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Brennan C, Cini E, Illingworth S, Chapman S, Simic M, Nicholls D, Chapman V, Simms C, Hayes E, Fuller S, Orpwood J, Tweedy N, Baksh T, Astaire E, Bhakta D. Greater rate of weight loss predicts paediatric hospital admission in adolescent typical and atypical anorexia nervosa. Eur J Pediatr 2024; 183:1789-1799. [PMID: 38252309 DOI: 10.1007/s00431-024-05436-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024]
Abstract
Hospital admissions for eating disorders (ED) are rapidly increasing. Limited research exists evidencing the factors that lead to hospital admissions or their outcomes. The current study aimed to identify predictors of hospital admission in adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN). Prospective observational study including participants (n = 205) aged 11-18 and diagnosed with AN or AAN at initial ED assessment, across eight London clinics. Physical health parameters at assessment, including heart rate, blood pressure, temperature and rate of weight loss, were compared between adolescents who were admitted to a paediatric ward following assessment and those who were not admitted. The mean rate of weight loss prior to assessment was significantly higher, and mean energy intake significantly lower, in the admitted vs not admitted groups (1.2 vs 0.6kg/week, p < 0.001 and 565 kcal/day vs 857 kcal/day, p < 0.001), independent of degree of underweight. No significant differences were identified between groups in all other parameters of physical risk. Underweight adolescents with AN were equally likely to be admitted as non-underweight adolescents with AAN. Conclusion: This study provides evidence on predictors of hospital admission, from a sample representing the London area. The assessment of weight loss speed, duration and magnitude are recommended as priority parameters that inform the risk of deterioration and the likelihood of hospital admission in adolescent AN and AAN. Further research investigating outcomes of these hospital admission is needed. What is Known: • Hospital admissions for eating disorders (ED) are rapidly increasing. • Limited research exists evidencing the factors that lead to hospital admissions, or their outcomes. What is New: • This study provides evidence on predictors of hospital admission in young people with typical and atypical anorexia nervosa. • Weight loss speed, duration, and magnitude are recommended as priority parameters that inform the risk of deterioration and the likelihood of hospital admission in this patient group.
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Affiliation(s)
- Cliona Brennan
- South London and Maudsley NHS Trust, London Metropolitan University, London, UK.
- The Michael Rutter Centre, De Crespigny Park, Camberwell, London, SE5 8AZ, UK.
| | - Erica Cini
- East London NHS Foundation Trust, Kings College London, University College London, London, UK
| | | | - Simon Chapman
- South London and Maudsley NHS Trust, Kings College Hospital London, London, UK
| | - Mima Simic
- South London and Maudsley NHS Trust, London, UK
| | - Dasha Nicholls
- Central Northwest London NHS Trust, Imperial College London, London, UK
| | | | | | | | - Sarah Fuller
- Northamptonshire NHS Trust, Northamptonshire, UK
| | | | | | | | | | - Dee Bhakta
- London Metropolitan University, London, UK
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Davis C, Lie HMME, Vasanwala RF, Tan JSK, Oh JY, Rajasegaran K, Chew CSE. Prevalence and risk factors associated with low bone mineral density in Asian adolescents with anorexia nervosa and atypical anorexia nervosa. Int J Eat Disord 2024; 57:819-826. [PMID: 37905973 DOI: 10.1002/eat.24076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE This retrospective study aimed to evaluate the prevalence and risk factors for low bone mineral density (BMD) at diagnosis in Asian adolescent females with anorexia nervosa (AN) and atypical AN. METHOD We analyzed the BMD results for 213 patients between 10 and 18 years of age, with AN and atypical AN receiving care at a pediatric hospital in Singapore. We used linear regression analyses to determine if type of eating disorder, premorbid weight, and duration of amenorrhea were risk factors for low BMD. For a subset of patients with repeat BMD evaluation, we used paired t-tests to assess the impact of weight or menstrual restoration on the change in BMD. RESULTS The prevalence of BMD height-for-age Z-scores <-2 at presentation was higher in patients with AN (13.0%) than atypical AN (2.3%) (p = .034). In multivariate regression, a diagnosis of atypical AN was protective against low BMD at the lumbar spine (B = 0.394, p = .009) and total body less head (B = 0.774, p = .010). Duration of amenorrhea was not associated with BMD across all sites. For those with repeat BMD measures, there was significantly less deterioration in the BMD Z-scores for patients with weight or menstrual restoration (R = -0.22 ± 0.59, NR = -0.69 ± 0.43, p = .029). CONCLUSIONS Duration of amenorrhea was not associated with BMD in this sample. A diagnosis of AN was correlated with lower BMD than atypical AN. Further research is needed to better understand the relationship between amenorrhea, weight status, and bone health in Asian adolescents with eating disorders. PUBLIC SIGNIFICANCE In this sample, 13% of Asian adolescents with AN and 2.3% of Asian adolescents with atypical AN have low BMD. In our study population, duration of amenorrhea was not correlated with BMD. Among adolescents with AN, a history of being underweight at the highest pre-morbid BMI, is correlated with low BMD. It is important for physicians to take a thorough weight history in evaluating bone health in this population.
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Affiliation(s)
- Courtney Davis
- Adolescent Medicine Service, KK Women's and Children's Hospital, Singapore, Singapore
- SingHealth Duke-NUS Paediatric Academic Clinical Programme, Singapore, Singapore
| | - Hannah Marian Mei En Lie
- Lee Kong Chian School of Medicine, Novena Campus, Clinical Sciences Building, Singapore, Singapore
| | - Rashida Farhad Vasanwala
- SingHealth Duke-NUS Paediatric Academic Clinical Programme, Singapore, Singapore
- Endocrinology Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Juliet Sher Kit Tan
- Adolescent Medicine Service, KK Women's and Children's Hospital, Singapore, Singapore
- SingHealth Duke-NUS Paediatric Academic Clinical Programme, Singapore, Singapore
| | - Jean Yin Oh
- Adolescent Medicine Service, KK Women's and Children's Hospital, Singapore, Singapore
- SingHealth Duke-NUS Paediatric Academic Clinical Programme, Singapore, Singapore
| | - Kumudhini Rajasegaran
- Adolescent Medicine Service, KK Women's and Children's Hospital, Singapore, Singapore
- SingHealth Duke-NUS Paediatric Academic Clinical Programme, Singapore, Singapore
| | - Chu Shan Elaine Chew
- Adolescent Medicine Service, KK Women's and Children's Hospital, Singapore, Singapore
- SingHealth Duke-NUS Paediatric Academic Clinical Programme, Singapore, Singapore
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Akgül S, Pehlivantürk Kızılkan M, Yıldırım A, Derman O. Prevalence of suicide attempt, suicide ideation and self-harm at diagnosis in adolescents with eating disorders. Int J Psychiatry Clin Pract 2024; 28:63-67. [PMID: 38592409 DOI: 10.1080/13651501.2024.2337796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/27/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Data concerning the suicide prevalence of eating disorder (ED) subtypes and predictive factors are lacking in youth. This study aimed to examine suicide attempts (SA), suicide ideation (SI) and self-harm (SH) upon diagnosis in adolescents with EDs. METHODS The prevalence of SA, SI and SH in ED subtypes was evaluated by retrospectively assessing the Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidal ideation and Safety (HEEADSSS) instrument of adolescents diagnosed with an ED. Clinical predictors of SI in anorexia nervosa (AN) and atypical AN (AAN) were assessed. RESULTS Among all participants (398), 41 (10.3%) reported SA, 126 (31.7%) SI and 60 (15.1%) SH. While SA did not differ statistically between ED subgroups (p = .123), they were two times more prevalent in the bulimia nervosa (BN) group (17.5%) than in the AN group (8.5%). In the BN group, SI was 2.3 times more prevalent than in the AN group (p = .001). The AN and ARFID groups exhibited substantially less SH (p = .036). Having a higher body mass index (BMI) was the only significant predictor of SI. CONCLUSIONS This study demonstrates that adolescents with EDs are at an increased risk for suicidality, highlighting the need for close screening, particularly in those with BN, AN-BP and AN with a higher BMI.
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Affiliation(s)
- Sinem Akgül
- Department of Pediatrics, Division of Adolescent Medicine, Hacettepe University, Ankara, Turkey
| | | | - Ayşegül Yıldırım
- Department of Pediatrics, Division of Adolescent Medicine, Hacettepe University, Ankara, Turkey
| | - Orhan Derman
- Department of Pediatrics, Division of Adolescent Medicine, Hacettepe University, Ankara, Turkey
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4
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Brennan C, Baudinet J, Simic M, Eisler I. The Role of the Dietitian within Family Therapy for Anorexia Nervosa (FT-AN): A Reflexive Thematic Analysis of Child and Adolescent Eating Disorder Clinician Perspectives. Nutrients 2024; 16:670. [PMID: 38474798 DOI: 10.3390/nu16050670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Despite dietitians being important members of the multidisciplinary team delivering family therapy for anorexia nervosa (FT-AN), their specific responsibilities and roles are unclear and their involvement in the treatment can be a contentious issue. METHODOLOGY Clinicians (n = 20) experienced in the delivery of FT-AN who were working at a specialist child and adolescent eating disorder service responded to an online survey about their experience of including a dietitian in FT-AN and how they understand the role. Both categorical and open-ended questions were used. Reflexive thematic analysis was used to analyse the qualitative free-text responses of clinician perspectives on the role of the dietitian in FT-AN. RESULTS All clinicians agreed that dietetics had a role within FT-AN and most frequently sought dietetic involvement in the early phases of FT-AN. Reflexive thematic analysis of responses identified three main themes. These were (1) collaboration is key, (2) confidence as a core consideration and (3) case-by-case approach. These themes evidenced the role of the dietitian within FT-AN and highlighted both the benefits and concerns of this involvement. CONCLUSIONS This study demonstrated that dietitians can take a core role as collaborators within therapy-led teams that facilitate joint working and sharing of expertise. However, dietetic input should be considered on a case-by-case basis, given its potential for creating an over-focus on nutrition and potentially diminishing parental confidence in feeding. When indicated for selected cases, nutritional counselling should be offered in joint sessions with the therapist rather than separately. The findings of the study were limited by the small sample size of participants recruited from a single centre and heterogeneity in the professional background of respondents. Although the integration of dietetics within the multidisciplinary team and the ability of dietitians to individualise patient care can enhance FT-AN treatment, potential benefits and disbenefits should be considered for each case.
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Affiliation(s)
- Cliona Brennan
- Maudsley Centre for Child and Adolescent Eating Disorders, South London, and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London SE5 8AZ, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AZ, UK
- Department of Human Nutrition and Dietetics, School of Health Sciences, London Metropolitan University, 166-220 Holloway Road, London N7 8DB, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AZ, UK
| | - Julian Baudinet
- Maudsley Centre for Child and Adolescent Eating Disorders, South London, and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London SE5 8AZ, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AZ, UK
| | - Mima Simic
- Maudsley Centre for Child and Adolescent Eating Disorders, South London, and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London SE5 8AZ, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AZ, UK
| | - Ivan Eisler
- Maudsley Centre for Child and Adolescent Eating Disorders, South London, and Maudsley NHS Foundation Trust, De Crespigny Park, Denmark Hill, London SE5 8AZ, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London SE5 8AZ, UK
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Jomah S, Hillel YD, Lowenthal A, Ziv A, Gurevich J, Haskiah F, Steinling S, Krause I. Cardiac involvement and its clinical significance in patients with anorexia nervosa. Eur J Pediatr 2024; 183:95-102. [PMID: 37934282 DOI: 10.1007/s00431-023-05305-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 11/08/2023]
Abstract
Cardiac complications are a major concern in patients with anorexia nervosa (AN) which contribute to morbidity and mortality. However, limited information exists regarding risk factors for the development of these complications. Our objective was to investigate the prevalence and associated risk factors of cardiac involvement among children and adolescents with AN admitted to a tertiary pediatric hospital. We collected demographic, clinical, and laboratory data from individuals with AN hospitalized between 2011 and 2020 in Schneider Children's Medical Center in Israel. Diagnosis was based on established criteria (DSM-5). Patients with other co-morbidities were excluded. Cardiac investigations included electrocardiograms (ECG) and echocardiograms. We conducted correlation tests between cardiac findings and clinical and laboratory indicators. A total of 403 AN patients (81.4% were females) with a median age of 15 ± 2 years were included in the study. Sinus bradycardia was the most common abnormality, observed in 155 (38%) participants. Echocardiogram was performed in 170 (42.2%) patients, of whom 37 (22%) demonstrated mild cardiac aberrations. Among those aberrations, 94.6% could be attributed to the current metabolic state, including pericardial effusion (15.3%) and valve dysfunction (8.8%). Systolic or diastolic cardiac dysfunction, tachyarrhythmias, or conduction disorders were not observed. Patients with new echocardiographic aberration had significantly lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension was higher in this group. CONCLUSIONS The prevalence of cardiac involvement, except for sinus bradycardia, was notably low in our cohort. The presence of cardiac aberrations is correlated with several clinical variables: lower body mass index (BMI) and the presence of amenorrhea and hypotension at admission. Patients presenting with these variables may be at high risk for cardiac findings per echocardiography. Dividing the patients into high and low risk groups may enable targeted evaluation, while avoiding unnecessary cardiac investigations in low-risk patients. WHAT IS KNOWN • Cardiac involvement in anorexia nervosa (AN) patients is a major concern, which contributes to morbidity and mortality. • It is unknown which patients are prone to develop this complication. WHAT IS NEW • Cardiac complications in our cohort are less frequent compared to previous studies, and it is correlated with lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension.
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Affiliation(s)
- Samer Jomah
- Department of Pediatrics "C", Schneider Children's Medical Center of Israel, Petah Tikva, Israel.
| | - Yotam Dizitzer Hillel
- Department of Pediatrics "C", Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Alexander Lowenthal
- Department of Pediatric Cardiology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Ziv
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Day Care Hospitalization, Adolescent Medicine Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Jeny Gurevich
- Department of Pediatrics, Barzilai Medical Center, Ashkelon, Israel
- Goldman Faculty of Medicine, Ben-Gurion University, Beer Sheba, Israel
| | - Feras Haskiah
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Institue, Sheba Medical Center, Ramat Gan, Israel
| | - Shelly Steinling
- Department of Dietary Services, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Irit Krause
- Department of Pediatrics "C", Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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6
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Partain P, Sim L, Fladager Muth J, Mattke A, Billings M, Jacobson R, Le Grange D, Lebow J. The Role of Primary Care in Bridging Adolescents Awaiting Eating Disorder Treatment. Pediatrics 2023; 152:e2023061672. [PMID: 37830161 DOI: 10.1542/peds.2023-061672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 10/14/2023] Open
Abstract
The striking rise in adolescent eating disorders since the severe acute respiratory coronavirus syndrome 2 pandemic has amplified demands for specialty eating disorders services and contributed to protracted delays in care. In the context of these delays, patients are at risk for increased weight loss, medical instability, escalating disease progression and poor prognosis. Primary care providers (PCPs) are frequently the first point of contact for young patients with eating disorders and are often left to bridge the gap while families struggle to establish specialty care. Yet, beyond case detection and medical comanagement, there are no evidence-based guidelines that can assist PCPs to prepare families for treatment, halt disease progression, and begin the lengthy process of weight and nutritional restoration in efforts to reduce medical complications and support a favorable prognosis. We present the case of a 13-year-old girl with a restrictive eating disorder to illustrate how PCPs can use intervention principles and strategies derived from evidence-based eating disorder treatment to successfully manage adolescent patients until they can access specialty treatment. We offer concrete guidelines for decision-making, as well as suggested behavioral and medical interventions for the PCP. With evidence-based tools, PCPs are well-positioned to support young patients with restrictive eating disorders and their family members as they begin the process of recovery from an eating disorder.
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Affiliation(s)
- Paige Partain
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Leslie Sim
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Joy Fladager Muth
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Angela Mattke
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Marcie Billings
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Robert Jacobson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic School of Medicine, Rochester, Minnesota
- Department of Quantitative Health Sciences, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Daniel Le Grange
- Department of Psychiatry, University of California San Francisco, San Francisco, California
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois
| | - Jocelyn Lebow
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic School of Medicine, Rochester, Minnesota
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7
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Nelson LR, Carlson JL, Halpern-Felsher BL, Nagata JM. Clinician confidence and practices for evaluating bone health in male and female adolescents and young adults with an eating disorder. Eat Disord 2023; 31:405-413. [PMID: 36404478 PMCID: PMC10191878 DOI: 10.1080/10640266.2022.2141714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Extensive literature exists on bone health in females with an eating disorder, yet few have studied males. Our study assessed clinician confidence and current practices for assessing bone health in patients with an eating disorder. We also aimed to identify any differences in practice based on patient sex. Our 31-item survey, distributed to adolescent clinicians in the United States via the Society for Adolescent Health and Medicine (SAHM) listserv, assessed clinician confidence and practices for assessing bone mineral density in both male and female adolescents with an eating disorder. Findings showed that clinicians (n = 104) were less confident in assessing bone mineral density in males compared to females (p < .001), yet there was no significant difference in rates of obtaining a DXA (p = .390). Although clinicians are less confident assessing bone health in males with an eating disorder than females, this does not appear to result in screening differences.
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Affiliation(s)
- Lance R. Nelson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, 770 Welch Road Suite 100, Palo Alto, California 94304
| | - Jennifer L. Carlson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, 770 Welch Road Suite 100, Palo Alto, California 94304
| | - Bonnie L. Halpern-Felsher
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, 770 Welch Road Suite 100, Palo Alto, California 94304
| | - Jason M. Nagata
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, 550 16 Street, San Francisco, CA 94158
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8
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Brennan C, Illingworth S, Cini E, Bhakta D. Medical instability in typical and atypical adolescent anorexia nervosa: a systematic review and meta-analysis. J Eat Disord 2023; 11:58. [PMID: 37024943 PMCID: PMC10080852 DOI: 10.1186/s40337-023-00779-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023] Open
Abstract
This review investigates the relationship between weight and risk of medical instability (specifically bradycardia, hypotension, hypothermia, and hypophosphatemia) in adolescents with typical and atypical anorexia nervosa. Atypical anorexia nervosa, listed as an example under the DSM-5 category of Other Specified Feeding and Eating Disorders (OSFED), describes patients who are not clinically underweight but otherwise meet criteria for anorexia nervosa. There is a lack of empirical evidence exploring medical complications in adolescents presenting with atypical anorexia nervosa. The small number of studies that do exist in this area indicate that medical instability exists across a range of weights, with weight loss being associated with increased medical risk, independent of underweight. The aim of this review was to collate and analyse results from available studies and identify indicators of medical risk in these two groups of adolescents with restrictive eating disorders. Studies were identified by systematic electronic search of medical databases, including PubMed and EMBASE. All studies investigated the relationship between weight and medical instability and included adolescents diagnosed with anorexia nervosa or atypical anorexia nervosa. One randomised controlled trial, five cohort studies and three chart reviews were included, with a total sample size of 2331 participants. Between 29 and 42% of participants presented with medical instability requiring hospitalisation, in the absence of underweight. Underweight adolescents were significantly more likely to have lower blood pressures (p < 0.0001) and bradycardia was significantly associated with greater weight loss (p < 0.05). There were no statistically significant associations found between degree of underweight and heart rate, temperature, or rate of weight loss (p = 0.31, p = 0.46 and p = 0.16, respectively). Adolescents that were less than 70% median body mass index were significantly more likely to have hypophosphatemia (p < 0.05). The findings of this review support the hypothesis that medical instability can occur across a range of weights in adolescent eating disorders, with rapid weight loss being an important indicator of increasing medical risk. Results were limited by the small number of existing studies that contained data for statistical analysis. Rapid weight loss should be considered as an important indicator of medical instability in adolescents presenting with both typical and atypical anorexia nervosa.
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Affiliation(s)
- Cliona Brennan
- South London and Maudsley NHS Trust, Maudsley Hospital, De Crespigny Park, London, SE5 8AZ, UK.
- London Metropolitan University, 166-220 Holloway Road, London, N7 8DB, UK.
| | - Sarah Illingworth
- London Metropolitan University, 166-220 Holloway Road, London, N7 8DB, UK
| | - Erica Cini
- East London NHS Foundation Trust, Emmanuel Miller Centre, 11 Gill Street, London, E14 8HQ, UK
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, De Crespigny Park, London, SE5 8AB, UK
- University College London, London, UK
| | - Dee Bhakta
- London Metropolitan University, 166-220 Holloway Road, London, N7 8DB, UK
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9
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Proctor KB, Rodrick E, Belcher S, Sharp WG, Kindler JM. Bone health in avoidant/restrictive food intake disorder: a narrative review. J Eat Disord 2023; 11:44. [PMID: 36949522 PMCID: PMC10031860 DOI: 10.1186/s40337-023-00766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 03/03/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Avoidant/restrictive food intake disorder (ARFID) is an eating/feeding disturbance characterized by severe food avoidance or restriction that results in faltering growth, nutritional deficiencies, dependence on formula supplementation, and/or significant psychosocial impairment. Compared to other eating disorders, ARFID is observed to have an earlier childhood onset and chronic course without intervention. Childhood represents a sensitive period for longitudinal growth and bone accrual, setting the stage for long-term health outcomes associated with longevity and quality of life, including risk for fracture and osteoporosis. RESULTS This narrative review discusses published scientific literature on bone health in individuals with ARFID by describing the current understanding of ARFID's effect on bone health, how common dietary constraints characteristic of ARFID may present unique risks to bone health, and the current clinical recommendations for bone health assessment. Reviewing what is known of clinical data from anorexia nervosa (AN) and similar cohorts, the chronicity and etiology of dietary restriction observed in ARFID are hypothesized to compromise bone health significantly. Although limited, examination of bone health in ARFID patients suggests children with ARFID tend to have shorter stature compared to healthy reference datasets and have lower bone density compared to healthy individuals, similar to those with AN. There remains a substantial knowledge gap in how ARFID may interrupt bone accrual during childhood and adolescence, and subsequent impact on attainment of peak bone mass and peak bone strength. The longitudinal effects of ARFID may be subtle and overlooked clinically in the absence of severe weight loss or growth stunting. Early identification and remediation of threats to bone mass accrual have significant personal and population-level implications. CONCLUSION For patients with ARFID, delayed identification and intervention to address feeding disturbances may have a long-lasting impact on various body systems and processes, including those relating to longitudinal growth and bone mass accrual. Further research employing rigorous prospective observational and/or randomized study designs are required to clearly define effects of ARFID, as well as clinical interventions aimed at addressing ARFID-related feeding disturbances, on bone accrual.
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Affiliation(s)
- Kaitlin B. Proctor
- Emory University School of Medicine and Children’s Healthcare of Atlanta, Athens, GA USA
| | - Eugene Rodrick
- Department of Nutritional Sciences, University of Georgia, Room 279 Dawson Hall, 305 Sanford Drive, Athens, GA 30606 USA
| | - Staci Belcher
- Department of Nutritional Sciences, University of Georgia, Room 279 Dawson Hall, 305 Sanford Drive, Athens, GA 30606 USA
| | - William G. Sharp
- Emory University School of Medicine and Children’s Healthcare of Atlanta, Athens, GA USA
| | - Joseph M. Kindler
- Department of Nutritional Sciences, University of Georgia, Room 279 Dawson Hall, 305 Sanford Drive, Athens, GA 30606 USA
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10
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Tanner AB. Unique considerations for the medical care of restrictive eating disorders in children and young adolescents. J Eat Disord 2023; 11:33. [PMID: 36864525 PMCID: PMC9980853 DOI: 10.1186/s40337-023-00759-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/20/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND The medical complications of eating disorders are often approached through an age-neutral lens. However, children and young adolescents may have unique medical complications related to the energy needs and timing of growth and development. Providers caring for patients in this vulnerable age range should understand how to identify, approach, and manage these potential age-related complications. REVIEW Evidence continues to accumulate that increasingly younger patients are being diagnosed with eating disorders. These children and young adolescents have significant risk for unique and potentially irreversible medical complications. Without early identification and treatment, restrictive eating disorders may negatively impact linear growth, bone development and brain maturation in children and young adolescents. Additionally, due to the energy needs of growth and development, unique considerations exist for the use of acute medical stabilization and the identification of patients at risk for refeeding syndrome with initial nutritional rehabilitation. This review presents an approach to the evaluation and management of children and young adolescents with eating disorders. CONCLUSION Children and young adolescents with restrictive eating disorders may have unique medical complications related to the energy needs and timing of linear growth and pubertal development. Significant risk exists for irreversible medical complications of impaired growth, bone, and brain health. Increased awareness of the energy needs for growth and development may improve early recognition, appropriate intervention, and future outcomes for children and young adolescents with restrictive eating disorders.
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Affiliation(s)
- Anna B Tanner
- Department of Pediatrics, Emory University, 30322, Atlanta, GA, Georgia. .,, Dunwoody, Georgia.
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11
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[Nutritional recovery of underweight adolescents with anorexia nervosa: analysis of a hospital protocol]. NUTR HOSP 2023; 40:13-18. [PMID: 36602137 DOI: 10.20960/nh.04201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction Background: anorexia nervosa (AN) is a severe psychiatric pathology that has one of the highest mortality rates among mental illnesses, estimated at 5.1 deaths per 1,000 people/year, and is associated with high comorbidity, both psychiatric and somatic. Aim: to characterize hospitalized adolescents and their nutritional rehabilitation using a standardized protocol. Methods: a descriptive-retrospective study of adolescent patients hospitalized at the San Carlos of Apoquindo Clinic with a diagnosis of AN, hemodynamically stable and without refeeding syndrome criteria, between 2015 and 2021. Epidemiological, clinical, and nutritional data of the patients were analyzed. Results: of 46 patients studied, 37 were female; the average length of stay was 45.4 (SD ± 36.1) days; 53.8 % of the patients had mood disorder as psychiatric comorbidity, and the most common personality trait was obsessive-compulsive (36.9 %); the most frequent somatic comorbidity was thyroid pathology (19.2 %). The initial oral caloric intake was 1467 (SD ± 479) kcal, with an average weekly increase of 400 kcal, reaching 2430 (SD ± 457) kcal at discharge. An average body mass index (BMI%) percentage change of 7.8 % (SD ± 6.1) was obtained. Conclusions: this is the first national study that describes the nutritional rehabilitation of adolescents with AN and the length of hospitalization required to achieve it.
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12
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Downey AE, Richards A, Tanner AB. Linear growth in young people with restrictive eating disorders: "Inching" toward consensus. Front Psychiatry 2023; 14:1094222. [PMID: 36937727 PMCID: PMC10020618 DOI: 10.3389/fpsyt.2023.1094222] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/17/2023] [Indexed: 03/06/2023] Open
Abstract
Background While the assessment of acute medical stability in patients with eating disorders should never be minimized, careful attention toward other specific age-related consequences of malnutrition can improve psychological outcomes and reduce long-term, potentially irreversible medical complications, like linear growth impairment. Review While the impact of malnutrition on linear growth is widely recognized, emerging data highlight consensus in several key areas: the time from onset to time of diagnosis, age at illness onset, pubertal stage at illness onset, and adequacy of weight restoration to achieve catch-up growth. This review provides concrete and actionable steps to help providers identify and explore deviations in expected growth and development while prioritizing early and aggressive weight restoration to provide the best opportunity for catch-up linear growth in patients with eating disorders. Conclusion The impact of restrictive eating disorders on growth and development cannot be overstated, particularly in pre- and peripubertal patients. While many consequences of malnutrition are reversible, the loss of genetic height potential may prove irreversible without early and aggressive weight restoration.
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Affiliation(s)
- Amanda E. Downey
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Amanda E. Downey,
| | - Alexis Richards
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Anna B. Tanner
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Accanto Health Perimeter Center East, Dunwoody, GA, United States
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13
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Vo M, Golden N. Medical complications and management of atypical anorexia nervosa. J Eat Disord 2022; 10:196. [PMID: 36522787 PMCID: PMC9756584 DOI: 10.1186/s40337-022-00720-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Atypical anorexia nervosa (AAN) is a new diagnosis in the 5th edition of the Diagnostic and Statistical Manual. Patients with AAN have been recognized to have similar, if not more severe, medical and psychological complications compared with patients with typical Anorexia Nervosa; yet studies on medical complications and optimal treatment of AAN are lacking. Here we review what is known regarding medical presentation and management of patients with AAN.
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Affiliation(s)
- Megen Vo
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road Suite 210, Palo Alto, CA, 94304, USA.
| | - Neville Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road Suite 210, Palo Alto, CA, 94304, USA
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14
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Akgül S, Bonny AE, Manos BE, Jackson K, Holland-Hall C. Rapid refeeding does not worsen anxiety in adolescents with anorexia nervosa: a pilot study. Eat Disord 2022; 30:587-601. [PMID: 34184971 DOI: 10.1080/10640266.2021.1939920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The study aimed to describe the progression of state anxiety in adolescents with anorexia nervosa (AN) hospitalized on a high calorie refeeding (HCR) protocol. Participants, 12-21 years, admitted for malnutrition due to AN were placed on a HCR protocol in which calories were advanced by 300 kcal/day. The State-Trait Anxiety Inventory for Children (STAIC) was given to participants within 24 hours of hospitalization and the state anxiety component of the STAIC was administered daily immediately before and after breakfast until discharge. Of 22 patients enrolled, 86% were female, mean age was 14.9 ± 2.0 years, and 95% had AN-restrictive type. The median state and trait anxiety scores at time of admission were 37.0 (28-55) and 35.5 (23-51), respectively. There was no significant difference in median pre-meal state anxiety from hospital day 1 to 6 (34.0(26-55) vs. 38.5(25-55), p-value = 0.079) or in median post-meal state anxiety from hospital day 1 to 6 (35.5(29-56) vs. 37(24-56), p-value = 0.484). Similarly, we found minimal correlation between change in caloric intake and change in pre-meal S-anxiety (Spearman correlation coefficient = -0.032) or post-meal S-anxiety (Spearman correlation = 0.032). While this was a small sample observing anxiety over one week, we found no evidence that state anxiety increased with advancing calories, providing additional support for the use of more rapid refeeding protocols.
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Affiliation(s)
- Sinem Akgül
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Andrea E Bonny
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,The Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA.,The Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brittny E Manos
- The Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kenneth Jackson
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, Ohio, USA.,Biostatistics Resource at Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Cynthia Holland-Hall
- The Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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15
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Nagata JM, Bojorquez-Ramirez P, Nguyen A, Ganson KT, McDonald CM, Machen VI, Downey A, Buckelew SM, Garber AK. Sex differences and associations between zinc deficiency and anemia among hospitalized adolescents and young adults with eating disorders. Eat Weight Disord 2022; 27:2911-2917. [PMID: 35624393 PMCID: PMC9556365 DOI: 10.1007/s40519-022-01396-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/18/2022] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To determine sex differences in and associations between zinc deficiency and anemia among adolescents and young adults hospitalized for medical complications of eating disorders. METHODS We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Descriptive statistics, crude, and adjusted logistic regression models were used to assess the association between zinc deficiency (< 55 mcg/dL) and anemia (< 13.6 g/dL in males [M] and < 11.8 g/dL in females [F]). RESULTS A total of 87 males and 450 females met eligibility criteria (age 15.98 ± 2.81, 59.4% anorexia nervosa; admission body mass index 17.49 ± 2.82). In unadjusted comparisons, plasma zinc in males and females were not statistically different (M 64.88 ± 14.89 mcg/dL vs F 63.81 ± 13.96 mcg/dL, p = 0.517); moreover, there were no differences in the percentage of males and females with zinc deficiency (M 24.14% vs F 24.89%). However, a greater percentage of males than females were anemic (M 50.00% vs F 17.61%, p < 0.001), with similar findings in the subgroup with anorexia nervosa. In logistic regression models stratified by sex and eating disorder diagnosis, zinc deficiency was significantly associated with anemia in males (AOR 3.43, 95% CI 1.16, 10.13), but not females (AOR 1.47, 95% CI 0.86, 2.54). CONCLUSIONS For the first time, we demonstrate that zinc deficiency is equally severe in males compared to females hospitalized with medical complications from eating disorders, with nearly a quarter of inpatients experiencing zinc deficiency. Anemia is more common in males than females hospitalized with eating disorders. LEVEL OF EVIDENCE Level V: descriptive cross-sectional study.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA.
| | | | - Anthony Nguyen
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Kyle T Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Christine M McDonald
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Vanessa I Machen
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Amanda Downey
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Sara M Buckelew
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Andrea K Garber
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
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16
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Downey AE, Cheng J, Adams SH, Buckelew SM, Kapphahn CJ, Machen VI, Rosen EL, Moscicki AB, Golden NH, Garber AK. Renal Function in Patients Hospitalized With Anorexia Nervosa Undergoing Refeeding: Findings From the Study of Refeeding to Optimize Inpatient Gains. J Adolesc Health 2022; 71:432-437. [PMID: 35705423 PMCID: PMC10863996 DOI: 10.1016/j.jadohealth.2022.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/19/2022] [Accepted: 04/23/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Among complications of malnutrition secondary to anorexia nervosa (AN) or atypical anorexia nervosa (AAN), renal impairment remains poorly elucidated. Evaluating renal function in hospitalized pediatric patients with AN and AAN undergoing refeeding will yield important information to guide clinicians in screening and managing renal dysfunction in this population. METHODS This is a secondary analysis of data from the Study of Refeeding to Optimize Inpatient Gains trial, a multicenter randomized clinical trial comparing higher calorie refeeding versus lower calorie refeeding in 120 adolescents and young adults hospitalized with medical instability secondary to AN or AAN. Baseline disease characteristics were obtained. Vital sign measurements, weight, electrolytes, and fluid status were evaluated daily to ascertain medical stability. Renal function on admission and throughout hospitalization was quantified using daily creatinine measurement and calculation of the estimated glomerular filtration rate (eGFR) using the modified Schwartz equation. Regression analysis and mixed linear models were utilized to evaluate factors associated with eGFR. RESULTS Of the 111 participants who completed treatment protocol, 33% had a baseline eGFR less than 90, suggesting renal impairment. Patients who experienced more rapid weight loss and more severe bradycardia were more likely to have low admission eGFR. While eGFR improved during refeeding, eGFR change by day based on refeeding treatment assignment did not reach statistical significance (95% confidence interval, -1.61, 0.15]; p = .095). DISCUSSION Renal impairment is evident on admission in a significant number of adolescents and young adults hospitalized with AN and AAN. We demonstrate that short-term medical refeeding yields improvement in renal function.
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Affiliation(s)
- Amanda E Downey
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California; Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California.
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco, California
| | - Sally H Adams
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Sara M Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Cynthia J Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Vanessa I Machen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Elaine L Rosen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, California
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles, California
| | - Neville H Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Andrea K Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California
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17
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Implementation of Standardized Care for the Medical Stabilization of Patients With Anorexia Nervosa. Pediatr Qual Saf 2022; 7:e582. [PMID: 36032191 PMCID: PMC9416762 DOI: 10.1097/pq9.0000000000000582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 06/30/2022] [Indexed: 11/26/2022] Open
Abstract
Approaches to refeeding patients with anorexia nervosa for medical stabilization vary across institutions, and there is no established standard of care. This study assessed the impact of a refeeding pathway on hospital length of stay and transfer to the psychiatry unit.
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18
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Nagata JM, Grandis A, Bojorquez-Ramirez P, Nguyen A, Downey AE, Ganson KT, Patel KP, Machen VI, Buckelew SM, Garber AK. Assessment of vitamin D among male adolescents and young adults hospitalized with eating disorders. J Eat Disord 2022; 10:104. [PMID: 35851069 PMCID: PMC9295348 DOI: 10.1186/s40337-022-00627-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/29/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Medical complications of eating disorders in males are understudied compared to females, as is the case of vitamin D deficiency. The aim of this study was to assess vitamin D levels among male and female adolescents and young adults hospitalized for medical complications of eating disorders. METHODS We retrospectively reviewed electronic medical records of patients aged 9-25 years (N = 565) admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Serum vitamin D (25-hydroxy) level was assessed at admission as was history of prior calcium, vitamin D, or multivitamin supplementation. Linear regression was used to assess factors associated with vitamin D levels. RESULTS A total of 93 males and 472 females met eligibility criteria (age 15.5 ± 2.8, 58.8% anorexia nervosa; admission body mass index 17.6 ± 2.91). Among male participants, 44.1% had 25-hydroxyvitamin D levels < 30 ng/mL, 18.3% had 25-hydroxyvitamin D levels < 20 ng/mL, and 8.6% had 25-hydroxyvitamin D levels < 12 ng/mL. There were no significant differences in 25-hydroxyvitamin D levels in males compared to females, except that a lower proportion (1.9%) of female participants had 25-hydroxyvitamin D levels < 12 ng/mL (p = 0.001). Only 3.2% of males reported calcium or vitamin D-specific supplementation prior to hospital admission, while 8.6% reported taking multivitamins. White race, prior calcium/vitamin D supplementation, and higher calcium levels were associated with higher vitamin D levels on admission. CONCLUSIONS Nearly half of patients admitted to the hospital for malnutrition secondary to eating disorders presented with low 25-hydroxyvitamin D levels; males were more likely than females to have severe vitamin D deficiency. These findings support vitamin D assessment as part of the routine medical/nutritional evaluation for hospitalized eating disorder patients, with particular attention on male populations.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA.
| | - Anna Grandis
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | | | - Anthony Nguyen
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | - Amanda E Downey
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Kyle T Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Khushi P Patel
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | - Vanessa I Machen
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | - Sara M Buckelew
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
| | - Andrea K Garber
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94143, USA
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19
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Abstract
Eating disorders can have serious consequences for adolescent patients. Early detection and coordination of treatment can improve outcomes. The coronavirus disease 2019 pandemic has negatively affected mental health, and eating disorders are no exception. The reported increase in eating disorder behaviors and referrals for treatment, combined with the shortage of treatment options, has underscored the role of the outpatient pediatrician. Detection of eating disorders in the primary care setting starts with analyzing vitals and weight trends. If suspecting an eating disorder, one should complete a thorough history with pertinent review of systems, physical examination, and an initial laboratory evaluation. Upon confirming a diagnosis, it is important for a pediatrician to decide on the level of care needed. Given long wait times for treatment centers, utilization of local resources is helpful for coordinating a multidisciplinary approach. Increased funding for eating disorder treatment initiatives could help alleviate the current strain on our health care system. [Pediatr Ann. 2022;51(4):e150-e153.].
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20
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Parker EK, Flood V, Halaki M, Wearne C, Anderson G, Gomes L, Clarke S, Wilson F, Russell J, Frig E, Kohn M. A standard enteral formula versus an iso-caloric lower carbohydrate/high fat enteral formula in the hospital management of adolescent and young adults admitted with anorexia nervosa: a randomised controlled trial. J Eat Disord 2021; 9:160. [PMID: 34895344 PMCID: PMC8666027 DOI: 10.1186/s40337-021-00513-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 11/19/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The nutritional rehabilitation of malnourished patients hospitalised with anorexia nervosa is essential. The provision of adequate nutrition must occur, while simultaneously, minimising the risk of refeeding complications, such as electrolyte, metabolic, and organ dysfunction. The aim of this study was to compare the efficacy and safety of an iso-caloric lower carbohydrate/high fat enteral formula (28% carbohydrate, 56% fat) against a standard enteral formula (54% carbohydrate, 29% fat). METHODS Patients (aged 15-25 years) hospitalised with anorexia nervosa were recruited into this double blinded randomised controlled trial. An interim analysis was completed at midpoint, when 24 participants, mean age 17.5 years (± 1.1), had been randomly allocated to lower carbohydrate/high fat (n = 14) or standard (n = 10) feeds. RESULTS At baseline, there was no significant difference in degree of malnutrition, medical instability, history of purging or serum phosphate levels between the two treatment arms. A significantly lower rate of hypophosphatemia developed in patients who received the lower carbohydrate/high fat formula compared to standard formula (5/14 vs 9/10, p = 0.013). The serum phosphate level decreased in both feeds, however it decreased to a larger extent in the standard feed compared to the lower carbohydrate/high fat feed (standard feed 1.11 ± 0.13 mmol/L at baseline vs 0.88 ± 0.12 mmol/L at week 1; lower carbohydrate/high fat feed 1.18 ± 0.19 mmol/L at baseline vs 1.06 ± 0.15 mmol/L at week 1). Overall, serum phosphate levels were significantly higher in the lower carbohydrate/high fat feed compared with standard feed treatment arm at Week 1 (1.06 ± 0.15 mmol/L vs 0.88 ± 0.12 mmol/L, p < 0.001). There was no significant difference in weight gain, number of days to reach medical stability, incidence of hypoglycaemia, or hospital length of stay. CONCLUSIONS The results of this study indicate that enteral nutrition provided to hospitalised malnourished young people with anorexia nervosa using a lower carbohydrate/high fat formula (28% carbohydrate, 56% fat) seems to provide protection from hypophosphatemia in the first week compared to when using a standard enteral formula. Further research may be required to confirm this finding in other malnourished populations. TRIAL REGISTRATION ANZCTR, ACTRN12617000342314. Registered 3 March 2017, http://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000342314.
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Affiliation(s)
- Elizabeth Kumiko Parker
- Department of Dietetics and Nutrition, Westmead Hospital, PO Box 533, Wentworthville, NSW, 2145, Australia. .,Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - Victoria Flood
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.,Western Sydney Local Health District, Westmead, NSW, 2145, Australia
| | - Mark Halaki
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Christine Wearne
- Department of Medical Psychology, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Gail Anderson
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Linette Gomes
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Simon Clarke
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia.,Centre for Research Into AdolescentS' Health (CRASH), Westmead Hospital, Westmead, NSW, 2145, Australia.,Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Frances Wilson
- Department of Psychiatry, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Janice Russell
- Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.,NSW Statewide Eating Disorder Service, Peter Beumont Unit, Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Elizabeth Frig
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Michael Kohn
- Department of Adolescent and Young Adult Medicine, Westmead Hospital, Westmead, NSW, 2145, Australia.,Centre for Research Into AdolescentS' Health (CRASH), Westmead Hospital, Westmead, NSW, 2145, Australia.,Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
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21
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Nelson LR, Halpern-Felsher BL, Nagata JM, Carlson JL. Clinician practices assessing hypothalamic-pituitary-gonadal axis suppression in adolescents with an eating disorder. Int J Eat Disord 2021; 54:2218-2222. [PMID: 34611918 DOI: 10.1002/eat.23625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Although extensive literature exists on hypothalamic-pituitary-gonadal (HPG) axis suppression in females with an eating disorder, there are few studies in males. Our study aimed to determine clinician practices for the assessment of HPG axis suppression and to identify differences in practice based on the sex of the patient. METHOD Our 31-item survey queried clinicians about confidence level and practices for assessing HPG suppression in male compared to female patients. RESULTS Findings showed that clinicians (n = 104) were less likely to evaluate HPG suppression in males compared to females, including assessment of sexual maturity rating (p < .050), screening of decreased libido compared to amenorrhea (p < .001) and lab assessment (luteinizing hormone and follicular-stimulating hormone: p < .001; estradiol/testosterone: p < .010; TSH: p < .050). Participants also felt less confident evaluating male patients (p < .001) and requested better screening tools for males (p < .001). DISCUSSION Our data suggest that clinician practices differ based on patient sex and that clinicians request tools for HPG suppression assessment in males. This is the first study examining specific practices and comfort levels of clinicians when assessing HPG axis suppression. Findings suggest that more guidance on the management of male patients may be needed to standardize care and to prevent short and long-term sequela of malnutrition.
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Affiliation(s)
- Lance R Nelson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Bonnie L Halpern-Felsher
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Jason M Nagata
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, California, USA
| | - Jennifer L Carlson
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California, USA
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22
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Anorexia Nervosa-What Has Changed in the State of Knowledge about Nutritional Rehabilitation for Patients over the Past 10 Years? A Review of Literature. Nutrients 2021; 13:nu13113819. [PMID: 34836075 PMCID: PMC8619053 DOI: 10.3390/nu13113819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/19/2021] [Accepted: 10/24/2021] [Indexed: 11/16/2022] Open
Abstract
Anorexia nervosa (AN) is a psycho-metabolic disorder with a high risk of somatic complications such as refeeding syndrome (RFS) and carries the highest mortality rate of all psychiatric illnesses. To date, the consensus on the care for patients with AN has been based on recommendations for a combination of alimentation and psychotherapy. It is important to establish an initial caloric intake that will provide weight gain and minimize the risk of complications in the treatment of undernourished patients. Research over the past few years suggests that current treatment recommendations may be too stringent and should be updated. The aim of this paper is to systematize the current reports on nutritional rehabilitation in AN, to present the results of studies on the safe supplementation of patients and its potential impact on improving prognosis and the healing process. This review of literature, from 2011-2021, describes the changing trend in the nutritional protocols used and the research on their efficacy, safety, and long-term effects. In addition, it presents previous reports on the potential benefits of introducing vitamin, pro-and prebiotic and fatty acid supplementation.
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Parmar DD, Alabaster A, Vance S, Ritterman Weintraub ML, Lau JS. Disordered Eating, Body Image Dissatisfaction, and Associated Healthcare Utilization Patterns for Sexual Minority Youth. J Adolesc Health 2021; 69:470-476. [PMID: 34053814 DOI: 10.1016/j.jadohealth.2021.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status. METHODS Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility. RESULTS BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9-2.2] and adjusted odds ratio 3.8 [3.4-4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services. CONCLUSIONS SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.
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Affiliation(s)
- Deepika D Parmar
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California; Pediatrics Residency Program, Kaiser Permanente Northern California, Oakland, California.
| | - Amy Alabaster
- Division of Research, Kaiser Permanente, Oakland, California
| | - Stanley Vance
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | | | - Josephine S Lau
- Division of Adolescent Medicine, The Permanente Medical Group, Kaiser Permanente Northern California, San Leandro, California
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Ganson KT, Murray SB, Nagata JM. Last word: A call to develop specific medical treatment guidelines for adolescent males with eating disorders. Eat Disord 2021; 29:344-350. [PMID: 31414975 DOI: 10.1080/10640266.2019.1652474] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Males with eating disorders are underdiagnosed and undertreated, which may be a result of inadequate guidance and training to assess and treat eating disorders for medical professionals. This may be particularly problematic for adolescent males given the focus of eating disorders research and treatment on adolescent females. Furthermore, there is a paucity of research to guide screening, medical treatment, and training of health professions in adolescent males with eating disorders. The development of eating disorders education and training for medical professionals are included in the 21st Century Cures Act, which further emphasizes the opportunity to develop treatment guidelines individualized to male patients. This last word calls for the development of specific medical treatment guidelines for adolescent males with eating disorders.
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Affiliation(s)
- Kyle T Ganson
- School of Social Work, Simmons University, Boston, MA, USA
| | - Stuart B Murray
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Jason M Nagata
- Department of Pediatrics, University of California, San Francisco, CA, USA
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25
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Lantzouni E, Grady R. Eating Disorders in Children and Adolescents: A Practical Review and Update for Pediatric Gynecologists. J Pediatr Adolesc Gynecol 2021; 34:281-287. [PMID: 33486085 DOI: 10.1016/j.jpag.2021.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/14/2021] [Indexed: 01/14/2023]
Abstract
Eating disorders (EDs) are common among female adolescents and young adults and can have serious and diverse health consequences. Pediatric gynecology providers have the opportunity to play a vital role in the recognition of EDs in this population. Early medical detection and referral for appropriate evidence-based treatment can lead to better health outcomes for youth. In this article we aim to increase the awareness of the pediatric gynecologist of typical and subtle presentations of EDs, provide guidance for screening, discuss common and serious medical complications, and review treatment considerations for gynecologic issues in patients with EDs.
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Affiliation(s)
- Eleni Lantzouni
- The Craig Dalsimer Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Rosheen Grady
- Division of Adolescent Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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26
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Oliveira SB. Why Is Avoidant-Restrictive Food Intake Disorder Relevant to the Pediatric Gastroenterologist? JAMA Pediatr 2021; 175:455-457. [PMID: 33492367 DOI: 10.1001/jamapediatrics.2020.5784] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Stephanie B Oliveira
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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27
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Evaluation of One Program's Use of the Society for Adolescent Health and Medicine Resident Curriculum. J Adolesc Health 2021; 68:1006-1010. [PMID: 33637404 DOI: 10.1016/j.jadohealth.2021.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE The publicly available Society for Adolescent Health and Medicine (SAHM) Resident Curriculum provides resources for blended learning. This report presents a formal evaluation of this blended learning curriculum. METHODS We adapted the SAHM curriculum for a required four-week rotation for pediatricians in training. We selected webinars, videos, articles, and Web sites from the SAHM curriculum to complement the local clinical context. We evaluated the effectiveness of our curriculum using resident pre- and post-self-assessments, weekly knowledge quizzes, and a standardized patient encounter. RESULTS Resident self-assessment improved in all domains except managing urologic conditions. Residents scored 85% or higher on knowledge quizzes. Standardized patients rated residents a mean of 90.2 out of 100 on adolescent communication and 89.0 out of 100 on parent communication. CONCLUSIONS A blended learning curriculum consisting of SAHM online materials and local clinical experiences improved resident self-assessment, knowledge, and communication skills.
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28
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Norris ML, Couturier J. Making Gains in Eating Disorders Outcomes Research. Pediatrics 2021; 147:peds.2020-043737. [PMID: 33753540 DOI: 10.1542/peds.2020-043737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Mark L Norris
- Department of Pediatrics, Faculty of Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ontario; and
| | - Jennifer Couturier
- Department of Child and Adolescent Psychiatry, McMaster Children's Hospital, Hamilton Health Sciences and Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
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29
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Proulx-Cabana S, Taddeo D, Jamoulle O, Frappier JY, Tremblay-Racine F, Stheneur C. Initial inpatient management of adolescents and young adults admitted with severe malnutrition due to anorexia nervosa: protocol for a systematic review. J Eat Disord 2021; 9:36. [PMID: 33691797 PMCID: PMC7944889 DOI: 10.1186/s40337-021-00389-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anorexia Nervosa (AN) is a highly prevalent disease in adolescents and young adults (AYAs). The quality of initial inpatient medical management in a patient with severe malnutrition due to AN is crucial to prevent further medical instability. This review aims to inventory evidence regarding initial refeeding and management of AYAs with AN in an inpatient setting, in order to avoid medical complications. METHODS A systematic review will be conducted using PubMed, MEDLINE, All EBM Reviews, Embase, PsycINFO, Cochrane Database and CINAHL. The search strategy consists of terms related to anorexia, hospitalization and Pediatrics. Randomized controlled trials, case-control studies, cross-sectional and cohort studies will be included. Participants will include adolescents and adults 18-24 years old diagnosed with AN and meeting criteria for severe disease. The primary outcome will be any of the following complications: hypophosphatemia, refeeding syndrome, hypoglycemia, cardiac arrythmia, hepatic cytolysis or death. Data will be extracted and the risk of bias will be assessed by one author and reviewed by a second author. Results will be presented in a systematic narrative synthesis format. The quality of evidence for all outcomes will be evaluated using the GRADE methodology. DISCUSSION This systematic review will examine current evidence on initial inpatient refeeding and help to document effectiveness of initial inpatient management in AYAs with severe AN in avoiding further medical complications. TRIAL REGISTRATION This study is registered on PROSPERO under the reference number CRD42019123608 .
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Affiliation(s)
- Stéphanie Proulx-Cabana
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1C5, Canada.
| | - Danielle Taddeo
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1C5, Canada
| | - Olivier Jamoulle
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1C5, Canada
| | - Jean-Yves Frappier
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1C5, Canada
| | - Fannie Tremblay-Racine
- Librarian, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1C5, Canada
| | - Chantal Stheneur
- CESP, Univ. Paris-Sud, UVSQ, INSERM U 1178, Université Paris-Saclay [Paris-Saclay University], 94805, Villejuif, France.,Clinique FSEF Varennes Jarcy, Fondation Sante des Etudiants de France, 91480, Varennes-Jarcy, France.,UFR des Sciences de la Santé Simone Veil [Simone Veil Health Science Training and Research Unit], Université de Versailles Saint-Quentin-en-Yvelines [Versailles Saint-Quentin-en-Yvelines University], Versailles, France
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30
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Garber AK, Cheng J, Accurso EC, Adams SH, Buckelew SM, Kapphahn CJ, Kreiter A, Le Grange D, Machen VI, Moscicki AB, Sy A, Wilson L, Golden NH. Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial. JAMA Pediatr 2021; 175:19-27. [PMID: 33074282 PMCID: PMC7573797 DOI: 10.1001/jamapediatrics.2020.3359] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome. OBJECTIVE To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa. DESIGN, SETTING, AND PARTICIPANTS In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach. INTERVENTIONS Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day. MAIN OUTCOMES AND MEASURES Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay. RESULTS Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant. CONCLUSIONS AND RELEVANCE In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02488109.
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Affiliation(s)
- Andrea K. Garber
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Jing Cheng
- Department of Preventive and Restorative Dental Sciences, University of California, San Francisco
| | - Erin C. Accurso
- Department of Psychiatry and Behavioral Medicine, University of California, San Francisco
| | - Sally H. Adams
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Sara M. Buckelew
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Cynthia J. Kapphahn
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Anna Kreiter
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Daniel Le Grange
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco,Department of Psychiatry and Behavioral Medicine, University of California, San Francisco,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois (emeritus)
| | - Vanessa I. Machen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
| | - Anna-Barbara Moscicki
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles
| | - Allyson Sy
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Leslie Wilson
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Neville H. Golden
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
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31
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Hornberger LL, Lane MA. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics 2021; 147:peds.2020-040279. [PMID: 33386343 DOI: 10.1542/peds.2020-040279] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.
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Affiliation(s)
- Laurie L Hornberger
- Division of Adolescent Medicine, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Margo A Lane
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
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33
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Goldberg HR, Katzman DK, Allen L, Martin S, Sheehan C, Kaiserman J, Macdonald G, Kives S. The Prevalence of Children and Adolescents at Risk for Avoidant Restrictive Food Intake Disorder in a Pediatric and Adolescent Gynecology Clinic. J Pediatr Adolesc Gynecol 2020; 33:466-469. [PMID: 32553711 DOI: 10.1016/j.jpag.2020.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/30/2020] [Accepted: 06/08/2020] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE The purpose of this study was to determine the prevalence of child and adolescent females at risk for Avoidant Restrictive Food Intake Disorder (ARFID) in a tertiary care pediatric and adolescent gynecology (PAG) clinic. DESIGN Cross-sectional study design. SETTING Tertiary care PAG clinic at the Hospital for Sick Children in Toronto, Ontario, Canada. PARTICIPANTS Females between 8 and 18 years of age presenting to the tertiary care PAG clinic. INTERVENTION Between October 2017 and April 2019, eligible patients completed a 3-part, self-administered questionnaire that included demographic and anthropometric information, reason(s) for referral, medical history, menstrual history and function, and the Eating Disorders in Youth-Questionnaire (EDY-Q). MAIN OUTCOME MEASURES The main outcome measure was the prevalence of child and adolescent females who were identified to be at risk for ARFID in a tertiary care PAG clinic. RESULTS Seven (3.7%) of 190 patients were identified to be at risk for ARFID based on the EDY-Q. All patients at risk for ARFID had a significantly lower body mass index (17.4 ± 1.6 vs 24.4 ± 6.7, P < .001) than patients not at risk for ARFID. CONCLUSIONS This study demonstrated that 3.7% of patients seeking treatment in a tertiary care PAG clinic were identified to be at risk for ARFID. Clinicians in tertiary care PAG clinics can play a pivotal role in the identification and referral of children and adolescents at risk for ARFID. Referral to the patients' primary care physician or to an eating disorder program is important so as not to delay the diagnosis and treatment.
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Affiliation(s)
- Hanna R Goldberg
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecology, Department of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Debra K Katzman
- Division of Adolescent Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Lisa Allen
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecology, Department of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Samantha Martin
- Division of Adolescent Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carolyn Sheehan
- Division of Gynecology, Department of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jenna Kaiserman
- Division of Gynecology, Department of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Gina Macdonald
- Division of Gynecology, Department of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Sari Kives
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecology, Department of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Lane-Loney SE, Zickgraf HF, Ornstein RM, Mahr F, Essayli JH. A Cognitive-Behavioral Family-Based Protocol for the Primary Presentations of Avoidant/Restrictive Food Intake Disorder (ARFID): Case Examples and Clinical Research Findings. COGNITIVE AND BEHAVIORAL PRACTICE 2020. [DOI: 10.1016/j.cbpra.2020.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW To review the recent literature on eating disorders and disordered eating behaviors among adolescent boys and young men, including epidemiology, assessment, medical complications, treatment outcomes, and special populations. RECENT FINDINGS Body image concerns in men may involve muscularity, and muscle-enhancing goals and behaviors are common among adolescent boys and young men. Recent measures, such as the Muscularity Oriented Eating Test (MOET) have been developed and validated to assess for muscularity-oriented disordered eating. Medical complications of eating disorders can affect all organ systems in male populations. Eating disorders treatment guidance may lack specificity to boys and men, leading to worse treatment outcomes in these population. Male populations that may have elevated risk of eating disorders and disordered eating behaviors include athletes and racial/ethnic, sexual, and gender minorities. SUMMARY Eating disorders and disordered eating behaviors in boys and men may present differently than in girls and women, particularly with muscularity-oriented disordered eating. Treatment of eating disorders in boys and men may be adapted to address their unique concerns.
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Affiliation(s)
- Jason M. Nagata
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Kyle T. Ganson
- School of Social Work, Simmons University, Boston, MA, USA
| | - Stuart B. Murray
- Department of Psychiatry and the Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
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36
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Accurso EC, Sim L, Muhlheim L, Lebow J. Parents know best: Caregiver perspectives on eating disorder recovery. Int J Eat Disord 2020; 53:1252-1260. [PMID: 31743480 PMCID: PMC7269124 DOI: 10.1002/eat.23200] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This study used mixed methods to evaluate caregiver perspectives on recovery from an eating disorder. METHOD Caregivers (N = 387) completed an online survey about their child's weight history, treatment history, illness trajectory, and recovery. RESULTS Children were predominantly females with adolescent onset anorexia nervosa and currently 18.4 years old on average. Qualitative analysis of caregivers' open-ended definitions of recovery revealed seven distinct recovery domains, including (a) weight (45%); (b) body image, eating disorder cognitions, and related emotions (54%); (c) eating behavior (71%); (d) independence and responsibility in eating disorder management (28%); (e) physical health (21%); (f) psychological well-being (31%); and (g) life worth living (27%). Most (72%) reported that their child had achieved partial or full recovery at some point in their lifetime. Only 20% reported that their child had ever achieved full recovery, but 93% of those had sustained recovery over time (i.e., no relapses since achieving recovery). Physical recovery occurred on average 2.7 years after eating disorder onset, followed shortly by social and emotional recovery (2.9 years), and finally behavioral (3.4 years) and cognitive (3.9 years) recovery, which occurred at weights 6-7 pounds higher than those at which physical recovery was achieved. DISCUSSION Findings suggest that caregivers hold a multifaceted view of recovery that includes not only weight restoration and symptom reduction, but also full engagement in social and occupational activities, establishment of a meaningful life, cognitive flexibility, and emotional well-being. These data support clinical observations that physical and behavioral recovery precede cognitive recovery.
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Affiliation(s)
- Erin C. Accurso
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA
| | - Leslie Sim
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, MN
| | | | - Jocelyn Lebow
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, MN
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Todisco P, Meneguzzo P, Vogazianos P, Garolla A, Antoniades A, Tozzi F. Relation between vitamin D and impulse behaviours in patients with eating disorder: a pilot observational study. EUROPEAN EATING DISORDERS REVIEW 2020; 28:587-593. [PMID: 32372472 DOI: 10.1002/erv.2740] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/14/2020] [Accepted: 04/08/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE There is growing evidence that vitamin D levels have a role not only in bone health and energy metabolism, but also for supporting nervous system and brain functions, including impulsivity. Impulsive behaviours are considered characteristics of great relevance in patients with Eating Disorders (ED) both for the course of the illness and for the treatment. The aim of this study is to examine the relationship between impulsive behaviours and vitamin D in patients with ED. METHOD 236 patients with a diagnosis of ED, consecutively recruited at an ED ward between 2014 and 2018, were enrolled. Patients were classified as impulsive or non-impulsive based on the presence of clinically relevant impulsive behaviours. RESULTS Impulsive patients were found to have statistically significant lower levels of vitamin D than non-impulsive (p = .007). A threshold value of 20.4 ng/ml for discriminating impulsive from non-impulsive patients was found. DISCUSSION This hypothesis generating study partially confirmed a relationship between vitamin D deficiency and impulsive behaviours in ED spectrum mediated by body weight, even if results were not confirmed after corrected by obesity. No definitive conclusion may be taken on whether the effect is reduced due to the loss of power. Future directions are discussed.
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Affiliation(s)
- Patrizia Todisco
- Eating Disorders Unit, Casa di Cura "Villa Margherita", Arcugnano (Vicenza), Italy
| | - Paolo Meneguzzo
- Eating Disorders Unit, Casa di Cura "Villa Margherita", Arcugnano (Vicenza), Italy.,Department of Neuroscience, University of Padova, Padova, Italy
| | - Paris Vogazianos
- Brain Sciences and Analytics, Stremble Venture Ltd, Germasogeia, Cyprus.,Department of Social and Behavioural Sciences, School of Humanities, Social & Education Sciences, European University of Cyprus, Engomi, Cyprus
| | - Alice Garolla
- Eating Disorders Unit, Casa di Cura "Villa Margherita", Arcugnano (Vicenza), Italy
| | - Athos Antoniades
- Brain Sciences and Analytics, Stremble Venture Ltd, Germasogeia, Cyprus
| | - Federica Tozzi
- Brain Sciences and Analytics, Stremble Venture Ltd, Germasogeia, Cyprus
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Tantillo M, Starr T, Kreipe R. The recruitment and acceptability of a project ECHO® eating disorders clinic: a pilot study of telementoring for primary medical and behavioral health care practitioners. Eat Disord 2020; 28:230-255. [PMID: 30829141 DOI: 10.1080/10640266.2019.1580125] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Early identification and intervention are critical to prevent physical and mental health complications, chronicity, and premature death associated with eating disorders. However, primary medical and behavioral health care clinicians often do not feel confident or competent to diagnose and manage patients with eating disorders. This pilot study describes an innovative telementoring project (Project ECHO® Eating Disorders) that builds a geographically defined collaborative learning community to bridge the knowledge gap between eating disorder specialists located in eating disorder service sites and community-based practitioners, often living in remote areas. We describe the program and recruitment strategies and review baseline participant evaluation findings. Continuing Medical Education (CME) evaluation findings are presented as a measure of practitioner acceptability and satisfaction. Content analysis of CME participant evaluation comments provides an understanding of the impact of the program on participant knowledge and intended practice changes. We end with implications for training, practice, and research.
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Affiliation(s)
- Mary Tantillo
- Western NY Comprehensive Care Center (WNYCCCED) and Project ECHO® Eating, Disorders Clinic, University of Rochester School of Nursing, Rochester, USA
| | - Taylor Starr
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, USA.,Associate Medical Director, WNYCCCED and Project ECHO® Eating Disorders Clinic, Rochester, USA
| | - Richard Kreipe
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, USA.,Medical Director, WNYCCCED and Project ECHO® Eating Disorders Clinic, Rochester, USA
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Ante Z, Luu TM, Healy-Profitós J, He S, Taddeo D, Lo E, Auger N. Pregnancy outcomes in women with anorexia nervosa. Int J Eat Disord 2020; 53:403-412. [PMID: 32100355 DOI: 10.1002/eat.23251] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Birth outcomes of women with anorexia nervosa are poorly understood. We hypothesized that hospitalization for anorexia nervosa before or during pregnancy is associated with an elevated risk of adverse maternal and infant birth outcomes. METHOD We performed a retrospective cohort study of 2,134,945 pregnancies in Quebec, Canada, from 1989 to 2016. The main exposure measure was anorexia nervosa requiring hospital treatment before or during pregnancy. Outcome measures included stillbirth, preterm birth, low birth weight, small-for-gestational age birth, preeclampsia, gestational diabetes, cesarean delivery, and other pregnancy disorders. We computed risk ratios and 95% confidence intervals (CI) for the association between anorexia nervosa and birth outcomes adjusted for maternal characteristics. RESULTS Compared with no hospitalization, anorexia nervosa hospitalization was associated with 1.99 times the risk of stillbirth (95% CI 1.20-3.30), 1.32 times the risk of preterm birth (95% CI 1.13-1.55), 1.69 times the risk of low birth weight (95% CI 1.44-1.99), and 1.52 times the risk of small-for-gestational age birth (95% CI 1.35-1.72). The associations with low birth weight and small-for-gestational age birth were more prominent in women hospitalized for anorexia nervosa during pregnancy or within 2 years of delivery. Hospitalization for anorexia nervosa was associated with certain maternal outcomes, including precipitate labor, acute liver failure, and admission to an intensive care unit. DISCUSSION Hospitalization for anorexia nervosa before or during pregnancy is associated with adverse infant and maternal outcomes. Infants are primarily at risk of stillbirth, preterm birth, low birth weight, and small-for-gestational age birth.
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Affiliation(s)
- Zharmaine Ante
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Institut national de santé publique du Québec, Montreal, Quebec, Canada
| | - Thuy Mai Luu
- Department of Pediatrics, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Quebec, Canada
| | - Jessica Healy-Profitós
- Institut national de santé publique du Québec, Montreal, Quebec, Canada.,University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Siyi He
- Institut national de santé publique du Québec, Montreal, Quebec, Canada.,University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Danielle Taddeo
- Department of Adolescent Medicine - Eating Disorders, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Quebec, Canada
| | - Ernest Lo
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Institut national de santé publique du Québec, Montreal, Quebec, Canada
| | - Nathalie Auger
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Institut national de santé publique du Québec, Montreal, Quebec, Canada.,University of Montreal Hospital Research Centre, Montreal, Quebec, Canada.,School of Public Health, University of Montreal, Montreal, Quebec, Canada
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40
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Workman C, Blalock DV, Mehler PS. Bone density status in a large population of patients with anorexia nervosa. Bone 2020; 131:115161. [PMID: 31765843 DOI: 10.1016/j.bone.2019.115161] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/29/2019] [Accepted: 11/20/2019] [Indexed: 12/19/2022]
Abstract
Anorexia nervosa (AN) is associated with multiple medical complications. One of the rare permanent complications of AN is the deleterious effect that it has on a patient's bone mineral density (BMD). We report on the Dual-Energy X-ray Absorptiometry (DXA) findings of 336 consecutive patients with AN. Also, we investigated the effects of different factors on these DXA results. These factors included age, body mass index (BMI), percentage of ideal body weight (IBW), duration of illness, duration of amenorrhea, medications such as proton pump inhibitors (PPI) or selective serotonin reuptake inhibitors (SSRI), tobacco use and 25-hydroxy vitamin D levels. This study demonstrated a concerning high prevalence of reduced bone mineral density in patients with AN. Thus, the implication being that those involved in the care of patients with AN need to be cognizant of this serious complication and not be assuaged by the young age of this patient population.
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Affiliation(s)
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Medical Center, Durham, NC, United States of America; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Philip S Mehler
- Eating Recovery Center, Denver, CO, United States of America; Departments of Medicine, Denver Health and University of Colorado Health Science Center, Aurora, CO, United States of America.
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41
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Marion M, Lacroix S, Caquard M, Dreno L, Scherdel P, Guen CGL, Caldagues E, Launay E. Earlier diagnosis in anorexia nervosa: better watch growth charts! J Eat Disord 2020; 8:42. [PMID: 32905240 PMCID: PMC7469097 DOI: 10.1186/s40337-020-00321-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A better understanding of the healthcare pathway of children and adolescents with anorexia nervosa (AN) may contribute to earlier detection and better disease management. Here we measured and compared the symptomatic time to diagnosis (TTD) (time between the first symptoms, as reported by parents, and the diagnosis) and the auxological TTD (time between the deviation in the weight growth curve and the diagnosis). METHODS We performed a monocentric retrospective study including all patients age 9 years to 16 years who were hospitalized in Nantes University Hospital for AN between 2013 and 2016. We analysed the two TTDs by medical record review and growth curve investigation. TTDs were described by medians and Kaplan-Meier curves. Two profiles of patients were compared according to the kinetics of growth deviation and the occurrence of symptoms. RESULTS Among the 137 patients included, the median symptomatic and auxological TTDs was 7.0 months (IQR: 4.0-12.0) and 7.2 months (IQR: 2.0-18.0). TTDs were significantly different but clinically similar. For 48% of the patients, a deviation in the growth curve could have been noted at a median of 9.7 months (IQR: 3.0-18.0) before the first symptoms were reported by parents. Those patients showed significantly slower weight loss than did patients with first symptoms reported before growth deviation (weight loss rate 0.41% vs 1.90% per month, p < 0.0001). CONCLUSIONS Careful study of growth curves remains an essential step in detecting eating disorders, possibly allowing for earlier detection of the disease in nearly half of these patients.
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Affiliation(s)
- Morgane Marion
- CHU de Nantes, Department of adolescent medicine, Pédiatrie générale, 7 quai Moncousu, 44000 Nantes, France
| | - Sylvie Lacroix
- CHU de Nantes, Department of adolescent medicine, Pédiatrie générale, 7 quai Moncousu, 44000 Nantes, France
| | - Marylène Caquard
- CHU de Nantes, Department of adolescent medicine, Pédiatrie générale, 7 quai Moncousu, 44000 Nantes, France
| | - Laurence Dreno
- CHU de Nantes Department of child psychiatry, University of Hospital Nantes, Nantes, France
| | - Pauline Scherdel
- CHU de Nantes, Centre d'Investigation Clinique (CIC004), Nantes, France
| | - Christèle Gras Le Guen
- CHU de Nantes, Centre d'Investigation Clinique (CIC004), Nantes, France.,CHU de Nantes, Department of Pediatrics, Nantes, France
| | - Emmanuelle Caldagues
- CHU de Nantes, Department of adolescent medicine, Pédiatrie générale, 7 quai Moncousu, 44000 Nantes, France
| | - Elise Launay
- CHU de Nantes, Department of Pediatrics, Nantes, France
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42
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Parker E, Maister T, Stefoska-Needham A, Wearne C, Anderson G, Gomes L, Clarke S, Kohn M. An audit of the changes in thiamine levels during higher caloric nutritional rehabilitation of adolescent patients hospitalised with a restrictive eating disorder. J Eat Disord 2020; 8:41. [PMID: 32884809 PMCID: PMC7460783 DOI: 10.1186/s40337-020-00318-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/05/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Routine supplementation of thiamine in patients with restrictive eating disorders prior to initiation of nutritional rehabilitation, is an example of a clinical guideline based on expert opinion rather than evidence-based recommendations. This study investigates whether adolescents hospitalised with a restrictive eating disorder commenced on a higher caloric refeeding regimen, present with or develop thiamine deficiency during their admission. METHODS An eighteen month retrospective audit of 119 consecutive admissions for nutritional rehabilitation was conducted on patients admitted with an eating disorder in a large tertiary teaching hospital in Western Sydney. Data from paper-based and electronic medical records were collected. Baseline and weekly blood thiamine levels were documented, as well as patient demographic information including admission weight, age, length of stay, percentage median body mass index, weight change throughout admission and caloric prescription. RESULTS Sixty admissions met inclusion criteria, mean age 17.2 years (SD 1.2); 88% female; BMI 16.8 kg/m2 (SD 1.8) on admission. A linear mixed effects model identified that median thiamine levels increased by 9.2 nmol/L per week (p < 0.001). No patient developed thiamine deficiency during their admission, one patient was admitted with thiamine levels below the normal range at 62 nmol (normal range 67 - 200 nmol/L) which resolved by the second week of admission. In 15 out of 60 patients (25%), thiamine levels were observed to rise above the upper limit. CONCLUSIONS Nutritional management of 60 malnourished adolescents hospitalised with an eating disorder was conducted safely with the provision of only 10 mg thiamine in a multivitamin daily, and no additional thiamine supplementation. The high caloric refeeding protocol, inclusive of a daily multivitamin, provided adequate thiamine to prevent thiamine deficiency. Further research should examine thiamine requirements in an exclusive severely malnourished population to assess the need for thiamine replacement in the most vulnerable group.
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Affiliation(s)
- Elizabeth Parker
- Department of Dietetics & Nutrition, Westmead Hospital, PO Box 533, Wentworthville, NSW 2145 Australia.,Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, 2006 NSW Australia
| | - Terri Maister
- SMART Foods Centre, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW 2522 Australia
| | - Anita Stefoska-Needham
- SMART Foods Centre, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW 2522 Australia
| | - Christine Wearne
- Department of Medical Psychology, Westmead Hospital, Westmead, NSW 2145 Australia
| | - Gail Anderson
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, NSW 2145 Australia
| | - Linette Gomes
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, NSW 2145 Australia
| | - Simon Clarke
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, NSW 2145 Australia.,Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia.,Centre for Research into AdolescentS' Health (CRASH), Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, NSW 2145 Australia
| | - Michael Kohn
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, NSW 2145 Australia.,Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia.,Centre for Research into AdolescentS' Health (CRASH), Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, NSW 2145 Australia
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43
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Accurso EC, Le Grange D, Graham AK. Attitudes Toward Family-Based Treatment Impact Therapists' Intent to Change Their Therapeutic Practice for Adolescent Anorexia Nervosa. Front Psychiatry 2020; 11:305. [PMID: 32390882 PMCID: PMC7192208 DOI: 10.3389/fpsyt.2020.00305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/26/2020] [Indexed: 11/13/2022] Open
Abstract
Community-based clinicians who treat patients with eating disorders rarely use empirically-supported treatments, and research demonstrates that clinicians make significant modifications when implementing family-based treatment (FBT) for anorexia nervosa. This study examined clinician attitudes toward FBT and explored the extent to which attitudes predicted intent to shift practices following training in FBT. Clinicians (N = 129) completed a standardized training in FBT for AN, either a two-day introductory training (n = 99) or a one-day "advanced" training (n = 30). Linear regressions were used to examine the association between therapists' attitudes toward FBT and their intent to use strategies consistent with FBT in the future, adjusting for pre-training use of strategies. Providers reported very positive attitudes toward evidence-based practices in general and moderately positive attitudes toward FBT. There were no significant differences between "novice" and "advanced" providers on attitudes toward evidence-based practices or FBT (ps > .10). For the subset of providers attending their first training in FBT, more positive attitudes toward FBT significantly predicted greater intent to use FBT-consistent strategies (p = .004), and more positive attitudes toward evidence-based practice significantly predicted lesser intent to use FBT-inconsistent strategies (p = .009). This study suggests that both general attitudes toward evidence-based practice and specific attitudes toward FBT may impact implementation. Future research might examine whether a brief intervention to improve attitudes toward FBT might increase the likelihood of seeking expert consultation post-training.
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Affiliation(s)
- Erin C Accurso
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel Le Grange
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Psychiatry & Behavioral Neuroscience, The University of Chicago, Chicago, IL, United States
| | - Andrea K Graham
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Nagata JM, Carlson JL, Golden NH, Murray SB, Long J, Leonard MB, Peebles R. Associations between exercise, bone mineral density, and body composition in adolescents with anorexia nervosa. Eat Weight Disord 2019; 24:939-945. [PMID: 29949128 PMCID: PMC6286679 DOI: 10.1007/s40519-018-0521-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/28/2018] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify the effect of duration of weight-bearing exercise and team sports participation on bone mineral density (BMD) and body composition among adolescents with anorexia nervosa (AN). METHOD We retrospectively reviewed electronic medical records of all patients 9-20 years old with a DSM-5 diagnosis of AN evaluated by the Stanford Eating Disorders Program (1997-2011) who underwent dual-energy X-ray absorptiometry. RESULTS A total of 188 adolescents with AN were included (178 females and 10 males). Using multivariate linear regression, duration of weight-bearing exercise (B = 0.15, p = 0.005) and participation in team sports (B = 0.53, p = 0.001) were associated with higher BMD at the hip and team sports (B = 0.39, p = 0.006) were associated with higher whole body BMC, controlling for covariates. Participation in team sports (B = - 1.06, p = 0.007) was associated with greater deficits in FMI Z-score. LBMI Z-score was positively associated with duration of weight-bearing exercise (B = 0.10, p = 0.018) and may explain the relationship between exercise and bone outcomes. CONCLUSION Duration of weight-bearing exercise and team sports participation may be protective of BMD at the hip and whole body BMC, while participation in team sports was associated with greater FMI deficits among adolescents with AN. LEVEL OF EVIDENCE Level V, descriptive retrospective study.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA. .,Department of Pediatrics, University of California, San Francisco, 3333 California Street, Suite 245, Box 0503, San Francisco, CA, 94143, USA.
| | - Jennifer L Carlson
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Neville H Golden
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Stuart B Murray
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Jin Long
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rebecka Peebles
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Abstract
This article provides background information, descriptions, and evidential support for the more recent treatments for adolescents with anorexia nervosa, including family-based treatment, adolescent focused therapy, cognitive behavioral therapy, systemic family therapy, and psychopharmacologic treatments. At this time, family-based treatment has the best evidence of efficacy and cost-effectiveness. Future directions in treatment research for adolescent anorexia nervosa are discussed.
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Affiliation(s)
- James Lock
- Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305, USA.
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46
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Abstract
Many eating disorder patients are successfully treated in outpatient settings. Family-based treatment allows youth to recover at home. Higher levels of care may be necessary for medical or psychiatric stabilization, or to provide added structure. Historically, hospital lengths of stay were long. Currently, insurance limitations encourage intermediate care levels to support patients not requiring inpatient treatment but not ready for outpatient care. Options include inpatient medical stabilization, locked units for individuals with suicidal ideation, and outpatient programs offering daily meal support and group therapy. Outpatient teams and families collaborate to determine the appropriate level of care.
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Affiliation(s)
- Jennifer Derenne
- Division of Child and Adolescent Psychiatry, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94304, USA.
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47
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Abstract
Eating disorders affect a significant number of individuals across the life span and are found among all demographic groups (including all genders, socioeconomic statuses, and ethnicities). They can cause malnutrition, which can have significant effects on every organ system in the body. Cardiovascular complications are particularly dangerous and cause eating disorders to have the highest mortality rate of all mental illnesses. This article outlines the medical assessment and treatment of malnutrition due to disordered eating.
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Affiliation(s)
- Rebecka Peebles
- Eating Disorder Assessment and Treatment Program, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Roberts Center for Pediatric Research, 2716 South Street, Room 14360, Philadelphia, PA 19146, USA.
| | - Erin Hayley Sieke
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard 9NW55, Philadelphia, PA 19104, USA
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48
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Abstract
PURPOSE OF REVIEW The diagnosis of anorexia nervosa is associated with the highest mortality rate of any psychiatric disorder, mainly caused by medical complications.The purpose of this article is to review the common medical consequences of anorexia nervosa focusing on the special considerations related to children and adolescents and recent updates on the pathophysiology of these complications and their prognosis significance. RECENT FINDINGS The main findings were related to the diagnostic and prognostic value of hypokalaemia, QTc prolongation, hypoglycaemia and orthostatic changes. A new modality to evaluate the heart in anorexia nervosa was explored (2DSTE) as well. Bone mineral density (BMD) loss is one of the few nonreversible consequences of anorexia nervosa. BMD loss does not seem to be significantly related to sex or to cut-off low-weight parameters in teenagers with anorexia nervosa, but rather to the amount of weight loss they have experienced. Brain volume deficits might be another irreversible complication in adolescents with anorexia nervosa. SUMMARY It is crucial for any healthcare provider to be informed about the medical consequences of anorexia nervosa, not only because they can be devastating, but also because they can play an essential role in motivating patients to get treated.
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49
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Buchman S, Attia E, Dawson L, Steinglass JE. Steps of care for adolescents with anorexia nervosa-A Delphi study. Int J Eat Disord 2019; 52:777-785. [PMID: 31058331 PMCID: PMC7147487 DOI: 10.1002/eat.23088] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/19/2019] [Accepted: 04/19/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Anorexia nervosa (AN) commonly develops during adolescence. Existing literature offers some treatment guidelines, but clear clinical criteria for initial recommendations and steps of care are needed. The aim of the present study was to develop expert consensus for a stepped-care algorithm for treatment of adolescents with AN. METHOD The Delphi approach was used to identify clinical parameters that guide initial treatment recommendations and recommendations for transitions between levels of care. The Delphi approach provides a useful expert consensus when empirical data are limited. Individuals with at least 10 years of experience in the field of adolescent AN and membership in one of three professional organizations were recruited. Twenty-five panelists participated in three rounds of iterative online questionnaires. RESULTS Consensus was achieved on several features of a treatment algorithm. Hospitalization is recommended when medical instability, suicidality, or acute food refusal are present at any point in treatment. Family-based treatment (FBT) is recommended as the first-line treatment, with a few exceptions. Consensus was not reached on when to transition from a higher level of care to a lower level of care. DISCUSSION Expert opinion was used to develop a consensus-based algorithm for care of adolescents with AN. Future research is needed to test whether these recommendations can be used to optimize outcomes for adolescents with AN.
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Affiliation(s)
- Samantha Buchman
- Weill Cornell Medicine, New York-Presbyterian Hospital, White Plains, New York
| | - Evelyn Attia
- Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York, New York
| | - Lisa Dawson
- Centre for Family-Based Mental Health Care, St. Vincent's Private Hospital Sydney, Eating Disorder Service, The Children's Hospital at Westmead, Camperdown, New South Wales, Australia
| | - Joanna E. Steinglass
- Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York, New York
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Nagata JM, Brown TA, Lavender JM, Murray SB. Emerging trends in eating disorders among adolescent boys: muscles, macronutrients, and biohacking. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:444-445. [PMID: 31122798 DOI: 10.1016/s2352-4642(19)30147-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA 94158, USA.
| | - Tiffany A Brown
- Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
| | - Jason M Lavender
- Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
| | - Stuart B Murray
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA 94158, USA
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