Mapping the evidence for the prevention and treatment of eating disorders in young people

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.

Addressing nutritional issues and eating behaviours among university students: a narrative review

University life is a critical period for establishing healthy eating habits and attitudes. However, university students are at risk of developing poor eating habits due to various factors, including economic conditions, academic stress and lack of information about nutritional concepts. Poor diet quality leads to malnutrition or overnutrition, increasing the risk of preventable diseases. Food environments on university campuses also play a significant role in shaping the dietary habits of students, with the availability of and accessibility to healthy food options being important factors influencing food choices and overall diet quality. Disordered eating habits and body dissatisfaction are prevalent among university students and can lead to eating disorders. Income and living arrangements also influence dietary habits, with low household income and living alone being associated with unhealthy eating habits. This study is a narrative review that aimed to address nutritional issues and eating behaviours, specifically among university students. We investigated the eating behaviours of university students, including their dietary patterns, food choices and food environments. The objective of this review was to provide insights into the nutritional issues and eating behaviours of university students, with the aim of identifying target areas for intervention to improve the overall health and wellbeing among college students. University food environments need to be restructured to promote healthy eating, including the availability, accessibility, affordability and labelling of healthy foods, and policies to limit the availability of unhealthy foods and drinks on campus.

Effectiveness of virtually delivered Body Project groups to prevent eating disorders in young women at risk: a protocol for a randomized controlled trial

BACKGROUND

Eating disorders (EDs) are a group of mental illnesses associated with significant psychological and physiological consequences. Overall, only about one-fifth of individuals with EDs receive treatment and treatment is effective for only about one-third for those who receive care. The development and implementation of effective prevention approaches for those at risk is therefore pivotal. The Body Project is the most effective ED prevention program for at-risk women according to several meta-analyses, but reach is limited since delivery, traditionally, has been in-person. Moreover, peer-led Body Project groups have been reported to produce stronger effects than clinician-led Body Project groups when delivered in-person. This has not yet been examined for virtually delivered Body Project groups. This study therefore seeks to investigate the effect of virtual Body Project groups delivered by peers versus clinicians on ED risk factors, ED symptoms, and prospective ED onset.

METHODS

Young women with body image concerns aged 16-25 years (N = 441) will be included in the study and randomized to three conditions: (i) virtually delivered Body Project groups led by clinicians; (ii) virtually delivered Body Project groups led by peers; and (iii) psychoeducational control group. Participants will complete assessments at five timepoints over two years (pretest, posttest, 6-months, 1-year, and 2-years).

DISCUSSION

Further research is needed to examine approaches to increase the potential for broad implementation of prevention of EDs. The virtual modality of the Body Project could markedly expand the reach for young women at risk. If findings confirm that peers can deliver virtual Body Project groups as effectively as clinicians, this will further enhance the implementation potential.

TRIAL REGISTRATION

The present study has been registered on clinicaltrials.gov (NCT05993728).

Co-producing principles to guide health research: an illustrative case study from an eating disorder research clinic

BACKGROUND

There is significant value in co-produced health research, however power-imbalances within research teams can pose a barrier to people with lived experience of an illness determining the direction of research in that area. This is especially true in eating disorder research, where the inclusion of co-production approaches lags other research areas. Appealing to principles or values can serve to ground collaborative working. Despite this, there has not been any prior attempt to co-produce principles to guide the work of a research group and serve as a basis for developing future projects.

METHODS

The aim of this piece of work was to co-produce a set of principles to guide the conduct of research within our lived experience led research clinic, and to offer an illustrative case for the value of this as a novel co-production methodology. A lived experience panel were recruited to our eating disorder research group. Through an iterative series of workshops with the members of our research clinic (composed of a lived experience panel, clinicians, and researchers) we developed a set of principles which we agreed were important in ensuring both the direction of our research, and the way in which we wanted to work together.

RESULTS

Six key principles were developed using this process. They were that research should aim to be: 1) real world-offering a clear and concrete benefit to people with eating disorders, 2) tailored-suitable for marginalised groups and people with atypical diagnoses, 3) hopeful-ensuring that hope for recovery was centred in treatment, 4) experiential-privileging the 'voice' of people with eating disorders, 5) broad-encompassing non-standard therapeutic treatments and 6) democratic-co-produced by people with lived experience of eating disorders.

CONCLUSIONS

We reflect on some of the positives as well as limitations of the process, highlighting the importance of adequate funding for longer-term co-production approaches to be taken, and issues around ensuring representation of minority groups. We hope that other health research groups will see the value in co-producing principles to guide research in their own fields, and will adapt, develop, and refine this novel methodology.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

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

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Feasibility of a virtually delivered eating disorder prevention program for young females with type 1 diabetes

OBJECTIVE

This study aimed to develop a virtual diabetes-specific version of the eating disorder (ED) prevention program the Body Project, and to assess feasibility and preliminary efficacy of this program for young females with type 1 diabetes.

METHOD

Young females with type 1 diabetes aged 16-35 years were invited to participate in the study. A total of 35 participants were allocated to five Diabetes Body Project groups (six meetings over 6 weeks) and completed pretest assessments; 26 participants completed all sessions and posttest assessments (<7 days after last meeting). Primary measures included ED risk factors and symptoms, and secondary outcomes included diabetes-specific constructs previously found to be associated with ED psychopathology (e.g., diabetes distress and illness perceptions).

RESULTS

The ease of recruitment, timely conduct of five groups, moderate drop-out rate and appreciation of the intervention by participants indicated that the Diabetes Body Project is feasible. Meaningful reductions occurred on the primary outcomes (i.e., ED psychopathology, body dissatisfaction, and thin ideal internalization) and on internalization of appearance ideals and appearance pressures at posttest (Cohen's d ranging from .63 to .83, which are medium to large effects). Small to medium effect sizes were found for diabetes illness perceptions and distress (.41 and .48, respectively).

DISCUSSION

The virtual Diabetes Body Project is a promising and much-needed intervention, worthy of more rigorous evaluation. A randomized controlled trial is warranted to determine its effectiveness compared with a control condition.

Facilitating improvements in young people's social relationships to prevent or treat depression: A review of empirically supported interventions

Interpersonal difficulties are often implicated in the onset of depressive disorders, and typically exacerbate depressive symptoms. This is particularly true for young people, given rapid changes in, and the increased importance of, their social relationships. The purpose of this narrative review was to identify empirically supported interventions that aim to prevent or treat depression in young people by facilitating improvements in their social environment. We conducted a search of controlled trials, systematic reviews and meta-analyses of such interventions, published between 1980 and June 2020. Our literature search and interpretation of results was informed by consultations with clinical experts and youth consumers and advocates. A number of promising approaches were identified with respect to prevention and treatment. Preliminary evidence was identified suggesting that school- and Internet-based approaches present a viable means to prevent the worsening of depressive symptoms in young people. Notably, delivering interpersonal psychotherapy-adolescent skills training (IPT-AST) in schools appears to be a promising early intervention strategy for young people at risk of full-threshold depressive disorder. In terms of treating depressive disorders in young people, there is strong evidence for the efficacy of interpersonal psychotherapy for adolescents (IPT-A), and preliminary evidence in favour of attachment-based family therapy (ABFT). Results are discussed with respect to recommendations for future research and practice.

Computational Psychiatry Research Map (CPSYMAP): A New Database for Visualizing Research Papers

The field of computational psychiatry is growing in prominence along with recent advances in computational neuroscience, machine learning, and the cumulative scientific understanding of psychiatric disorders. Computational approaches based on cutting-edge technologies and high-dimensional data are expected to provide an understanding of psychiatric disorders with integrating the notions of psychology and neuroscience, and to contribute to clinical practices. However, the multidisciplinary nature of this field seems to limit the development of computational psychiatry studies. Computational psychiatry combines knowledge from neuroscience, psychiatry, and computation; thus, there is an emerging need for a platform to integrate and coordinate these perspectives. In this study, we developed a new database for visualizing research papers as a two-dimensional "map" called the Computational Psychiatry Research Map (CPSYMAP). This map shows the distribution of papers along neuroscientific, psychiatric, and computational dimensions to enable anyone to find niche research and deepen their understanding ofthe field.

Clinical study on electroacupuncture for obese patients with binge eating disorder: A retrospective study

Binge eating disorder (BED) is a common dietary disorder among obese people. Obesity and eating disorders are related to mental health and physical health. At present, there is no definite and effective method for treatment in clinic. The curative effect of electroacupuncture on obesity is definite. Although there is no conclusive evidence to support its long-term benefits, electroacupuncture has been increasingly used in clinic. This retrospective study determined the prognosis and outcome of electro-acupuncture on obese patients with BED.One hundred forty-three patients with BED and obesity were found from 658 people who participated in the scientific experiment of obesity treatment in Nanjing Hospital of Traditional Chinese Medicine and Nanjing Brain Hospital from March 2015 to June 2018, and 84 patients (aged 18-40 years old) with valid data and uninterrupted treatment were found to be eligible for this retrospective study. According to the intervention methods, the patients were divided into electro-acupuncture combined with cognitive group (n = 32), cognitive therapy group (n = 28), and control group (n = 24). In this study, the 5th edition of Diagnosis and Statistics Manual of Mental Diseases, fasting blood glucose, fasting insulin, total cholesterol (TC), triglyceride, high-density lipoprotein, low-density lipoprotein, body fat rate, muscle mass, visceral index grade, nutrient intake (energy, protein, fat, carbohydrate), body weight, and weight changes before and after treatment were observed.Compared with the cognitive therapy group, negative emotion score, TC, triglyceride, high-density lipoprotein, waist circumference, BW, BMI, body fat percentage of the electroacupuncture combined with cognitive group were lower, while positive emotional scores were higher, and there were significant differences in negative emotional scores, TC, waist circumference and BMI (P < .05). The dietary energy and three major nutrients in the electroacupuncture combined with cognitive group were lower than those in the cognitive group and the blank group (P < .05).The current results suggest that electroacupuncture combined with cognitive therapy is more effective than cognitive therapy alone in treating obese patients with BED. Future prospective studies are necessary to further study the mechanism of electroacupuncture on the obese with BED.

Exercise interventions for mental disorders in young people: a scoping review

AIMS

This scoping review determines the breadth and outcomes of controlled trials testing the effect of physical activity/exercise interventions across mental health outcomes in young people with a mental disorder.

METHODS

The literature search was conducted using the open-access 'Evidence Finder', a comprehensive youth mental health-specific database that is systematically populated from MEDLINE, Embase, PsycINFO and Cochrane CENTRAL databases.

RESULTS

Sixteen publications were identified after meeting the following eligibility criteria: (1) participants were young people (mean age 12-25.9 years) with a mental disorder diagnosed by a trained clinician or by reaching a predefined cut score on a symptom measure, (2) interventions were exercise, (3) designs were randomised or non-randomised controlled trials, (4) outcomes were mental health related. Eight studies included young people with depression, three included people with psychosis/schizophrenia, three included people with eating disorders and two included people with anxiety. The available evidence suggests that moderate-to-vigorous-intensity exercise may be beneficial, particularly for reducing depression. The available evidence for other intervention intensities, and for other mental disorders, is mixed.

CONCLUSIONS

Overall, the evidence regarding the impact of exercise interventions on a range of mental health outcomes in clinical populations of young people with various mental disorders looks promising but requires further development. Findings from this scoping review can inform the development of future exercise interventions in the youth mental health field.

Adolescents with full or subthreshold anorexia nervosa in a naturalistic sample: treatment interventions and patient satisfaction

BACKGROUND

Despite major research efforts, current recommendations of treatment interventions for adolescents with anorexia nervosa are scarce, and the importance of patient satisfaction for treatment outcome is yet to be established. The overall aim of the present study was to examine treatment interventions and patient satisfaction in a naturalistic sample of adolescents with anorexia nervosa or subthreshold anorexia nervosa and possible associations to outcome defined as being in remission or not at treatment follow-up.

METHODS

Participants were identified through the Swedish national quality register for eating disorder treatment (SwEat). The samples consisted of 1899 patients who were follow-up registered 1 year after entering treatment and 474 patients who had completed a 1-year patient satisfaction questionnaire. A two-step cluster analysis was used for identifying subgroups of patients who received certain combinations and various amounts of treatment forms.

RESULTS

Patients who received mainly family-based treatment and/or inpatient care were most likely to achieve remission at 1-year follow-up, compared to patients in the other clusters. They were also younger, in general. Individual therapy was the most common treatment form, and was most appreciated among the adolescents. At 1-year follow-up, many patients reported improvements in eating habits, but far fewer reported improvements regarding cognitive symptoms. Overall, the patients rated the therapist relationship in a rather positive way, but they gave quite low ratings to statements associated with their own participation in treatment.

CONCLUSIONS

The results indicate that young adolescents who receive mainly family-based treatment and/or inpatient care respond more rapidly to treatment compared to older adolescents who receive mainly individual therapy or mixed treatment interventions. At 1-year follow-up, the adolescents reported improvements in behavioral symptoms and seemed quite satisfied with the therapist relationship.

Momentary Analysis of Tinnitus: Considering the Patient

Ecological momentary assessment is a valuable research technique meant to capture real-time data and contextualize disease. While more common in neuropsychiatric research, this methodology is exceptionally fit for tinnitus. Tinnitus has been shown to be affected by many patient-level and environment-specific factors. From an individual's baseline anxiety to the level of ambient noise in their environment, the level of bother experienced by those with tinnitus can vary widely. Only assessing tinnitus within a clinical environment can distort the true impact of the disease. Ecological data can minimize bias while generating an individualistic picture of the burden being experienced by the patient. Individual data can also compliment new research methods rooted in precision medicine, providing clearer, better-suited treatments for each patient on the tinnitus spectrum.

Identifying research priorities in eating disorders: A Delphi study building consensus across clinicians, researchers, consumers, and carers in Australia

OBJECTIVE

Eating disorders are underrepresented among successful applications for medical research funding. Developing agreement on the top research priorities may assist in fostering collaborations, innovation, and meaningful consumer and carer involvement. This study aimed to develop consensus among Australian clinicians, researchers, consumers, carers, and interested members of affiliated industries, on the priorities for eating disorders research.

METHOD

The Delphi expert consensus method was used. Participants were 291 members of the Australia New Zealand Academy for Eating Disorders (ANZAED) or the National Eating Disorders Collaboration (NEDC). Three panels were formed based on participant expertise: "ED Specialists," Consumers/Carers, and Affiliates. A total of 32 potential research areas (29 in Survey 1, 3 in Survey 2) were rated on a 5-point scale of importance, with 80% agreement across all three panels required for endorsement as a priority. Participants also ranked 7 broad research domains in order of priority.

RESULTS

Research areas describing early intervention and evidence-based treatments were the most highly rated, with more than 90% endorsement from each of the three panels. The research domains of accessible evidence-based treatments, early intervention and detection, and origins of eating disorders, were the most highly ranked. The ED specialists and Consumers/Carers panels had very similar patterns of responding, while the Affiliates panel showed small differences.

DISCUSSION

Using the Delphi expert consensus method resulted in a collaborative consensus driven eating disorders research agenda for the Australian context and forms a model upon which other countries may also develop their funding priorities.

Social Media, Thin-Ideal, Body Dissatisfaction and Disordered Eating Attitudes: An Exploratory Analysis

Disordered eating attitudes are rapidly increasing, especially among young women in their twenties. These disordered behaviours result from the interaction of several factors, including beauty ideals. A significant factor is social media, by which the unrealistic beauty ideals are popularized and may lead to these behaviours. The objectives of this study were, first, to determine the relationship between disordered eating behaviours among female university students and sociocultural factors, such as the use of social network sites, beauty ideals, body satisfaction, body image and the body image desired to achieve and, second, to determine whether there is a sensitive relationship between disordered eating attitudes, addiction to social networks, and testosterone levels as a biological factor. The data (N = 168) was obtained using validated surveys (EAT-26, BSQ, CIPE-a, SNSA) and indirect measures of prenatal testosterone. The data was analysed using chi-square, Student’s t-test, correlation tests and logistic regression tests. The results showed that disordered eating attitudes were linked to self-esteem (p < 0.001), body image (p < 0.001), body desired to achieve (p < 0.001), the use of social media (p < 0.001) and prenatal testosterone (p < 0.01). The findings presented in this study suggest a relationship between body image, body concerns, body dissatisfaction, and disordered eating attitudes among college women.

Consumo de formulações emagrecedoras e risco de transtornos alimentares em universitários de cursos de saúde

RESUMO Objetivo Avaliar o consumo de formulações emagrecedoras e sua possível associação com o risco de transtornos alimentares (TAs) em universitários de cursos de saúde de diversos níveis socioeconômicos. Métodos Estudo epidemiológico transversal, realizado com 276 universitários matriculados em quatro cursos da área da saúde. Para a obtenção dos dados, utilizaram-se três instrumentos autoaplicáveis: o Eating Attitudes Test (EAT-26), o Bulimic Investigatory Test of Edinburgh (BITE) e, para investigar o consumo de formulações emagrecedoras, um questionário elaborado pela própria equipe de pesquisa. Para análise dos dados, aplicou-se o teste qui-quadrado, adotando-se o nível de significância de 5%. Resultados Vinte e um universitários apresentaram risco de TA pela escala EAT-26, correspondente a 7,6% dos pesquisados. A frequência do uso de formulações emagrecedoras foi de 7,2%. Houve associação significativa (p < 0,001) entre o uso de formulações emagrecedoras e a presença de risco para TA (33,3%), com percentual muito elevado quando comparado ao percentual de entrevistados sem risco de TA que estavam em uso de medicamentos (5,1%). Conclusões O consumo de formulações emagrecedoras esteve associado tanto à presença de risco para TA, nas escalas EAT-26 e BITE, quanto aos níveis socioeconômicos, principalmente para a classe de renda C.

The relationship between a trusted adult and adolescent outcomes: a protocol of a scoping review

BACKGROUND

Although documentation of harm towards children and young people has existed for centuries, it was not until the 1960s that it became a specific focus for health professionals. Since that time, the importance of protective social networks has become better understood. The concept of trusted adults has come into sharper focus, with children being encouraged to develop networks of dependable adults to turn to for support in times of need. While many child protection processes highlight risks to younger children, there has been less emphasis on older children. The role of trusted adults may be particularly important during adolescence, due to burgeoning independence, developing sexuality, relationship formation, and associated vulnerabilities. While important choices relating to health and education are made during this period, there is little formal evidence relating to the impact of trusted adults on such outcomes. This review therefore aims to focus on the role and influence of trusted adults for adolescents.

METHODS

This study is a scoping review. A broad range of databases will be searched, including MEDLINE, ERIC, Education Abstracts, Web of Science, ASSIA, Sociological Abstracts, and PsycINFO. Predefined inclusion/exclusion criteria will be used, with a focus on outcomes relating to health and education. Two reviewers will blind screen papers independently at all screening stages, with conflicts being resolved by a third reviewer. Quantitative and qualitative studies, as well as unpublished (grey) literature/reports, will be included. We will use the World Health Organization's 'second decade' definition of adolescence. We aim to collate and map evidence in a broad overview and produce meta-analyses of homogenous data. Where this is not possible, a narrative summary will be produced.

DISCUSSION

There appears to be sparse knowledge regarding the role of trusted adults for adolescents. Potential benefits to health and wellbeing may impact on educational attainment, and vice versa. These areas are of particular relevance during the second decade, when decisions that affect future direction, achievement, and wellbeing are being made. The increased understanding of the role of trusted adults provided by this review may help to inform practice and policy and lead to potential benefits for the health and education of adolescents.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD 42017076739.

Open-access evidence database of controlled trials and systematic reviews in youth mental health

AIM

To present an update to an evidence-mapping project that consolidates the evidence base of interventions in youth mental health. To promote dissemination of this resource, the evidence map has been translated into a free online database (https://orygen.org.au/Campus/Expert-Network/Evidence-Finder or https://headspace.org.au/research-database/). Included studies are extensively indexed to facilitate searching.

METHODS

A systematic search for prevention and treatment studies in young people (mean age 6-25 years) is conducted annually using Embase, MEDLINE, PsycINFO and the Cochrane Library. Included studies are restricted to controlled trials and systematic reviews published since 1980.

RESULTS

To date, 221 866 publications have been screened, of which 2680 have been included in the database. Updates are conducted annually.

CONCLUSIONS

This shared resource can be utilized to substantially reduce the amount of time involved with conducting literature searches. It is designed to promote the uptake of evidence-based practice and facilitate research to address gaps in youth mental health.

Parental perceptions of barriers to mental health services for young people

AIM

This study explores a range of barriers that parents encountered in accessing mental health services. The study also explored whether parents experienced similar barriers to accessing services in 2003 and 2013.

METHODS

One hundred and thirty-four parents of young people attending an initial assessment at a Child and Adolescent Mental Health Service (CAMHS) or headspace centre completed a questionnaire assessing 10 general barriers to care. These data were compared to those collected from 129 participants at CAMHS in 2003.

RESULTS

The ranking of barriers to mental health care for their children was similar for both survey years, with 'wait time being too long' and 'help being too expensive' the two highest ranked barriers. Cost factors were related to not knowing that the services did not charge fees and having to take time off work to attend appointments. Multiple referral steps and uncertain wait times were the main concerns regarding wait times. The overall strength with which barriers were endorsed remained relatively low; however, at least 40% of the sample agreed they had experienced four of the barriers in both years.

CONCLUSIONS

Despite relatively low endorsement of barriers, there are substantial proportions of parents who experienced some barriers to services, and services should continue working to reduce them to facilitate timely access. There is a particular need for more service-related information to clarify that public sector mental health services do not charge fees. Methods such as rapid initial assessment and actively managing wait lists may go some way to reducing perceived wait time barriers.

Mindfulness in Anorexia Nervosa: An Integrated Review of the Literature

BACKGROUND

Anorexia nervosa is a serious psychiatric illness with limited evidenced-based treatment options. Mindfulness appears useful in many conditions, but few studies focus on its use in individuals with anorexia nervosa.

OBJECTIVE

To examine and summarize studies of mindfulness in individuals with anorexia nervosa and identify areas for future research.

DESIGN

An integrated review was conducted by searching health care computerized databases.

RESULTS

Results were mixed among the eight studies that met inclusion criteria. Multimodal mindfulness-based therapies appear effective, while brief interventions may be equally useful or result in greater anxiety compared to distraction. Qualitative data support that some participants feel mindfulness is challenging but beneficial.

CONCLUSION

Mindfulness as a concurrent part of therapy and/or when routinely practiced may be more clinically useful than single-episode mindful eating interventions. Due to the complexity of the concept of mindfulness and limited existing data, additional research is needed.

A systematic review investigating the behaviour change strategies in interventions to prevent misuse of anabolic steroids

We examined intervention effectiveness of strategies to prevent image- and performance-enhancing drug use. Comprehensive searches identified 14 interventions that met review inclusion criteria. Interventions were predominantly educational and delivered within school sport settings, but targeted a wide range of mediating factors. Identification of effective components was limited across studies by brief or imprecise descriptions of intervention content, lack of behavioural outcome measures and short-term follow-up times. However, studies with components in addition to information provision may be more promising. Interventions outside of sport settings are required to reflect the transition of this form of substance use to the general population.

Efficacy of a prevention program for eating disorders in schools: a cluster-randomized controlled trial

BACKGROUND

Previous prevention programs in the school context have not addressed both genders, have been time-consuming, or have had deficits in the evaluation method. The aim of the present study was to evaluate the impact of a universal prevention program for female and male adolescents on eating disorder pathology and related risk factors.

METHODS

Between February 2012 and July 2014, 2515 students in 23 schools from 8th or 11th grade were assessed for eligibility in this longitudinal cluster-randomized controlled trial with a six months follow-up. Of those students, 2342 were cluster-randomized to the intervention condition which received a six school hours universal prevention program or to the no treatment control condition.

RESULTS

The complete case population comprised 724 students in the intervention (54.3% female, M = 14.3 years, SD = 1.61) and 728 in the control condition (57.0% female, M = 14.7 years, SD = 1.63). Random-effects analysis of covariance on the primary outcome showed no significant differences between the intervention and control groups in their eating disorder pathology change scores six months after the intervention. Regarding secondary outcomes, participants in the intervention group showed a greater increase in knowledge about eating disorders both after the intervention (p < .001, ES = 1.06) and six months later (p = .01, ES = 0.40). Greater reductions in anxiety severity were observed in the intervention group post-intervention (p = .02, ES = 0.22) which was not maintained at the six months follow-up. Results differed between participants from grade 8 and 11.

CONCLUSION

The present universal prevention program can be particularly recommended for adolescents from grade 11.

TRIAL REGISTRATION

ISRCTN 97989348.

Findings from a couple-based open trial for adult anorexia nervosa

Adult anorexia nervosa (AN) often is persistent, significantly erodes quality of life for both the patient and loved ones, and carries high medical and psychiatric comorbidity. Whereas individual psychotherapy for adult AN leads to improvement in some patients, recent findings indicate that the magnitude of improvement is limited: Only a small percentage of individuals fully recover and dropout rates are high. Thus, it is important to build upon current interventions to improve treatment response. We present results from an open trial of a couple-based intervention for adult anorexia nervosa as an adjunct treatment to standard multidisciplinary care. Twenty couples received treatment over approximately 26 weeks, including a couple-based intervention, individual CBT sessions, psychiatry visits for medication management, and nutritional counseling sessions. The results indicate that patients improved at posttest and 3-month follow-up on a variety of AN-related measures, anxiety and depression, and relationship adjustment. Partners also improved on anxiety, depression, and relationship adjustment. In an exploratory analysis, the multicomponent couple treatment intervention was benchmarked to well-conducted randomized controlled trials of individual therapy for AN; the couple intervention seems to compare favorably on AN-related measures and was associated with a lower dropout rate. In spite of methodological limitations, the findings suggest that including partners in the treatment of adult AN holds potential for bolstering treatment outcomes. (PsycINFO Database Record

Prevention of eating disorders: A systematic review and meta-analysis

OBJECTIVE

To systematically review and quantify the effectiveness of Eating Disorder (ED) prevention interventions.

METHODS

Electronic databases (including the Cochrane Controlled Trial Register, MEDLINE, PsychInfo, EMBASE, and Scopus) were searched for published randomized controlled trials of ED prevention interventions from 2009 to 2015. Trials prior to 2009 were retrieved from prior reviews.

RESULTS

One hundred and twelve articles were included. Fifty-eight percent of trials had high risk of bias. Findings indicated small to moderate effect sizes on reduction of ED risk factors or symptoms which occurred up to three-year post-intervention. For universal prevention, media literacy (ML) interventions significantly reduced shape and weight concerns for both females (-0.69, confidence interval (CI): -1.17 to -0.22) and males (-0.32, 95% CI -0.57 to -0.07). For selective prevention, cognitive dissonance (CD) interventions were superior to control interventions in reducing ED symptoms (-0.32, 95% CI -0.52 to -0.13). Cognitive behavioural therapy (CBT) interventions had the largest effect size (-0.40, 95% CI -0.55 to -0.26) on dieting outcome at 9-month follow-up while the healthy weight intervention reduced ED risk factors and body mass index. No indicated prevention interventions were found to be effective in reducing ED risk factors.

CONCLUSIONS

There are a number of promising preventive interventions for ED risk factors including CD, CBT and ML. Whether these actually lower ED incidence is, however, uncertain. Combined ED and obesity prevention interventions require further research.

Adolescents with full or subthreshold anorexia nervosa in a naturalistic sample - characteristics and treatment outcome

BACKGROUND

Anorexia Nervosa (AN) destroys developmentally important early years of many young people and knowledge is insufficient regarding course, treatment outcome and prognosis. Only a few naturalistic studies have been conducted within the field of eating disorder (ED) research. In this naturalistic study we included adolescents with AN or subthreshold AN treated in outpatient care, and the overall aim was to examine sample characteristics and treatment outcome. Additional aims were to examine potential factors associated with remission as an outcome variable, and possible differences between three time periods for treatment onset.

METHODS

Participants were identified through the Swedish national quality register for eating disorder treatment (SwEat), in which patients are registered at treatment onset and followed up once a year until end of treatment (EOT). Inclusion criteria were: medical or self-referral to one of the participating treatment units between 1999 and 2014, 13-19 years of age at initial entry into SwEat and diagnosed with AN or subthreshold AN. The total sample consisted of 3997 patient from 83 different treatment units.

RESULTS

The results show that 55% of the participants were in remission and approximately 85% were within a healthy weight range at EOT. Of those who ended treatment according to plan, 70% were in remission and 90% within a healthy weight range. The average treatment duration was approximately 15 months. About one third of the patients terminated treatment prematurely, which was associated with a decreased chance of achieving remission. Remission rates and weight recovery increased over time, while treatment duration decreased. Considering treatment outcome, the results did not show any differences between patients with AN or subthreshold AN.

CONCLUSIONS

The present study shows a relatively good prognosis for adolescent patients with AN or subthreshold AN in routine care and the results indicate that treatment for adolescents with ED in Sweden has become more effective over the past 15 years. The results of the present study contribute to the scope of treatment research and the large-scale naturalistic setting secures the generalizability to a clinical environment. However, more research is needed into different forms of evidence, new research strategies and diversity of treatment approaches.

TRIAL REGISTRATION

Registered in FOU in Sweden (Researchweb.org) 2014-04-14, ID nr 147301.

Evidence mapping for decision making: feasibility versus accuracy - when to abandon high sensitivity in electronic searches

Background: Mapping the evidence is a relatively new methodological approach and may be helpful for the development of research questions and decisions about their relevance and priority. However, the amount of data available today leads to challenges for scientists sometimes being confronted with literature searches retrieving over 30,000 results for screening.

Objectives: We conducted an evidence mapping of the topic “diabetes and driving” to investigate its suitability for an evidence-based national clinical guideline. In addition, we compared a highly sensitive search with a highly specific one.

Methods: Based on a systematic review, our database searches were limited to publications from 2002 to present in English and German language.

Results: Due to the strongly focused topic and the limits, our sensitive search identified a manageable number of references including sufficient evidence to answer our research question. Using the specific search strategy, we achieved a reduction of citations by 25%, concurrently identifying 88% of relevant references.

Conclusions: Evidence mapping with the intention of gaining an overview of a research field does not require high level accuracy in contrary to systematic reviews. Keeping this distinction in mind, a mass of extraneous information will be avoided by using specific instead of highly sensitive search strategies.

Recognizing Binge-Eating Disorder in the Clinical Setting: A Review of the Literature

OBJECTIVE

Review the clinical skills needed to recognize, diagnose, and manage binge-eating disorder (BED) in a primary care setting.

DATA SOURCES

A PubMed search of English-language publications (January 1, 2008-December 11, 2014) was conducted using the term binge-eating disorder. Relevant articles known to the authors were also included.

STUDY SELECTION/DATA EXTRACTION

Publications focusing on preclinical topics (eg, characterization of receptors and neurotransmitter systems) without discussing clinical relevance were excluded. A total of 101 publications were included in this review.

RESULTS

Although BED is the most prevalent eating disorder, it is underdiagnosed and undertreated. BED can be associated with medical (eg, type 2 diabetes and metabolic syndrome) and psychiatric (eg, depression and anxiety) comorbidities that, if left untreated, can impair quality of life and functionality. Primary care physicians may find diagnosing and treating BED challenging because of insufficient knowledge of its new diagnostic criteria and available treatment options. Furthermore, individuals with BED may be reluctant to seek treatment because of shame, embarrassment, and a lack of awareness of the disorder. Several short assessment tools are available to screen for BED in primary care settings. Pharmacotherapy and psychotherapy should focus on reducing binge-eating behavior, thereby reducing medical and psychiatric complications.

CONCLUSIONS

Overcoming primary care physician- and patient-related barriers is critical to accurately diagnose and appropriately treat BED. Primary care physicians should take an active role in the initial recognition and assessment of suspected BED based on case-finding indicators (eg, eating habits and being overweight), the initial treatment selection, and the long-term follow-up of patients who meet DSM-5 BED diagnostic criteria.

What is an evidence map? A systematic review of published evidence maps and their definitions, methods, and products

BACKGROUND

The need for systematic methods for reviewing evidence is continuously increasing. Evidence mapping is one emerging method. There are no authoritative recommendations for what constitutes an evidence map or what methods should be used, and anecdotal evidence suggests heterogeneity in both. Our objectives are to identify published evidence maps and to compare and contrast the presented definitions of evidence mapping, the domains used to classify data in evidence maps, and the form the evidence map takes.

METHODS

We conducted a systematic review of publications that presented results with a process termed "evidence mapping" or included a figure called an "evidence map." We identified publications from searches of ten databases through 8/21/2015, reference mining, and consulting topic experts. We abstracted the research question, the unit of analysis, the search methods and search period covered, and the country of origin. Data were narratively synthesized.

RESULTS

Thirty-nine publications met inclusion criteria. Published evidence maps varied in their definition and the form of the evidence map. Of the 31 definitions provided, 67 % described the purpose as identification of gaps and 58 % referenced a stakeholder engagement process or user-friendly product. All evidence maps explicitly used a systematic approach to evidence synthesis. Twenty-six publications referred to a figure or table explicitly called an "evidence map," eight referred to an online database as the evidence map, and five stated they used a mapping methodology but did not present a visual depiction of the evidence.

CONCLUSIONS

The principal conclusion of our evaluation of studies that call themselves "evidence maps" is that the implied definition of what constitutes an evidence map is a systematic search of a broad field to identify gaps in knowledge and/or future research needs that presents results in a user-friendly format, often a visual figure or graph, or a searchable database. Foundational work is needed to better standardize the methods and products of an evidence map so that researchers and policymakers will know what to expect of this new type of evidence review.

SYSTEMATIC REVIEW REGISTRATION

Although an a priori protocol was developed, no registration was completed; this review did not fit the PROSPERO format.

Anorexia nervosa: aetiology, assessment, and treatment

Anorexia nervosa is an important cause of physical and psychosocial morbidity. Recent years have brought advances in understanding of the underlying psychobiology that contributes to illness onset and maintenance. Genetic factors influence risk, psychosocial and interpersonal factors can trigger onset, and changes in neural networks can sustain the illness. Substantial advances in treatment, particularly for adolescent patients with anorexia nervosa, point to the benefits of specialised family-based interventions. Adults with anorexia nervosa too have a realistic chance of achieving recovery or at least substantial improvement, but no specific approach has shown clear superiority, suggesting a combination of re-nourishment and anorexia nervosa-specific psychotherapy is most effective. To successfully fight this enigmatic illness, we have to enhance understanding of the underlying biological and psychosocial mechanisms, improve strategies for prevention and early intervention, and better target our treatments through improved understanding of specific disease mechanisms.

Self-Help And Recovery guide for Eating Disorders (SHARED): study protocol for a randomized controlled trial

Background

We describe the theoretical rationale and protocol for Self-Help And Recovery guide for Eating Disorders (SHARED), a trial investigating whether a guided self-care intervention (Recovery MANTRA) is a useful addition to treatment as usual for individuals with anorexia nervosa. Recovery MANTRA, a 6-week self-care intervention supplemented by peer mentorship, is a module extension of the Maudsley Model of Treatment for Adults with Anorexia Nervosa and targets the maintenance factors identified by the cognitive-interpersonal model of the illness.

Methods

Patients accessing outpatient services for anorexia nervosa are randomized to either treatment as usual or treatment as usual plus Recovery MANTRA. Outcome variables include change in body weight at the end of the intervention (primary) and changes in body weight and eating disorder symptoms at immediate and extended follow-up (6-months; secondary). Change is also assessed for the domains identified by the theoretical model, including motivation, hope, confidence to change, positive mood, cognitive flexibility, therapeutic alliance and social adjustment. Feedback from peer mentors is gathered to understand the impact on their own well-being of providing guidance.

Discussion

Results from this exploratory investigation will determine whether a larger clinical trial is justifiable and feasible for this affordable intervention, which has potential for high reach and scalability.

Trial registration

ClinicalTrials.gov NCT02336841.

To ingest or rest? Specialized roles of lateral hypothalamic area neurons in coordinating energy balance

Survival depends on an organism’s ability to sense nutrient status and accordingly regulate intake and energy expenditure behaviors. Uncoupling of energy sensing and behavior, however, underlies energy balance disorders such as anorexia or obesity. The hypothalamus regulates energy balance, and in particular the lateral hypothalamic area (LHA) is poised to coordinate peripheral cues of energy status and behaviors that impact weight, such as drinking, locomotor behavior, arousal/sleep and autonomic output. There are several populations of LHA neurons that are defined by their neuropeptide content and contribute to energy balance. LHA neurons that express the neuropeptides melanin-concentrating hormone (MCH) or orexins/hypocretins (OX) are best characterized and these neurons play important roles in regulating ingestion, arousal, locomotor behavior and autonomic function via distinct neuronal circuits. Recently, another population of LHA neurons containing the neuropeptide Neurotensin (Nts) has been implicated in coordinating anorectic stimuli and behavior to regulate hydration and energy balance. Understanding the specific roles of MCH, OX and Nts neurons in harmonizing energy sensing and behavior thus has the potential to inform pharmacological strategies to modify behaviors and treat energy balance disorders.

Evaluation of an online training program in eating disorders for health professionals in Australia

BACKGROUND

Early detection and treatment of eating disorders is instrumental in positive health outcomes for this serious public health concern. As such, workforce development in screening, diagnosis and early treatment of eating disorders is needed. Research has demonstrated both high rates of failure to accurately diagnose and treat cases early and low levels of perceived access to training in eating disorders by health professionals-representing an urgent need for clinician training in this area. However, significant barriers to the access of evidence-based training programs exist, including availability, cost and time, particularly when large geographic distances are involved. Online learning presents a solution to workforce challenges, as it can be delivered anywhere, at a fraction of the cost of traditional training, timing is user controlled, and a growing body of research is demonstrating it as effective as face-to-face training. The Centre for Eating and Dieting Disorders in Australia has developed an Online Training Program In Eating Disorders, to educate health professionals in the nature, identification, assessment and management of eating disorders. The aim of the current study was to evaluate the ability of this online learning course to improve clinician levels of knowledge, skill and confidence to treat eating disorders. As well as its effect on stigmatised beliefs about eating disorders known to effect treatment delivery.

METHODS

One-hundred-eighty-seven health professionals participated in the program. A pre training questionnaire and a post training evaluation examined participants' levels of knowledge, skill and confidence to treat eating disorders, as well attitudes and beliefs about people with eating disorders.

RESULTS

Significant improvements in knowledge, skill, and confidence to treat eating disorders was found between pre and post program assessment in health professionals who completed the course, along with a significant decrease in stigmatised beliefs about eating disorders.

DISCUSSION

The results of this study demonstrated that the online training program was an effective tool in increasing health professionals' level of knowledge, skill and confidence to treat people with eating disorders. The results also demonstrated that online training reduced health professionals' personal bias towards people with eating disorders. Limitations of this study include the use of self-report measures rather than observation of the health professional in clinical practice. As a result, it is not possible to make determinations regarding the translation of these results to clinical settings.

CONCLUSIONS

The findings of this study suggest that online training programs may present an innovative solution to the considerable workforce development challenges faced by clinicians needing training in eating disorders.