Prevalence and management of people with eating disorders presenting to primary care: A national study

The Essentials: Upskilling a National Health Workforce in the Identification and Treatment of Eating Disorders

OBJECTIVE

Health practitioners report limited skills and lack of confidence in managing and treating people with eating disorders. The purpose of this study was to evaluate the national rollout of comprehensive basic training in identification, assessment, treatment, and management of people with eating disorders to clinicians.

METHODS

The Essentials: Training Clinicians in Eating Disorders is a core competency eLearning program. As part of a nation-wide multidisciplinary workforce training strategy, 7500 course places were provided free of charge to public and private health care professionals across all jurisdictions of Australia between January 2020 and March 2022.

RESULTS

A total of 7370 health professionals enrolled during the study period. All learning outcomes showed improvement with large effect (Cohen's d = 1.2-2), with the largest improvements for self-reported knowledge of requirements for working with children and adolescents. Effects did not depend on years of working with eating disorders suggesting that the training was beneficial across levels of experience. Those who started with very low knowledge of eating disorders or higher willingness to treat eating disorders were most likely to complete the course. Most participants reported that the course was relevant to their clinical practice, that they expected their clinical practices to change, and that they would recommend the course to other health professionals.

DISCUSSION

The strategy to provide government-funded core competency training in eating disorder care to healthcare professionals met key objectives by reaching health professionals eligible to provide government-rebated services in public and private settings across all jurisdictions including regional and remote areas.

Educating primary care physicians about eating disorders: Pilot data from a microlearning programme

BACKGROUND

Over two-thirds of people present to their primary care physician (or general practitioner; GP) as a first point of contact for mental health concerns. However, eating disorders (EDs) are often not identified in a primary care setting. A significant barrier to early detection and intervention is lack of primary care physician training in EDs; compounded by the significant time commitments required for training by already time-poor general practitioners. The aim of the current study was to pilot and evaluate a microlearning programme that can be delivered to general practitioners with high workloads to help support patients with, or at risk of, developing an ED.

METHODS

Fifty-one Australian general practitioners aged between 25-to-60 years old were recruited. Participants completed a baseline questionnaire to ascertain their experience working in general practice and with EDs. Participants then completed an online programme consisting of a series of 10 case studies (vignettes) delivered over a 6-10 week period related to various facets of ED care. Following conclusion of the programme, participants were asked to complete an evaluative questionnaire related to the content of the programme; perceived knowledge, confidence, willingness-to-treat, skill change; and their overall experience of microlearning.

RESULTS

All 51 GPs completed the programme and reached completion criteria for all vignettes, 40 of whom completed the programme evaluation. Participants indicated improved skill, confidence, willingness-to-treat, and knowledge following the completion of the pilot programme. Almost all (97.5%; n = 39) found microlearning to be an effective method to learn about EDs; with 87.5% (n = 35) of participants reporting they felt able to apply what was learnt in practice. Qualitative feedback highlighted the benefit of microlearning's flexibility to train general practitioners to work with complex health presentations, specifically EDs.

CONCLUSIONS

Findings from the current study lend support to the use of microlearning in medical health professional training; notably around complex mental health concerns. Microlearning appears to be an acceptable and effective training method for GPs to learn about EDs. Given the significant time demands on GPs and the resulting challenges in designing appropriate training for this part of the workforce, this training method has promise. The pre-existing interest in EDs in the current study sample was high; future studies should sample more broadly to ensure that microlearning can be applied at scale.

Evaluation of an online modular eating disorders training (PreparED) to prepare healthcare trainees: a survey study

BACKGROUND

Eating disorders (EDs) are serious, complex disorders for which broad-based clinical training is lacking. This study aimed to evaluate the efficacy of a free, brief, web-based curriculum, PreparED, in increasing comfort and confidence with, and knowledge about EDs in healthcare trainees, and to obtain program feedback from key stakeholders (i.e., learners).

METHODS

This programmatic evaluation study was designed as a quantitative, repeated measures (i.e., pre- and post-test intervention) investigation. A convenience sample of two groups of healthcare trainees across geographically diverse training sites completed an anonymous survey pre- and post- engagement with PreparED. The survey included items to assess prior exposure to EDs, as well as program feasibility. The main educational outcomes included (1) Confidence and Comfort with EDs and (2) Knowledge of EDs. User experience variables of interest were likeability, usability, and engagement with the training modules. Mixed effects linear regression was used to assess the association between PreparED and educational outcome variables.

RESULTS

Participants (N = 67) included 41 nutrition graduate students and 26 nurse practitioner students recruited from Teacher's College/Columbia University in New York, NY, USA, Columbia University School of Nursing in New York, NY, USA and North Dakota State University School of Nursing in Fargo, ND, USA. Confidence/Comfort scores and Knowledge scores significantly improved following engagement with PreparED (β = for effect of intervention = 1.23, p < 0.001, and 1.69, p < 0.001, respectively). Neither training group nor prior exposure to EDs moderated the effect on outcomes. All learners agreed the program was easy to follow; the overwhelming majority (89.4%) felt the length of the modules was "just right." All participants perceived that PreparED had increased their knowledge of EDs, and the majority (94.0%) reported greater confidence in and comfort with caring for people with these disorders, including assessment of symptoms, awareness of associated medical complications, and likelihood of future screening.

CONCLUSIONS

Findings suggest that brief, user-friendly, online courses can improve knowledge and attitudes about EDs, filling a critical gap in healthcare training.

The acceptability, feasibility, and preliminary efficacy of a supported online self-help treatment program for binge-eating disorder

Introduction

Studies in transdiagnostic eating disorder (ED) samples suggest supported online self-help programs (eTherapies) are effective and may improve access to treatment; however, their evaluation in those with binge-eating disorder (BED) is limited. Given BED's high prevalence and low levels of treatment uptake, further eTherapy evaluation is needed to broaden access to effective, evidence-based treatment options. The aim of this study was to investigate the acceptability, feasibility, and preliminary efficacy of a supported eTherapy for those with BED or subthreshold BED, and to examine symptom change across the duration of therapy.

Method

Nineteen women with BED completed a supported, 10-session Cognitive Behavioural Therapy-based eTherapy in an uncontrolled, pre-post, and 3 months follow up intervention study. Key outcomes were assessed by the Eating Disorder Examination Questionnaire (EDE-Q): objective binge episode (OBE) frequency and ED psychopathology. Feasibility was evaluated via program adherence and dropout, whilst acceptability was assessed through participant feedback post-treatment. Weekly symptom change (ED psychopathology) during treatment was assessed by the Eating Disorder Examination - Questionnaire Short (EDE-QS).

Results

Generalised estimating equations showed statistically and clinically significant reductions in OBEs and ED psychopathology (large effects) post-treatment, with these decreases maintained at follow up. Across weekly assessment, a marked slowing in the rate of change in ED psychopathology was observed after four sessions of the program. Program feasibility was high (i.e., 84% of content completed), as was program acceptability (i.e., 93% of participants expressed high levels of satisfaction).

Discussion

These results support the acceptability, feasibility, and preliminary efficacy of a supported eTherapy program for those with BED and suggest the variability of symptom change across the duration of therapy. Future research should further investigate findings in an adequately powered randomised controlled trial.

Prevention and early intervention in eating disorders: findings from a rapid review

BACKGROUND

Eating disorders (EDs) are complex psychological disorders, with low rates of detection and early intervention. They can lead to significant mental and physical health complications, especially if intervention is delayed. Given high rates of morbidity and mortality, low treatment uptake, and significant rates of relapse, it is important to examine prevention, early intervention, and early recognition initiatives. The aim of this review is to identify and evaluate literature on preventative and early intervention programs in EDs.

METHODS

This paper is one of a series of Rapid Reviews, designed to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded, and released by the Australian Government. To provide a current and rigorous review, peer-reviewed articles between 2009 and 2021 published in English were searched across three databases: ScienceDirect, PubMed and Ovid/Medline. Priority was given to high-level evidence including meta-analyses, systematic reviews, Randomised Control Trials, and large population studies. Findings from selected studies pertaining to prevention and early intervention in EDs were evaluated and are presented in this review.

RESULTS

In total, 130 studies were identified in the current review, 72% relating to prevention and 28% to early intervention. Most programs were theory-driven and targeted one or more ED risk factors such as thin-ideal internalisation and/or body dissatisfaction. There is reasonable evidence to support prevention programs reducing risk factors, particularly as part of school or university-based programs, with established feasibility and relatively high acceptance among students. There is increasing evidence around the use of technology (to increase dissemination potential) and for use of mindfulness approaches (targeting emotional resilience). Few longitudinal studies assessing incident cases following participation in a prevention program exist.

CONCLUSIONS

Although several prevention and early intervention programs have been shown to significantly reduce risk factors, promote symptom recognition, and encourage help-seeking behaviour, most of these studies have been conducted in older adolescent and university aged students, past the age of peak ED onset. One of the most targeted risk factors, body dissatisfaction, is found in girls as young as 6 years old, indicating a need for further research implementing prevention initiatives at younger ages. Follow-up research is limited; thus, the long-term efficacy and effectiveness of studied programs is unknown. Greater attention should be paid to the implementation of prevention and early intervention programs in identified high-risk cohorts or diverse groups, where a more targeted approach may be necessary.

Eating disorders in young people

OBJECTIVE

Eating disorders (EDs) have their onset most frequently in adolescence and young adulthood. Treatment for EDs lack efficacy, and we have made little progress in improving outcomes for patients over the course of the last several decades. As with other mental health conditions, early intervention may greatly improve outcomes, yet, little research exists in this area.

CONCLUSIONS

More effective evidence-based treatments are sorely needed for EDs, particularly for early stages of the illness to minimise the potential harms of treatment and long-standing illness. Treatment service models would also benefit from taking an approach that ensures continuation of care from adolescence to young adulthood.

Informing care through lived experiences: perspectives of consumers and carers regarding dietetic care for eating disorders in Australia

PURPOSE

Dietitians are important members of eating disorder treatment teams. Previous research indicates little is known about the experience of receiving nutrition care for eating disorders. This study aimed to explore the perspectives of consumers and carers regarding the care received from primary care dietitians for eating disorders.

METHODS

This study qualitatively explored the perceptions of individuals aged ≥ 15 years, who (i) identified as having an eating disorder or (ii) had cared for someone with an eating disorder, and had received care from a dietitian in a primary care setting. Thematic analysis was used to identify themes from interview transcripts. Synthesized member checking was utilized to assess whether the identified themes resonated with participants' experiences. Twenty-four individuals (21 consumers, 3 carers) participated in a semi-structured interview. Seventeen participants completed member checking and all supported the identified themes and subthemes.

RESULTS

Three themes emerged inductively from the data: (1) valuing a person-centered approach to dietetic care; (2) the therapeutic alliance is central to engaging in dietetic care; and (3) sharing the complex journey.

CONCLUSIONS

This study advances the understanding of the aspects of dietetic care perceived as most helpful by consumers and carers. These insights highlight the importance of person-centeredness, empathy, trust and collaboration within eating disorder care. The findings can be used by dietitians and health professionals to inform practice. Further research is needed to understand how dietitians can be supported to provide optimal nutrition care to people and families impacted by eating disorders.

LEVEL OF EVIDENCE

V. Qualitative study.

Eating Disorders

Eating disorders are common behavioral disorders associated with substantial psychological and physical morbidity and mortality. Persons with eating disorders frequently present to primary care providers, who may also be responsible for their general medical management. This article reviews the diagnosis, medical assessment, and treatment of the most common eating disorders.

The impact of the COVID-19 pandemic and associated public health response on people with eating disorder symptomatology: an Australian study

OBJECTIVE

People with lived experience of eating disorders (ED) may be particularly vulnerable to the COVID-19 pandemic and associated public health response due to exasperating situations such as social isolation, presence of other mental and physical health conditions, disruptions to treatment, etc. This study investigates the association of the pandemic with ED symptomatology to consider impact and identify risk factors for clinical consideration.

METHODS

Participants with self-reported ED diagnosis and/or symptomatology over 16 years were invited to complete an online survey during the first months of the pandemic in Australia. Questions included history of ED, occurrence of co-occurring mental health conditions, change in ED symptoms since the start of the pandemic, and validated measures of ED illness, state mental health and loneliness.

RESULTS

Of 1723 participants (mode age 24.9 years, 91.6% identifying as female, EDE-Q Global Score x = 4.08, SD = 1.18, 79.0% reporting co-occurring mental health condition, predominantly obsessive-compulsive disorder and/or anxiety), 88.0% reported an increase in body image concerns, 74.1% in food restriction, 66.2% binge eating and 46.8% driven exercise during the pandemic. Increased ED symptomatology was associated with poorer state mental health (i.e., depression, anxiety, and stress) and loneliness across the ED symptom profile. Most participants were negatively impacted by various aspects of the public health response, more so for those with more acute ED illness as measured by the Eating Disorder Examination Questionnaire (EDE-Q).

CONCLUSIONS

Associated with the COVID-19 pandemic is a mental health crisis, particularly for those with a lived experience of an eating disorder. With 40.5% of participants not having sought formal diagnostic assessment and less than half in treatment, this study provides evidence for the detrimental impact of the pandemic on people with a lived experience of an eating disorder, especially for those not yet supported by the health care system.

Impact of patient characteristics on clinicians' decisions to involve dietitians in eating disorder treatment

BACKGROUND & AIMS

Dietetic involvement in eating disorder (ED) treatment is often initiated by other members of a patient's treating team. This study aimed to examine the impact of patient characteristics on clinicians' decisions to involve a dietitian in a patient's ED treatment, as well as the influence of clinician characteristics on their decision-making.

METHODS

ED clinicians were recruited to complete an online survey, which used case vignettes to assess their likelihood of referring patients to a dietitian or consulting with a dietitian for guidance. Questions were also included measuring clinician anxiety, beliefs about the therapy they deliver, beliefs about dietitians and views on evidence-based practice, to determine if these were related to their responses to case vignettes.

RESULTS

Fifty-seven clinicians completed the survey, with the largest group being clinical psychologists (n=22, 39%). ED diagnosis, weight status, medical co-morbidities and progress in treatment were all shown to be influential on whether clinicians involved dietitians in ED treatment. Clinician characteristics and their beliefs about dietitians were generally not correlated with the likelihood of seeking dietetic input.

CONCLUSIONS

This study indicates that clinicians' decisions to involve dietitians in ED treatment are systematic rather than random decisions influenced by individual clinician characteristics. Clinicians require further education on the potential for malnutrition regardless of patients'ED diagnosis or weight status, and the dietitian's role in addressing this. This article is protected by copyright. All rights reserved.

Identification of high risk and early stage eating disorders: first validation of a digital screening tool

BACKGROUND

Eating disorders are amongst the deadliest of all mental disorders, however detection and early intervention rates remain extremely low. Current standardised screening questionnaires can be arduous or confronting and are ill-validated for online use, despite a universal shift to digital healthcare. The present study describes the development and pilot validation of a novel digital screening tool (the InsideOut Institute-Screener) for high risk and early stage eating disorders to drive early intervention and reduced morbidity.

METHODS

We utilised a mixed cross-sectional and repeated measures longitudinal survey research design to assess symptom severity and recognised parameters of statistical validity. Participants were recruited through social media and traditional advertising, and through MTurk. An Eating Disorders Examination Questionnaire (EDE-Q) global score of 2.3 and assessment of eating disorder behaviours was used to determine probable ED. 1346 participants aged 14-74 (mean [SE] age 26.60 [11.14] years; 73.8% female, 22.6% male) completed the survey battery. 19% were randomised to two-week follow-up for reliability analysis.

RESULTS

Strong positive correlations between the IOI-S and both the EDE-Q global (r_s = .88) and SCOFF (r_s = .75) total score were found, providing support for the concurrent validity of the scale. Inter-item correlations were moderate to strong (r_s = .46-.73). Correlations between the IOI-S and two measures of social desirability diverged, providing support for the discriminant validity of the scale. The IOI-S demonstrated high internal consistency (α = .908, ω = .910) and excellent two-week test-retest reliability (.968, 95% CI 0.959-0.975; p ≤ 0.1). The IOI-S accurately distinguished probable eating disorders (sensitivity = 82.8%, specificity = 89.7% [AUC = .944], LR⁺  = 8.04, LR^- = 0.19) and two stepped levels of risk.

CONCLUSIONS AND RELEVANCE

The present study provides excellent initial support for the psychometric validity of the InsideOut Institute digital screening tool, which has the potential to streamline early intervention in the hopes of reducing current high morbidity and mortality. Further validation should be undertaken in known clinical populations. Eating disorders are amongst the deadliest of all mental disorders, however detection and early intervention rates remain extremely low. The present study describes the initial psychometric validation of a novel digital screening tool (the InsideOut Institute Screener) for high risk and early stage eating disorders, for self-referral and/or use in primary care. 1346 participants aged 14-74 of all genders completed a survey battery designed to assess common parameters of statistical validity. Strong support was found for the screener's ability to accurately measure eating disorder risk and symptomatology. The screener was highly positively correlated with a well known and extensively validated long form self-report questionnaire for eating disorder symptomatology. This study is a pilot validation and the genesis of a project that aims ultimately to drive early intervention leading to reduced morbidity and mortality rates in this illness group.

What role do dietitians have in providing nutrition care for eating disorder treatment? An integrative review

BACKGROUND

Dietitians are recognised as experts in nutrition care and essential members of multidisciplinary healthcare teams. However, the role of dietitians in caring for people with eating disorders is not well understood. The present review aimed to identify, critically appraise and synthesise the current evidence exploring the views and experiences of dietitians, other health professionals, patients and carers regarding the role of dietitians in the treatment of eating disorders.

METHODS

CINAHL, MEDLINE, Embase, Scopus and PsycINFO were searched in April 2020 and again in February 2021. Studies were included if they were original research; explored views and experiences of the role of dietitians in the treatment of eating disorders, including perceptions of patients, carers and other health professionals regarding nutrition care for eating disorders; and the full-text article was available in English. Title and abstract screening, full-text screening, quality assessment and data extraction were completed in duplicate. Quality assessment was conducted using the Mixed Methods Assessment Tool. Thematic synthesis was used for data analysis.

RESULTS

Fourteen studies met the inclusion criteria. Quantitative, qualitative and mixed-methods study designs were included. Four themes emerged inductively from the data: (i) dietitians as collaborators, educators and counsellors; (ii) dietitians individualising care and desiring a holistic approach; (iii) opportunities for dietitians to gain confidence; and (iv) experiencing nutrition care as a patient or carer.

CONCLUSIONS

This review suggests that dietitians have a varied role in eating disorder treatment but desire further training. Understanding the training needs of dietitians can identify practice gaps and opportunities to enhance clinician confidence.

Transitioning to digital first line intervention - validation of a brief online screener for early identification of a suspected eating disorder: study protocol

BACKGROUND

Only one in four people with eating disorders seeks treatment, and of those who do seek treatment, 20% go on to experience a chronic course. Early intervention has been associated with better prognosis, with those seeking specialised intervention in the early stages of their illness more than twice as likely to achieve remission. Current screening measures typically require expert administration and are rarely validated across a spectrum of DSM-5 eating disorder presentations or for online use. In light of COVID-19 and increasing reliance on telehealth technologies in the intervention and delivery of mental health services, online assessments suitable for self-referral are likely to be the first step to seeking care. InsideOut Institute has developed a 6-item online screening tool for the purposes of identifying eating disorder risk and symptomatology, aimed specifically at increasing help-seeking behaviour in subsyndromal and early presentations.

METHODS

This study investigates the reliability and validity of the InsideOut Institute Screener (IOI-S), using a cross-sectional survey research design. Participants aged 14 and over will complete an extensive baseline survey battery for evaluation. 50% of participants will be randomly selected for one follow-up re-test of the IOI-S only, 2 weeks post initial testing. The IOI-S will be analysed for statistical reliability on two parameters: internal consistency and test re-test reliability, and for statistical validity on four parameters: concurrent validity, sensitivity and specificity, convergent and discriminant validity.

DISCUSSION

The rapid and ongoing shift to digital intervention has highlighted gaps and opportunities in our pathways to care. Adequate screening for eating disorders is a major gap. This study aims to validate an online screening tool for use in telehealth early intervention, designed for users seeking information for a suspected eating disorder. The screener meets those at risk 'where they are' (i.e. online) and may improve timely referrals to relevant services. This is of particular salience as face-to-face healthcare and traditional frontline interventions are disrupted, and we are challenged to re-design our practices to deliver diagnostic and treatment services in highly adaptive digital contexts.