An update on the medical consequences of anorexia nervosa

A prospective observational study comparing rates of medical instability between adolescents with typical and atypical anorexia nervosa

BACKGROUND

Recognition of atypical anorexia nervosa (AAN) has challenged underweight as a defining factor of illness severity in anorexia nervosa (AN). The present study aimed to compare rates of medical instability in adolescents with underweight (AN) and non-underweight (AAN) anorexia nervosa.

METHODS

The study examined assessment data from specialist eating disorder services in the UK between January and December 2022. Participants (n = 205) aged 11-18 years were recruited across eight eating disorder clinics and diagnosed with AN (n = 113) or AAN (n = 92) after clinical assessment. Parameters associated with risk of medical instability were compared between AN and AAN groups, using t tests and regression analysis.

RESULTS

Rates of bradycardia and hypotension did not differ significantly between AN and AAN groups (p = 0.239 and p = 0.289). Although white blood cell counts were lower in the AN group, rates of leukopaenia could not be statistically compared as a result of there being too few counts in at least one group. No incidences of hypophosphataemia were found in the sample. A significant regression equation was found for percentage median body mass index, but not rate of weight loss, as a predictor of blood pressure, serum phosphorous and magnesium.

CONCLUSIONS

Our findings indicate that medical instability occurs across a range of body weights in young people with AN and AAN. Although certain parameters of risk such as blood pressure, serum phosphorous and magnesium may be worsened at lower weight, both AN and AAN are serious mental health conditions that can lead to medical instability.

Characterizing Medical Complications in Publicly Insured Youth With Eating Disorders

PURPOSE

The present study describes the occurrence of eating disorder (ED)-related medical diagnoses in a publicly insured sample of youth with EDs. The study also compares ED medical diagnoses with other psychiatric disorders and identifies high-risk demographic groups. Improved screening practices are needed in public mental health systems where treatment is critical for youth with EDs.

METHODS

Medicaid claims data were obtained from the state of California, including beneficiaries ages 7-18 who had at least one service episode between January 1, 2014, and December 31, 2016. From this population we extracted demographic and claims data for those youth who received an ED diagnosis during the 3-year period as a primary or secondary diagnosis (n = 8,075). Random subsamples of youth with moderate/severe mental illness were drawn for comparison: primary or secondary diagnosis of mood/anxiety disorder (N = 8,000) or psychotic disorder (n = 8,000) were also extracted. Medical diagnoses were compared within youth with EDs (across diagnostic categories) and across psychiatric diagnoses (EDs, mood/anxiety disorders, psychotic disorders). Logistic regression analyses were used to adjust for demographic characteristics.

RESULTS

Three-quarters of youth with EDs received no diagnosis of an ED-related medical complication. Bradycardia was the most prevalent diagnosis suggestive of medical instability. Odds of medical diagnosis were greater for ED than other psychiatric disorders but varied with age and gender. Across all diagnoses, Latinx youth were less likely to receive ED-related diagnoses suggesting medical instability.

DISCUSSION

Most publicly insured youth with EDs received no ED-related medical diagnosis, underscoring the structural barriers to receiving expert medical care.

Greater rate of weight loss predicts paediatric hospital admission in adolescent typical and atypical anorexia nervosa

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.

Anorexia Nervosa and Osteoporosis: A Possible Complication to Remember

Anorexia nervosa (AN) belongs to the spectrum of food disorders and affects approximately 2.9 million people worldwide. It is responsible for numerous and serious medical complications. Osteoporosis is a common complication, and the decrease in bone mineral density (BMD) is one of the few potentially irreversible consequences of AN. When associated with AN, it can manifest at a very young age, possibly leading to irreparable damage. We describe the case of a 30-year-old woman with a one-year evolution diagnosis of AN, complaining of back pain. Physical examination revealed a slight elevation of the right shoulder and pain at compression of paravertebral right dorsal musculature with a palpable strained muscle. Full-length X-ray imaging of the dorsal spine revealed a slight dextroconvex dorsolumbar scoliosis. A dorsal spine computerized tomography (CT) was performed, confirming a fracture of the upper platform of the sixth dorsal vertebrae. Osteodensitometry showed lumbar spine osteoporosis and femoral osteopenia. The decrease in BMD and, later on, the development of osteoporosis can occur in both types of AN. It is a severe complication that affects up to 50% of these patients. It can be irreversible and increase the lifetime risk of bone fractures and, therefore, morbimortality. Low body weight and body mass index (BMI) strongly correlate with the decrease in BMD. Treatment of osteoporosis associated with AN is not standardized and clearly labeled. Weight gain is described as the strategy with the most impact in reversing the loss of bone mass and increasing the BMD. The regularization of gonadal function also seems to independently potentiate the increase of BMD. The occurrence of long bone and vertebrae fractures frequently results in a decrease in height and chronic back pain, culminating in greater morbimortality and healthcare costs. This clinical case aims to show theclose relationship between restrictive food disorders and the decrease of BMD and the subsequent development of osteoporosis and its complications. Although rare in young and healthy people, when associated with restrictive food disorders, it should raise a red flag in its clinical evaluation. Preventing osteoporosis development and reduction of fracture risk in this population is essential. The current absence of consistent evidence regarding screening of osteoporosis in this particular group should raise awareness and promote further larger-scale studies to establish standardized recommendations concerning not only screening but also pharmacological treatment of osteoporosis in patients with AN.

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Hypercapnia in hospitalized children and adolescents with anorexia nervosa as a predictive marker for readmission: a prospective study

PURPOSE

To determine whether hypercapnia is associated with risk of hospital readmission related to anorexia nervosa (AN) in children and adolescents.

METHODS

We performed a prospective study of patients ≤ 18 years old admitted due to AN decompensation from November 2018 to October 2019. Both subtypes of AN, restricting subtype (AN-R) and binge-eating/purging subtype (AN-BP), were included. Study participants were evaluated upon admission, at discharge and six months after discharge. T-tests or Mann-Whitney U tests was used to compare means values. Pearson or Spearman correlations were used to measure the association between two variables. Logistic regression models were developed to evaluate the relationship between scoring methods and readmission.

RESULTS

Of the 154 persons admitted during the study period, 131 met the inclusion criteria. Median age was 15.1 years. At admission, 71% of participants were malnourished and 33 (25%) had been previously admitted. We observed a marked decrease in venous pH and stable pCO2 elevation during follow-up period. Hypercapnia at discharge was associated with a twofold increased likelihood of readmission and the odds of readmission increased as discharge pCO2 rose. These findings did not depend on AN subtype or participant sex. Electrolytes persisted within the normal range.

CONCLUSION

Hypercapnia and respiratory acidosis are common alterations in children and adolescents hospitalized due to AN decompensation. Hypercapnia persists for at least 6 months after discharge despite clinical improvement and is associated with higher odds of readmission. This is the first study to identify an abnormal laboratory finding as a potential predictor of readmission in AN.

LEVEL OF EVIDENCE

IV: Multiple time series without intervention.

Exploring YouTube Videos About Anorexia Nervosa on the Basis of Reliability, Popularity, and Contributions of Healthcare Professionals: A Cross-Sectional Study

BACKGROUND

 Anorexia nervosa, an eating disorder, is characterized by a distorted body image, intense fear of gaining weight, and self-imposed starvation. The aim of this study is to analyze type of information as well as its quality and reliability on YouTube about anorexia nervosa.  Methodology: A cross-sectional observational study was conducted on 59 Youtube videos using anorexia nervosa-related keywords in June 2023. The characteristics of the YouTube videos, such as the language of the information, the time of upload, and the qualifications of the uploaders, were recorded. The content and quality of 59 videos were assessed using the Global Quality Score (GQS) and reliability grading systems.

RESULTS

The videos accumulated a total of 256,602 likes, 5,644 dislikes, and 17,761 comments. Treatment-related content accounted for 81.36% of the videos, while descriptions of symptoms comprised 79.66%. Doctors contributed to 18.6% of the total uploads, making them the second-largest group of uploaders after the 'Other' category. The median reliability score for doctors is 4, the same as the hospital healthcare organization. This indicates that the perceived reliability of doctors as a source of information is as high as that of hospital healthcare organizations.

CONCLUSIONS

In conclusion, this study highlights the importance of critically evaluating information on anorexia nervosa videos on YouTube. Despite variations in popularity, the overall quality and reliability remained consistent. Doctors were perceived as reliable sources of information, comparable to hospital healthcare organizations. Ensuring accurate and trustworthy content is crucial for supporting those affected by anorexia nervosa and promoting reliable information to the public.

Medical instability in typical and atypical adolescent anorexia nervosa: a systematic review and meta-analysis

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.

Anorexia Nervosa and Somatoform Dissociation: A Neglected Body-Centered Perspective

Dissociation in anorexia nervosa (AN) is common (literature reported 29% of dissociative disorders in eating disorders) and higher in patients with binge-purging AN (BP-AN) than in those with restricter AN (R-AN). However, the distinction between somatoform (SomD) and psychoform dissociation (PsyD) is understudied. We aimed to assess the differences in PsyD and SomD, eating-related, general, and body-related psychopathology, and childhood trauma between subtypes of AN. Then, we attempted to describe a subgroup of patients with AN with marked SomD comparing them to patients without SomD, also controlling the results for PsyD and AN subtypes. Inpatients with AN (n = 111; 109 women and 2 men) completed self-reported questionnaires evaluating dissociation, eating-related, body-related, and general psychopathology, and childhood abuses. Patients with BP-AN reported higher SomD and PsyD and a more severe clinical picture than those with R-AN. The SomD-group (n = 41) showed higher eating concerns, trait-anxiety, body-related variables, and sexual/physical abuse compared to the no-SomD group (n = 70), independently of AN subtype and PsyD symptoms. Results described particular features of patients with AN and SomD. Data, clinically, suggest a careful assessment, for both SomD and PsyD, especially when a history of bodily-impacting trauma is present, potentially fostering dissociation-informed interventions.

Maintaining Factors of Anorexia Nervosa Addressed from a Psychotherapeutic Group for Parents: Supplementary Report of a Patient's Therapeutic Success

(1) Background: Anorexia nervosa is an eating disorder (ED) where up to 30% of individuals remain unresponsive to treatments, whether they partially respond, or do respond and later relapse. It has been broadly reported how presenting maladaptive family functioning and communication style contributes to treatment drop-out, poor treatment compliance, and poor long-term outcomes. We studied the mother and father of a patient with AN, binge-purge subtype (according to DSM-IV TR) who achieved remission after her parents but not her attended an intervention through a psychotherapy group for parents (PGP). (2) Methods: We previously reported this patient's case report, and now, through an Interpretative Phenomenological Analysis (IPA) approach, we aimed to explore the understanding and meanings ascribed by the mother and father to their experience at the PGP and to their daughter's clinical and functional improvement. (3) Results: We identified two main stages along the process: one related to the presence of maintaining factors of their daughter's disorder, and the other related to the emergence of a reflective function and to the implementation of behavioral, emotional and cognitive changes. (4) Conclusions: The interview revealed both parents' experience at the PGP promoted a change process, where they were able to modify their previous style of communication and functioning, and to identify them as a contributors to maintain their daughter's disorder. Reflective function (RF) emerged in the mother and father throughout the psychotherapeutic process. Both parents also revealed some elements that were intergenerationally transmitted, that affected three generations and contributed to maintaining the ED. We observed the multilevel open-group structure of the PGP, enhancing the mother's and father's change process.

Parent-Focused Psychotherapy for the Preventive Management of Chronicity in Anorexia Nervosa: A Case Series

Background: Anorexia nervosa (AN) is a complex eating disorder where involvement of family plays a central role in first line treatment in adolescents, but which is not so for adults where poor response to treatment is frequent. Given the reluctance of some patients to receive treatment, we set out to explore the hypothesis that certain family dynamics may be involved in the maintenance of the disorder. Methods: We aimed to understand what is underlying in the cases of patients who present clinical improvement with their parents, but not the ones who received a parent-focused psychotherapeutic intervention. We conducted a mixed methods study. On the one hand we performed a case series of 14 patients who dropped out of treatment while their parents actively attended the intervention, and on the other hand, we followed the evolution of the parents of those patients reluctant to continue treatment, through non-participant observation. Results: We present preliminary evidence where we found the parent-focused psychotherapeutic intervention was able to elicit a reflective function of the parents. We also observed that the intervention modified certain family dynamics that could be related to maintaining factors of the disorder. In patients, we found that in parallel to the assistance of their parents to psychotherapeutic treatment, and even when they were receiving no intervention, they showed significant clinical improvement of symptomatology and global functioning; we observed 9 of 14 of them who voluntarily decided to return to pharmacological treatment. Conclusions: This parent-focused intervention elicited changes in reflective functioning of participant parents; the intervention produced favorable changes in family dynamics, which we believe is probably related to improvement of global functioning, symptomatology, and insight of patients.

Evaluating and optimizing bone health in children with chronic health conditions

Paediatric health care providers (HCPs) play an important role in optimizing bone health. Early intervention is essential to maximize the accrual of peak bone mass in adolescence and young adulthood and to reduce osteoporosis and fracture risk later in life. Children and adolescents with chronic health conditions may have several risk factors for poor bone health, including underlying inflammatory conditions, reduced weight-bearing activity, delayed puberty, and inadequate intake of calcium and vitamin D. Some medications-particularly glucocorticoids-can compromise bone mass and place a child at risk for fragility fractures. This practice point describes a targeted approach to identifying bone health risk factors in children and youth with chronic health conditions, highlights office initiatives aimed at optimizing bone mass accrual, and links HCPs to useful web-based tools and medical references. Indications for referral to a bone health specialist and bone-specific pharmacotherapeutic interventions are also reviewed.

L'évaluation et l'optimisation de la santé osseuse chez les enfants ayant des affections chroniques

Les professionnels de la santé des enfants jouent un rôle important dans l'optimisation de la santé osseuse. Il est essentiel d'intervenir rapidement pour maximiser le pic de masse osseuse à l'adolescence et au début de l'âge adulte et d'ainsi réduire le risque d'ostéoporose et de fractures plus tard dans la vie. Les enfants et les adolescents ayant une affection chronique peuvent présenter plusieurs facteurs de risque de mauvaise santé osseuse, notamment des maladies inflammatoires sous-jacentes, des activités avec mise en charge limitées, un retard pubertaire et un apport insuffisant de calcium et de vitamine D. Certains médicaments, et particulièrement les glucocorticoïdes, peuvent compromettre la masse osseuse et exposer l'enfant à un risque de fractures de fragilisation. Le présent point de pratique décrit une approche ciblée pour déterminer les facteurs de risque liés à la santé osseuse chez les enfants et les adolescents ayant une affection chronique, expose les mesures à prendre en cabinet pour optimiser l'acquisition de la masse osseuse et propose des outils en ligne utiles et des références médicales à l'intention des professionnels de la santé des enfants. Les indications pour diriger les patients vers un spécialiste de la santé osseuse et pour procéder à des interventions pharmacologiques visant les os sont également abordées.

Eating disorders are associated with increased risk of fall injury and fracture in Swedish men and women

In this retrospective cohort study, men and women with eating disorders (n = 8867) had higher risk of injurious falls and hip fractures than age, sex, and county-matched controls (n = 88670).

INTRODUCTION

Eating disorders have been associated with decreased bone mineral density and increased fracture risk, but the association with fall injuries without fracture has not previously been investigated. Furthermore, fracture risk in men with eating disorders has been insufficiently studied.

METHODS

In the present study, 8867 patients (9.4% men) with a diagnosed eating disorders and 88670 age-, sex-, and county-matched controls were investigated.

RESULTS

The mean (standard deviation) age of the patients and controls was 41.6 (13.7) years and the follow-up time 9.6 (5.2, 14.4) years (median, interquartile range) for patients and 10.1 (5.5, 14.2) years for controls. The proportions of injurious falls without fracture (17.3% vs. 9.0%) and of hip fracture (1.6% vs. 0.7%) were substantially greater in patients with an eating disorder than in their corresponding population controls. In an unadjusted Cox proportional hazards model, individuals with an eating disorder had a higher risk of injurious falls without fracture (Hazard ratio (HR) 95% confidence interval (CI): 2.07 (1.96-2.18), and hip fracture (HR 2.30 (1.92-2.75)) than the risk observed in the controls. The HR for any investigated outcome associated with an eating disorder did not differ by sex or age (interaction term p > 0.10). The risk of injurious falls without fracture and hip fracture was increased in both women (HR 2.07 (1.95-2.19) and HR 2.41 (1.98-2.93), respectively) and men (HR 2.09 (1.76-2.49) and HR 1.84(1.12-3.02), respectively), with an eating disorder.

CONCLUSION

The risk of injurious falls without fracture and of hip fracture is increased in both women and men with eating disorders, indicating measures to prevent both falls and fractures are important in these patients, regardless of age and sex.

Secondary Osteoporosis

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.

Long-term cardiac assessment in a sample of adolescent-onset anorexia nervosa

BACKGROUND

High mortality rates have been reported in patients with anorexia nervosa, mainly due to cardiovascular alterations. The purpose of the present study was to assess cardiac structural and functional abnormalities some 20 years after initial treatment in a sample of adolescent-onset anorexia nervosa (A-AN) and to compare them with matched healthy controls (HC).

METHODS

A sample of 29 women diagnosed and treated for AN during adolescence (A-AN) were assessed more than 20 years later. A complete cardiac evaluation was carried out including an electrocardiogram (ECG) and a standard 2D echocardiography. Thirty matched HC were also assessed.

RESULTS

In the A-AN group, four subjects had a body mass index lower than 18.5 and met full DSM 5 criteria for AN at follow-up (Low-Weight group). They were compared with the rest of the sample (n = 25) who had normalized their weight (Normal-Weight group), though some still showed some eating disorder symptoms. Both groups were compared with the HC group. Subjects in the Low-Weight group presented statistically significant decreases in the left ventricular end-diastolic and left atrium dimensions and left ventricular mass in comparison with the Normal-Weight group and the HC. No other differences in cardiac parameters were found between groups.

CONCLUSIONS

Echocardiographic and ECG parameters of adults who had presented A-AN twenty years earlier and currently maintained normal weight were similar to those of HC who had never been treated or diagnosed with AN. Adult subjects with A-AN who still had low weight in the long term present certain cardiac abnormalities similar to those seen in short-lasting disease. More studies are needed to confirm these results in a larger sample.

A systematic review of cognitive behavior therapy and dialectical behavior therapy for adolescent eating disorders

BACKGROUND

Eating disorders have serious psychological and physical consequences. Current evidence-based treatments for adolescents with eating disorders have modest effects, underscoring the need to improve current treatment approaches. Cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) have been proposed as alternative treatment options, with burgeoning research in this area. This review aims to summarize and critically analyze the current literature on the feasibility, acceptability, effectiveness, and efficacy of CBT and DBT for adolescent eating disorders, and then proposes areas of future research.

METHODS

PsycINFO and PubMed were searched using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify studies examining the feasibility, acceptability, effectiveness and/or efficacy of CBT or DBT for adolescent eating disorders.

RESULTS

Eligible studies (N = 50; CBT: n = 40, DBT: n = 10) indicated that both treatments are reasonably feasible, acceptable, and possibly effective for adolescent eating disorders across diagnoses and levels of care, though efficacy trials are lacking.

CONCLUSIONS

CBT and DBT demonstrate promise as alternatives to family-based approaches for adolescent eating disorders. Adequately powered trials to establish the effectiveness and efficacy of CBT and DBT are needed, particularly ones that compare these treatments against other leading approaches. Despite high rates of relapse and likelihood for severe and enduring illness, there is a dearth of evidence-based treatment options for adolescents with eating disorders. Potentially viable but less well-studied treatments for adolescents with eating disorders include cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). This systematic review of CBT and DBT for adolescent eating disorders focuses on feasibility (i.e., how easy it was to implement the treatment), acceptability (i.e., how well the intervention was received by patients and therapists), effectiveness (i.e., how well the intervention performed under routine, real-world circumstances), and efficacy (i.e., how well the intervention performed in highly-controlled research settings). This review concludes that research supports the feasibility and acceptability of these approaches, as well as preliminary evidence of their effectiveness. However, the field is lacking studies that systematically compare CBT and DBT to other evidence-based approaches. Recommendations to advance research on CBT and DBT for adolescent eating disorders are provided, including a call for efficacy studies that clarify their performance compared to other leading approaches.

Nurses' perceptions on and experiences in conflict situations when caring for adolescents with anorexia nervosa: A qualitative study

Anorexia nervosa (AN), which primarily affects adolescent girls and young women, is characterized by excessive dieting, leading to severe weight loss and a pathological fear of becoming overweight, or unhealthy behaviours that hinder weight gain. Caring for patients who have AN is particularly challenging for nursing staff, who are on the front line and have the closest contact with patients. However, little is known about how nursing staff care for adolescent patients with AN in Taiwan. This study aimed to explore nurses' perceptions on and experiences in conflict situations in caring for adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, ten nursing staff from the paediatric ward at a university-affiliated medical centre in central Taiwan shared their experiences. Recorded interviews were transcribed and analysed by content analysis. This analysis identified three themes with eight subthemes: (i) struggling to develop therapeutic relationships, (ii) selective focusing, and (iii) difficulty changing minds. The findings of this study indicated a need for ongoing support for nursing staff, the development of therapeutic relationships with adolescent patients with AN, extensive nursing staff preparation, and the development of in-service training programs to enable nursing staff to care for these patients with greater understanding.

MTHFR Polymorphisms in Girls with Anorexia Nervosa: Implications on Body Weight

The development of atypical vs typical anorexia nervosa (AN) might be explained by the genetic background. We assessed the link between the subtypes of AN and the genetic polymorphisms of the thrombotic panel and the methyltetrahydrofolate reductase (MTHFR) gene. This cross-sectional pilot study recruited 48 girls with AN and 10 age-matched control girls with normal menstruation. We recorded anthropometric parameters and obtained blood samples for genotyping and hormonal assessment. Classification of AN was performed according to the DSM-V criteria. Girls with AN had 2.66 times higher odds of carrying at least one genetic polymorphism from the MTHFR panel (C677T and A1298C) compared with girls without AN (OR = 2.660, p-value = 0.041; CI 95% 1.057-6.720). The presence of atypical vs typical AN was associated independently with the presence of any of the assessed MTHFR polymorphisms (C677T, OR = 4.929, 95% CI 1.076-22.579, p-value = 0.040; A1298C, OR = 0.097, 95% CI 0.011-0.866, p-value = 0.037) in age and estrogen adjusted models. The atypical presentation of AN is mainly linked with higher prevalence of the MTHFR C677T and lower prevalence of the A1298C polymorphism.

Biased Ghrelin Receptor Signaling and the Dopaminergic System as Potential Targets for Metabolic and Psychological Symptoms of Anorexia Nervosa

Anorexia Nervosa (AN) is a complex disease that impairs the metabolic, mental and physiological health of affected individuals in a severe and sometimes lethal way. Many of the common symptoms in AN patients, such as reduced food intake, anxiety, impaired gut motility or overexercising are connected to both the orexigenic gut hormone ghrelin and the dopaminergic system. Targeting the ghrelin receptor (GhrR) to treat AN seems a promising possibility in current research. However, GhrR signaling is highly complex. First, the GhrR can activate four known intracellular pathways Gαq, Gαi/o, Gα12/13 and the recruitment of β-arrestin. Biased signaling provides the possibility to activate or inhibit only one or a subset of the intracellular pathways of a pleiotropic receptor. This allows specific targeting of physiological functions without adverse effects. Currently little is known on how biased signaling could specifically modulate GhrR effects. Second, GhrR signaling has been shown to be interconnected with the dopaminergic system, particularly in the context of AN symptoms. This review highlights that a biased agonist for the GhrR may be a promising target for the treatment of AN, however extensive and systematic translational studies are still needed and the connection to the dopaminergic system has to be taken into account.

Bladder and voiding dysfunction in adolescents with anorexia nervosa: a novel finding and potential causes

PURPOSE

This study aimed to investigate the bladder capacity (BC) and bladder dynamics of adolescents with anorexia nervosa (AN).

METHODS

The participants consisted of 15 adolescents newly diagnosed with AN according to the DSM 5 criteria and in the acute weight loss period who were questioned about the symptoms of lower urinary tract (LUT) dysfunction. Functional bladder capacity (FBC) and voided volume with uroflowmetry were measured for each subject; the larger volume of the two was chosen for the bladder capacity. Uroflowmetry was used to obtain uroflow curves for the participants whose patterns were labeled as pathologic if they were outside the bell-shape.

RESULTS

Fourteen (93.3%) of the patients exhibited at least one of the LUT dysfunction symptoms (pathologic voiding symptom/urinary incontinence/pathologic uroflow pattern). BC was observed to increase in 86.6% (n = 13) of the patients. Eighty% of the patients (n = 12) showed pathological uroflow patterns. In patients with pathological uroflow patterns, which showed insufficiency of bladder contraction, assistance of abdominal muscles was needed during voiding.

CONCLUSION

The novel findings presented in this study are the increase of BC in adolescents with AN, the presence of at least one type of voiding or bladder dysfunction, and the pathology of uroflow patterns of most patients show that the bladder dynamics is affected in AN. The most important contribution of this study to the literature is that impaired bladder dynamics was determined to be a medical complication of AN.

LEVEL OF EVIDENCE

Case-control analytic study, Level III.

Eating disorders in adolescent boys and young men: an update

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.