential influence of eating disorder symptoms on outcomes after bariatric surgery is needed in order to optimize weight outcomes following surgery.

Changes in body image during inpatient treatment for eating disorders predict outcome

This study investigated changes and predictors during inpatient treatment of 55 adult in a transdiagnostic sample of patients with eating disorders. Patients were assessed at admission and discharge with the Body Attitude Test (BAT), Symptom Check List 90 Revised, Circumplex of Interpersonal Problems, Body Mass Index (BMI) and Eating Disorder Inventory 2 (EDI-2). Significant changes were found in all measures. Regression analyses showed that BAT changes during treatment were the strongest predictor of EDI-2 changes. No predictors of changes in BMI were found. Improvement of body image is important for the efficacy of inpatient treatment.

Discerning thoughts from feelings: the cognitive-affective division in eating disorders

This article delineates the phenomenon of "cognitive-affective division" in eating disorders, used to refer to the difficulty some patients face in translating what they "think" cognitively to what they "feel" emotionally. A clinical description of cognitive-affective division is first presented, drawing on existing research, before moving on to discuss psychological theories that might shed some light on this often-seen but seldom understood phenomenon. These include the role of emotion awareness and alexithymia, cognitive and emotional development, and neuropsychological theories. We discuss implications for treatment and further research of the cognitive-affective division in eating disorders.

Validating the Eating Disorder Inventory-3 (EDI-3): A Comparison Between 561 Female Eating Disorders Patients and 878 Females from the General Population

The Eating Disorder Inventory (EDI) is used worldwide in research and clinical work. The 3(rd) version (EDI-3) has been used in recent research, yet without any independent testing of its psychometric properties. The aim of the present study was twofold: 1) to establish national norms and to compare them with the US and international norms, and 2) to examine the factor structure, the internal consistency, the sensitivity and the specificity of subscale scores. Participants were Danish adult female patients (N = 561) from a specialist treatment centre and a control group (N = 878) was women selected from the Danish Civil Registration system. Small but significant differences were found between Danish and international, as well as US norms. Overall, the factor structure was confirmed, the internal consistency of the subscales was satisfactory, the discriminative validity was good, and sensitivity and specificity were excellent. The implications from these results are discussed.