Eating disorders across the lifespan

Treatment of avoidant-restrictive food intake disorder in an older adult: A proof-of-concept case study

OBJECTIVE

Cognitive behavioral therapy for Avoidant Restrictive Food Intake Disorder (ARFID; CBT-AR) is an emerging treatment for ARFID. However, this treatment modality has yet to be examined among older adults (e.g., older than 50 years) or with adults presenting with feeding tubes. To inform future versions of CBT-AR, we present the results of a singular case study (G) of an older male with the sensory sensitivity phenotype of ARFID who presented for treatment with a gastrostomy tube.

METHODS

G was a 71-year-old male who completed eight sessions of CBT-AR in a doctoral training clinic. ARFID symptom severity and comorbid eating pathology changes were examined pre- and post-treatment.

RESULTS

Posttreatment, G reported significant decreases in ARFID symptom severity and no longer met diagnostic criteria for ARFID. Furthermore, throughout treatment, G reported significant increases in his oral food consumption (vs. calories being pushed through the feeding tube), solid food consumption, and the feeding tube was ultimately removed.

DISCUSSION

This study provides proof of concept that CBT-AR is potentially effective for older adults and/or those presenting for treatment with feeding tubes. Validation of patient efforts and severity of ARFID symptoms emerged as core to treatment success and should be emphasized when training clinicians in CBT-AR.

PUBLIC SIGNIFICANCE

Cognitive behavior therapy for ARFID (CBT-AR) is the leading treatment for this disorder; however, it has yet to be tested among older adults or those with feeding tubes. This single-patient case study demonstrates that CBT-AR may be efficacious in reducing ARFID symptom severity among older adults with a feeding tube.

Malnutrition is associated with increased disease risk in older people in the Makkah region of Saudi Arabia: A cross-sectional study

Introduction

There is little research on the nutritional status of older people in Saudi Arabia. This study investigated the factors associated with the nutritional status of older people in the Makkah region, Saudi Arabia. We hypothesized that older people who are at risk of malnutrition are at higher risk of different diseases.

Materials and methods

This cross-sectional study surveyed 271 people aged ≥60 years from October 2021 to January 2022. We collected data on demographics, body mass index, the Geriatric Depression Scale-Short Form, Geriatric Oral Health Assessment Index, Mini Nutritional Assessment, Eating Attitudes Test, and Household Dietary Diversity score.

Results

Among the 271 participants, 13.3% were malnourished and 53.9% were at risk of malnutrition. The oral health (P < 0.001), depression (P < 0.001), and eating disorder (P < 0.002) scores were significantly associated with malnutrition. Congestive heart failure, asthma, peripheral vascular disease, Alzheimer's disease, and hypertension were more prevalent among malnourished participants—this supports our original hypothesis. The HDD score showed no significant differences between men and women.

Conclusion

Malnutrition was associated with overweight or obesity, poor oral health, and depression. Older people in the Makkah region, Saudi Arabia, had a high risk of malnutrition.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders

Eating disorders (ED) are complex mental illnesses and are not a result of personal choice. Full recovery from an ED is possible. The severity and inherent lethality of an ED is undisputed, and the role of the registered dietitian nutritionist (RDN) is essential. Clinical symptomology presents at varying developmental milestones and is perpetuated through a sociocultural evaluation of beauty and drive for ascetic idealism. ED are globally prevalent in 4.4% of the population aged 5 to 17 years, yet affect individuals across the entire lifespan, including all cultures and genders. The Behavioral Health Nutrition Dietetic Practice Group, along with the Academy of Nutrition and Dietetics Quality Management Committee, revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Eating Disorders. Including the RDN in ED treatment is vital for all levels of care. The RDN must be perceptive to negative symptoms indicative of psychological triggers when exploring food belief systems, patterns of disinhibition, and nutrition misinformation with clients. Through a conscious awareness of medical, psychological, and behavioral strategies, the implementation of the SOP and SOPP supports a dynamic and holistic view of ED treatment by the RDN. The SOP and SOPP are complementary resources for RDNs and are intended to be used as self-evaluation tools for assuring competent practice in ED and for determining potential education, training, supervision, and mentorship needs for advancement to a higher practice level in a variety of settings.

Examining day hospital treatment outcomes for sexual minority patients with eating disorders

OBJECTIVE

Epidemiological data support that sexual minorities (SM) report higher levels of eating pathology. Theories suggest these disparities exist due to stressors specific to belonging to a minority group; however, few studies have specifically explored differences between SM and heterosexual individuals in clinical eating disorder samples. Thus, the present study compared SM and heterosexual patients with eating disorders on demographic characteristics and eating disorder and psychological outcomes during day hospital treatment.

METHOD

Patients (N = 389) completed surveys of eating pathology, mood, anxiety, and skills use at treatment admission, 1-month post-admission, discharge, and 6-month follow-up. Overall, 19.8% of patients (n = 79) identified as SM, while 8.0% (n = 32) reported not identifying with any sexual orientation. SM were more likely to present across genders (17.7% of females, 24.2% of males, 33.3% of transgender patients, and 87.5% of nonbinary patients).

RESULTS

SM patients were significantly more likely to endorse major depressive disorder, panic disorder, and self-harm at admission than their heterosexual counterparts. Multilevel models demonstrated that across time, SM patients demonstrated greater eating pathology, emotion dysregulation, depressive symptoms, and anxiety symptoms. Significant interactions between sexual orientation and time were found for eating pathology and emotion dysregulation, such that although SM patients started treatment with higher scores, they improved at a faster rate compared to heterosexual patients.

DISCUSSION

Consistent with minority stress theory, SM patients report greater overall eating disorder and comorbid symptoms. Importantly, results do not support that there appear to be significant disparities in treatment outcome for SM patients in this sample of day hospital patients.

The prevalence and correlates of eating disorders in adult emergency department patients

OBJECTIVE

This study describes the prevalence of eating disorders among adult patients who present to the emergency department for medical care and examines the relationship between eating disorders, depression, and substance use disorders.

METHOD

Emergency department patients aged 21-65 years (n = 1,795) completed a computerized questionnaire that included validated screening tools for eating disorders, risky drinking behavior, other substance use, and depression. Analyses were conducted comparing individuals who screened positive for an eating disorder with those who did not based on demographics (gender, age, race, income, education), body mass index (BMI), risky drinking behavior, other substance use, and depression.

RESULTS

Nearly 16% (15.9%) of all patients screened positive for an eating disorder regardless of their reason for presenting to the emergency department. Patients who screened positive for an eating disorder were significantly more likely to have a BMI > 30 (odds ratio [OR] = 2.68, confidence interval [CI] = 1.98, 3.62, p < .001), to also screen positive for depression (OR = 3.19, CI = 2.28, 4.47, p < .001) and to be female (OR = 2.37, CI = 1.76, 3.19, p < .001). No differences in the prevalence of positive screens for eating disorders were seen across age or racial groups, level of education or income, or for any of the included substance use variables.

DISCUSSION

Eating disorders are common among adult emergency department patients and are associated with high rates of comorbid depression and higher BMI. Given the significant morbidity and mortality associated with eating disorders, targeted screening may be warranted in the emergency department setting.

Aging male symptomatology and eating behavior

OBJECTIVE

The literature on eating disorders in older males is still very limited. We assessed the relationship between aging male symptomatology and eating behavior in middle-aged and older men.

METHOD

We distributed anonymous questionnaires to men aged 40-75 years living in or near Innsbruck, Austria, covering demographic items, current eating disorder symptoms (as defined by DSM-5), and associated measures of eating pathology, body image, and sports activity (including exercise addiction). We also administered the Aging Males' Symptoms scale (AMS), and classified respondents as "high-AMS" (AMS score ≥37; N = 82) or "low-AMS" (AMS score <37; N = 386).

RESULTS

High-AMS men reported a significantly higher mean current BMI, a greater prevalence of eating disorder symptoms, higher scores on the Eating Disorder Examination Questionnaire, greater risk of exercise addiction, and more negative body image than low-AMS men.

DISCUSSION

We found a marked association between aging-male symptomatology and eating-disorder symptomatology in aging men. Our findings suggest that clinicians should carefully inquire about eating disorder symptoms in men aged 40 and above reporting aging-male symptomatology. Importantly, several men in the study reported "purging" via excessive exercise (as opposed to the more common methods of vomiting or use of laxatives or diuretics), and therefore this should be a subject of inquiry in clinical evaluations. To pursue these findings, subsequent studies of eating disorders in older men should consider assessing endocrinological measures, particularly testosterone levels, and should use longitudinal designs.

Disordered eating in three different age groups in Cyprus: a comparative cross-sectional study

OBJECTIVE

The objective of this study was to evaluate disordered eating behaviours (DEBs) in different age groups in a Cypriot non-clinical population sample.

STUDY DESIGN

Comparative cross-sectional study.

METHOD

A total of 1716 participants from the Cyprus component of the I.Family study completed the Eating Attitudes Test-26 (EAT-26). The EAT-26 score ≥20 was used to define participants at risk for DEBs. Participants were divided according to age: adolescence (12-18 years old), young adulthood (25-45 years old) and middle adulthood (46-60 years old).

RESULTS

Mean EAT-26 total scores were higher for middle adulthood men and women compared with the two younger age groups. Young adulthood women had the highest percentage of behavioural symptoms of DEBs: binge eating (35%) and laxatives/diet pills/diuretics (12%) compared with the other age groups. Men and women in young adulthood had the highest percentage of participants with EAT-26 scores ≥20. In logistic regression analysis, age group did not prove a significant predictor of DEB risk in a model adjusting for sex, body mass index and physical activity.

CONCLUSION

DEB can present at any age and was not confined to adolescence.

Psychological predictors of eating pathology in older adult women

Eating pathology is generally considered to affect females during adolescence and early adulthood. However, in recent years, there has been an increased recognition that disordered eating occurs in middle-aged and elderly women and that the presentation is similar to that of eating disorders in younger women. In the research presented here, results of an Internet survey of older adult women (N = 245; aged 60-90 years) indicate that the factors significantly associated with eating pathology-perfectionism, depression, and sociocultural pressures to be thin-closely parallel those reported for both younger and middle-aged women.

Prevention of eating disorders: A systematic review of randomized, controlled trials

OBJECTIVE

This systematic review evaluated the efficacy of universal, selective, and indicated eating disorder prevention.

METHOD

A systematic literature search was conducted in Medline, PsycINFO, Embase, Scopus, and the Cochrane Collaboration Library databases to January 2016. Studies were included if they were randomized, controlled trials (RCT) and tested an eating disorder prevention program. We retrieved 13 RCTs of universal prevention (N = 3,989 participants, 55% female, M age = 13.0 years), 85 RCTs of selective prevention (N = 11,949 participants, 99% female, M age = 17.6 years), and 8 RCTs of indicated prevention (N = 510 participants, 100% female, M age = 20.1 years). Meta-analysis was performed with selective prevention trials. As there were a limited number of universal and indicated trials, narrative synthesis was conducted.

RESULTS

Media literacy had the most support for universal prevention. Most universal approaches showed significant modest effects on risk factors. Dissonance-based was the best supported approach for selective prevention. Cognitive-behavior therapy (CBT), a healthy weight program, media literacy, and psychoeducation, were also effective for selective prevention and effects were maintained at follow-up. CBT was supported for indicated prevention and effects were maintained at follow-up.

DISCUSSION

The modest effects for universal prevention were likely due to floor effects. The evidence for selective prevention suggests that empirically supported approaches should be disseminated on a wider basis. Our findings suggest CBT should be offered for indicated populations. Overall, results suggest efficacy of several prevention programs for reducing risk for eating disorders, and that wider dissemination is required. © 2016 Wiley Periodicals, Inc.

Binge eating disorder in elderly individuals

OBJECTIVE

To preliminarily describe the clinical features of elderly individuals with binge eating disorder (BED).

METHOD

The psychological and general medical characteristics of 20 elderly individuals (65 years of age and older) who met DSM-IV-TR for BED were systematically evaluated.

RESULTS

Elderly individuals with BED reported an average (SD) of 4.5 (2.9) binge eating episodes per week. Weight and shape concerns were of significant importance for participants' schema for self-evaluation. Mood disorders were the most frequent co-occurring psychiatric disorders. Despite having a mean (SD) body mass index of 36.4 (10.6), most participants presented in good general medical health.

DISCUSSION

Regarding eating pathology, psychiatric comorbidity, and associated obesity, BED in this group of elderly individuals was similar to BED in younger adults. However, other than presenting with obesity, the participants reported good general medical health. BED might be a problem for a subset of physically healthy elderly individuals. Studies further examining psychiatric and medical presentation, including metabolic profile, of elderly individuals with BED may be warranted.

Eating disorder behaviors are increasing: findings from two sequential community surveys in South Australia

Background

Evidence for an increase in the prevalence of eating disorders is inconsistent. Our aim was to determine change in the population point prevalence of eating disorder behaviors over a 10-year period.

Methodology/Principal Findings

Eating disorder behaviors were assessed in consecutive general population surveys of men and women conducted in 1995 (n = 3001, 72% respondents) and 2005 (n = 3047, 63.1% respondents). Participants were randomly sampled from households in rural and metropolitan South Australia. There was a significant (all p<0.01) and over two-fold increase in the prevalence of binge eating, purging (self-induced vomiting and/or laxative or diuretic misuse) and strict dieting or fasting for weight or shape control among both genders. The most common diagnosis in 2005 was either binge eating disorder or other “eating disorders not otherwise specified” (EDNOS; n = 119, 4.2%).

Conclusions/Significance

In this population sample the point prevalence of eating disorder behaviors increased over the past decade. Cases of anorexia nervosa and bulimia nervosa, as currently defined, remain uncommon.