Eating disorders and quality of life: A review of the literature

Adverse outcomes and mortality in individuals with eating disorder-related electrolyte abnormalities in Ontario, Canada: a population-based cohort study

BACKGROUND

Individuals with eating disorders are at a higher risk of electrolyte abnormalities than the general population. We conducted the first representative cohort study assessing whether electrolyte abnormalities in people with eating disorders were associated with mortality and physical health outcomes.

METHODS

This was a retrospective population-based cohort study in Ontario including people aged 13 years or older with an eating disorder and an outpatient electrolyte measure within 1 year (between Jan 1, 2008 and June 30, 2019). An electrolyte abnormality was any of hypokalaemia, hyperkalaemia, hyponatraemia, hypernatraemia, hypomagnesaemia, hypophosphataemia, metabolic acidosis, or metabolic alkalosis. The primary outcome was all-cause mortality. Secondary outcomes were hospitalisation, a cardiac event, infection, acute or chronic kidney disease, fracture, and bowel obstruction. In additional analyses, we examined a younger cohort (<25 years old) and individuals with no previously diagnosed secondary outcome. We involved people with related lived or family experience in the study.

FINDINGS

6163 patients with an eating disorder and an electrolyte measure within 1 year since diagnosis (mean age 26·8 years [SD 17·5]; 5456 [88·5%] female, 707 [11·5%] male; median follow-up 6·4 years [IQR 4-9]) were included. Ethnicity data were not available. The most common electrolyte abnormalities were hypokalaemia (994/1987 [50·0%]), hyponatraemia (752/1987 [37·8%]), and hypernatraemia (420/1987 [21·1%]). Overall, mortality occurred in 311/1987 (15·7%) of those with an electrolyte abnormality versus 234/4176 (5·6%) in those without (absolute risk difference 10·1%; adjusted hazard ratio 1·23 [95% CI 1·03-1·48]). Hospitalisation (1202/1987 [60·5%] vs 1979/4176 [47·4%]; 1·35 [1·25-1·46]), acute kidney injury (206/1987 [10·4%] vs 124/4176 [3%]; 1·91 [1·50-2·43]), chronic kidney disease (245/1987 [12·3%] vs 181/4176 [4·3%]; 1·44 [1·17-1·77]), bone fracture (140/1987 [7·0%] vs 167/4176 [4·0%]; 1·40 [1·10-1·78]), and bowel obstruction (72/1987 [3·6%] vs 57/4176 [1·4%]; 1·62 [1·12-2·35]) were associated with an electrolyte abnormality, but not infection or a cardiovascular event. Findings were consistent in young individuals (<25 years old) and those without secondary outcomes at baseline, by eating disorder type, and by sex.

INTERPRETATION

Electrolyte abnormalities are associated with death and poor physical health outcomes, supporting the importance of monitoring and possible interventions to prevent adverse outcomes. Findings also call for a refinement of the definition of severity of eating disorder and replication of these findings in other jurisdictions.

FUNDING

None.

A systematic review of eating disorders and family functioning

The purpose of the current review was to address four questions: 1) Are there differences in family functioning or family environment among patients with different eating disorder (ED) diagnoses? 2) Are there differences in the perception of family functioning or family environment among different family members? 3) Is family functioning or family environment related to ED symptomatology? 4) Does family functioning or family environment change as a result of ED treatment? and 4a) If so, does this impact ED treatment outcome? Although most studies found no differences among ED diagnostic groups, those that did generally found worse family functioning among those with binge/purge symptoms than among those with the restricting subtype of anorexia nervosa. Differences in perceptions of family functioning among family members were found, with patients generally reporting worse functioning than their parents. Worse family functioning was generally found to be related to worse ED symptoms. The variety of treatment approaches and different assessments of outcome made it somewhat unclear whether family functioning consistently improves with ED treatment. More research is needed on family functioning and EDs, particularly in understudied groups such as males, and those with ED diagnoses other than anorexia nervosa or bulimia nervosa.

Incidence and prevalence of eating disorders among U.S. military service members, 2016-2021

OBJECTIVE

Despite unique experiences that may increase eating disorder risk, U.S. military service members are an understudied population. The current study examined incidence and prevalence of eating disorder diagnoses in U.S. military personnel.

METHOD

This retrospective cohort study utilized Military Health System Data Repository (MDR) data on eating disorder diagnoses (2016-2021). Active duty, Reserve, and National Guard U.S. military service members who received care via TRICARE Prime insurance were identified by ICD-10 eating disorder diagnostic codes.

RESULTS

During the 6-year surveillance period, 5189 Service members received incident eating disorders diagnoses, with a crude overall incidence rate of 6.2 cases per 10,000 person-years. The most common diagnosis was other/unspecified specified eating disorders, followed by binge-eating disorder, bulimia nervosa, and anorexia nervosa. There was an 18.5% overall rise in total incident cases across the surveillance period, but this trend was not statistically significant (p = 0.09). Point prevalence significantly increased across the 6-year timeframe for total eating disorders (p < 0.001). Period prevalence for 6-year surveillance period was 0.244% for total eating disorders, 0.149% for other/unspecified eating disorder, 0.043% for bulimia nervosa, 0.038% for binge-eating disorder, and 0.013% for anorexia nervosa.

DISCUSSION

Overall crude incidence estimates for total eating disorders were higher than reported in prior research that included only active duty Service members and required an eating disorder diagnosis code in the first or second diagnostic position of the medical record. Comprehensive and confidential studies are needed to more thoroughly characterize the nature and scope of eating disorder symptomatology within U.S. military personnel.

PUBLIC SIGNIFICANCE

U.S. military service members are a vulnerable population with regard to eating disorder symptoms. Previously reported incidence and prevalence estimates using data from the Military Health System may have been underestimated due to overly stringent case definitions. Given personal and occupational barriers (e.g., career consequences), confidential studies of military personnel may provide more complete data on the scope of eating disorders to inform screening and clinical practice guidelines for military populations.

Improvements in Quality of Life and Readiness for Change After Participating in an Eating Disorder Psychoeducation Group: A Pilot Study

Psychoeducation groups are an integral part of eating disorder treatment in community programs, yet research on their efficacy remains limited. This study examines the impact of participating in a 10-week psychoeducation group on changes in quality of life and in readiness and motivation. Seventy-five adults who had eating disorders were included in the study. We administered the Eating Disorder Quality of Life Scale (EDQLS) and Readiness and Motivation Questionnaire (RMQ) before and after the group. After participation, respondents reported an 11-point increase in the EDQLS score and 9-, 8-, and 9-point increases, respectively, in the total action, confidence, and internality components of the RMQ score. In group exit evaluations, participants reported that the psychoeducation group improved their quality of life and their readiness and motivation to recover.

Eating Disorders in Sexual and Gender Minority Adolescents

PURPOSE OF REVIEW

To consolidate recent literature addressing eating disorders and disordered eating behaviors among sexual and gender minority (SGM) adolescents, including but not limited to lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents.

RECENT FINDINGS

Sexual and gender minority adolescents are at heightened vulnerability to eating disorders and disordered eating behaviors compared to their cisgender and heterosexual peers, potentially due to minority stress, gender norms, objectification, and the influence of the media, peers, and parents. We report findings from recent literature on the epidemiology and prevalence, assessment, mental health comorbidity, quality of life and psychosocial functioning, risk and protective factors, and treatment and interventions for eating disorders in sexual and gender minority adolescents. Addressing eating disorders in sexual and gender minority adolescents requires an integrated approach consisting of screening, tailored treatment, and comprehensive support to address intersectional challenges. Gender-affirming and trauma-informed care approaches may be considered.

Perfectionism, disordered eating and well-being in aesthetic sports: The mediating role of passion

Aesthetic athletes face higher risks of disordered eating, and perfectionism is one of the determinants involved. While research suggests that perfectionism in sport may play a role in physical and psychological well-being, its influence remains to be confirmed. As such, further examination of the influence of perfectionism on health is warranted as it could lead to better interventions. This preregistered research sought to shed new light on these relationships by investigating the mediating role of passion in the perfectionism-disordered eating relationship as well as physical and psychological well-being in aesthetic sports. In Study 1, 229 American recreational and competitive athletes practicing either gymnastics (n = 150) or artistic swimming (n = 79) were recruited on MTurk to complete an online questionnaire. The same recruitment procedure was used for Study 2, with 107 American gymnasts (n = 69) and artistic swimmers (n = 38) completing the questionnaire at two timepoints, one year apart. Results from path analyses showed that socially prescribed perfectionism was associated with obsessive passion, which in turn was associated with disordered eating. Self-oriented perfectionism was associated with both obsessive and harmonious passion, the latter being more adaptative as it was associated with physical and psychological well-being. Thus, the way one engages in aesthetic sports matters, as engaging with obsessive passion may take a toll on one's health and lead to disordered eating. Conversely, fostering harmonious engagement seems to temper the negative associations between perfectionism and health outcomes and promote positive relationships with athlete's well-being, but requires further study.

Exploring the associations between muscularity teasing and eating and body image disturbances in Chinese men and women

This study described muscularity teasing in both men and women and explored its associations with eating and body image disturbances in adults from China. A total of 900 Chinese adults (50% women) were recruited online. Correlation and regression analyses were conducted to examine the relationships between muscularity teasing and a battery of measures on eating and body image disturbances. Gender differences in the associations were examined. Men reported more muscularity teasing than women (31.6% men vs. 15.6% women; χ2(1,N = 900) = 31.99, p < .001). Muscularity teasing was significantly and positively correlated with all measures in both men and women. Muscularity teasing explained significant, unique variance in all measures for men and women, except for body fat dissatisfaction in women, beyond covariates (i.e., age, body mass index, and weight teasing). The relationships between muscularity teasing and eating and body image disturbances were generally stronger in men than women. Findings further suggest that muscularity teasing is an important factor related to eating and body image disturbances in men and women, but muscularity teasing might be more detrimental to men's eating behaviors and body image. Future research is needed to further explore the directionality and mechanisms of the links between muscularity teasing and eating and body image disturbances.

Direct and indirect effects of psychological well-being and therapeutic alliance on therapy outcome in eating disorders

Introduction

Outcome research in eating disorders (EDs) is commonly focused on psychopathological dysfunction. However, Ryff's model of psychological well-being (PWB) has shown promising-yet preliminary-results with ED patients. Additionally, despite substantial evidence highlighting the association between the therapeutic alliance and treatment outcome, findings in ED samples remain unclear. The present study aimed at exploring the direct effect of PWB dimensions and the early therapeutic alliance on ED patients' individual treatment responses, as well as the mediating role played by the early therapeutic alliance in the relationship between PWB dimensions and overall pre-post symptom change.

Methods

A sample of N = 165 ED patients assigned female at birth, who were receiving treatment in a residential program, completed the Psychological Well-Being Scale at treatment intake and the Working Alliance Inventory after the first four psychotherapy sessions. Patients also completed the Outcome Questionnaire-45.2 at the same time point and during the week prior to discharge.

Results

The PWB dimensions of autonomy, positive relations, and self-acceptance were associated with clinically significant change, while the dimensions of personal growth and self-acceptance were associated with reliable change. The early therapeutic alliance showed both direct and indirect effects on therapy outcome, predicting clinically significant and reliable symptom reduction. It also emerged as a significant mediator in the relationship between all PWB dimensions and overall symptomatic change.

Conclusion

The identification of individual, adaptive characteristics in ED patients that might influence their development of an early therapeutic alliance may help therapists to predict relationship ruptures and tailor their interventions to enhance treatment effectiveness.

Quality of Life and Clinical Impairment in Spanish Adolescent Anorexia Nervosa Patients

Eating disorders have serious physical, mental and social consequences that can affect the quality of life of the sufferer. This study aimed to evaluate the relationship between the severity of ED-related psychopathology and clinical impairment in adolescents with anorexia nervosa (AN) as well as their perception of health-related quality of life. Eighty-six Spanish young women with AN completed a set of questionnaires assessing eating disorder pathology, clinical impairment, and quality of life. The set included the following instruments: the Eating Disorder Examination Questionnaire, Clinical Impairment Assessment, Short Form-12 Item Health Survey, and the Eating Disorder-Specific Heath-Related Quality of Life instrument. Descriptive and regression analyses were applied to identify associations between variables. Higher scores on clinical impairment domains were associated with greater impairment of mental and physical health. Moreover, clinical impairment domains and concerns due to ED were related to a lower quality of life. In conclusion, adolescents with AN have a poor quality of life. Moreover, the findings suggest that the clinical features of impairment may serve as severity indicators of quality of life.

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.

Self-reported health related quality of life in children and adolescents with an eating disorder

BACKGROUND

Eating disorders in children and adolescents can have serious medical and psychological consequences. The objective of this retrospective quantitative study is to gain insight in self-reported Health Related Quality of Life (HRQoL) of children and adolescents with a DSM-5 diagnosis of an eating disorder.

METHOD

Collect and analyse data of patients aged 8-18 years, receiving treatment for an eating disorder. At the start and end of treatment patients completed the KIDSCREEN-52, a questionnaire measuring HRQoL.

RESULTS

Data of 140 patients were analysed. Children diagnosed with Anorexia Nervosa, Bulimia Nervosa, and Other Specified Feeding or Eating Disorder all had lower HRQoL on multiple dimensions at the start of treatment, there is no statistically significant difference between these groups. In contrast, patients with Avoidant Restrictive Food Intake Disorder only had lower HRQoL for the dimension Physical Well-Being. HRQoL showed a significant improvement in many dimensions between start and end of treatment, but did not normalize compared to normative reference values of Dutch children.

CONCLUSION

The current study showed that self-reported HRQoL is low in children with eating disorders, both at the beginning but also at the end of treatment. This confirms the importance of continuing to invest in the various HRQoL domains.

Self-compassion promotes positive mental health in women with anorexia nervosa: A two-week daily diary study

Despite the importance of positive mental health, little is known about its facilitators in people with eating disorders (EDs). Drawing on past research, we hypothesized that self-compassion might be a contributing factor to positive mental health in individuals with EDs. In a two-week daily diary study of women (N = 32) with anorexia nervosa, we investigated whether self-compassion levels-on average, on a given day, and from one day to the next-predicted social safeness (i.e. a sense of social connection and warmth) and positive affect, both indicators of positive mental health. Multilevel modeling revealed that, controlling for ED symptoms, (1) higher daily self-compassion, (2) increases in self-compassion from the previous day, and (3) higher trait self-compassion, were associated with greater positive affect and social safeness. Findings suggest that in addition to reducing ED symptoms in people with EDs, as documented by prior research, the cultivation of self-compassion might facilitate improved emotional and social well-being in this population.

Examining the placement of atypical anorexia nervosa in the eating disorder diagnostic hierarchy relative to bulimia nervosa and binge-eating disorder

OBJECTIVE

Some individuals meet the criteria for atypical anorexia nervosa and another eating disorder simultaneously. The current study evaluated whether allowing a diagnosis of atypical anorexia nervosa to supersede a diagnosis of bulimia nervosa (BN) or binge-eating disorder (BED) provided additional information on psychological functioning.

METHODS

Archival data from 650 university students (87.7% female, 69.4% white) who met Eating Disorder Diagnostic Survey for DSM-5 eating disorder criteria and completed questionnaires assessing quality of life, eating disorder-related impairment, and/or eating pathology at a single time point. Separate regression models used diagnostic category to predict quality of life and impairment. Two diagnostic schemes were used: the DSM-5 diagnostic scheme and an alternative scheme where atypical anorexia nervosa superseded all diagnoses except anorexia nervosa. Model fit was compared using the Davidson-Mackinnon J test. Analyses were pre-registered (https://osf.io/2ejcd).

RESULTS

Allowing an atypical anorexia nervosa diagnosis to supersede a BN or BED diagnosis provided better fit to the data for eating disorder-related impairment (p = .02; n = 271), but not physical, psychological, or social quality of life (p's ≥ .33; n = 306). Allowing an atypical anorexia nervosa diagnosis to supersede a BN or BED diagnosis provided a better fit in cross-sectional models predicting purging (p = .02; n = 638), but not body dissatisfaction, binge eating, restricting, or excessive exercise (p's ≥ .08; n's = 633-647).

DISCUSSION

The current data support retaining the DSM-5 diagnostic scheme. More longitudinal work is needed to understand the predictive validity of the atypical anorexia nervosa diagnosis.

PUBLIC SIGNIFICANCE

The current study examined how changes to the diagnostic categories for eating disorders may change how diagnoses are associated with quality of life and impairment. Overall, findings suggest that the diagnostic hierarchy should be maintained.

Sensitivity to change in well-being and health-related quality of life in adults with eating disorder symptoms: ICECAP-A versus EQ-5D-5L

OBJECTIVE

Economic evaluations of treatments help to inform decisions on allocating health care resources. These evaluations involve comparing costs and effectiveness in terms of quality of life. To calculate quality-adjusted life years, generic health related quality of life is often used, but is criticized for not being sensitive to change in mental health populations. Another approach, using experienced well-being measured through capabilities with the ICECAP-A, has been proposed as an alternative. The aim of this study was to investigate whether changes in individuals with eating disorder (ED) symptoms can be better captured using health related quality of life (EQ-5D-5L) or well-being (ICECAP-A).

METHOD

Measurements at two time points with an interval of 1 year were used from a sample of 233 participants with self-reported ED symptoms. An analysis of variance was used to test whether the EQ-5D-5L and ICECAP-A differed in sensitivity to change over time. In order to compare the two questionnaires in terms of clinically significant outcome, the reliable change index and clinical cut-off score were calculated.

RESULTS

The two questionnaires did not differ in sensitivity to change. More individuals had recovered but also more had deteriorated according to the EQ-5D-5L compared to the ICECAP.

DISCUSSION

The present study revealed no differences in sensitivity to change in health-related quality of life or well-being in individuals with ED symptoms in the context of mild clinical change. Results corroborated the pervasiveness of low quality of life in this population, even after alleviation of ED symptoms.

PUBLIC SIGNIFICANCE STATEMENT

Measuring treatment benefits in terms of improvements in quality of life is an integral part of economic evaluations in health care. It was expected that these treatment benefits would be better captured as changes in well-being (measured with the ICECAP-A) than as changes in health-related quality of life (measured with the EQ-5D-5L) for individuals with ED symptoms. Based on the results of this study, no preference for one of the two approaches was found.

Understanding and treating body image disturbances in eating disorders through body illusion interventions: a scoping review protocol

BACKGROUND

We plan a scoping review aimed to synthesize what is known about the use of sensory-driven body illusion (BI) interventions for understanding and treating body image disturbance (BID) in people diagnosed with clinical eating disorders (EDs) and people with subclinical ED symptomatology. Our study will provide an outline of the current literature, identify gaps within the literature, and suggest novel directions for future research.

METHODS/DESIGN

The scoping review process will be guided by the methodological framework of Arksey and O'Malley, subsequent recommendations by Levac et al., and the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews guidelines. The following electronic databases will be systematically searched: MEDLINE (via PubMed), Web of Science, PsycINFO, and Scopus. Furthermore, to identify additional studies, we will use a search engine such as Google Scholar, and for grey literature, we will include Proquest for Dissertations and Theses. A search strategy has been identified and agreed upon by the research team in conjunction with a research librarian. Two researchers will screen the titles and abstracts independently and then assess the full text of the selected citations for the inclusion criteria. A third reviewer will be involved in cases of disagreement. Data will be extracted, collated, and charted to summarize all the relevant methods, outcomes, and key findings in the articles.

DISCUSSION

A better understanding of this topic will aid in the development and refinement of current treatments aimed at treating BID in people with EDs. Implications and recommendations for research, policy, and practice in the context of the ED community will be discussed.

SYSTEMATIC REVIEW REGISTRATION

https://osf.io/3bcm6/?view_only=83b2e8a2445d4266909992e3dfb51929.

Measuring population health and quality of life: Developing and testing of the significant quality of life measure (SigQOLM)

Quality of life (QOL) should ideally be determined by a broader spectrum of measurable parameters. This study aims to develop and validate a study instrument that is designed to determine a holistic measure of health and non-health aspects of QOL, and it is called the 'Significant Quality of Life Measure' (SigQOLM). This study involves five phases which aim to (i) explore and understand the subject matter content, (ii) develop a questionnaire, (iii) assess its content validity and face validity, (iv) conduct a pilot study, and lastly (v) perform a field-test by using the questionnaire. For the field-testing phase, a cross-sectional study was conducted which elicited responses from healthcare workers via a self-administered survey for all the SigQOLM items. Based on the results, the overall framework of the SigQOLM consists of four elements, 18 domains with 69 items. The element of "Health" is measured by nine domains, while "Relationships", "Functional activities, and "Survival" are measured by three domains respectively. The SigQOLM has been developed successfully and then validated with a high level of reliability, validity, and overall model fit. Therefore, the SigQOLM will provide researchers and policymakers another viable option to elicit a more comprehensive outcome measure of QOL which shall then enable them to implement specific interventions for improving the QOL of all the people, both healthy or otherwise.

An investigation of the dual continua model of mental health in the context of eating disorder symptomatology using latent profile analysis

OBJECTIVE

The dual continua model of mental health suggests that mental well-being and mental illness are two distinct continua that are interrelated in their contributions to overall mental health. This study investigated the dual continua model in individuals with eating disorder symptoms.

METHOD

Female university students (N = 346) completed measures of mental well-being, eating disorder symptomatology, clinical impairment and psychological distress. Confirmatory factor and latent profile analyses were used to derive underlying mental health profiles.

RESULTS

Results revealed two oblique factors representing the mental well-being and eating disorder symptomatology constructs and four unique mental health profiles that were partially consistent with the dual continua model emerged: 'flourishing', 'vulnerable', 'partially symptomatic and content', and 'languishing'. The derived mental health profiles had unique characteristics described by psychological distress and clinical impairment.

CONCLUSIONS

The results did not provide conclusive evidence for the dual continua model as they could also be interpreted in a manner consistent with the unidimensional approach. While the dual continua model is a promising avenue to understand mental health in a way that looks beyond symptoms, these results caution against its rapid adoption and encourage future research to understand how eating disorder symptomatology and positive mental health assets contribute to overall mental health.

Effects of family-based treatment on adolescent outpatients treated for anorexia nervosa in the Eating Disorder Unit of Helsinki University Hospital

BACKGROUND

Family therapy for adolescent anorexia nervosa (AN) has stronger evidence of efficacy in comparison with individual therapy, and family-based treatment (FBT) is the most evaluated in numerous randomized clinical trials. However, few studies have focused on how FBT performs outside of research settings. The current study is the first to assess clinical outcomes of FBT for adolescent AN in Finland, in a specialized outpatient clinic.

AIM

The naturalistic outcome of outpatient FBT for adolescent AN was investigated.

METHODS

Fifty-two female patients and their families who received FBT at a tertiary eating disorders unit participated in the study. Data on their pre-treatment parameters, treatment details, and condition at the end of treatment (EOT) was collected from their medical records.

RESULTS

At EOT, a majority (61.5%) had achieved a full weight restoration [percentage of expected body weight (%EBW) ≥ 95%]. Participants with an %EBW ≥ 95 at EOT had a significantly higher pre-treatment %EBW than those with an EBW < 95% at EOT. Participants with an EBW ≥ 95% at EOT showed significantly higher total weight gain during the treatment period, a higher rate of regular menstrual periods at EOT, significantly lower rates of dietary restrictions, and less cognitive or behavioral symptoms of the eating disorder overall, compared to participants who did not achieve a normal body weight. In 22 cases (42.3%), there was no need for further treatment at the end of FBT. Participants who needed further treatment after FBT, compared to those who did not, showed significantly higher rates of psychiatric comorbidity, history of mental health treatment, and need for psychopharmacological treatment.

CONCLUSIONS

In this naturalistic study, and in line with previous studies, FBT for AN appeared to be an effective and sometimes sufficient intervention, especially for patients with milder weight deficit and less severe psychiatric comorbidities. The results show that FBT can be successfully implemented in Finland and suggest that training more ED clinicians in FBT would be beneficial.

TRIAL REGISTRATION

The study was retrospectively registered on February 8th, 2023, in ClinicalTrials.gov Protocol Registration and Results System, identifier: NCT05734573.

Anorexia nervosa and the COVID-19 pandemic among young people: a scoping review

BACKGROUND

The extent to which the recent global COVID-19 Pandemic has impacted young people with restrictive eating disorders [i.e., anorexia nervosa (AN) and atypical anorexia nervosa (AAN)] is unclear. We conducted a scoping review of the literature to identify how the pandemic has impacted this population and to identify gaps in the current literature to inform future research efforts.

MAIN BODY

We searched PubMed, EMBASE, the Web of Science, The Cochrane Library, PsycInfo, ProQuest Dissertations and Theses Global, LitCovid, Google Scholar, and relevant agency websites from 2019 to 2022. We included studies that focused on young people with AN/AAN globally. Of the 916 unduplicated articles screened, 17 articles met the inclusion criteria, reporting on 17 unique studies including 4,379 individuals. Three key findings were identified. First, an increase in hospitalizations related to eating disorders was found during COVID-19 among young people with AN and AAN. Multiple studies cited increased medical instability, even though the overall duration of disease was shorter compared to pre-pandemic levels. Second, changes in eating disorder-related symptomology during the pandemic were reported in this population, as well as poorer overall behavioral and mental health. Suggested reasons behind changes included boredom or minimal distraction from pathological thoughts, increased social isolation, increased social media and online use (e.g., reading blogs or watching YouTube), gym and school closures, changes in routines due to lockdowns and quarantines, and worries over gaining the "Quarantine 15". Third, there was an increase in the use of telemedicine as a treatment modality for the treatment of AN. Challenges were reported by both clinicians and patients regardless of past experience using telemedicine. When compared to no treatment, telemedicine was recognized as the best option during COVID-19 lockdowns; however some individuals expressed the preference for in-person treatment and planned to return to it once it became available.

CONCLUSION

The pandemic significantly impacted young people with restrictive eating disorders as seen by increased hospitalizations and requests for outpatient care. A primary driver of the changes in eating disorder symptomatology may be lockdowns and quarantines. Further research investigating how the series of lockdowns and re-openings impacted individuals with AN/AAN is warranted.

Validation of the Spanish version of the eating disorders quality of life instrument (EDQOL)

BACKGROUND

The Eating Disorders Quality of Life instrument (EDQOL) is a disease-specific health related quality of life self-report questionnaire designed for disordered eating patients. Although the EDQOL is one of the most suitable and widely used questionnaires in many countries, no prior research has addressed the psychometric properties of the Spanish adaptation of the EDQOL. Therefore, the aim of this study is to examine the psychometric properties of the Spanish version of the EDQOL among ED patients.

METHODS

141 female eating disorder patients, with a mean age of 18.06 years (SD = 6.31), completed the EDQL in addition to the Eating Disorder Examination Questionnaire (EDEQ), the Depression, Anxiety and Stress Scales (DASS-21), the Clinical Impairment Assessment (CIA 3.0) and the Health Survey (SF-12). We calculated item/scale characteristics, internal consistencies and bivariate correlations with other measures of quality of life and adjustments. We assessed the goodness-of-fit of the 4-factor model using confirmatory factors analysis and explored the sensitivity of change following skill-based interventions.

RESULTS

The fit of the 4-factor model was acceptable (Root Mean Square Error of Approximation: 0.07, Standard Root Mean Square Residual: 0.07). Cronbach's alpha was excellent for the total (.91) and acceptable for all subscales (0.78-0.91). The construct validity was found with measures of psychological distress, depression, anxiety, quality of life and clinical impairment. The psychological and physical/cognitive scales and the EDQOL global scale were responsive to change.

CONCLUSION

The Spanish EDQOL version is a useful instrument to assess quality of life in eating disorder patients and to evaluate outcomes of skills-based interventions.

Eating disorder outcomes: findings from a rapid review of over a decade of research

BACKGROUND

Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality.

METHODS

This paper forms part of a Rapid Review series scoping the evidence for the field of ED, 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 studies published between 2009 and 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review.

RESULTS

Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates.

CONCLUSION

Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.

An examination of eating disorder fears in imaginal exposure scripts

OBJECTIVE

Eating disorders (EDs) are maintained by fear and anxiety, which lead to disordered eating behaviors thought to prevent the occurrence of feared outcomes. Fear of weight gain and food are among the most common fears present in the EDs. However, theory and clinical observation suggest that the feared consequences of eating or weight gain are diverse and individualized. Further research is needed to delineate specific fears underlying ED pathology.

METHOD

167 participants with any ED participated in an online four-session imaginal exposure intervention. Imaginal exposure scripts were rated by trained coders using items derived from the Eating Disorder Fear Interview to identify fears present. Frequencies of fears present in scripts were quantified.

RESULTS

Two-thirds of scripts mentioned fears of food and weight or body-related fears. In over half of scripts, fear of judgment and fear of loss of control were identified. Diagnostic differences were found, including that those with anorexia nervosa (AN) and bulimia nervosa (BN) had highest fears of food, whereas those with AN and other specified feeding and eating disorder (OSFED) had higher weight gain/body-focused fears.

LIMITATIONS

We were underpowered to make comparisons between ED diagnoses other than AN, BN, and OSFED.

CONCLUSIONS

Imaginal exposure scripts contained a large number of fears related to food, weight/shape, judgment, and loss of control, among others. These findings extend the current understanding of ED fears and provide evidence for the individualized and varied nature of fears. Identification of ED fears can further inform research on designing personalized, exposure-based treatment approaches.

Associations between Parents' Body Weight/Shape Comments and Disordered Eating Amongst Adolescents over Time-A Longitudinal Study

Parents are key influencers of adolescents' attitudes on weight, shape, and eating, and make more positive than negative comments, with negative comments most impactful. This study examined prospective unique associations of parental positive and negative comments in a community sample of adolescents with paediatric psychosocial quality of life (PED-QoL), Eating Disorder Weight/Shape Cognitions (EDEQ-WS), BMI percentile, and Psychological Distress (K10) scales. Data were from 2056 adolescents from the EveryBODY study cohort. Multiple regressions were conducted for the impacts of parental positive and negative comments on four dependent variables at one year after controlling for their stage of adolescence (early, middle, late). Multiple imputation and bootstrapping were used for handling missing data and violations of normality. Results indicated that positive maternal comments on eating were associated with increased EDCs and better quality of life at one year. Paternal positive weight shape comments were associated with a decrease in psychological distress, but positive eating comments saw a decrease in quality of life. Findings highlight the nuances of parental comments and how these are perceived and interpreted, and could alert health care workers and family practitioners who have weight, shape, and eating conversations to be aware of the potential influence of their communication.

Practical Considerations for Using the Eating Disorder Examination Interview with Adolescents

Approximately 35 years after its initial publication, the Eating Disorder Examination (EDE) remains one of the most widely used semi-structured interviews for assessing eating disorder diagnoses and symptomatology. Although the interview provides certain advantages over other common measurement approaches (ie, questionnaires), there are particular considerations regarding the EDE that warrant attention, including in its use with adolescents. The aims of this paper are therefore to: 1) provide a brief overview of the interview itself, as well as a description of its origin and underlying conceptual framework; 2) describe relevant factors for administering the interview with adolescents; 3) review potential limitations regarding use of the EDE with adolescents; 4) address considerations for using the EDE with pertinent subpopulations of adolescents who may experience distinct eating disorder symptoms and/or risk factors; and 5) discuss the integration of self-report questionnaires with the EDE. Advantages of using the EDE include the ability for interviewers to clarify complex concepts and mitigate inattentive responding, enhanced orientation to the interview timeframe to improve recall, increased diagnostic accuracy compared to questionnaires, and accounting for potentially salient external factors (eg, food/eating rules imposed by a parent/guardian). Limitations include more extensive training requirements, greater assessment burden, variable psychometric performance across subgroups, lack of items evaluating muscularity-oriented symptoms and avoidant/restrictive food intake disorder diagnostic criteria, and lack of explicit consideration for salient risk factors other than weight and shape concerns (eg, food insecurity).

Exploring the moderating role of mindfulness, mindful eating, and self-compassion on the relationship between eating-disordered quality of life and orthorexia nervosa

Orthorexia nervosa (ON) is characterised by an obsessive focus on healthy eating, following restrictive dietary practices and dietary restrictions escalating over time. The aim of this study was to explore mindfulness, mindful eating, self-compassion and quality of life in a female population. Two hundred eighty-eight participants completed Orthorexia, Self-Compassion, Mindful eating, Mindfulness and Eating Disorder Quality of Life scales. The results indicated that there was a negative relationship between ON and mindfulness, self-compassion and mindful eating. Furthermore, the present study found a positive relationship between lower quality of life and ON, while findings indicated that self-compassion and the awareness facet of mindfulness moderated the relationship between ON and QOL. The present results contribute to a better understanding of orthorexic eating behaviours in a female population, and identify the moderating capacity of self-compassion and mindfulness. Further implications and future directions are discussed.Level of evidence Level V, cross-sectional descriptive study.

Epidemiology of eating disorders: population, prevalence, disease burden and quality of life informing public policy in Australia-a rapid review

BACKGROUND

Understanding of the epidemiology and health burden of eating disorders has progressed significantly in the last 2 decades. It was considered one of seven key areas to inform the Australian Government commissioned National Eating Disorder Research and Translation Strategy 2021-2031, as emerging research had highlighted a rise in eating disorder prevalence and worsening burden-of-illness. The aim of this review was to better understand the global epidemiology and impact of eating disorders to inform policy decision-making.

METHODS

Using a systematic Rapid Review methodology, ScienceDirect, PubMed and Medline (Ovid) were searched for peer-reviewed studies published between 2009 and 2021. Clear inclusion criteria were developed in consultation with experts in the field. Purposive sampling of literature was conducted, which predominately focused on higher-level evidence (meta-analyses, systematic reviews, and large epidemiological studies), synthesised, and narratively analysed.

RESULTS

135 studies were deemed eligible for inclusion in this review (N = 1324). Prevalence estimates varied. Global Lifetime prevalence of any eating disorder ranged from 0.74 to 2.2% in males, and 2.58-8.4% in females. Australian 3-month point-prevalence of broadly defined disorders was around 16% in females. Eating disorders appeared more prevalent in young people and adolescents, particularly females (in Australia: eating disorders ~ 22.2%; disordered eating ~ 25.7%). Limited evidence was found on sex, sexuality and gender diverse (LGBTQI +) individuals, particularly males, who had a six-fold increase in prevalence compared to the general male population, with increased illness impact. Similarly, limited evidence on First Australian's (Aboriginal and Torres Strait Islander) suggests prevalence rates similar to non-Indigenous Australians. No prevalence studies were identified specifically assessing culturally and linguistically diverse populations. Global disease burden of any eating disorder was 43.4 age-standardised disability-adjusted-life-years per 100,000; increasing by 9.4% between 2007 and 2017. Australian's total economic cost was estimated at $84 billion from years-of-life lost due to disability and death, and annual lost earnings ~ $1.646 billion."

CONCLUSIONS

There is no doubt that eating disorder prevalence and impact are on the rise, particularly in at-risk and understudied populations. Much of the evidence came from female-only samples, and Western, high-income countries which more readily have access to specialised services. Future research should examine more representative samples. There is an urgent need for more refined epidemiological methods to better understand these complex illnesses over time, to guide health policy and development-of-care.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Caring for a child with an eating disorder: Understanding differences among mothers and fathers of adolescent and adult children

OBJECTIVE

This study investigated treatment-engagement fears, self-efficacy, and accommodating and enabling in mothers and fathers of adolescent and adult children with eating disorders.

METHODS

This study involved a secondary analysis of pre-treatment data from a subsample of 143 parents (95 mothers; 48 fathers) from a Canada-wide multi-site study. Parents completed the Caregiver Traps Scale, Parents Versus Anorexia Scale, and the Accommodation and Enabling Scale for Eating Disorders. Data were analysed using factorial Multivariate Analysis of Variance and mediation via multiple regression.

RESULTS

Mothers reported higher levels of treatment-engagement fears than fathers. Among mothers, higher fear predicted lower self-efficacy and more accommodating and enabling behaviours. Among fathers, neither fear nor self-efficacy predicted accommodating and enabling. No differences in treatment-engagement fear or self-efficacy between parents of adolescent child and adult children were found at pre-treatment.

CONCLUSIONS

Mothers' and fathers' experience different levels of fear related to their involvement in their ill-child's treatment at pre-treatment, and that fear is uniquely related to variables that impact treatment outcomes. There is a need to support parents even when their child is an adult. This study can inform family-based treatments vis-a-vis tailoring interventions for mothers and fathers and providing support to parents of children with eating disorders across the lifespan.

Subjective disgust and facial electromyography responses towards unedited and morphed overweight self-pictures in women with varying levels of eating disorder symptomatology

Individuals with an eating disorder (ED) often report to be disgusted by their body. Body-related self-disgust could play an important role in the development and maintenance of EDs. We investigated if women with relatively high ED symptom scores indeed respond with disgust upon exposure to their body as indexed by facial electromyography (fEMG) of the m. levator labii superioris and self-report. Given that one's self-disgust may increase/decrease depending on the relative distance of the own body to the thin ideal, we also assessed women's disgust for overweight- and thin-morphs of their body. Female undergraduate students (N = 104) were photographed and presented with their (morphed) body pictures, next to disgust-relevant and overweight body control pictures. Higher levels of ED symptoms were associated with stronger self-reported disgust to unedited body-pictures and overweight-morphs. Disgust to thin-morphs was unrelated to ED symptoms. Participants generally showed heightened facial disgust towards overweight morphs, yet the strength of facial disgust was unrelated to ED symptoms. Thus, the findings provide evidence for the involvement of heightened body-related self-disgust in ED symptomatology, albeit only on the basis of self-report.

Internet-based cognitive behavior therapy for eating disorders - Development and feasibility evaluation

BACKGROUND

Eating disorders (ED) are severe psychiatric conditions, characterized by decreased quality of life and high mortality. However, only a minority of patients with ED seek care and very few receive treatment. Internet-delivered cognitive behavioral therapy (ICBT) has the potential to increase access to evidence-based treatments.

AIMS

The aims of the present study were to (1) develop and evaluate the usability of an Internet-delivered guided self-help treatment based on Enhanced Cognitive Behavioral Therapy (ICBT-E) for patients with full or subthreshold bulimia nervosa (BN) or binge eating disorder (BED) with a user centered design process, and (2) to evaluate its feasibility and preliminary outcome in a clinical environment.

METHOD

The study was undertaken in two stages. In Stage I, a user-centered design approach was applied with iterative phases of prototype development and evaluation. Participants were eight clinicians and 30 individuals with current or previous history of ED. In Stage II, 41 patients with full or subthreshold BN or BED were recruited to a single-group open trial to evaluate the feasibility and preliminary outcome of ICBT-E. Primary outcome variables were diagnostic status and self-rated ED symptoms.

RESULTS

The user-centered design process was instrumental in the development of the ICBT-E, by contributing to improvements of the program and to the content being adapted to the needs and preferences of end-users. The overall usability of the program was found to be good. ICBT-E targets key maintaining factors in ED by introducing healthy eating patterns and addressing over-evaluation of weight and shape. The results indicate that ICBT-E, delivered in a clinical setting, is a feasible and promising treatment for full or subthreshold BN or BED, with a high level of acceptability observed and treatment completion of 73.2 %. Participation in ICBT-E was associated with significant symptom reductions in core ED symptomology, functional impairment as well as depressive symptoms, and the results were maintained at the 3-month follow-up.

CONCLUSIONS

ICBT-E was developed with end-users' preferences in mind, in accordance with the identified recommendations, and the program was perceived as usable by end-users. The study demonstrated the potential of ICBT-E, which marks a step forward in the effort to make powerful, empirically supported psychological interventions targeting ED more widely available and accessible.

Disordered Eating and Body Dissatisfaction in Transgender and Gender-Expansive Adults: An Evaluation and Integration of the Gender Minority Stress and Resilience and Tripartite Influence Models

Transgender and gender-expansive (TGE) people, including transgender and nonbinary individuals, experience elevated rates of body dissatisfaction and disordered eating compared to cisgender individuals, but little is known about why. To address this research gap, we compared the ability of TGE-specific factors as proposed in the gender minority stress and resilience (GMSR) model, general psychological factors contained in the tripartite influence (TI) model, and an integration of these frameworks to explain body dissatisfaction and disordered eating among TGE individuals. Regression analyses were conducted to test the models' abilities to explain experiences reported in a survey of 93 U.S. TGE adults, including 43 transgender women respondents (46.2%) and 31 transgender men respondents (33.3%). Participants were diverse with regard to age (M = 34.19, SD = 12.02) and ethnoracial background (e.g., 29.0% Hispanic/Latinx, 17.2% Black/African American, 6.5% American Indian/Alaska Native; 5.4% multiracial). Results demonstrated both models' abilities to explain body dissatisfaction and disordered eating independently, except for the relationship between body dissatisfaction and the thinness-oriented TI model. An integration of the models better explained body dissatisfaction and disordered eating compared to either model alone. Notably, some findings did not align with the two frameworks, suggesting existing models may not adequately describe pathways through which disordered eating emerges in TGE populations. Specifically, body dissatisfaction showed no significant relationship with disordered eating and was not well explained by the TI model, and higher gender identity pride was related to greater disordered eating symptoms. Implications for clinical care and future research are discussed.

Broad and Narrow Transdiagnostic Risk Factors in Eating Disorders: A Preliminary Study on an Italian Clinical Sample

Eating disorders are multifaceted psychopathologies and the transdiagnostic approach is currently considered a useful framework to understand their complexity. This preliminary study aimed to investigate both broad (i.e., intolerance of uncertainty and emotion dysregulation) and narrow (i.e., extreme body dissatisfaction) transdiagnostic risk factors underlying eating disorders. 50 Italian female patients seeking treatment for an eating disorder were involved (M_age = 31.6 years ± 12.8, 18–65). They completed self-report measures assessing emotion regulation difficulties, intolerance of uncertainty, extreme body dissatisfaction, general psychological distress, and eating disorder symptomatology. To explore whether the abovementioned transdiagnostic factors predicted patients’ psychological distress and eating disorder symptoms, two linear regressions were performed. Emotion dysregulation emerged as the only significant predictor of distress, while extreme body dissatisfaction was the only significant predictor of overall eating disorder symptomatology. Then, to analyze the differences between patients with anorexia nervosa and bulimia nervosa in intolerance of uncertainty and emotion regulation problems, t-tests were conducted. The two groups differed significantly in intolerance of uncertainty levels only, with higher scores obtained by patients with anorexia nervosa. Overall, our findings suggest that emotion dysregulation and extreme body dissatisfaction may be relevant constructs in eating disorders in general, while intolerance of uncertainty may be more involved in restrictive eating disorders. The clinical implications of such results are discussed.

Validating the Danish version of the Eating Disorder Quality of Life Scale (EDQLS) in anorexia nervosa

PURPOSE

The aim of this study was to explore the factor structure of the Danish translation of the eating disorder quality of life scale and evaluate the internal reliability and convergent validity of the scale in a Danish cohort of women with AN.

METHODS

The total sample comprised 211 patients diagnosed with anorexia nervosa age 13-40 years. Patients completed questionnaires assessing eating disorder psychopathology, physical and social functioning, and well-being.

RESULTS

Factor analyses were not able to support the current division of the scale into 12 factors. We found excellent internal consistency of the eating disorder quality-of-life scale total score. We found relevant associations between quality of life and pre-determined variables.

CONCLUSION

This study supports the use of the total score of the eating disorder quality of life scale in assessing quality of life in patients with anorexia nervosa. However, future studies should explore the factor structure of the scale further.

LEVEL OF EVIDENCE

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

Weight gain attempts and substance use behaviors among adults across five countries

Weight gain attempts are common among adolescents, yet a paucity of research has explored these behaviors among adults, particularly in relation to substance use behaviors. To address this gap in the literature, pooled data from the 2018 and 2019 International Food Policy Study (N = 42,108) were analyzed. The association of weight gain attempts in the past 12 months with four important and relatively common substance use behaviors (alcohol use, binge-drinking, cigarette smoking, marijuana use) was examined using multiple modified Poisson regression analyses that adjusted for theoretically relevant covariates. Among men and women, weight gain attempts were associated with a higher likelihood of cigarette smoking in the past 30 days, marijuana use in the past 12 months, and binge-drinking one or more times per month in the past 12 months among men only. Among women, weight gain attempts were associated with a lower likelihood of alcohol use one or more times per month in the past 12 months. Our findings contribute to the literature demonstrating that substance use behaviors are more prevalent among adults who report weight gain attempts in a large international sample.

Adverse childhood experiences among adults with eating disorders: comparison to a nationally representative sample and identification of trauma

BACKGROUND

Adverse childhood experiences (ACEs) are prevalent, impact long-term physical and mental health, and are associated with eating disorders (EDs) in adulthood. The primary objectives of the current study were: (1) to examine and compare ACEs between two samples: treatment-seeking adults, and a nationally representative sample of adults, (2) to characterize ACEs items and total scores across demographic and diagnostic information in adults seeking treatment for an ED, (3) to statistically classify ACEs profiles using latent class analysis, and (4) to examine associations between ACEs profiles and diagnosis.

METHODS

This cross-sectional study assessed patients with a DSM-5 ED receiving treatment between October 2018 and April 2020 at the inpatient, residential, or partial hospitalization levels of care at one of two private ED treatment facilities. ACEs were assessed with the Adverse Childhood Experiences Survey at admission. Generalized linear models and Welch's t-tests were used to compare ACEs in the current sample with national estimates. A latent class analysis was conducted to examine subgroups of ACEs responses, and differences in these classes by ED diagnoses were examined with multinomial logistic regression.

RESULTS

Patients with EDs had significantly higher ACEs scores (M = 1.95, SD = 1.90) than the nationally representative sample (M = 1.57, SD = 4.72; t = 6.42, p < .001). Within patients with EDs, four latent classes of ACEs item endorsement were identified. Patients with other specified feeding or eating disorder (OSFED) and binge eating disorder (BED) were more likely to fall into the "Household ACEs" and "Abuse ACEs" groups, respectively, compared to anorexia nervosa-restricting subtype (AN-R).

CONCLUSIONS

Patients with EDs reported more ACEs than the nationally representative sample, and differences in total ACEs and latent class membership were found across ED diagnoses. The current study can inform the development of trauma-informed care for patients with EDs.

Motivation to change predicts naturalistic changes in binge eating and purging, but not fasting or driven exercise among individuals with eating disorders

We examined the naturalistic relations between motivation to change and change in four specific eating disorder (ED) behaviors-binge eating (BE), purging, fasting, and driven exercise-in a community-based sample of individuals with EDs over two consecutive 6-week periods. We conducted cross-lagged generalized estimating equations using the transtheoretical model's four stages of change to predict changes in the ED behaviors 6 weeks later. Individuals reported lower pre-contemplation for behaviors typically associated with more distress (e.g., BE, purging) than they did for behaviors associated with less distress (e.g., fasting and driven exercise). Action predicted decreases in BE and purging frequencies but not fasting or driven exercise frequencies. Naturalistic relations between ED behavior severity/frequency and motivation to change these features can be detected over 6-week intervals; that is, attempts at change in individuals' natural environments can be successful over relatively brief periods of time, especially when individuals experience the motivation to change these features. The process of motivation to change ED behaviors is not linear, and our study highlights the movement between stages of change among individuals with EDs. Future research is needed to examine how much of the observed changes are sustained.

Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

Further support for the validity of the social appearance anxiety scale (SAAS) in a variety of German-speaking samples

PURPOSE

Eating disorders (ED) and social anxiety disorder are highly comorbid with potentially shared symptoms like social appearance anxiety (SAA) referring to a fear of being negatively evaluated by others' because of overall appearance. SAA constitutes a risk factor for eating psychopathology and bridges between EDs and social anxiety disorder.

METHODS

The present studies examined internal consistency, factor structure, test-retest reliability, gender and age invariance, convergent validity and differences between individuals with and without an ED of a German version of the social appearance anxiety scale (SAAS) in four independent samples (n₁ = 473; n₂ = 712; n₃ = 79; n₄ = 33) including adolescents and patients with EDs.

RESULTS

Consistently, the SAAS showed excellent internal consistency (ωs ≥ 0.947) and a one-factorial structure. Convergent validity was shown via high correlations of the SAAS with social anxiety (e.g., social interaction anxiety r = 0.642; fear of negative evaluation rs ≥ 0.694), body image disturbance measures (e.g., shape concerns rs ≥ 0.654; weight concerns rs ≥ 0.607; body avoidance rs ≥ 0.612; body checking rs ≥ 0.651) and self-esteem (r = -0.557) as well as moderate correlations with general eating psychopathology (e.g., restrained rs ≥ 0.372; emotional r = 0.439; external eating r = 0.149). Additionally, the SAAS showed gender and age invariance and test-retest reliability after 4 weeks with r = 0.905 in Study 2 and was able to discriminate between individuals with and without an ED in Study 4.

CONCLUSION

Hence, the German version of the SAAS can reliably and validly assess SAA in female and male adolescents or adults with or without an ED. Additionally, the SAAS might be used in a therapeutic context to especially target patient groups suffering from EDs with comorbid social anxiety.

LEVEL OF EVIDENCE

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

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders

OBJECTIVE

Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group - anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder.

METHOD

Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13-60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis).

RESULTS

Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group.

CONCLUSION

Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.

Physical Fitness-Not Physical Activity Levels-Influence Quality of Life in Anorexia Nervosa

Background: Incorporating physical activity (PA) has been a challenge for health care professionals working with anorexia nervosa (AN) patients. This has contributed to partial physical fitness (PFit) recovery that persists after weight restoration. Objective: This cross-sectional study aimed to examine the relationships between PA, sedentary behaviors, PFit, and quality of life (QoL) in a group of adolescents after hospitalization. Methods: QoL, PA, and sedentary behaviors were measured using the Health-Questionnaire Short-Form 36 (SF-36) and accelerometers, while PFit was assessed through cardiorespiratory fitness, body composition (anthropometry), and strength (six repetition maximum) tests in a total of 63 patients. Results: Light-PA (LPA), moderate-PA (MPA), moderate-to-vigorous-PA (MVPA), and relative sedentary time (%ST) did not meet the recommendations (p < 0.001). Only 22% of the patients met MVPA criteria, and ~82% exceeded %ST. SF-36 scores were lower than normative values except the physical component scale. Absolute cardiorespiratory fitness was reduced (p < 0.001) in 84% of the patients, and was positively associated to body weight, body mass index (BMI), circumferences, and muscle areas. Additional positive significant relationships were found between QoL, muscular strength, and body composition, and negative associations between vigorous-to-very vigorous PA and BMI, skinfolds, and percent body fat. Regression analyses revealed lower body strength as an explanatory factor for improved QoL (OR 1.03, 95%CI 1.00−1.07). Conclusions: PFit and QoL scores are poor after hospitalization. LPA, MPA, and MVPA do not meet recommendations. PFit management—with emphasis on improving muscular fitness—may be a valuable strategy for QoL improvement in AN after hospitalization.

Multiple perspectives and dialogue in understanding experiences of living with eating disorders: Two narratives-four unpackings

BACKGROUND

This is a response to Conti et al.'s article, "Listening in the dark: why we need stories of people living with severe and enduring anorexia nervosa" (published in JED, 2016), and its call for relational metaphors and a relational approach to supplement the traditional medical/psychological diagnostic language used to describe the life experiences and complex emotions of people affected by an eating disorder.

METHODS

Four authors with different backgrounds unpack two narratives, 'The Prima Donna with the Green Dress' and 'Breaking down the Wall', both narrated during fieldwork in multifamily therapy. The narratives are unpacked from the perspective of a therapist within multifamily therapy, a researcher who conducted the fieldwork, a researcher based in phenomenology and a researcher based in narrative inquiry. The authors enter into dialogue with the narratives, and with each other.

RESULTS

The four authors focus on different elements within the narratives and understand them differently. One, focuses on strength and pride, and art expression as a different form of language for people living with an eating disorder. Another, on the experience of isolation, boundaries, and balancing openness and closedness. A third, sees the narratives as expressing a wish to see and be seen, and the fourth focuses on the absence of, and longing for, a shared space to explore.

CONCLUSION

The aim is not to reach a correct or shared interpretation of the narratives but to explore how different perspectives may contribute to different insights, not only about one family in particular but about, more generally, the experiences of people living with an eating disorder. Our work shows the significance of engaging with multiple perspectives and dialogue as supplements to the traditional medical/psychiatric diagnostic language in both clinical practice and research.

Exploring changes in alexithymia throughout intensive dialectical behavior therapy for eating disorders

OBJECTIVE

Alexithymia is proposed as a prominent clinical feature of eating disorders (EDs). However, despite theoretical reason to believe that alexithymia could interfere with the success of treatments, few studies have tested whether alexithymia changes over the course of treatment. The goals of the current study were to evaluate (a) changes in alexithymia over the course of intensive Dialectical Behaviour Therapy (DBT) for EDs, and (b) associations between alexithymia and ED symptoms over time.

METHOD

A mixed-diagnostic group of patients with EDs (N = 894) completed the Eating Disorders Examination-Questionnaire (EDE-Q) and the Toronto Alexithymia Scale (TAS-20) throughout intensive treatment and at various lengths of follow-up (6, 12, 24 months).

RESULTS

Results suggested that even after controlling for relevant covariates, there were significant decreases in alexithymia from intake to discharge and discharge to follow-up. Models exploring changes in self-reported ED symptoms indicated that TAS-20 scores significantly related to ED symptoms across timepoints, such that greater alexithymia was associated with greater severity of symptoms.

CONCLUSIONS

Altogether, findings support an association between alexithymia and ED symptoms over treatment and suggest that emotion-focussed therapies like DBT may result in decreases in alexithymia. Future research should explore whether this effect is consistent across therapies without an emotional focus.

Exploring eating and exercise-related indicators during COVID-19 quarantine in Portugal: concerns and routine changes in women with different BMI

PURPOSE

The present study aimed to understand how quarantine associated with COVID-19 was experienced by women from different BMI groups (underweight, normal weight, pre-obesity, and obesity), by exploring the changes introduced in eating and exercise routines and the differences between BMI groups regarding shape concern, weight concern, and binge eating behaviours reported during this time.

METHODS

This study comprised 580 women aged between 18 and 65 years old, who completed self-report measures, during the mandatory confinement in Portugal due to COVID-19. The total sample was divided into four groups, according to their BMI.

RESULTS

Results revealed that overall, there were no significant differences between the groups regarding the eating and exercise routine changes introduced during quarantine. However, significant differences between the four groups were found in the reported body and eating-related difficulties (shape concern, weight concern, and binge eating behaviours), with the pre-obesity and obesity groups presenting significant higher levels.

CONCLUSIONS

Our study suggests that, even though the changes introduced to the eating and exercise routine are independent of BMI, the pre-obesity and obesity group represent a major vulnerability group for the development of eating disorders. We hope this study allows professionals to understand the need to develop different guidelines and strategies for the pre-obesity and obesity female population during the deconfinement period.

LEVEL OF EVIDENCE

Level V-Descriptive study.