Effectiveness of delivering evidence-based eating disorder treatment via telemedicine for children, adolescents, and youth

Striving to support the supporters: A mixed methods evaluation of the strive support groups for caregivers of individuals with an eating disorder

This mixed-methods study evaluated a peer-led support group for ED caregivers; the Eating Disorders Families Australia strive support groups. Quantitatively, 110 past or current strive attendees completed an online survey assessing their own and their care recipients' demographic profiles, strive's impact on caregiving experiences, and caregivers' psychological distress, burden, caregiving skills and self-efficacy. Qualitative assessment comprised open-ended survey questions about caregivers' strive experiences, reinforced by in-depth focus group assessment of nine participants. Quantitative analyses revealed that participants felt more confident and supported, and less isolated in their caregiving since attending strive. Caregivers displayed mid-range psychological distress and caregiver burden, and moderate caregiver skills and self-efficacy. Qualitatively, the most helpful aspects of strive were the shared experience among participants, education, and support. The most difficult elements were emotional distress and overly dominant members. Reflections discussed the necessity of caregiver support and factors impacting strive attendance. Participants recommended resuming face-to-face contact and differentiating groups based on participant characteristics (e.g. care recipients' age/stage of illness). The current findings provide support for the importance and overall positive contribution of support groups led by caregivers, such as strive.

Mental Health, Climate Change, and Bodily Autonomy: An Analysis of Adolescent Health Policy in the Post-Pandemic Climate

The COVID-19 pandemic exacerbated the vulnerability of adolescents and young adults (AYAs) who face economic disadvantage, depend on social safety net resources, have politically targeted identities, are geopolitically displaced, and/or are racially or ethnically marginalized. A rapid change in social safety net policies has impacts that reverberate throughout interrelated domains of AYA health, especially for vulnerable AYAs. The authors analyze policy-related changes in mental health, climate change, and bodily autonomy to offer a paradigm for an equitable path forward.

Innovative Strategies for Addressing Adolescent Health in Primary Care Through Telehealth

With recent gains in telehealth access across health sectors, this editorial explores adolescent-specific health issues where innovative use of virtual care is improving outcomes and access for adolescents. These include contraception, obesity, gender-affirming care, mental health, and eating disorder care. Clinicians caring for adolescents should be aware of advances in this field to maximize opportunities for their patients to receive evidence-based care in a manner that supports health equity and confidentiality concerns while understanding the evolving regulatory landscape of telehealth.

Eating Disorder Clinical Presentation and Treatment Outcomes by Gender Identity Among Children, Adolescents, and Young Adults

PURPOSE

Current eating disorder treatment approaches for youth were developed for use with cisgender girls, which limits the understanding of effectiveness for cisgender boys and transgender and gender expansive (TGE) youth. Here, we compare treatment outcomes for cisgender boys and TGE youth with cisgender girls receiving family-based treatment for an eating disorder.

METHODS

Patients were aged 6-24 and either active in treatment or discharged from September 1, 2020, to November 1, 2022 (N = 1,235). Patient exposure to treatment varied given individualized length of treatment. Outcomes include eating disorder symptoms, depression, anxiety, suicidality, caregiver burden, and parental confidence in supervising treatment. Treatment outcomes for cisgender boys and TGE youth were compared with cisgender girls.

RESULTS

Patients included n = 975 cisgender girls, n = 152 cisgender boys, and n = 108 TGE youth. Anorexia nervosa was the most common diagnosis. Cisgender boys reported significantly lower eating disorder (b = -2.7 [-4.1, -1.3]), anxiety (b = -1.6 [-2.2, -0.9]), and depression (b = -1.7 [-2.4, -0.9]) symptoms at admission compared with cisgender girls. TGE patients had significantly higher anxiety (b = 1.08 [0.28, 1.91]) and depression (b = 1.72 [0.78, 2.65]) symptoms compared with cisgender girls. Cisgender boys started with significantly lower suicidal ideation (b = -1.28 [-2.19, -0.43]) and TGE patients with significantly higher suicidal ideation (b = 1.63 [0.76, 2.51]) than cisgender girls. All symptoms improved during treatment and improved at similar rates over time in treatment regardless of gender identity.

DISCUSSION

Early evidence from this study supports the use of family-based treatment for cisgender boys and TGE youth with eating disorders. Further research is needed on the long-term outcomes of this approach for youth of all genders.

Updates in the treatment of eating disorders in 2023: a year in review in eating disorders: the Journal of treatment & Prevention

Empirical evidence is unequivocal in illustrating that the majority of patients with eating disorders will not fully recover during treatment. To that end, the need for optimized treatment approaches and improved patient outcomes cannot be overstated. While empirical efforts are underway to optimize outcomes, this article reviews treatment-related research findings published in Eating Disorders: The Journal of Treatment & Prevention during 2023. Importantly, this review encapsulates research addressing (i) between-session patient behaviors, (ii) the integration of technology into treatment approaches, (iii) methods to augment emotional regulation in the context of eating disorder treatment, (iv) methods to measure progress, and potentially risk markers for patient dropout, during treatment, (v) optimizing treatment approaches for inpatient settings, and (vi) augmenting family therapy-based approaches. Incorporating novel technological advances may be critical in enhancing the scalability of eating disorder treatments, since treatment uptake remains an ongoing challenge for the field. Moreover, expanding the scope of non-outpatient eating disorder treatment settings, while ensuring fidelity to theoretical models developed in outpatient settings, is critical as treatment is effectively administer across the spectrum of levels of patient care.

Families tackling adolescent anorexia nervosa: family wellbeing in family-based treatment or other interventions. A scoping review

PURPOSE

Family-based treatment (FBT) has contributed significantly to the treatment of anorexia nervosa (AN) in young people (YP). However, parents are concerned that FBT and the active role of parents in the task of refeeding may have a negative impact on family relations. The aim of the review is to assess whether families engaged in FBT for AN are more or less impacted in their family wellbeing and caregiver burden, compared to families with a YP diagnosed with AN, who are not undergoing treatment with FBT.

METHOD

Computerized searches across six databases complemented by a manual search resulted in 30 papers being included in the scoping review.

RESULTS

The review identified 19 longitudinal studies on change in family wellbeing in families in FBT-like treatments, and 11 longitudinal studies on change in family wellbeing in treatment where parents are not in charge of refeeding. Only three randomized controlled studies directly compare FBT to treatment without parent-led refeeding.

CONCLUSION

The available research suggests no difference between intervention types regarding impact on family wellbeing. Approximately half of the studies find improvements in family wellbeing in both treatment with and without parent-led refeeding, while the same proportion find neither improvement nor deterioration. As parents play a pivotal role in FBT, there is a need for good quality studies to elucidate the impact of FBT on family wellbeing. Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Eating disorder virtual intensive outpatient program: patient satisfaction according to age group

The COVID-19 pandemic has required a shift to telehealth services. However, not all patients are similarly satisfied with this shift, with some studies finding that midlife and older adults are less comfortable with telehealth. The current study examined patient satisfaction with a virtual intensive outpatient program (VIOP) for eating disorders (EDs) among 305 adults (ages 18-25, ages 26-39, and ages 40+), and compared adult satisfaction to satisfaction among children/adolescents (n = 33) receiving VIOP treatment between August 2020 and March 2022 from a large ED treatment facility. It was hypothesized that adults aged 40+ would report lower satisfaction than younger age groups. Patients completed several questions regarding satisfaction with treatment upon discharge, including a question about likelihood of recommending the program, which was used to calculate a Net Promoter Score (NPS). The NPS was 33.3 for children/adolescents, 33.3 for 18-25 year-olds, 57.7 for 26-39 year-olds, and 30.9 for the 40+ year age group. NPS of 31-50 = quality services; 51-70 = excellent customer experiences. Satisfaction was high, with no statistically significant differences between age groups after Bonferroni correction. The current study adds to the limited literature on the treatment experiences of midlife adults with EDs.

Traditional versus virtual partial hospital programme for eating disorders: Feasibility and preliminary comparison of effects

OBJECTIVE

Minimal research has examined teletherapy for group or intensive eating disorder (ED) treatment, particularly partial hospital programme (PHP). This study compared treatment outcomes for individuals treated before and after a pandemic-driven implementation of virtual PHP.

METHOD

Patients received care at ED treatment centres using the Renfrew Unified Treatment for Eating Disorders and Comorbidity. Patients treated with virtual PHP were compared to patients treated with traditional PHP. Measures of ED symptomology and behaviours, depressive symptoms, anxiety severity, anxiety sensitivity, experiential avoidance, mindfulness, and body mass index (BMI; reported for anorexia nervosa [AN] patients only) were collected at intake and discharge. Multiple regression analyses were conducted to examine the effect of treatment group on outcomes, controlling for intake score, comorbidity, discharge status, AN diagnosis, and step-down status.

RESULTS

Differences in treatment type were only found for binge eating frequency, with those in virtual PHP reporting significantly lower binge eating episodes at discharge than those in traditional PHP. Body mass index showed significantly less improvement in virtual PHP than in traditional PHP.

CONCLUSIONS

Preliminary results suggest virtual PHP is feasible and effective, potentially increasing access to evidence-based, intensive ED treatment. However, additional research is needed to establish efficacious support for weight gain among individuals with AN in virtual programs.

Early weight gain as a predictor of weight restoration in avoidant/restrictive food intake disorder

BACKGROUND

Previous research has demonstrated that early weight gain in family-based treatment (FBT) is predictive of remission for adolescents with anorexia nervosa (AN). However, no published data has addressed if early weight gain is also predictive of reaching weight restoration (i.e., 95% EBW) in patients with avoidant/restrictive food intake disorder (ARFID). Furthermore, no studies have evaluated the performance of the statistical models used to predict weight restoration at the end of treatment. This study sought to examine whether early weight gain in ARFID is predictive of weight restoration at 20 weeks using ROC analysis. Additionally, this study assessed how accurately the model classified patients and what types of misclassifications occurred.

METHODS

Participants (n = 130, 57.7% cisgender female 70.0% white) received virtual outpatient FBT. Receiver operating characteristics (ROC) were used to predict successful weight restoration at end of treatment, using early weight gain as the predictor. Twenty weeks was considered as the end of treatment, to align with the definition of end of treatment in FBT clinical trials. ROC analyses demonstrated that gaining at least 6.2 pounds by week 5 of treatment was the strongest predictor of achieving 95% EBW at 20 weeks (AUC = 0.72 [0.63, 0.81]). ROC analyses misclassified 35% of patients; the most common misclassification was predicting that a patient would not achieve 95% EBW when they actually did (61.6%). A logistical regression model, which included the patients' %EBW at admission in addition to early weight gain as a predictor, outperformed the ROC analyses (AUC = 0.90 [0.85, 0.95]) and provided additional context by showing the probability that a patient would succeed.

CONCLUSION

Taken together, research demonstrates that early weight gain is a useful predictor of 95% EBW at 20 weeks of treatment for patients with ARFID who require weight restoration. Furthermore, results suggest that statistical models need to take into account additional information, such as %EBW at admission, along with early weight gain in order to more accurately predict which patients will reach weight restoration at week 20.

Improvements in Adolescents' Disordered Eating Behaviors in a Collaborative Care Digital Mental Health Intervention: Retrospective Observational Study

BACKGROUND

Young people today are exhibiting increasing rates of disordered eating behaviors, as well as eating disorders (EDs), alongside other mental and behavioral problems such as anxiety and depression. However, limited access to mental health care means that EDs, disordered eating behaviors, and comorbid mental health problems are often underdiagnosed and undertreated. Digital mental health interventions (DMHIs) offer accessible and scalable alternatives to traditional treatment modalities, but their effectiveness has not been well established among adolescents with EDs and disordered eating behaviors.

OBJECTIVE

This study uses data from a collaborative care pediatric DMHI to determine whether participation in a DMHI is associated with a reduction in adolescents' disordered eating behaviors.

METHODS

Adolescent members in care with Bend Health Inc completed the SCOFF questionnaire at baseline (before the start of care) and approximately every month during care to assess disordered eating behaviors. They also completed assessments of mental health symptoms at baseline. Member characteristics, mental health symptoms, and disordered eating behaviors of adolescents with elevated SCOFF scores at baseline (before the start of care) were compared to those of adolescents with nonelevated SCOFF scores at baseline. Members participated in web-based coaching or therapy sessions throughout the duration of mental health care.

RESULTS

Compared to adolescents with nonelevated SCOFF scores (n=520), adolescents with elevated SCOFF scores (n=169) were predominantly female and exhibited higher rates of elevated anxiety and depressive symptoms. SCOFF scores decreased over time in care with the DMHI for 61.4% (n=70) of adolescents with elevated SCOFF scores, and each additional month of participation was associated with greater improvements in disordered eating behaviors (F1,233=72.82; P<.001).

CONCLUSIONS

Our findings offer promising preliminary evidence that participation in mental health care with a collaborative care DMHI may be beneficial in the reduction of disordered eating symptoms in adolescents, including those who are experiencing comorbid anxiety and depressive symptoms.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

The assessment of caregiver self-efficacy in a virtual eating disorder setting

BACKGROUND

Caregiver self-efficacy is thought to be a key component for successful family-based treatment (FBT) for individuals with eating disorders. As such, interventions aimed at enhancing caregiver self-efficacy, often measured via the Parents Versus Anorexia scale, have been a focal point of FBT literature. However, studies looking at the relationship between caregiver self-efficacy and treatment outcomes have been mixed. We aimed to better understand the influence of caregiver self-efficacy on eating disorder treatment outcomes during FBT.

METHODS

Caregiver self-efficacy was measured using the Parents Versus Eating Disorders (PVED) scale, an adapted version of the Parents Versus Anorexia scale, in a sample of 1051 patients with an eating disorder and 1528 caregivers (patients can have more than one caregiver) receiving virtual FBT. Across two multilevel models, we tested how caregiver self-efficacy changed over time and its association with changes in eating disorder symptoms and weight over the first 16 weeks of treatment.

RESULTS

Over treatment, PVED scores increased (b = 0.79, SE = 0.04, CI [0.72, 0.86]) and starting PVED scores were predictive of improved eating disorder symptoms (b = - 0.73, SE = 0.22, CI [- 1.15, - 0.30]), but not weight (b = - 0.96, SE = 0.59, CI [- 2.10, 0.19]). We also found that PVED change-from-baseline scores were predictive of weight (b = - 0.48, SE = 0.03, CI [- 0.53, - 0.43]) such that patient weight was lower when caregiver reports of PVED were higher. Likewise, the association between caregiver change in PVED scores and weight varied as a function of treatment time (b = 0.27, SE = 0.01, CI [0.24, 0.29]). Results were consistent when isolating patients with anorexia nervosa.

CONCLUSIONS

Caregiver self-efficacy during FBT improved over time but was not robustly associated with treatment outcomes. This may, in part, be due to psychometric properties of the PVED scale. We describe these issues and illustrate the need for development of a new measure of self-efficacy for caregivers supporting their loved ones through eating disorder treatment.

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.

The effectiveness of lived experience involvement in eating disorder treatment: A systematic review

OBJECTIVE

This systematic review sought to understand the effectiveness of lived experience mentoring, by people recovered from an eating disorder, with clinical samples currently receiving eating disorder treatment.

METHODS

The systematic review was conducted using PsycINFO, MEDLINE, Scopus, and ProQuest Dissertations and Theses Global and reviewing reference lists of included papers. Articles were included if they: (1) were intervention studies that included peer (recovered from an eating disorder) involvement, (2) delivered the intervention to clinical samples (or carers with direct involvement in treatment), (3) were in English, and (4) included quantitative results.

RESULTS

Eleven studies were included across randomized control trials (RCTs), case series, and a case study; there was variation in quality. Findings varied considerably with some concluding that lived experience mentoring led to significant improvements for mentees, while other studies found no significant differences. Mentor outcomes were often not evaluated. Of those that did assess mentors, there is preliminary evidence for some benefits to participation but also the potential for harm.

DISCUSSION

There is a need for further research in this area using high-quality RCTs that address the risk of bias. It is important that lived experience peer mentors are monitored on key outcomes, provided with adequate training and ongoing supervision, and are reimbursed for their involvement.

PUBLIC SIGNIFICANCE

This systematic review is the first review to focus on the use of peer mentors recovered from an eating disorder contributing to interventions for people receiving treatment for an eating disorder. All included studies present quantitative results. Given the emerging interest of lived experience mentoring, understanding its effectiveness for both mentees and impacts on mentors continues to be of critical importance.

Digitally Delivered Dietary Interventions for Patients with Eating Disorders Undergoing Family-Based Treatment: Protocol for a Randomized Feasibility Trial

BACKGROUND

Eating disorders (EDs) affect 9% of the United States population, and anorexia nervosa (AN), specifically, has the second highest mortality rate of all psychiatric disorders. Yet, only 20% are able to access treatment. Access to care issues include long waitlists, lack of trained specialists, financial, and geographic barriers, all of which highlight the need for effective telehealth interventions. Family-based therapy (FBT) is a first-line treatment for adolescents and young adults with EDs, and weight gain early in treatment is considered a primary predictor of success with FBT. However, nutrition requirements for patients with EDs are uniquely complex. A variety of dietary interventions for guiding the renourishment process are used in practice, but empirical data on the effectiveness and acceptability of the various interventions are sparse. The significance of nutritional restoration and issues with access to first-line treatments underscore the need for further research exploring virtually delivered dietary interventions.

OBJECTIVE

Our objective is to compare the effectiveness and acceptability of 2 digitally delivered dietary interventions frequently used in eating disorder treatment settings: (1) calorie-based meal plans and (2) the Plate-by-Plate approach. Specifically, we will explore any potential differences in weight restoration achieved over 8 weeks of treatment as a primary measure of effectiveness, as well as additional treatment outcomes (ED symptoms, anxiety, depression, caregiver burden, and perceived effectiveness and acceptability for both caregivers and clinicians).

METHODS

Patients (N=100) with either AN or avoidant restrictive food intake disorders (ARFID) aged 6-24 years seeking treatment at a nationwide virtual eating disorder treatment program, were enrolled between May and August 2022. Upon admission, patients were randomly assigned to receive either the calorie-based intervention or Plate-by-Plate approach from their registered dietitian, all of whom have received training as study interventionists. While we were primarily interested in responses during the first 8 weeks of treatment, patients will be followed for up to 12 months. Descriptive statistics were used to describe patient characteristics and demographics. Weight changes and other treatment outcomes between groups will be compared using generalized linear models. Semistructured caregiver and clinician interview transcripts will undergo qualitative analysis.

RESULTS

Enrollment ran from March to August 2022, and we anticipate completion of data collection by November 2022. Analyses will be completed in January 2023.

CONCLUSIONS

This study contributes to existing FBT literature by thoroughly exploring the acceptability of dietary interventions and their influence on weight restoration, an area in which research is sparse.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41837.

Grazing Prevalence and Associations with Eating and General Psychopathology, Body Mass Index, and Quality of Life in a Middle-Income Country

Research from high-income countries has shown that grazing is a common but problematic eating pattern, particularly when associated with a sense of loss of control. However, it is unclear whether these patterns hold globally. Thus, the goal of this study was to extend previous research by examining the prevalence and clinical correlates of compulsive grazing (CG) and non-compulsive grazing (NCG) in a middle-income country. Participants (N = 2297) comprised adult residents from Rio de Janeiro, Brazil. Recruitment of this population-based household survey occurred from September 2019 to February 2020. The short inventory of grazing was used to operationalise grazing subtypes. Chi-square analyses, logistic regression, and univariate tests were conducted using the complex samples procedure. The point prevalence of regular CG was 10.2% (n = 239) and was consistent with high-income countries, while NCG was 29.8% (n = 679) and was less frequent than reported in high-income countries. Additionally, similar to high-income countries, CG was associated with a higher body mass index and higher odds of eating disorders, eating disorder symptomatology, depression, anxiety, and a lower physical and mental health-related quality of life, than no grazing and NCG. Overall, this study demonstrated that grazing patterns in high-income countries extend to middle-income countries.