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James RM, O'Shea J, Micali N, Russell SJ, Hudson LD. Physical health complications in children and young people with avoidant restrictive food intake disorder (ARFID): a systematic review and meta-analysis. BMJ Paediatr Open 2024; 8:e002595. [PMID: 38977355 DOI: 10.1136/bmjpo-2024-002595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/18/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Avoidant restrictive food intake disorder (ARFID) is a feeding and eating disorder with known acute and longstanding physical health complications in children and young people (CYP) and commonly presents to paediatricians. OBJECTIVE To systematically review the published literature on physical health complications in CYP with ARFID using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS A systematic search of PubMed, Embase, Web of Science, PsycINFO and Cochrane Library was performed on 14 February 2024. Studies reporting physical health complications in CYP ≤25 years with ARFID were included. We pooled studies for meta-analysis comparing ARFID with healthy controls or anorexia nervosa (AN). RESULTS Of 9058 studies found in searches, we included 132 studies. We found evidence for low weight, nutritional deficiencies and low bone mineral density. CYP with ARFID can present across the weight spectrum; however, the majority of CYP with ARFID were within the healthy weight to underweight range. Most studies reported normal range heart rates and blood pressures in ARFID, but some CYP with ARFID do experience bradycardia and hypotension. CYP with ARFID had higher heart rates than AN (weighted mean difference: 12.93 bpm; 95% CI: 8.65 to 17.21; n=685); heterogeneity was high (I2: 81.33%). CONCLUSION There is a broad range of physical health complications associated with ARFID requiring clinical consideration. Many CYP with ARFID are not underweight yet still have complications. Less cardiovascular complications found in ARFID compared with AN may be related to chronicity. PROSPERO REGISTRATION NUMBER CRD42022376866.
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Affiliation(s)
| | | | - Nadia Micali
- UCL GOS Institute of Child Health, London, UK
- Capital Region of Denmark Mental Health Services, Kobenhavn, Hovedstaden, Denmark
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Fekih-Romdhane F, Hallit R, Malaeb D, Sakr F, Dabbous M, Sawma T, Obeid S, Hallit S. Psychometric properties of an Arabic translation of the Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS) in a community sample of adults. J Eat Disord 2023; 11:143. [PMID: 37612764 PMCID: PMC10463449 DOI: 10.1186/s40337-023-00874-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/20/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND No epidemiological data is yet available on Avoidant/Restrictive Food Intake Disorder (ARFID) in Arab countries, which may in part be due to the lack of measures available in Arabic language. This constitutes a major obstacle to further progress of our understanding of the nature, aetiology, course, treatment, and prevention of ARFID, especially as some evidence suggested that ARFID may vary across cultures and food environments. We aimed to contribute to the literature in the eating disorders field by examining the psychometric properties of an Arabic translation of the Nine Item ARFID Screen (NIAS). METHOD This was a cross-sectional, web-based study. A total of 515 Lebanese community adults (mean age of 27.55 ± 10.92 years, 69.9% females) participated. The forward-backward method was adopted to translate the NIAS from English to Arabic. RESULTS Confirmatory Factor Analyses provided evidence for the adequate fit indices for the three-factor model (i.e., Picky eating, Fear, and Appetite) and the 9-item version of the NIAS. An adequate reliability of the Arabic NIAS was achieved, with McDonald's ω ranging from .75 to .90 for the total score and all three subscores. Multi-group analyses demonstrated measurement invariance by sex (males vs. females) and weight groups (underweight/healthy weight [BMI ≤ 25] vs. overweight/obese [BMI > 25]) at the configural, metric, and scalar levels. Adequate patterns of correlations between the NIAS and measures of disordered eating symptoms, psychological distress and well-being were seen. In particular, fear was significantly associated with non-ARFID disordered eating symptoms. Appetite and Picky eating, but not Fear, were inversely correlated with well-being. All three NIAS subscores and the total score were positively correlated with psychological distress. CONCLUSION Findings provided evidence that the Arabic NIAS is a short, valid and reliable self-report measure to screen for ARFID symptoms. In light of these findings, we recommend its use for clinical and research purposes among Arabic-speaking adults.
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Affiliation(s)
- Feten Fekih-Romdhane
- The Tunisian Center of Early Intervention in Psychosis, Department of Psychiatry "Ibn Omrane", Razi Hospital, 2010, Manouba, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Rabih Hallit
- School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, P.O. Box 446, Jounieh, Lebanon
- Department of Infectious Disease, Bellevue Medical Center, Mansourieh, Lebanon
- Department of Infectious Disease, Notre Dame des Secours University Hospital, Postal Code 3, Byblos, Lebanon
| | - Diana Malaeb
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
- College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Fouad Sakr
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Mariam Dabbous
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Toni Sawma
- School of Arts and Sciences, Social and Education Sciences Department, Lebanese American University, Jbeil, Lebanon
| | - Sahar Obeid
- School of Arts and Sciences, Social and Education Sciences Department, Lebanese American University, Jbeil, Lebanon.
| | - Souheil Hallit
- School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, P.O. Box 446, Jounieh, Lebanon.
- Psychology Department, College of Humanities, Effat University, 21478, Jeddah, Saudi Arabia.
- Applied Science Research Center, Applied Science Private University, Amman, Jordan.
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon.
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Di Cara M, Rizzo C, Corallo F, Cardile D, Calabrò RS, Quartarone A, Buda M, Cucinotta F. Avoidant Restrictive Food Intake Disorder: A Narrative Review of Types and Characteristics of Therapeutic Interventions. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1297. [PMID: 37628296 PMCID: PMC10453506 DOI: 10.3390/children10081297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023]
Abstract
The diagnosis of avoidant/restrictive food intake disorder (ARFID) was added to the diagnostic and statistical manual of mental disorders (DSM-5) just 10 years ago. This disorder consists of the failure to meet one's nutritional and/or energy needs, which may result in significant weight loss, significant nutritional deficit or functioning dependent on enteral nutrition or oral supplements. In children with this disorder, development is often problematic, and there is also marked interference with psychosocial functioning at all ages. The causes leading to food avoidance in these patients may be related to a lack of interest, to the sensory properties of the food or to the possible adverse consequences associated with it. Given the multitude of aspects involved in this disorder and the impact it has especially on younger patients, more and more studies are addressing treatments and related benefits and/or complications. A narrative review of currently published studies was performed for articles published before 5 March 2023 on therapeutic interventions in patients with ARFID. Because of the large number of results obtained, this review was conducted only via PubMed in order to analyze and discuss children and adolescent ARFID treatments reported in literature. The treatments most often referred to in the literature are cognitive behavioral therapy, family-based therapy and pharmacological treatment. All the data on these treatments are promising. However, due to the recent introduction of this disorder and the limited data still available, a multidisciplinary approach seems to be the best option.
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Affiliation(s)
| | | | | | - Davide Cardile
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113 Via Palermo, C.da Casazza, 98124 Messina, Italy; (M.D.C.); (F.C.); (R.S.C.); (A.Q.); (M.B.); (F.C.)
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Kerem L, Van De Water AL, Kuhnle MC, Harshman S, Hauser K, Eddy KT, Becker KR, Misra M, Micali N, Thomas JJ, Holsen L, Lawson EA. Neurobiology of Avoidant/Restrictive Food Intake Disorder in Youth with Overweight/Obesity Versus Healthy Weight. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2022; 51:701-714. [PMID: 33769133 PMCID: PMC8464625 DOI: 10.1080/15374416.2021.1894944] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Avoidant/restrictive food intake disorder (ARFID) occurs across the weight spectrum, however research addressing the coexistesnce of ARFID with overweight/obesity (OV/OB) is lacking. We aimed to establish co-occurrence of OV/OB and ARFID and to characterize divergent neurobiological features of ARFID by weight. METHOD Youth with full/subthreshold ARFID (12 with healthy weight [HW], 11 with OV/OB) underwent fasting brain fMRI scan while viewing food/non-food images (M age = 16.92 years, 65% female, 87% white). We compared groups on BOLD response to high-calorie foods (HCF) (vs. objects) in food cue processing regions of interest. Following fMRI scanning, we evaluated subjective hunger pre- vs. post-meal. We used a mediation model to explore the association between BMI, brain activation, and hunger. RESULTS Participants with ARFID and OV/OB demonstrated significant hyperactivation in response to HCF (vs. objects) in the orbitofrontal cortex (OFC) and anterior insula compared with HW participants with ARFID. Mediation analysis yielded a significant indirect effect of group (HW vs. OV/OB) on hunger via OFC activation (effect = 18.39, SE = 11.27, 95% CI [-45.09, -3.00]), suggesting that OFC activation mediates differences in hunger between ARFID participants with HW and OV/OB. CONCLUSIONS Compared to youth with ARFID and HW, those with OV/OB demonstrate hyperactivation of brain areas critical for the reward value of food cues. Postprandial changes in subjective hunger depend on BMI and are mediated by OFC activation to food cues. Whether these neurobiological differences contribute to selective hyperphagia in ARFID presenting with OV/OB and represent potential treatment targets is an important area for future investigation.
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Affiliation(s)
- Liya Kerem
- Neuroendocrine Unit, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School
- Division of Pediatric Endocrinology, Mass General Hospital
for Children
| | - Avery L. Van De Water
- Neuroendocrine Unit, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School
- Division of Women’s Health, Department of Medicine
and Department of Psychiatry, Brigham and Women’s Hospital and Harvard
Medical School
| | - Megan C. Kuhnle
- Neuroendocrine Unit, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School
| | - Stephanie Harshman
- Neuroendocrine Unit, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School
| | - Kristine Hauser
- Neuroendocrine Unit, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School
| | - Kamryn T. Eddy
- Eating Disorders Clinical and Research Program,
Massachusetts General Hospital, Department of Psychiatry and Harvard Medical
School
| | - Kendra R. Becker
- Eating Disorders Clinical and Research Program,
Massachusetts General Hospital, Department of Psychiatry and Harvard Medical
School
| | - Madhusmita Misra
- Neuroendocrine Unit, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School
- Division of Pediatric Endocrinology, Mass General Hospital
for Children
| | - Nadia Micali
- Department of Psychiatry, Great Ormond Street Institute of
Child Health, University College London
- Department of Psychiatry, Faculty of Medicine and Child and
Adolescent Psychiatry Division, Department of Child and Adolescent Health,
University of Geneva
| | - Jennifer J. Thomas
- Eating Disorders Clinical and Research Program,
Massachusetts General Hospital, Department of Psychiatry and Harvard Medical
School
| | - Laura Holsen
- Division of Women’s Health, Department of Medicine
and Department of Psychiatry, Brigham and Women’s Hospital and Harvard
Medical School
| | - Elizabeth A. Lawson
- Neuroendocrine Unit, Department of Medicine, Massachusetts
General Hospital and Harvard Medical School
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Micronutrient Deficiencies Presenting with Optic Disc Swelling Associated with or without Intracranial Hypertension: A Systematic Review. Nutrients 2022; 14:nu14153068. [PMID: 35893919 PMCID: PMC9331791 DOI: 10.3390/nu14153068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a neurological disorder characterised by optic disc swelling secondary to raised intracranial pressure (ICP) of unknown cause. Obesity is the most established and prevalent risk factor in developed countries. As obesogenic diets are high in calories and nutrient-poor, there may be associated nutritional deficiencies that contribute to the clinical presentation of IIH. Yet none, aside from iron deficiency, are currently included in the inclusion or exclusion criteria for the diagnosis of IIH. Our primary aim was to determine which micronutrient deficiencies, aside from iron deficiency, could present with optic disc swelling associated with or without intracranial hypertension that could potentially meet current IIH diagnostic criteria. To this end, we conducted a systematic search of articles published between 1 January 1980 and 18 December 2020 reporting cases of optic disc swelling associated with micronutrient deficiencies. In total, 65 cases met the eligibility criteria from initial searches: all were case reports and case series with a high risk of bias. Our findings suggest that patients with IIH or unexplained optic disc swelling ought to be screened, investigated, and treated for associated micronutrient deficiencies in vitamin A, B1 and B12; and weight loss interventions in IIH patients ought to promote better nutrition in addition to overall calorie restriction.
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Food Aversion Leading to Nutritional Optic Neuropathy in a Child With Severe Vitamin A Deficiency. J Neuroophthalmol 2021; 41:e718-e719. [PMID: 33136685 DOI: 10.1097/wno.0000000000001142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dolman L, Thornley S, Doxtdator K, Leclerc A, Findlay S, Grant C, Breakey VR, Couturier J. Multimodal therapy for rigid, persistent avoidant/restrictive food intake disorder (ARFID) since infancy: A case report. Clin Child Psychol Psychiatry 2021; 26:451-463. [PMID: 33334145 DOI: 10.1177/1359104520981401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Avoidant/restrictive food intake disorder (ARFID) is a feeding and eating disorder that results in nutritional inadequacies, weight loss, and/or dependence on enteral feeds, and for which three clinical subtypes have been described. We present a unique case of an 11-year-old boy with rigid ARFID since infancy and features of all three ARFID subtypes. The patient presented with a life-long history of sensory aversion, limited intake and phobia of vomiting resulting in restriction to a single food item (yogurt) for more than 5 years. He presented with severe iron-deficiency anaemia, and deficiencies of vitamins A, C, D, E and zinc. We employed a multimodal therapeutic approach that incorporated elements of cognitive-behavioural therapy (CBT), family-based therapy (FBT) and pharmacological management with an antidepressant medication (sertraline) and an atypical antipsychotic agent (olanzapine). Over the course of a 7-week admission, our approach assisted the patient in successful weight restoration and incorporation of at least three new food items into his daily diet. While there are currently no first-line recommendations for ARFID management, our study lends support to the efficacy of CBT, FBT and pharmacological management for ARFID patients, including complex cases with multiple subtype features. Further research is needed to strengthen ARFID clinical guidelines.
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Affiliation(s)
- Lena Dolman
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | | | - Sheri Findlay
- Division of Adolescent Medicine, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Christina Grant
- Division of Adolescent Medicine, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Vicky R Breakey
- Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Jennifer Couturier
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
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Macro- and Micronutrient Intake in Children with Avoidant/Restrictive Food Intake Disorder. Nutrients 2021; 13:nu13020400. [PMID: 33513954 PMCID: PMC7911718 DOI: 10.3390/nu13020400] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 11/30/2022] Open
Abstract
Although case studies in avoidant/restrictive food intake disorder (ARFID) indicate severe nutritional deficiencies in those with a highly limited amount or variety of food intake, systematic analyses on food intake in treatment-seeking children and adolescents with ARFID are lacking. Within this study, n = 20 patients with an interview-based diagnosis of ARFID (0–17 years) were included and compared to n = 20 healthy controls individually matched for age and sex. Children or parents completed three-day food diaries and a food list. Macronutrient, vitamin, and mineral supply was determined based on the percentage of their recommended intake. The results showed a significantly lower total energy and protein intake in ARFID versus controls, with trends for lower fat and carbohydrate intake. ARFID subtypes of limited amount versus variety of food intake significantly differed in macro-, but not micronutrient intake. Those with ARFID met only 20–30% of the recommended intake for most vitamins and minerals, with significantly lower intake relative to controls for vitamin B1, B2, C, K, zinc, iron, and potassium. Variety of food intake was significantly reduced in ARFID versus controls in all food groups except carbohydrates. This study demonstrated that ARFID goes along with reduced everyday life macro- and micronutrient intake, which may increase the risk for developmental and health problems. Future studies additionally assessing serum nutrient levels in a larger sample may further explore differences in food intake across diverse ARFID presentations.
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Bourne L, Bryant-Waugh R, Cook J, Mandy W. Avoidant/restrictive food intake disorder: A systematic scoping review of the current literature. Psychiatry Res 2020; 288:112961. [PMID: 32283448 DOI: 10.1016/j.psychres.2020.112961] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/24/2020] [Accepted: 03/27/2020] [Indexed: 01/16/2023]
Abstract
Avoidant/restrictive food intake disorder (ARFID) was recently introduced to psychiatric nosology to describe a group of patients who have avoidant or restrictive eating behaviours that are not motivated by a body image disturbance or a desire to be thinner. This scoping review aimed to systematically assess the extent and nature of the ARFID literature, to identify gaps in current understanding, and to make recommendations for further study. Following an extensive database search, 291 unique references were identified. When matched against pre-determined eligibility criteria, 78 full-text publications from 14 countries were found to report primary, empirical data relating to ARFID. This literature was synthesised and categorised into five subject areas according to the central area of focus: diagnosis and assessment, clinical characteristics, treatment interventions, clinical outcomes, and prevalence. The current evidence base supports ARFID as a distinct clinical entity, but there is a limited understanding in all areas. Several possible avenues for further study are indicated, with an emphasis placed on first parsing this disorder's heterogeneous presentation. A better understanding of the varied mechanisms which drive food avoidance and/or restriction will inform the development of targeted treatment interventions, refine screening tools and impact clinical outcomes.
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Affiliation(s)
- Laura Bourne
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
| | - Rachel Bryant-Waugh
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Julia Cook
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - William Mandy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
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Strand M, von Hausswolff-Juhlin Y, Welch E. A systematic scoping review of diagnostic validity in avoidant/restrictive food intake disorder. Int J Eat Disord 2019; 52:331-360. [PMID: 30489647 DOI: 10.1002/eat.22962] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Avoidant/restrictive food intake disorder (ARFID) was introduced as a new diagnosis in the DSM-5. This systematic scoping review explores how ARFID as a diagnostic entity is conceptualized in the research literature and evaluates the diagnostic validity according to the Feighner criteria. METHOD A systematic scoping review of papers on ARFID in PubMed/MEDLINE and Web of Science was undertaken, following PRISMA and Joanna Briggs Institute guidelines. RESULTS Fifty-one original research publications, 23 reviews and commentaries, and 20 case reports were identified. The use of ARFID as a conceptual category varies significantly within this literature. At this time, the ARFID diagnosis does not fulfil the Feighner criteria for evaluating the validity of diagnostic constructs, the most urgent problem being the demarcation toward other disorders. A three-dimensional model-lack of interest in food, selectivity based on sensory sensitivity, and fear of aversive consequences-is gaining support in the research literature. DISCUSSION The introduction of the ARFID diagnosis has undoubtedly increased the recognition of a previously largely neglected group of patients. However, this article points to an inability of the current DSM-5 diagnostic criteria to ensure optimal diagnostic validity, which risks making them less useful in clinical practice and in epidemiological research. To increase the conceptual validity of the ARFID construct, several possible alterations to the current diagnostic criteria are suggested, including a stronger emphasis of the three identified subdomains and further clarifying the boundaries of ARFID.
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Affiliation(s)
- Mattias Strand
- Stockholm Centre for Eating Disorders, Stockholm, Sweden.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Yvonne von Hausswolff-Juhlin
- Stockholm Centre for Eating Disorders, Stockholm, Sweden.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Elisabeth Welch
- Stockholm Centre for Eating Disorders, Stockholm, Sweden.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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