Eighty-five per cent of what? Discrepancies in the weight cut-off for anorexia nervosa substantially affect the prevalence of underweight

Evaluating differences in setting expected body weight for children and adolescents in eating disorder treatment

OBJECTIVE

Weight restoration or weight gain is a common goal in eating disorder treatment. However, approaches to determine expected body weight (EBW) vary. A standardized approach based on normative data for a patient's age and gender uses weight associated with median BMI (mBMI). An individualized approach predicts EBW based on a patient's individual growth trajectory. Little research has examined differences in these approaches.

METHOD

Weight and clinical data were collected from patients ages 6-20 enrolled in virtual eating disorder treatment. EBW associated with mBMI was compared with EBW using the individualized approach. Linear mixed effects models examined differences in weight, eating disorder symptoms, depression, and anxiety, and whether EBW approach varied by patient characteristics.

RESULTS

Patients (N = 609) were on average age 15.6 (2.29), 85% were cisgender female, and predominantly diagnosed with anorexia nervosa (83.1%). The individualized approach led to significantly higher EBW on average (mean difference = 8.4 lbs [SE: .75]; p < .001) compared to mBMI; 70% of patients had a higher EBW using the individualized approach. Notably, EBW varied based on gender and diagnosis and it took longer on average to achieve individualized EBW. Time was the strongest predictor of changes in psychosocial outcomes and there were no significant differences by EBW approach.

DISCUSSION

Results from this study indicate that an individualized approach led to significantly higher EBWs compared with using mBMI. As underestimation of EBW may lead to higher risk of relapse, eating disorder professionals should consider using an individualized approach for setting EBW.

PUBLIC SIGNIFICANCE

For eating disorder patients who need to gain weight, accurately estimating target body weight for eating disorder treatment is critical to recovery and preventing relapse. An individualized, patient-centered approach to estimating target body weight more accurately estimated target body weight than the standardized, median body mass index approach. Using an individualized approach to treatment may improve a patient's likelihood of full recovery.

A Moving Target: How We Define Avoidant/Restrictive Food Intake Disorder Can Double Its Prevalence

Objective: The DSM-5 criteria for avoidant/restrictive food intake disorder (ARFID) include ambiguities. Diagnostic criteria that allow for clinical judgment are essential for clinical practice. However, ambiguities can have major implications for treatment access and comparability and generalizability of research studies. The purpose of this study was to determine the degree to which distinct operationalizations of the diagnostic criteria for ARFID contribute to differences in the frequency of individuals who are eligible for the ARFID diagnosis. Methods: Because criteria B, C, and D are rule-outs, we focused on criterion A, identified 19 potential operational definitions, and determined the extent to which these different methods impacted the proportion of individuals who met criteria for ARFID in a sample of children, adolescents, and young adults (n = 80; September 2016-February 2020) enrolled in an avoidant/restrictive eating study. Results: Within each criterion, the proportion of individuals meeting diagnostic criteria differed significantly across the methodologies (all P values < .008). Using the strictest definition of each criterion, 50.0% (n = 40) of participants met criteria for ARFID. In contrast, under the most lenient definition of each criterion, the number nearly doubled, resulting in 97.5% (n = 78) meeting ARFID criteria. Conclusions: Comparison of diagnostic definitions for ARFID among children, adolescents, and young adults confirmed a broad range of statistically distinct proportions within a single sample. Our findings support the need for additional contextual support and consensus among disciplines on operationalization in both research and clinical settings.

Assessment of fracture risk in women with eating disorders: The utility of dual-energy x-ray absorptiometry (DXA)-Clinical cohort study

OBJECTIVE

Eating disorders (EDs) are associated with decreased bone mineral density (BMD) and increased fracture risk. The association between BMD and fracture risk in EDs is not well elucidated. We aimed to assess BMD in an ED cohort of patients with active disease and patients in remission, and to assess the predictive value of BMD on incidence of fractures.

METHOD

We included 344 female patients (median age 19, IQR 16; 24) referred to ED treatment. Later, patients were invited to follow-up including assessment of remission status and a dual-energy x-ray absorptiometry (DXA)-scan. Information on fractures was obtained through the Danish National Registry of Patients.

RESULTS

Patients with current anorexia nervosa (AN) had significantly lower BMD compared to controls at lumbar spine (16% lower, p < .0001), femoral neck (18% lower, p < .0001), and total hip (23% lower, p < .0001). Recovered AN patients had higher BMD compared to those with current disease (p < .0001 for all measures), but lower BMD compared to controls at lumbar spine (p < .01) and hip (p < .001). BMD did not differ between BN patients and controls. In patients with active eating disorders not otherwise specified, BMD was lower only at the total hip (p < .005). We found no association between BMD and fracture risk.

CONCLUSION

We confirm that AN is associated with low BMD, whereas BN is not. Remission is associated with higher BMD compared to patients with active AN, but a deficit remains. We found no significant association between BMD and fracture risk, challenging the benefit of the widespread use of DXA scans in young women with ED.

CLINICAL TRIAL REGISTRATION

The study is registered in ClinicalTrials.gov, number NCT00267228.

Grasping the weight cut-off for anorexia nervosa in children and adolescents

OBJECTIVE

The Diagnostic and Statistical Manual of Mental Disorders 5 suggests the 5th age-adjusted body mass index (BMI) percentile as the numeric cut-off for anorexia nervosa (AN) in children and adolescents. We aimed to investigate the degree to which the 5th age-adjusted percentile as the numeric cut-off for AN in youths reflects the clinical population of patients accepted for treatment.

METHOD

From a specialized eating disorder clinic, 305 patients with AN below 18 years of age were grouped according to age-adjusted BMI percentiles [below the 5th (low), above the 10th (high), and between the 5th and the 10th (medium)]. The distribution of eating disorder diagnoses and severity measured by the Eating Disorder Examination was compared.

RESULTS

Full-syndrome anorexia nervosa (F.50.0) was found in 182 (59.5%) patients and atypical anorexia nervosa (F.50.1) in 123 patients (40.5%). The number of patients in the low, medium, and high BMI percentile groups was 189 (62.0%), 34 (11.1%), and 82 (26.9%), respectively. Patients in the low BMI group differed from patients in the medium BMI group by a lower frequency of vomiting. The high BMI group presented with more weight and shape concern than the lower BMI group. Age was not a confounder of these associations.

DISCUSSION

We question the applicability of the 5th BMI percentile as a substantiated cut-off for the weight criterion in anorexia nervosa in youths and argue that the cut-off should not be ascribed great clinical importance as this may hinder early detection of illness and initiation of treatment.

Impact of low-weight severity and menstrual status on bone in adolescent girls with anorexia nervosa

Clinicians currently use different low-weight cut-offs both to diagnose anorexia nervosa (AN) and to determine AN severity in adolescent girls. The purpose of this study was to evaluate the clinical utility of existing cut-offs and severity criteria by determining which are most strongly associated with risk for low bone mineral density (BMD). Height adjusted BMD Z scores were calculated for 352 females: 262 with AN and 90 healthy controls (controls) (12-20.5 years), using data from the BMD in Childhood Study, for the lumbar spine, whole body less head, and total hip. For most cut-offs used to define low weight (5th or 10th BMI percentile, BMI of 17.5 or 18.5, and 85 or 90% of median BMI), AN had lower BMD Z scores than controls. AN at >85 or >90% expected body weight for height (EBW-Ht) did not differ in BMD Z scores from controls, but differed significantly from AN at ≤85 or ≤90% EBW-Ht. Among AN, any amenorrhea was associated with lower BMD. AN had lower BMD than controls across DSM-5 and The Society for Adolescent Health and Medicine (SAHM) severity categories. The SAHM moderate severity classification was differentiated from the mildly malnourished classification by lower BMD at hip and spine sites. Amenorrhea and %EBW-Ht ≤ 85 or ≤ 90% are markers of severity of bone loss within AN. Among severity categories, BMI Z scores (SAHM) may have the greatest utility in assessing the degree of malnutrition in adolescent girls that corresponds to lower BMD.

Are eating disorders and their symptoms increasing in prevalence among adolescent population?

BACKGROUND

A debate concerns whether eating disorders are increasing in prevalence. The role of socio-economic status (SES) for adolescent eating disorders (ED) is another matter of debate.

AIMS

To ascertain whether self-reported eating disorders or their symptoms have increased in prevalence in adolescent population from the early 2000s to early 2010s.

METHODS

A person-identifiable classroom survey, Adolescent Mental Health Cohort study, was carried out among the 9th graders in comprehensive schools in Tampere, Finland, during academic year 2002-2003, and replicated among then 9th graders during academic years 2012-2013. Eating disorders were elicited with questionnaires tailored according to DSM-IV criteria for anorexia nervosa and bulimia nervosa.

RESULTS

No changes were observed between 2002-2003 and 2012-2013 in the prevalence of anorexia and bulimia, most of the symptoms of anorexia and bulimia, or the proportion of adolescents having received treatment due to eating disorders among the girls or the boys. Eating disorders, treatment contacts due to eating disorders, and eating disorder symptoms were not systematically associated with either low or high parental socio-economic status.

CONCLUSION

Based on this dataset, eating disorders are not increasing in the adolescent population. Adolescent eating disorders are not associated with socio-economic status of their family.

Reassessment of patients with Eating Disorders after moving from DSM-IV towards DSM-5: a retrospective study in a clinical sample

PURPOSE

To compare the relative prevalence of eating disorders moving from DSM-IV to DSM-5, and to reassess the overall medical impairment in the revised diagnostic classes.

METHODS

We applied DSM-5 to 206 patients (age 15-56 years) previously studied and classified according to DSM-IV. Medical impairment was classified as low, medium, or high, based on a cumulative score of clinical severity (SCS), computed as the sum of specific weights assigned to different pathological conditions and their ascertained prognostic impact.

RESULTS

Application of DSM-5 produced a decrease in Eating Disorders Not Otherwise Specified (EDNOS) by 17 %, an increase in anorexia (AN) by 14 % and bulimia (BN) by 2.4 %; 44.6 % of EDNOS migrated to AN, 8 % to BN, and 30.8 % was reclassified as Other Specified Feeding and Eating Disorders (OSFED). Mean SCS was higher in AN than in other diagnoses independent of classification. Differently from EDNOS, no high score was found in OSFED. BMI (OR 0.74, 95 % CI 0.56-0.98) and duration of amenorrhea >1 year (OR 6.63, 95 % CI 1.29-34.16) resulted significantly associated with the risk for medium-high SCS level in AN classified with DSM-5.

CONCLUSION

The results confirmed that DSM-5 reduces the number of EDNOS. DSM-5 seems to better represent the clinical picture in OSFED than in EDNOS. The clinical relevance of BMI and duration of amenorrhea should be considered even more now that they are no longer used as diagnostic hallmarks of AN.

A comparison of clinical characteristics between adolescent males and females with eating disorders

BACKGROUND

Eating disorders (ED) are serious disorders that have a negative impact on both the psychological and the physiological well-being of the afflicted. Despite the fact that ED affect both genders, males are often underrepresented in research and when included the sample sizes are often too small for separate analyses. Consequently we have an unclear and sometimes contradictory picture of the clinical characteristics of males with ED. The aim of the present study was to improve our understanding of the clinical features of adolescent males with eating disorders.

METHODS

We compared age at presentation, weight at presentation, history of significantly different premorbid weight and psychiatric (Attention Deficit Hyperactivity Disorder (ADHD)) and somatic comorbidity (celiac disease and diabetes) of 58 males to 606 females seeking medical care for eating disorders at the Children's Hospital in Uppsala, Sweden during the years 1999-2012. As all boys were diagnosed with either AN or Other Specified Feeding or Eating Disorder (OSFED) atypical AN, the age and weight comparisons were limited to those girls fulfilling the diagnostic criteria for AN or OSFED atypical AN.

RESULTS

There was no significant difference in age at presentation. Differences in weight at presentation and premorbid weight history were mixed. A significantly higher percentage of males had a history of a BMI greater than two standard deviations above the mean for their corresponding age group. As well, there was a higher prevalence of ADHD among the males whereas celiac disease and diabetes only was found among the females.

CONCLUSIONS

A better understanding of the clinical characteristics of males with ED at presentation should improve our ability to identify males with ED and thereby aid in tailoring the best treatment alternatives.

Is the Eating Disorder Questionnaire-Online (EDQ-O) a valid diagnostic instrument for the DSM-IV-TR classification of eating disorders?

BACKGROUND

The Eating Disorder Questionnaire-Online (EDQ-O) is an online self-report questionnaire, which was developed specifically to provide a DSM-IV-TR classification of anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and eating disorder not otherwise specified (EDNOS), without using a face-to-face clinical interview.

OBJECTIVE

The purpose of the present study was to examine the psychometric quality of the EDQ-O.

METHODS

The validity of the EDQ-O was determined by examining the agreement with the diagnoses obtained from the Longitudinal, Expert, and All DATA (LEAD) standard. Participants included 134 new patients of a specialist center for eating disorders located in the Netherlands.

RESULTS

Assessment of the validity of the EDQ-O yielded acceptable to good AUC (area under the receiver operating characteristic curve) values with a range from 0.72 to 0.83. Most other diagnostic efficiency statistics were also good except for a low sensitivity for AN (0.44), a low positive predictive value for BN (0.50), and a relatively low sensitivity for BED (0.66).

CONCLUSION

The results of the present study suggest that the EDQ-O performs acceptably as a diagnostic instrument for all DSM-IV-TR eating disorder classifications. However, suggestions are made to further improve the validity of the EDQ-O.

Factors associated with successful completion in an adolescent-only day hospital program for eating disorders

The purpose of this study was to examine factors associated with completion of an adolescent-only eating disorder day hospital program. A total of 65 adolescents were included. Completers were compared to non-completers on multiple variables including diagnosis, weight, and medication use. Adolescents who completed the program were more likely to have been prescribed antidepressants and less likely to purge. The two groups did not differ significantly on other variables. Few factors differentiated completers from non-completers of the eating disorder day hospital program. Further research is needed to determine the role medications or purging may play in completing treatment.

Comparing operational definitions of DSM-5 anorexia nervosa for research contexts

OBJECTIVE

DSM-5 anorexia nervosa (AN) criteria include several changes that increase reliance on clinical judgment. However, research contexts require operational definitions that can be applied reliably and that demonstrate validity. The present study evaluated different operational definitions for DSM-5 AN.

METHOD

DSM-5 AN criteria were applied to diagnostic interview data from 364 women varying two features: threshold for determining low weight for Criterion A (body mass index [BMI] <17.0 kg/m(2) vs. <18.5 kg/m(2)) and explicit endorsement of weight phobia (Criterion B explicit vs. inferred). Resulting groups of individuals with DSM-5 AN were compared on estimated frequency. In addition, AN groups were compared to non-eating disorder controls and individuals with an other specified feeding or eating disorder (OSFED) on external validators.

RESULTS

All operational DSM-5 definitions produced higher lifetime frequency estimates than reported for DSM-IV AN, with a particularly large increase associated with the broadest definition. All definitions produced significant differences in comparison to controls on external validators that were associated with medium to large effect sizes. Only definitions that required a lower weight threshold or explicit endorsement of weight phobia demonstrated significant differences compared to OSFED on external validators, and these were of small effect size. The specific combination of BMI <18.5 kg/m(2) with inferred weight phobia exhibited few meaningful distinctions from the OSFED group.

DISCUSSION

To balance inclusivity, syndromal reliability, and validity, an operational definition for DSM-5 AN in research contexts should define low weight as BMI <18.5 kg/m(2) and require measurable rather than inferred weight phobia.

DSM-IV versus DSM-5: implementation of proposed DSM-5 criteria in a large naturalistic database

OBJECTIVE

Problems with the current DSM-IV eating disorder (ED) section have resulted in proposed changes toward the upcoming DSM-5 (http://www.dsm5.org/ProposedRevisions/Pages/EatingDisorders.aspx). We investigated consequences of these by implementing the proposal in a large naturalistic database.

METHOD

Patients were 2,584 children/adolescents and adults enrolled at specialized ED clinics in Sweden. DSM-IV diagnoses anorexia nervosa, bulimia nervosa, and "not otherwise specified" examples were compared with DSM-5 anorexia, bulimia, and binge ED, as well as atypical anorexia, subthreshold bulimia, and binge eating, purging disorder, and the residual unspecified category. Assessment methods included a semistructured diagnostic interview and self-ratings of ED and psychiatric symptoms.

RESULTS

We studied age-separated diagnostic distributions and explained variance in clinical variables associated with the two systems. Results showed some improvement of diagnostic specification as well as a slight increase in explained variance.

DISCUSSION

Remaining problems with the proposed changes were also highlighted, and possible further refinement is discussed.

Critical appraisal of the provisional DSM-5 criteria for anorexia nervosa and an alternative proposal

DSM-V will be highly influential in shaping conceptions and perceptions of eating disorders by the lay public, patients, and health care providers over the next 10-15 years. DSM not only influences how medical and mental health care professionals diagnose and treat patients but also impacts health insurance policies, research funding, and clinical trials. Revisions to diagnostic criteria must be carefully considered, empirically based, and consistent with current thinking both within the field and across relevant fields. Resultant criteria should be descriptive and non-judgmental and based on empirical findings without recourse to assumed etiologies. In this forum, we review problems with the current DSM IV diagnostic criteria, concerns with the proposed DSM-5 diagnostic criteria, and present an alternative classification scheme for anorexia nervosa (AN), which more accurately captures the phenomenology of the disorder and is congruent in terminology with other fields of biomedicine.

Empirical classification of eating disorders

Current diagnostic criteria for anorexia nervosa (AN) and bulimia nervosa (BN) account for a minority of individuals with clinically significant disorders of eating, raising concerns about the clinical utility of current definitions. This review examines evidence for the validity of current and alternative approaches to defining eating disorders and implications for draft criteria for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Although this review largely supports the predictive validity of distinctions among AN, BN, and the newly proposed binge eating disorder (BED), it also highlights that our tendency to "study what we define" has created a gap between the problems that people have and what we know about those problems. Future research on the causes and consequences of eating disorders should include more heterogeneous groups to enable identification of meaningful boundaries that distinguish between disorders based on etiological and predictive validity.

The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. In this meta-analysis, the authors aimed to inform Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others-such as purging disorder and non-fat-phobic AN-may be best conceptualized as distinct syndromes. (PsycINFO Database Record (c) 2009 APA, all rights reserved).