Medical Complications of Eating Disorders in Youth

Sexual orientation discrimination and eating disorder symptoms in early adolescence: a prospective cohort study

BACKGROUND

Sexual orientation discrimination increases the risks of negative health outcomes for sexual minorities. Previous studies have found increased rates of eating disorder symptoms in sexual minority individuals, which is attributable to minority stress and discrimination that they experience. Emerging research suggests relationships between sexual orientation discrimination and eating disorder symptoms. However, there is a lack of studies focusing on early adolescents. The objective of this study was to determine prospective associations between discrimination based on sexual orientation and eating disorder symptoms in a national sample of 10-13-year-old early adolescents in the U.S.

METHODS

We examined prospective data from Year 2 (2018-2020) and Year 3 (2019-2021) of the Adolescent Brain Cognitive Development (ABCD) Study (N = 8976). Multiple logistic regression analyses were used to estimate associations between self-reported experiences of sexual orientation discrimination in Year 2 and eating disorder symptoms in Year 3, adjusting for potential confounders, including eating disorder symptoms in Year 2. Sexual orientation discrimination was assessed based on the Perceived Discrimination Scale, which measures adolescents' perception of being treated unfairly based on various sociodemographic characteristics. Eating disorder symptoms were based on the parent-reported Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5).

RESULTS

In this demographically diverse sample of early adolescents (N = 8976, age range 10-13 years at Year 2), 5.5% of adolescents reported sexual orientation discrimination in Year 2. The prevalence of parent-reported eating disorder symptoms in Year 3 varied from 1.0 to 8.3%. In the adjusted models, sexual orientation discrimination was prospectively associated with worry about weight gain (adjusted odds ratio [aOR] 2.33, 95% confidence interval [CI] 1.15-4.69) and self-worth tied to weight (aOR 1.60, 95% CI 1.01-2.53) one year later.

CONCLUSIONS

Early adolescents who have experienced sexual orientation discrimination have higher odds of experiencing eating disorder symptoms, particularly worrying about weight gain and tying self-worth to weight. Clinicians may consider screening for sexual orientation discrimination and providing affirmative, trauma-informed care when evaluating and treating even younger sexual minority adolescents for eating disorder symptoms.

Growing up in a larger body: youth- and parent-reported triggers for illness and barriers to recovery from anorexia nervosa

BACKGROUND

A significant portion of youth with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) have history of 'overweight/obesity' (i.e., body mass index ≥ 85th percentile for age-and-sex) prior to the onset of the eating disorder (ED) diagnosis, but research on this population remains limited. The present study used semi-structured interviews to explore themes related to triggers of weight loss, treatment, and recovery among youth with AN/AAN and history of 'overweight/obesity,' and their parents.

METHOD

The sample included eleven youth and parent dyads (Median [IQR] age of youth = 16.0 (1.5) years, 90.9% female, 90.9% White, 27.3% Hispanic) who were evaluated for an ED in a multidisciplinary ED program at a pediatric hospital between November 2020 and April 2021. Nine youth and separately, nine parents of these 11 dyads completed semi-structured interviews with the research team. Seven matched pairs of patients and parents completed demographic surveys and study interviews. Interviews were recorded, transcribed, and coded by four research team members using a reflexive thematic approach.

RESULTS

Weight stigma was the most frequently reported theme for a trigger for weight loss that led to the onset for developing AN/AAN by both youth and parents. Regarding barriers to recovery, themes from more than a half of youth included uncertainty of weight goals in treatment and feeling they are "not sick enough." Notable themes for attitudes towards treatment from most parents included general agreement with clinician recommendations, but also an uncertainty of weight restoration goals and a belief that their child need to have a "normal" weight.

CONCLUSION

These results highlighted how the majority of interviewed youth with history of 'overweight/obesity' reported weight stigma as both a trigger for the development of AN/AAN as well as a barrier to recovering. Internalized weight stigma among parents may influence their attitudes towards weight restoration as a treatment goal where these youth and parents may experience uncertainty of weight goals in treatment. This study demonstrated triggers and barriers to treatment that may be unique to youth with ED and history of 'overweight/obesity' and more research is needed to address weight stigma in multidisciplinary ED treatment for this understudied population.

Exploring Reciprocal Associations Between Self-Reported Anxiety and Eating Disorder Symptoms Longitudinally: A Bivariate Latent Change Score Approach

OBJECTIVE

Consistent data support an association between anxiety and eating disorders (EDs), and theoretical models of EDs suggest that anxiety may be involved in the etiology and maintenance of ED symptoms over time. However, the directionality of relations between these variables remains under-characterized, particularly within treatment settings.

METHOD

We used bivariate latent change score models to explore longitudinal associations between anxiety and ED symptoms in a sample of ED patients (N = 548, 93.2% female, Mage = 21.16, 78.8% White, 79.6% Non-Hispanic/Latinx) throughout intensive treatment and at 6- and 12-month follow-up.

RESULTS

Best-fitting models exploring change in each variable independently (i.e., univariate models) suggested that changes in ED and anxiety symptoms decreased over time, but that change was influenced by an individual's symptom severity at the previous timepoint. Models exploring associations between changes in both variables over time (i.e., bivariate latent change score models) suggested the best fit for a model where both anxiety and ED symptoms at one timepoint were associated with later change in the other. Specifically, parameters within these models suggested that higher levels of anxiety were associated with increased subsequent reductions in ED symptoms, whereas elevations in ED symptoms were associated with decreased later reductions in anxiety.

CONCLUSIONS

Our findings suggest that anxiety and ED symptoms are intricately related both within and outside of intensive treatment. Future multi-modal research exploring real-time links between anxiety and ED symptoms throughout treatment is critical to extend this work and inform improvements in targeted, mechanistic interventions for this population.

Weight Stigma in the Development, Maintenance, and Treatment of Eating Disorders: A Case Series Informing Implications for Research and Practice

Weight-centric health practices are based on the principle that excess weight predicts chronic disease, informing a growing sociopolitical movement to address an "obesity epidemic." This hyper-focus on preventing obesity may contribute to weight stigma (i.e., the devaluation and discrimination of individuals based on body size) and other iatrogenic outcomes for youth, including the development and maintenance of eating disorders (EDs). Current evidence-based treatments for EDs include language and practices that may reinforce fears of fatness, body shame, and unhealthy dietary restriction without guidance on addressing weight stigma. Here, we present case examples from three adolescent patients across ED presentations and body sizes to (1) elucidate the role of weight stigma in ED development, (2) highlight the ubiquity and harms of weight stigma within ED treatments, and (3) outline thoughtful protocol adaptations to avoid further harm and facilitate recovery. We conclude with a call for immediate action to advance research characterizing the harms of weight-centric approaches in existing ED interventions to reduce the risk of iatrogenic effects on youth with EDs and advance weight-inclusive approaches to ED treatment.

Exploring the moderating roles of dispositional mindfulness and body image flexibility in the association between body dissatisfaction and disordered eating in Chinese adolescents

OBJECTIVES

Previous research suggests potential moderating roles of dispositional mindfulness and body image flexibility in the association between body dissatisfaction and disordered eating. However, relevant research is mainly conducted on adult women from Western countries, and limited evidence exists for adolescent samples, especially from non-Western contexts (e.g., China). Thus, this study aimed to examine the moderating roles of dispositional mindfulness and body image flexibility in the relationship between body dissatisfaction and disordered eating in Chinese adolescents.

METHOD

We recruited 545 Chinese adolescents (53.9% boys, aged 12-16 years) who completed measures of body dissatisfaction, dispositional mindfulness, body image flexibility, and disordered eating. Moderation analyses were examined with PROCESS macro on SPSS.

RESULTS

In separate models, both higher dispositional mindfulness and body image flexibility weakened relationships between body dissatisfaction and disordered eating. However, when both dispositional mindfulness and body image flexibility were entered into the same moderation model, only body image flexibility showed a significant moderating effect.

DISCUSSION

Both dispositional mindfulness and body image flexibility may weaken the association between body dissatisfaction and disordered eating in adolescents. However, body image flexibility might have a stronger effect than dispositional mindfulness. These findings suggest that interventions aimed at reducing body dissatisfaction to prevent disordered eating in adolescents may pay more attention to adolescents' body image flexibility.

Is Adherence to the Saudi Healthy Plate Dietary Guidelines Associated with Eating Concerns Symptoms among Saudi Young Females?

BACKGROUND

Food-based dietary guidelines (FBDGs) offer broad recommendations based on scientific evidence, focusing on food groups rather than nutrients that should be included in the diet. Emerging adulthood (18-30 years) is a critical period for poor dietary quality and mental health. Eating habits (EHs) are formed early in life and are influenced by various factors, such as emotional state, which can lead to either binge or restricted eating, ultimately increasing the risk of eating disorders (EDs). This cross-sectional study aimed to investigate the extent of adherence to the Saudi Healthy Plate Dietary Guidelines (SHPDGs) and its potential association with Eating Concerns (ECs) among Saudi females (aged 18-30 years) from all provinces in the Kingdom of Saudi Arabia.

METHODS

A validated online questionnaire was used to assess eating behaviors (EBs) using the Starting The Conversation (STC) instrument and EC symptoms using the Eating Disorders Screen for Primary Care (ESP) screening tool.

RESULTS

The total sample size was 1092 participants with a mean age of 23.02 ± 3.47. Only 0.7% of the participants adhered to the SHPDGs and were free of EC symptoms. Conversely, 50.4% of participants who exhibited EC symptoms had poor adherence to the SHPDGs. Across Saudi Arabian provinces, high adherence to the SHPDGs was more prominent in both the Eastern and Western provinces (37.5%) than in the Central and Southern provinces (0%). The most striking result was that the Central province exhibited a high percentage of poor adherence to the SHPDGs (25.6%). Moreover, high adherence to SHPDGs was not associated with the probability of ECs.

CONCLUSIONS

The present study revealed a trend of poor adherence to SHPDGs among Saudi females, with a large proportion also experiencing EC symptoms. Accordingly, the authors recommend increasing awareness within the Saudi community about SHPDGs using educational campaigns on social media platforms to enhance the importance of adopting a healthy diet, especially among females, and demonstrate that the impact on their health and well-being is that they are experiencing multiple phases that involve pregnancy and giving birth involves specific nutritional requirements.

Wernicke Encephalopathy Caused by Avoidance-Restrictive Food Intake Disorder in a Child: A Case-Based Review

BACKGROUND

Wernicke encephalopathy (WE) is an acute and potentially fatal neuropsychiatric disorder resulting from thiamine deficiency: its etiology and clinical presentation can be heterogeneous and arduously recognized, especially in children and adolescents.

CASE PRESENTATION

An 8-year-old girl arrived to the emergency room with ataxic gait, nystagmus, and mental confusion after a 10-day history of repeated severe vomiting; her recent clinical history was characterized by restricted nutrition due to a choking phobia, which caused substantial weight loss. Brain magnetic resonance imaging revealed a bilaterally increased T2 signal in the medial areas of the thalami and cerebral periaqueductal region. Diagnosis of WE based on clinical and neuroradiological findings was established and confirmed after labwork showing low serum thiamine. Following psychiatric evaluation, the patient was also diagnosed with avoidance-restrictive food intake disorder (ARFID), which required starting cognitive behavioral therapy and introducing aripiprazole. The patient displayed improvement of the radiological findings after one month and complete resolution of her neurological symptoms and signs.

CONCLUSIONS

Eating disorders like ARFID might forerun acute signs of WE; this possibility should be considered even in pediatric patients, especially when atypical neurological pictures or feeding issues come out.

Perceptual Dysfunction in Eating Disorders

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

Disparities in Medical Assessment Practices for Adolescents at Risk for Eating Disorders

PURPOSE

The United States Preventative Services Task Force found insufficient evidence to support universal screening for eating disorders (EDs) but did recommend assessing high-risk adolescents through laboratory tests, close follow-up, and referrals to other specialties. Yet, it is unclear whether youth at high risk for EDs receive such assessment and whether patient characteristics influence such practices.

METHODS

Using the Rochester Epidemiological Project, we identified adolescents (13-18 years) at risk for EDs (i.e., weight loss, underweight, or loss of appetite not explained by a medical condition) who presented for a medical appointment between January 1, 2005 to December 31, 2017 (n = 662; M age = 15.8 years; 66% female; 76% white). Patient and visit characteristics, assessment practices (i.e., tests, referrals, and follow-up), and ED diagnoses within 5 years following index visit were extracted.

RESULTS

Adolescents who received referrals to other providers were 4 times more likely to be diagnosed with a future ED (p < .001) and were diagnosed 137.8 days sooner (Est = -137.8, p = .04) compared to those who did not receive referrals. Compared to males, females were 2.2 times more likely to receive referrals (p < .001). Compared to those presenting at a lower body mass index, adolescents with a higher body mass index were more likely to receive medical tests (HR = 1.0, p < .01) and less likely to receive recommendations to improve eating/weight (HR = 0.99, p < .01) or follow up visits (HR = 0.99, p < .01).

DISCUSSION

Disparities in assessment practices for adolescents at high-risk for EDs underscore the need for improved tools to enhance early detection and treatment.

An Update on Eating Disorders

Abstract:

It is no surprise that eating disorders (EDs) are increasing all over the planet. With the emergence of global westernization, development in technology, and societal changes, nearly all regions of the globe have been influenced by the concept of a perfect body image and height. EDs are a considerable public concern, a bewilderment for psychologists and a challenge for physicians. The primary EDs include anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). AN is an ED that is psychological and possibly life-threatening. Usually, people with AN experience an exceedingly low body weight due to their height and body shape. The highest rate of occurrence is between 14 and 17 years of age. BN is an extreme, lifethreatening, neurological ED in which you have binge eating cycles. You may not have any sense of balance in your diet throughout these binges. The weight-control engagement of patients with AN and BN results in various physiological shifts. EDs can control your lives and can be quite hard to cope with. Yet you will develop a better understanding of who you are by therapy, return to healthy eating and exercise, and undo any of the severe complications of AN. Investigation into EDs has yielded valuable new information over the past few decades, notably involving the psychological features and care of patients. The purpose of this study/review is to expand the knowledge of the people about these EDs, their global burden, diagnostic criteria, risk factors, medical complications, management, and the newly added avoidant/restrictive food intake disorder.

TransitionED: A protocol for Co-designing and implementing Canadian practice guidelines for transitions for youth with eating disorders

OBJECTIVE

Limited guidelines inform the transition from paediatric to adult healthcare for youth and young adults (YYA) with eating disorders (EDs). This study will develop, implement, and evaluate Canadian Clinical Practice Guidelines for ED transition, including identifying the relevant measurement and evaluation tools for transition readiness and continuity of care.

METHODS

This study consists of three phases. Phase 1 involves conducting a scoping review of the evidence on transition interventions, outcomes, and measurement tools for YYA with EDs, along with guideline development using the modified Delphi method. Phase 2 identifies the contextual/cultural factors relevant to guideline implementation and co-designing an implementation protocol with governance committees and research partners. Phase 3 involves the application and evaluation of the proposed guide lines using the implementation protocol, and assessing the acceptability and feasibility of a prototype transition intervention in two Canadian paediatric ED programs.

CONCLUSIONS

Results will provide the knowledge needed to enhance the lives of YYA, improve the effectiveness of the ED care system, and support the scale of the transition guidelines across Canada. These guidelines will have international relevance by potentially informing the field on how to support young people with EDs transitioning in similar funding structures and systems of care.

Parental self-efficacy: Longitudinal impact on clinical outcomes across levels of care in adolescent anorexia nervosa

OBJECTIVE

Parental self-efficacy in the domain of weight restoration for adolescents with restrictive eating disorders is central to success in family-based interventions. We sought to characterize this parental self-efficacy during a brief hospitalization for medical stabilization and follow-up among patients with anorexia nervosa (AN) or atypical AN (AAN) enrolled in the StRONG clinical trial to understand the potential impact of inpatient treatment on caregiver empowerment.

METHODS

Patients were enrolled upon hospital admission and refed per protocol. We examined correlates of the Parents Versus Anorexia (PVA) scale, a measure of parental self-efficacy in the domain of weight restoration, at admission, discharge, 10-days, 1-month, and 3-months post-discharge. Multi-level models evaluated associations among PVA scores and change in %median BMI and Eating Disorder Examination-Questionnaire (EDE-Q) global scores over 3-months post-discharge.

RESULTS

Parents of N = 67 adolescents and young adults M(SD) age 15.79 (2.20) years and 85.00 (11.86) %median BMI participated. PVA scores did not change significantly during hospitalization (p = .053), which lasted on average 10.7 ± 4.5 days. PVA scores increased post-discharge (p = .009), with significant increase between discharge and 1-month post-discharge (p = .045). PVA scores were not associated with subsequent clinical outcomes. Rather, a main effect of time significantly predicted higher %median BMI and improved EDE-Q scores (p < .001).

DISCUSSION

The finding that parental self-efficacy did not deteriorate during the inpatient stay is promising given the medical necessity of hospitalization to ensure short-term safety in some cases and the importance of parental self-efficacy to support long-term recovery.

PUBLIC SIGNIFICANCE

Family-based treatment is the recommended treatment for young people with AN and AAN, serious psychiatric illnesses that may require inpatient medical stabilization. Prior evidence suggests that parental self-efficacy in the outpatient setting is a key component of treatment success. The current study suggests that parental self-efficacy and longer-term treatment outcomes are not undermined by a brief inpatient hospitalization.

An exploration of the association between premorbid weight status on patient and caregiver factors at pre and post-treatment among youth with anorexia nervosa/atypical anorexia nervosa

Patients with atypical anorexia nervosa (AAN) or anorexia nervosa (AN) with premorbid history of higher weight (PHW; median BMI ≥ 85th %ile) may report greater eating disorder (ED) pathology, anxiety, and depression, than patients with premorbid history of lower weight (PLW; mBMI <85th %ile). Less is known about caregiver attitudes or treatment outcome related to premorbid weight history. The current study examined associations between premorbid weight history and patient/caregiver factors at presentation, during treatment, and end of treatment among adolescents (N = 138) diagnosed with AN/AAN and their caregivers who received interdisciplinary ED treatment. The sample comprised adolescents with PHW (n = 58, 40.6 %) or PLW (n = 82, 59.4 %). Adolescents with PHW did not differ with regard to patient- or caregiver-reported ED symptoms, comorbid psychopathology, rates of treatment completion, and attainment of estimated body weight compared to PLW (ps > .05). Adolescents with PHW (vs. PLW) were more likely to be diagnosed with AAN (67.9 %, p < .001), identify as cisgender male (p < .001) and to have lost more weight prior to presentation (p < .001). Perceived caregiver burden was lower among adolescents with PHW vs. PLW (p < .001). Further research should expand on this preliminary study exploring associations between premorbid weight history on patient and caregiver factors at treatment presentation and conclusion to enhance the efficacy of evidence-based treatment across the weight-spectrum.

Parental dieting impacts inpatient treatment outcomes for adolescents with restrictive eating disorders

OBJECTIVE

Parental feeding practices and disordered eating are potential risk factors for the development of disordered eating in children and adolescents. This study measured the relationship between parental dieting behaviours and inpatient treatment outcomes for adolescents with restrictive eating disorders (EDs).

METHOD

Parents of adolescents with restrictive EDs (N = 45) admitted to a specialty integrated inpatient-partial hospital meal-based ED treatment programme completed questionnaires assessing parental eating and exercise behaviours. Adolescent clinical data, including percentage median body mass index (%mBMI) at admission and discharge and rate of weight gain, were abstracted from the electronic medical record.

RESULTS

Adolescents whose parents reported dieting had a slower rate of weight gain (3.47 lbs./week) compared to participants whose parents were not dieting (4.54 lbs./week; p = 0.017). Additionally, participants whose parents reported dieting had a lower %mBMI at programme discharge (M = 93.56) than participants whose parents did not report dieting (M = 95.99; p = 0.033).

CONCLUSION

Parental dieting behaviours may impact an adolescent's response to inpatient ED treatment. Findings suggest a need to assess parental dieting behaviour, and when appropriate, provide additional psychoeducation regarding the potential risks of weight or shape-focussed dialogue and the benefits of modelling adaptive meal behaviours.

Adolescents with anorexia nervosa or atypical anorexia nervosa with premorbid overweight/obesity: What should we do about their weight loss?

Traditionally, anorexia nervosa (AN) was understood to exist exclusively among underweight individuals and weight was used to assess level of severity and course of treatment. Recent trends have found a growing number of individuals presenting with AN or atypical AN (AAN) (i.e., those who remain with weight in a "normal" or "healthy" range despite significant weight loss) have a premorbid history of overweight/obesity. Individuals with AN/AAN and premorbid overweight/obesity represent an especially metabolically vulnerable population as with either AN or AAN, there is marked weight loss. Patients with AAN present a specific challenge as healthcare professionals must identify a clinically significant eating disorder in adolescents of potentially "normal" weights and then must balance their knowledge and training of traditional treatment of AN with obesity treatment and prevention. Currently, there are no evidence-based treatments to guide medical and mental health professionals regarding weight restoration, medical stabilization, and psychological treatment in patients with AN/AAN with a history of overweight/obesity while also addressing risk prevention for obesity.

Eating Disorders and Metabolic Diseases

Eating disorders are complex diseases with multifactorial causes. According to the Diagnostic and Statistical Manual of Mental Disorders text version (DSM-5-TR) and the WHO International Classification of Diseases and Related Health Problems (ICD-11), the major types of eating disorders include anorexia nervosa, bulimia nervosa, and binge eating disorder. The prevalence of eating disorders is alarmingly increasing globally. Moreover, the COVID-19 pandemic has led to more development and worsening of eating disorders. Patients with eating disorders exhibit high rates of psychiatric comorbidities and medical comorbidities such as obesity, diabetes, and metabolic syndrome. This paper aims to review and discuss the comorbidities of eating disorders with those metabolic diseases. Eating disorder treatment typically includes a combination of some or all approaches such as psychotherapy, nutrition education, and medications. Early detection and intervention are important for the treatment of eating disorders.

Considerations in Evidence-Based Treatment of Adolescents With Atypical Anorexia Nervosa

There is emerging evidence suggesting atypical anorexia nervosa (AAN), an eating disorder (ED) introduced in the DSM-5, is as serious an ED as anorexia nervosa (AN) in terms of medical risk and ED pathology. Medical hospitalizations among individuals with AAN have significantly increased over the years and individuals with AAN are noted to have longer illness durations and greater weight loss prior to receiving care than individuals with AN. Additionally, AAN is noted to be two to three times more common than AN in community samples of adolescents. Given that AAN is a newer diagnosis, research knowledge and evidence-based treatment guidelines are emerging, yet pivotal. Thus, this article discusses specific considerations during assessment and treatment using Family Based Treatment (FBT) among adolescents diagnosed with AAN and clinical and ethical concerns involved while providing effective care and mitigating any weight bias or stigma related to historical and current weight status.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Post-traumatic stress symptoms in parents of adolescents hospitalized with Anorexia nervosa

The current study was a planned secondary analysis to examine post-traumatic stress symptoms (PTSS) in parents of youth hospitalized for medical stabilization due to anorexia nervosa (AN). Questionnaires were administered to 47 parents (34 mothers, 13 fathers; 10 parental dyads) after admission; follow-up occurred at discharge and 4 weeks, 3 months, and 6 months post-discharge. PTSS were present in the majority of mothers (55.9%) and fathers (61.5%). PTSS were not associated with illness severity, but were associated with parental report of mood symptoms, avoidance, inflexibility, and symptom accommodation. Parental PTSS may negatively impact the adolescent rate of weight gain post-discharge. As hospitalization of a child for medical management of AN can be a traumatizing experience for parents, astute attention should be paid by medical staff to their needs. More work needs to be done to understand the impact of PTSS on parents of adolescents with AN.

Emergency Department Utilization by Patients With Eating Disorders: A National Population-Based Study

Background There is a scarcity of national United States (U.S) data on emergency department (ED) utilization by patients with eating disorders. This study aims to determine the most common reasons for ED visits of patients with eating disorders, as well as baseline characteristics of patients who present due to eating disorders. Methods We obtained data from the Nationwide Emergency Department Sample (NEDS), the largest all-payer ED database in the United States. Each ED visit in NEDS 2018 can have only one "principal" diagnosis, which is the main reason for the visit and up to 34 "secondary" diagnoses. We abstracted data for all ED visits with "any" diagnosis of an eating disorder, using the ICD-10 code "F50". We highlighted the 10 most common "principal" diagnoses based on the organ system involved and the 10 most specific "principal" diagnoses for all ED visits by patients with any diagnosis of eating disorder. We then highlighted baseline characteristics of ED visits with a "principal" diagnosis of an eating disorder. Results There were a total of 56,901 ED visits for patients with eating disorders in 2018. Among these, 7,979 had an eating disorder as the "principal" diagnosis. Patients who visited the ED principally for eating disorders were more likely to be young females and came from higher-income households; about a third were admitted with 22.1 million U.S. dollars in aggregate ED charges. Mental disorders, and injuries and poisoning were the most common principal diagnosis by organ system categories, while eating disorders, major depression disorder (MDD), hypokalemia, and dehydration are common specific reasons for ED visits among patients with eating disorders. Conclusions Eating disorders, and its medical complications and psychiatric comorbidities such as MDD are common reasons for ED visits among patients with eating disorders. Management of the underlying eating disorder and their psychiatric comorbidities through a multidisciplinary approach in the outpatient setting is invaluable in reducing ED utilization by these patients.

DEVELOPMENT OF ANOREXIA NERVOSA IN A FEMALE ADOLESCENT IN A DYSFUNCTIONAL FAMILY ENVIRONMENT WITH IMPAIRED ATTACHMENT AND EMOTIONAL REGULATION: A CASE REPORT

A 17-year-old female patient was admitted to the psychoneurological department of Kyiv Clinical Railway Hospital No. 1, due to deterioration of her mental state, a significant decrease in body weight, and no effect of outpatient treatment. The complex treatment program, directed on the correction of all multidimensional disorders with the preliminary psychodiagnostics examination of the patient and her parents according to the FACES-III, DERS, which were monitored in dynamics during the 3,6,9 and 12 months of treatment, was applied. The patient's parents were additionally assessed by TAS, HADS, and the CQLS. We noted that the functioning of the family as a whole influenced the emotional regulation of each of its members; in turn, the emotional regulation of the parents had a direct influence on the patient's emotional regulation, and the patient's emotional regulation influenced changes body weight. The patient's personal psychotherapy and ABFT allowed us to decrease the gap in the attachment relationship between parents and patient and create a safe emotional base for reducing the stress of the relationship with parents at home, which was confirmed by positive dynamics of FACES-III, decrease in difficulties of emotional regulation on DERS and restoration of the patient's normal weight.

Findings from a web content analysis of resources targeting sporting coaches aimed at educating or upskilling on eating disorders and disordered eating in athletes

BACKGROUND

Eating disorders (ED) and disordered eating (DE) are highly prevalent in athletes. Coaches can play a role in the prevention of EDs and DE behaviours and are well placed to support athletes with an ED. However, coaches feel under-qualified and lack time and resources for supporting athletes and it is unclear the quality of training and resources available to upskill coaches in this space. Therefore, a web-based content analysis was undertaken to determine the type and source of online education resources currently available to coaches to help identify, prevent, manage and refer on for ED/DE behaviours.

METHODS

Three major search engines were searched using a combination of the following terms: (1) DE or ED resource and (2) coaches or sport. Included websites were specific for DE/EDs in athletes; targeted at coaches or sporting organisations; written in the English language; and published by a reputable site.

RESULTS

Twenty four out of 600 websites met inclusion criteria. The main reasons for exclusion were irreputable sites and websites not targeting coaches. The majority of included webpages were from professional bodies (n = 17) and targeted coaches (n = 24) and sporting organisations (n = 15), with an average quality rating of 4.2 out of 6. All websites provided educational resources but none provided official training. The most common topics discussed on these websites was ED/DE signs and symptoms (n = 17), and the effects of ED/DE on performance, mental and physical health (n = 11).

CONCLUSION

Few reputable online resources were identified in the current review. There is a need for more comprehensive education and training resources aimed at coaches and athletic organisations to help prevent, identify, manage and refer on for ED/DE behaviours.

Description of characteristics and outcomes of a cohort of patients with severe and enduring eating disorders (SE-ED)

OBJECTIVE

To describe the characteristics of the patients, as well as the treatment outcomes for the people treated in an Endocrinology and Nutrition unit with a diagnosis of SE-ED (> 7 years evolution despite evidence-based conventional treatment).

METHODS

A descriptive observational study was conducted. Patients with a diagnosis of SE-ED (anorexia nervosa and bulimia nervosa) treated in the Endocrinology and Nutrition service of the Virgen del Rocío University Hospital between 2014 and 2019 were included.

RESULTS

67 patients were contacted and accepted to participate in the study. 95.5% were women. 67.2% were diagnosed with AN (anorexia nervosa) and 32.8% with BN (bulimia nervosa). Their median ages (years) at the onset of symptoms, beginning of follow-up and at present were 17, 32 and 42.5 respectively. Their median time of follow-up was 9 years. 73.1% had mental comorbitidy and AN patients had more osteoporosis (48.9% vs 22.7%, p = 0.04) and hypogonadotropic hypogonadism (31.1% vs. 4.5%, p = 0.014).

DISCUSSION

The SE-ED patients in our sample began treatment years after the onset of symptoms, which may have led to their chronification. This emphasizes the importance of an early diagnosis in eating disorders. They presented with a high rate of physical complications and mental comorbidity. In the current sample, it was determined that patients with AN presented with higher rates of osteoporosis and hypogonadotropic hypogonadism than patients with BN.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies. At present, the criteria for severe and enduring eating disorders (SE-ED) are not sufficiently clearly defined. It has been calculated that approximately 20% of patients with anorexia nervosa (AN) and 10% of patients with bulimia nervosa (BN) suffer a chronification. We evaluated the characteristics of the patients, as well as the treatment outcomes for the people treated in an Endocrinology and Nutrition unit with a diagnosis of SE-ED (which was made based on an evolution greater than 7 years despite conventional treatment). The SE-ED patients in our sample began treatment years after the onset of symptoms, which may have led to their chronification. They presented with a high rate of physical complications and mental comorbidity. In the current sample, it was determined that patients with AN presented with higher rates of osteoporosis (health condition that weakens bones, making them fragile and more likely to break) and hypogonadotropic hypogonadism (illness in which testes or ovaries produce little or no sex hormones due to a problem in the pituitary gland) than patients with BN.

The shifting perspectives study protocol: Cognitive remediation therapy as an adjunctive treatment to family based treatment for adolescents with anorexia nervosa

BACKGROUND

Adolescents with anorexia nervosa have set-shifting inefficiencies that can be exacerbated by starvation and that may interfere with outcomes of treatment interventions. Cognitive Remediation Therapy (CRT), an adjunctive treatment focused on improving set-shifting, can target inefficiencies and may augment treatment effectiveness. The best way to add CRT to the standard of care (Family Based Treatment, FBT) for adolescents with anorexia remains understudied.

METHODS/DESIGN

This is a randomized controlled trial designed to determine if CRT is effective in increasing flexibility in adolescents with anorexia and/or their parents. Participants are adolescents 12-18 years old with anorexia and their parents. 54 family groups will be randomized into one of three groups: FBT only, FBT plus Parent-focused CRT, or FBT plus Adolescent-focused CRT. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study.

DISCUSSION

This is the first study of its kind to apply CRT to parents. All forms of CRT in the context of anorexia have targeted the individual with anorexia's thinking style. We propose that it may be impactful to target the parent of the adolescent with anorexia as parents carry the burden of treatment and re-nourishment of their child during FBT and may have similar thinking styles.

CONCLUSION

This study takes an experimental therapeutics approach to further our understanding of the mechanisms of treatment for adolescents with anorexia. It focuses on increasing cognitive flexibility in patients or their parents and determining the appropriate dose of CRT needed to achieve positive change.

TRIAL REGISTRATION

ClinicalTrails.gov Identifier NCT03928028.

Leveraging general risk surveillance to reduce suicide in early adolescents: Associations between suicidality, disordered eating, and other developmental risk factors

OBJECTIVE

Suicide is a leading cause of death in early adolescents (i.e., children ages 11-14), underscoring the need for a more complex understanding of suicidality in youth. Syndemics framework posits that the overlap of multiple maladaptive behaviors (or risk factors) produces worse health outcomes compared to each behavior alone. The use of this framework in preventing suicide necessitates that identification of developmental risk factors that occur in tandem to suicide (e.g., disordered eating behaviors and substance use) may be important for intervening on those at greatest risk of suicide.

METHOD

The present study uses latent class analysis (LCA) to evaluate the relationship between suicidality and disordered eating behaviors in early adolescence, and associations with other developmental risk factors in an epidemiological sample of middle school students (N = 3,811).

RESULTS

Lifetime prevalence ranged from 6.8% to 18.2% for suicidality, and 5.3%-48.7% for disordered eating behavior. Our final model identified six independent classes, and each class had differential associations with several additional developmental risk factors.

CONCLUSION

By pinpointing specific classes of individuals who may be at risk for multiple developmental risk factors, our results have important implications for public health intervention and prevention efforts for a wide range of adolescent risk behaviors, including suicidality.

Advances in Eating Disorders

Eating disorders (EDs) are a group of mental disorders characterized by an altered food intake and the presence of inappropriate behaviors for the control of body weight, framed as an excessive concern regarding one's weight and figure [...].

Medical management of eating disorders: an update

PURPOSE OF REVIEW

Eating disorders are associated with numerous medical complications. The aim of this study was to review recent progress in improving the medical management of patients with eating disorders.

RECENT FINDINGS

With close medical monitoring and electrolyte supplementation, accelerated refeeding protocols improve weight restoration without increasing the risk of refeeding syndrome. Olanzapine improves weight restoration better than placebo, without leading to adverse metabolic effects seen in individuals not in starvation. Alterations of the gut microbiome in anorexia nervosa have been demonstrated, but their clinical relevance remains unclear.

SUMMARY

Medical complications of eating disorders may facilitate the first contact with health professionals and treatment initiation. Medical complications of anorexia nervosa generally occur due to starvation, malnutrition and their associated physiological effects, whereas medical complications of bulimia nervosa are generally due to purging behaviors. Most medical complications in patients with binge eating disorder are secondary to obesity. Most medical complications of eating disorders can be effectively treated with nutritional management, weight normalization and the termination of purging behaviors. In summary, eating disorders are associated with many medical complications that have to be carefully assessed and managed as early as possible to improve long-term outcomes.

Thiamine Deficiency in Adolescents with Eating Disorders: A Prospective Cohort Study

Background: Pediatric eating disorders (PED) patients are prone to nutritional deficiencies. Thiamine deficiency is well described in other malnutrition states but is not routinely screened for in PED. In the current study we evaluated the prevalence of thiamine deficiency among PED patients on their first admission to an outpatient day hospital for eating disorders (DH). Methods: In this prospective cohort study, we measured whole blood thiamine pyrophosphate concentrations (TPP) in addition to a routine laboratory workup in 69 girls on their first admission to DH. Two subgroup analyses were performed: (I) Patients with a previous dietary intervention (“diet” group, n = 30) or naïve-to-treatment patients (“naïve” group, n = 39) and (II) Type of PED: Restrictive (group R, n = 44) or binge-eating/purging (group BP, n = 25). Results: Thiamine deficiency was identified in four girls (6%), all in the “naïve” group. Three of them had BP, and one had R. Patients in the “diet” group had a significantly higher TPP compared to the “naïve” group (55.5 µg/L vs. 46.7 µg/L, p = 0.004). TPP levels returned to normal after two weeks of the treatment program in all deficient patients. Conclusion: Thiamine deficiency was uncommon among PED patients and was easily replenished. Screening for deficiency should be performed among treatment-naïve patients. Keynotes: Whole blood thiamine pyrophosphate concentrations (TPP) are seldom screened for among PED patients. In the current study, we detected thiamine deficiency in only 6% of patients on their first admission to an outpatient day hospital for eating disorders. All deficient patients did not have a recent dietary intervention. We recommend considering screening for thiamine deficiency in treatment-naïve PED patients.