Somatic problems and self-injurious behaviour 18 years after teenage-onset anorexia nervosa

Non-suicidal self-injury among individuals with an eating disorder: A systematic review and prevalence meta-analysis

OBJECTIVE

This study aimed to quantify the prevalence of non-suicidal self-injury across eating disorders (EDs) and within diagnostic categories through systematic review and proportional, or so-called prevalence, meta-analysis.

METHOD

Included studies had to contain individuals with a verified diagnosis of an ED. The last literature search was conducted on September 11, 2023, for studies published on or before September 2023 without a restriction on earliest publication year. Results were synthesized and analyzed using the "metaprop" package in R and presented using forest plots. Bias was assessed by a Peters' regression test and funnel plot.

RESULTS

79 studies published between 1985 and 2023 were included encompassing 32,334 individuals with an ED. Importantly, 42 studies were not included in any other meta-analyses on self-injury in EDs to date. Overall prevalence of non-suicidal self-injury was 34.59% (95%CI = 30.49-38.81). Prevalence in anorexia nervosa restrictive type, binge/purge type, bulimia nervosa, binge eating disorder and other specified feeding/eating disorder were 23.19% (95%CI = 16.96-30.03%), 41.98% (95%CI = 32.35-51.91%), 36.97% (95%CI = 30.69-43.46%), 21.21% (95%CI = 14.93-28.12%) and 37.65% (95%CI = 28.59-47.09%), respectively. Prevalence estimations could not be estimated for other ED categories due to lack of a sufficient number of studies.

DISCUSSION

Non-suicidal self-injury is prevalent across both binge/purge and restrictive EDs. Considering the transdiagnostic nature of self-injurious behaviors in ED, the results highlight the importance of assessment and monitoring of self-injury in people with ED, irrespective of specific diagnoses. The method of determining self-injury varied across studies and may limit this study.

PUBLIC SIGNIFICANCE

This study highlights the prevalence of self-injury across eating disorders irrespective of diagnosis and within specific EDs. While diagnoses known to exhibit self-injurious behaviors (e.g., bulimia nervosa, anorexia nervosa binge/purge subtype) demonstrated the highest prevalence of self-injury, all diagnoses were found to have a prevalence greater than 20%. These findings suggest the importance of assessing and monitoring all individuals with an eating disorder for the presence of self-injury.

Non-suicidal self-injury, suicidal thoughts and behaviors in individuals with an eating disorder relative to healthy and psychiatric controls: A systematic review and meta-analysis

OBJECTIVE

Eating disorders (ED) may be associated with an increased prevalence of non-suicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs) relative to healthy (HC) and psychiatric (PC) controls. However, precise estimates of differences in prevalence between individuals with EDs and controls are unclear. We compared the prevalence of NSSI, suicidal ideation (SI), suicide attempts (SA), and deaths by suicide in controls and individuals with EDs.

METHOD

We searched MEDLINE, PsycINFO, EMBASE, and CINAHL for peer-reviewed publications reporting the prevalence of NSSI and/or STBs in EDs and HC or PC group (PROSPERO: CRD42021286754). A series of random-effects meta-analyses were conducted to estimate pooled odds ratios (ORs) for NSSI, SI, SA, and death by suicide in EDs.

RESULTS

Across 32 studies, individuals with an ED had a significantly increased prevalence of NSSI (HC: OR = 6.85 [95% CI: 3.60, 13.04]; PC: OR = 2.74 [95% CI: 1.49, 5.06]), SI (HC: OR = 3.63 [95% CI: 2.43, 5.41]; PC: OR = 3.10 [95% CI: 2.01, 4.78]), and SA (HC: OR = 5.16 [95% CI: 4.27, 6.24]; PC: OR = 1.37 [95% CI: 0.37, 4.99]) relative to HC and PC groups. A 2.93-times increased odd of death by suicide did not achieve statistical significance. There was a high-level of heterogeneity between studies.

DISCUSSION

Our findings indicate that ED populations have an increased prevalence of NSSI, SI, and SA but not death by suicide compared to controls and emphasize the need for effective clinical strategies to address these behaviors in ED populations.

PUBLIC SIGNIFICANCE

This review provides evidence for an increased prevalence of non-suicidal self-injury, suicidal ideation, and suicide attempts in populations with eating disorders compared to controls. Our findings emphasize the need for effective clinical strategies to address these behaviors in patients with eating disorders.

Increased risk of somatic diseases following anorexia nervosa in a controlled nationwide cohort study

OBJECTIVE

To assess the risk of somatic diseases in connection with anorexia nervosa (AN).

METHOD

This matched cohort study was based on Danish registries of all patients born 1961-2008 with a first-time diagnosis of AN in 1994-2018 at age 8-32 and matched controls without an eating disorder. For 13 somatic disease categories, time from inclusion date to time of first somatic diagnosis, accounting for censoring, was studied by use of time-stratified Cox models.

RESULTS

A total of 9985 AN patients born 1961-2008 and 49,351 controls were followed for a median (interquartile range) of 9.0 (4.4-15.7) years. During the first 2 years after entry there was a 60% higher hazard for any somatic disease among patients with AN than among controls, while the ratio from three to 11 years was reduced to 1.18. Regardless of age at diagnosis, the hazard among patients and controls were no different at approximately a decade after diagnosis of AN and the cumulative risk for patients for 12 of 13 disease categories was always higher or no less that for controls. For all disease categories, the hazard ratio (HR) was higher when close to entry. For most disease categories, age at diagnosis of AN did not modify the effect.

DISCUSSION

While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls. Large HRs were seen in the early years after diagnosis during which patients require extensive medical interventions.

PUBLIC SIGNIFICANCE

Based on Danish registries, a large sample of almost 10,000 patients with AN born 1961-2008 and almost 50,000 matched controls were followed for a median of 9 years. While around 90% of all individuals had any somatic disease at the end of follow-up, the cumulative incidence over time was higher for patients with AN than for controls.

Factors associated with refeeding hypophosphatemia in adolescents and young adults hospitalized with anorexia nervosa

BACKGROUND

Refeeding hypophosphatemia (RH) in individuals with anorexia nervosa (AN) is a potentially fatal complication of nutrition restoration; yet, little is known about risk. This retrospective cohort study examined factors found in hospitalized youth with AN that may contribute to RH.

METHODS

We reviewed medical records of 300 individuals diagnosed with AN admitted between the years of 2010 and 2016. Logistic regression examined factors associated with RH. Multivariate regression examined factors associated with phosphorus nadir.

RESULTS

For 300 participants, the mean (SD) age was 15.5 (2.5) years, 88.3% were White, and 88.3% were female. Participants lost an average of 11.3 (9.7) kg of body weight and were 82% (12.1) of median body mass index (BMI). Age (P = .022), nasogastric (NG) tube feeding (P = .054), weight gain (P = .003), potassium level (P = .001), and magnesium level (P = .024) were contributors to RH. Odds of RH were 13.7 times higher for each unit reduction in magnesium, 9.2 times higher for each unit reduction in potassium, three times higher in those who received NG feeding, 1.5 times higher for each kg of weight gain, and 1.2 times higher for each year of age. Regarding phosphorus nadir, serum magnesium level (P < .001) and admission BMI (P = .002) contributed significantly.

CONCLUSION

The results indicate that age, NG feeding, weight gain, electrolyte abnormalities, and BMI on admission are potential indicators of the development of RH in youth. This study identifies clinical risk factors associated with RH and may guide further investigation.

What Are the Effects of Restrictive Eating Disorders on Growth and Puberty and Are Effects Permanent? A Systematic Review and Meta-Analysis

PURPOSE

The objective of the study was to examine (1) the effect of restrictive eating disorders (EDs) on growth and pubertal development in children and young people (CYP) and (2) potential reversibility of this with recovery and associated factors. EDs can impact growth and puberty in CYP, but reports have conflicted over effect on height and permanence of growth impairment and pubertal delay.

METHODS

This is a systematic review and meta-analysis, searching PubMed, EMBASE, PsycINFO, and Web of Science from May 31, 2018, to inception. We included observational studies or systematic reviews regarding growth and puberty in EDs in CYP aged <18 years or in studies reporting outcomes in adults known to have had an ED under age 18 years. Cross-sectional studies were pooled for meta-analysis for effects on height.

RESULTS

A total of 27 studies were included. Growth and pubertal delay were commonly reported, but evidence for catch-up growth found in the majority. However, catch-up growth was not seen in all and may be suboptimal. Meta-analysis of 459 subjects (213 with anorexia nervosa and 246 controls) found no significant difference in height at baseline, with weighted mean difference -.13 cm (95% CI -2.64 to 2.38 cm; p = .9; I² = 68.5%). Younger age and longer duration of illness are potential risks for growth delay; weight gain appears protective for catch-up growth. Findings are primarily generalisable to females, given limited data on males.

CONCLUSIONS

CYP with restrictive EDs are at risk of growth impairment and pubertal delay, though potentially reversible. Attention to growth in EDs is important, especially in the young. Weight restoration should be encouraged to avoid adverse effects and allow opportunity for catch-up.

Premorbid BMI predicts binge-purge symptomatology among individuals with anorexia nervosa

OBJECTIVE

A finding consistent with the transdiagnostic approach to eating disorders is that about half of those with restricting anorexia nervosa (AN) eventually undergo a transition to the binge/purge (BP) subtype or to bulimia nervosa. Given evidence that individuals with bulimic symptoms exhibit elevated weights premorbidly, we tested the hypothesis that among those with AN, highest premorbid BMI would predict which individuals with AN would develop AN-BP.

METHOD

The current study used longitudinal data from a community sample of adolescents with AN in Sweden. Premorbid weights were obtained from growth charts, and participants were re-assessed at 6, 10, and 18 years after first presentation with AN.

RESULTS

A greater highest premorbid BMI z score predicted a greater likelihood of developing binge/purge symptoms over 18 years.

DISCUSSION

Among individuals who develop an eating disorder, premorbid BMI may be implicated in the type and course of the eating disorder that emerges.

Relationship between Risk Behavior for Eating Disorders and Dental Caries and Dental Erosion

The aim of this study was to evaluate whether there is an association between risk behavior for eating disorders (EDs) and dental erosion and caries. A controlled cross-sectional study was conducted in Brazil, involving 850 randomly selected female adolescents. After evaluating risk behavior for eating disorders through the Bulimic Investigatory Test of Edinburgh, 12 adolescents were identified with severe risk behavior for EDs and matched to 48 adolescents without such risk. Dental examinations, anthropometric measurements, and eating habits and oral hygiene were performed. Adolescents with high severity eating disorder condition were not more likely to show dental caries (p = 0.329; OR = 2.2, 95% CI: 0.35–13.72) or dental erosion (p = 0.590; OR = 2.33; 95% CI: 0.56–9.70). Adolescents with high body mass index (BMI) were five times more likely to have high severity eating disorder condition (p = 0.031; OR = 5.1; 95% CI: 1.61–23.07). Therefore, high severity risk behavior for EDs was not significantly associated with dental caries and dental erosion. However, high BMI was a risk factor for developing eating disorders and should be an alert for individuals with this condition.

Applying evidence-based management to anorexia nervosa

AIM

This paper considers how the three principles of evidence based practice (clinical expertise, scientific evidence, and patient preference) can be applied to the complexity of treatment for anorexia nervosa AN.

METHOD

A narrative review of the evidence of these three domains is presented. Clinical cases are used to illustrate how the formulation and management can be put into practice at different stages of illness.

RESULTS

The management of anorexia nervosa is complex. First, individuals with the illness do not regard the manifestations of the illness as a source of concern rather they are embraced and integrated into their identity. This contrasts to the reaction of other people who are terrified by the overt signs of ill health. Thus engagement into treatment is problematic. Second, the core symptom restricted eating, produces malnutrition which impacts on brain, body, and the social network. Thus a mixture of psychological and physical problems gradually accumulates over the course of the illness. This means that the treatment targets increase over time.

CONCLUSION

Thus treatment has to work with motivation and readiness to change and tackle the various domains of ill health.