Eating Disorders During Emerging Adulthood: A Systematic Scoping Review

Efficacy of Eating Disorder Focused Family Therapy for Adolescents With Anorexia Nervosa: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review and evaluate the efficacy of eating disorder focused family therapy (FT-ED) in comparison to all other forms of psychotherapy for children and adolescents with anorexia nervosa. A secondary aim is to assess the relative efficacy of different variations of FT-ED (e.g., shorter vs. longer dose, parent-focused).

METHODS

A search with relevant terms was systematically conducted on four databases. Twenty-three publications across 18 randomized controlled trials met inclusion criteria. Outcomes of interest included variables related to weight, eating psychopathology, and remission status. Study quality was assessed, and data were extracted by two independent researchers.

RESULTS

Adolescents receiving FT-ED gained significantly more weight by the end of treatment in comparison to those receiving individual psychotherapy. FT-ED that was delivered just to parents or to parents and child separately offered preferable weight outcomes and rates of recovery at the end of treatment in comparison to conjoint FT-ED. No other outcomes tested in the meta-analysis were statistically significant at the end of treatment or follow-up.

DISCUSSION

Currently available data suggest the use of FT-ED in its conjoint or separated/parent focused format is the best outpatient treatment option for adolescents with anorexia nervosa when immediate weight gain is paramount. The variability of outcome measurement, including the tools used and timepoints chosen, limit comparison among no more than a handful of studies. The field would benefit from the standardization of measurement and reporting guidelines for future clinical trials.

TRIAL REGISTRATION

PROSPERO number: CRD42023396263.

Prevalence and correlates of appearance- and performance-enhancing drugs and substances use among a national sample of college students aged 18-30

Objective: To identify the lifetime prevalence and correlates of appearance- and performance-enhancing drugs and substances (APEDS) use among a national sample of US college and university students. Participants: Student participants from the 2020-2021 Healthy Minds Study (N = 7,401; ages 18-30 years). Methods: Lifetime prevalence of five forms of APEDS was estimated. Modified Poisson regression analyses were conducted to determine the sociodemographic correlates of protein and creatine supplement use. Results: Lifetime protein (23.8%) and creatine (7.7%) supplement use were most common among the sample. Older age within young adulthood, male sex, perceiving oneself to be normal weight or somewhat overweight, any athletics participation, and 2-3 or ≥ 5 h/week of exercise were associated with greater likelihood of lifetime protein and creatine supplement use. Conclusions: Awareness and prevention efforts on the potential harms of APEDS use are needed on campuses, particularly among males and those who participate in athletics and high-frequency exercise.

Attention-deficit/hyperactivity symptoms and loss of control eating in emerging adults: Role of psychological resilience

OBJECTIVE

This study aimed to fill a gap in the literature regarding the role of resilience in the relationship between symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) and loss of control (LOC) eating in a nonclinical sample of emerging adults. Resilience was examined as a potential moderator and as a potential mediator of ADHD symptoms and engagement in LOC eating behaviors. Improved understanding of this relationship may inform clinical intervention and risk screening methodologies for disordered eating behaviors in college students.

METHODS

Participants were undergraduate students (N = 386) from a private university in the northeastern United States. Linear regression analysis examined whether greater ADHD symptoms related to greater LOC eating. Pathway analyses examined resilience as either a moderator or mediator of the relationship between ADHD symptoms and LOC eating.

RESULTS

A direct positive relationship was found between ADHD symptoms and LOC eating (p < .05). Resilience partially mediated this relationship, such that increased ADHD symptoms indirectly related to increased LOC eating through low resilience (p < .05).

CONCLUSION

Findings indicate that undergraduate students with greater ADHD symptoms engaged in more frequent LOC eating, and that low resilience was a partial mediator of this positive relationship.

Parental perceptions of participation in young adult-focused eating disorder treatment

BACKGROUND

Eating disorders (ED) are serious mental illnesses affecting young adults (YA). Parent-supported treatment for this age cohort is an important consideration given the unique developmental needs and norms of familial social support, but more research is needed to understand parental perceptions of treatment involvement.

METHODS

33 parent-supports of YA with ED completed self-report assessments at admission and discharge of participation in brief, intensive, young-adult focused eating disorder treatment. Assessments measured programme satisfaction, parental self-efficacy, and parent and YA report of eating disorder-related psychopathology. Repeated measures ANOVAs were used to examine pre-post outcome differences and between group differences among parent-supports and their YA (i.e., the patients) on eating disorder psychopathology, clinical impairment, and family functioning using the EDEQ/P-EDEQ Global, P-CIA/CIA, and Family Assessment Device Family Functioning scales. Group differences across time points were examined with paired sample t-tests adjusted for multiple comparisons. Changes in parental self-efficacy were examined separately using two-tailed paired sample t-tests.

RESULTS

Parents reported high acceptability and learning, improvements in self-efficacy, and significant reductions of YA psychopathology at post-treatment. Parents reported comparable reductions in ED psychopathology post-treatment, but significantly greater reductions in clinical impairment compared to YA. Measures of family functioning did not improve for either parent or YA at post-treatment.

CONCLUSION

Results from this study suggest that parental involvement in a YA programme is feasible and acceptable from a parental perspective and improves parental self-efficacy.

'I've never been so stressed in my life': a qualitative analysis of young adults' lived experience amidst pandemic restrictions in Prince Edward Island, Canada

OBJECTIVES

This qualitative study aimed to explore how young adults experienced the COVID-19 pandemic in relation to extensive lockdowns, social isolation and psychosocial distress. Specifically, this research focused on how the pandemic impacted those who did not contract COVID-19 and lived in a low-risk geographical location. The focus was young adults given they have large social circles (high risk for disease transmission) and have an increased propensity to mental health conditions. These insights can inform planning for future pandemics.

DESIGN

This paper draws on 30 in-depth semistructured interviews. Data were analysed inductively following the principles of a constructivist grounded theory approach.

SETTING AND PARTICIPANTS

30 young adults living in Prince Edward Island during the COVID-19 pandemic, a Canadian province with a low number of COVID-19 cases at the time of data collection.

RESULTS

We developed four themes that describe the experience of young adults during the COVID-19 pandemic: (1) life course disruption, (2) fear and anxiety about the COVID-19 virus, (3) isolation and loss of hope and (4) strategies for managing adversity. Our findings highlight the areas of young adults' lives that were affected by extensive social changes related to the COVID-19 pandemic. We demonstrate that even individuals who had not contracted the virus were considerably impacted.

CONCLUSION

We provide a detailed description of the comprehensive impact of COVID-19 on low-risk young adults not previously infected with the COVID-19 virus. By reflecting on the biographical disruption experienced by young adults, we highlight the need and opportunity to direct healthcare resources towards identifying and addressing the secondary impacts of pandemics. Consequently, these findings can guide decisions relating to future pandemic restrictions to better account for the experiences of individuals living through them.

Moderators of treatment effect in a randomised controlled trial of single- and multi-family therapy for anorexia nervosa in adolescents and emerging adults

INTRODUCTION

Multi-family therapy for anorexia nervosa (MFT-AN) is a novel, group-based intervention that intensifies single-family therapy for anorexia nervosa (FT-AN), with the aim of improving outcomes. The current study explored treatment moderators in a randomised controlled trial (N = 167) of FT-AN and MFT-AN for young people (adolescents/emerging adults aged 13-20 years) with anorexia nervosa.

METHODS

Data were analysed using multiple linear regression. Six hypothesised baseline participant and parent factors were tested as possible moderators of treatment effect on end-of-treatment and follow-up percentage of median Body Mass Index (%mBMI); age, eating disorder symptom severity, perceived family conflict (young person and parent ratings) and parent-rated experiences of caregiving (positive and negative).

RESULTS

Greater parent-rated positive caregiving experiences moderated treatment outcomes at follow-up (β = -0.47, 95%CI: -0.91, -0.03, p = 0.04), but not end-of-treatment. Participants who had fewer parent-rated positive caregiving experiences at baseline had higher weight at follow-up if they had MFT-AN compared to FT-AN. No other hypothesised baseline factors moderated treatment outcome (p's > 0.05).

DISCUSSION

The current study suggests MFT-AN may be indicated for families who present with fewer positive caregiving experiences to treatment. The MFT-AN group context may help to promote mentalisation and hope for these families, which may be harder to achieve in single-family treatment. Future research is needed to empirically evaluate how and why MFT-AN supports this group more.

TRIAL REGISTRATION

ISRCTN registry: ISRCTN11275465, registered 29 January 2007.

TransitionED: A protocol for Co-designing and implementing Canadian practice guidelines for transitions for youth with eating disorders

OBJECTIVE

Limited guidelines inform the transition from paediatric to adult healthcare for youth and young adults (YYA) with eating disorders (EDs). This study will develop, implement, and evaluate Canadian Clinical Practice Guidelines for ED transition, including identifying the relevant measurement and evaluation tools for transition readiness and continuity of care.

METHODS

This study consists of three phases. Phase 1 involves conducting a scoping review of the evidence on transition interventions, outcomes, and measurement tools for YYA with EDs, along with guideline development using the modified Delphi method. Phase 2 identifies the contextual/cultural factors relevant to guideline implementation and co-designing an implementation protocol with governance committees and research partners. Phase 3 involves the application and evaluation of the proposed guide lines using the implementation protocol, and assessing the acceptability and feasibility of a prototype transition intervention in two Canadian paediatric ED programs.

CONCLUSIONS

Results will provide the knowledge needed to enhance the lives of YYA, improve the effectiveness of the ED care system, and support the scale of the transition guidelines across Canada. These guidelines will have international relevance by potentially informing the field on how to support young people with EDs transitioning in similar funding structures and systems of care.

Transition from an adolescent to an adult eating disorder treatment centre: A qualitative investigation of the experience of inpatients with anorexia nervosa and their carers using interpretative phenomenological analysis

AIMS

To capture the subjective experience of eating disorder patients and their immediate family members in the transition between adolescent and adult treatment services and to explore how both groups make sense of this specific experience.

DESIGN

Qualitative study in the form of in-depth interviews using interpretative phenomenological analysis.

SETTINGS

Participants were recruited from a university department of a large psychiatric hospital specialising in eating disorders between July 2021 and September 2022.

PARTICIPANTS

A convenience sample of 18 participants was recruited, including 12 patients aged 19-30 years (m = 22.5, SD = 3.8) and six of their respective caregivers.

RESULTS

Four main themes were identified in relation to the participants' experience of transition to adult care: (1) the detailed description of the transition process, (2) the emotions associated with this experience, (3) the challenges encountered and (4) recommendations for improving the process. Two fundamental meaning-making processes emerged: the feeling of being "lost in transition" and the opportunity to "become an adult". The results highlighted the factors that characterise this experience for patients and their families, and the need for practical and psychological support during the transition process.

CONCLUSIONS

This study provides a unique insight into the experience of patients and their immediate family members regarding the transition from adolescent to adult care. It reveals the multidimensional impact of the transition experience and highlights the need for increased support for family members. These findings may provide new insights into interventions that promote successful transition and encourage rethinking the organisation of this crucial stage of the care pathway.

National roll-out of early intervention for eating disorders: Process and clinical outcomes from first episode rapid early intervention for eating disorders

AIM

First Episode Rapid Early Intervention for Eating Disorders (FREED) is an early intervention model for young people with recent-onset eating disorders (ED). Promising results from a previous single-centre study and a four-centre study (FREED-Up) have led to the rapid national scaling of FREED to ED services in England (FREED-4-All). Our aim was to evaluate duration of an untreated ED (DUED), wait time target adherence, and clinical outcomes in FREED-4-All and compare these to the (benchmark) findings of the earlier FREED-Up study.

METHOD

FREED services submit de-identified data to the central FREED team quarterly. The current study covers the period between September 2018 and September 2021. This FREED-4-All dataset includes 2473 patients. These were compared to 278 patients from the FREED-Up study.

RESULTS

DUED was substantially shorter in the FREED-4-All dataset relative to the FREED-Up study (15 vs. 18 months). Adherence to the wait time targets was comparable in both cohorts (~85% of engagement calls attempted in <2 days, ~50%-60% of assessments offered in <14 days, ~40% of treatment offered in <28 days). Patients in the FREED-4-All dataset experienced significant improvements in ED and general psychological symptoms from pre- to post-treatment that were comparable to the FREED-Up study. These findings should be interpreted cautiously as only 6% of FREED-4-All patients had post-treatment data.

CONCLUSIONS

Data from the FREED-4-All evaluation suggest that FREED is replicating at scale. However, these data are flawed, uncertain, proximate, and sparse and should therefore be used carefully alongside other evidence and clinical experience to inform decision making.

Tonight, I'm disordered eating: The effects of food delivery app use, loneliness, and mood on daily body dissatisfaction and disordered eating urges

With the recent proliferation of food delivery applications ('apps'; FDAs), accessing a meal is more convenient and immediate than ever. However, these apps may foster dysregulated eating behaviours, including maladaptive eating to cope with negative emotional states. Using ecological momentary assessment (EMA), the current study assessed whether FDA use at baseline predicted levels of EMA-assessed disordered eating urges and body dissatisfaction, whether negative mood and loneliness impacted disordered eating urges and body dissatisfaction at the state level, and whether the latter relationships were moderated by FDA usage frequency. Participants (N = 483; 78.7% women; 20.1% men; 1.2% other) completed a baseline questionnaire and were characterised as current FDA users (49.3%) or non-users (50.7%). Participants then completed a smartphone-facilitated investigation into their experiences of loneliness, negative mood, body dissatisfaction, and disordered eating urges, six times per day for 7-days. Across the entire sample, current FDA users at baseline reported greater EMA-assessed urges to overeat. At the state level, loneliness and negative mood predicted greater body dissatisfaction, with the latter also predicting greater urges for restrictive eating and overeating. Among current FDA users at baseline, at the state level, loneliness predicted greater body dissatisfaction, and negative mood predicted greater body dissatisfaction and urges for overeating. No moderating effects were observed for baseline FDA usage frequency. These results elucidate FDA use and daily experiences of loneliness and negative mood as factors elevating eating disorder (ED)-related risk. Further extensions of this research with nuanced measures of state FDA use are required.

How does the increase in eating difficulties according to the Development and Well-Being Assessment screening items relate to the population prevalence of eating disorders? An analysis of the 2017 Mental Health in Children and Young People survey

OBJECTIVE

We examine the test accuracy of the Development and Well-Being Assessment (DAWBA) eating disorder screening items to explore whether the increased eating difficulties detected in the English National Mental Health of Children and Young People (MHCYP) Surveys 2021 reflect an increased population prevalence.

METHODS

Study 1 calculated sensitivity, specificity, and positive and negative predictive values from responses to the DAWBA screening items from 4057 11-19-year-olds and their parents, in the 2017 MHCYP survey. Study 2 applied the positive predictive value to data from 1844 11-19-year-olds responding to the 2021 follow-up to estimate the prevalence of eating disorders in England compared to 2017 prevalence.

RESULTS

Parental report most accurately predicted an eating disorder (93.6%, 95% confidence interval: 92.7-94.5). Sensitivity increased when parent and child answers were combined, and with a higher threshold (of two) for children. The prevalence of eating disorders in 2021 was 1% in 17-19-year-olds, and .6% in 11-16-year-olds-similar to the prevalence reported in 2017 (.8% and .6%, respectively). However, estimates for boys (.2%-.4%) and young men (.0%-.4%) increased.

DISCUSSION

We found tentative evidence of increased population prevalence of eating disorders, particularly among young men. Despite this, the DAWBA screening items are useful for ruling out eating disorders, particularly when parents or carers screen negative, but are relatively poor at predicting who will have a disorder. Data from both parents and children and applying a higher cut point improves accuracy but at the expense of more missed cases.

PUBLIC SIGNIFICANCE STATEMENT

The prevalence of eating disorders did not markedly change from 2017 to 2021, but we found tentative evidence of an increase, particularly among young men. This is despite larger increases in problematic eating, which need further investigation. The DAWBA screen is best suited to ruling out eating disorders which limits its clinical applications as it would provide many false positives requiring further assessment.

Orthorexia nervosa and dieting in a non-clinical sample: a prospective study

PURPOSE

Orthorexia Nervosa (ON) is characterised by excessive attention to a dietary regimen perceived as healthy. A critical factor in the distinction between ON and other eating disorders (EDs) is the dichotomy of quality-versus-quantity of food intake. We investigated whether specific types of diet or dieting frequency are associated with orthorexic features, explored the overlap between ON and EDs symptoms, and examined which constructs are predictive of ON after 6 months.

METHODS

A total of 1075 students (75.1% female, mean age 20.9) completed a set of questionnaires assessing Orthorexia, Eating Disorders, Obsessions and Compulsions, Anxiety and Depression; 358 individuals (79.9 female, mean age 20.9) agreed to participate in the study and completed the same questionnaires after 6 months. Different regression models were defined to investigate our hypothesis.

RESULTS

Findings suggest that ON is associated with the number and type of diets followed over a lifetime. Moreover, participants with EDs, body dissatisfaction, or a dysfunctional idea of thinness are more likely to report a greater degree of ON features. After 6 months, the best predictors of ON characteristics are the same ON characteristics assessed at the first administration, with a significant role in the ideal of thinness.

CONCLUSIONS

ON is more frequent in individuals with a previous diagnosis of EDs and in individuals who followed a restrictive diet or a vegan/vegetarian one; the number of lifetime diets, beliefs, and behaviors related to the ideals of thinness or body dissatisfaction is common features of ON. Moreover, considering that having ON features in the past is the best ON predictor in the present, we can presume that ON is a construct stable over time.

LEVEL OF EVIDENCE

Level IV: Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Adult and child and adolescent psychiatrists' experiences of transition in anorexia nervosa: a qualitative study

BACKGROUND

Young patients suffering from anorexia nervosa (AN) frequently need further treatment in Adult Mental Health Services (AMHS). The transition period from Child and Adolescent Mental Health Services (CAMHS) to AMHS is a critical time, with a high risk of disengagement from healthcare. We explored physicians' perspectives of the transition to triangulate the multiple perspectives of physicians, parents and those with a lived AN experience to more comprehensively characterize the challenges in this process of treatment transition.

METHODS

Using purposive sampling, we recruited 16 physicians confronted with transition in AN (adult psychiatrists, child and adolescent psychiatrists and pediatrician) and conducted semi-structured interviews, which were anonymized, transcribed, and analyzed following the reflexive thematic analysis framework.

RESULTS

Our analysis produced three main themes. First, a shared agreement on the transition's malfunction, where participants depicted transition as a dissatisfying, violent event. Second, the conception of AN as a disorder with specific needs, challenging the transition process especially regarding physicians' engagement. Finally, the ideal transition conceived as a serene experience of separation, with unanimous agreement on the necessity to start the transition depending on patients' needs rather than their age, in order to turn transitions into moments of care.

CONCLUSION

Our results are in line with other qualitative research studying transition in AN and in other chronic diseases, either focusing on the experience of healthcare workers, families, or patients. Our research shows transition in AN as an anxiety-inducing experience for physicians, patients and families alike. Moreover, we highlight a gap in the way physicians perceive and assist the patient's greater autonomy, depending on their specialty. Helping physicians to manage their patient's autonomy, which is a cornerstone of the transition readiness concept, could be a very efficient way to improve transitions in AN. Anorexia Nervosa (AN) is a severe disease, which most of the time starts during adolescence. Transition from Child and Adolescent Mental Health Services to Adult Mental Health Services is at risk of disengagement from healthcare. In order to better understand this process, we interviewed expert physicians about their experiences of transition in AN using a qualitative thematic analysis which highlighted three main themes. First, a shared agreement on the transition's malfunction. Second, the conception of AN as a disorder with specific needs challenging the transition process. Finally, the ideal transition conceived as a serene experience of separation, which needs to be started depending on patients' needs rather than their age. We also show differences in the way physicians perceive and assist the patient's greater autonomy acquired during the transition. Helping physicians to support their patients in acquiring autonomy, which is a cornerstone of the transition readiness concept, could be a very efficient way to improve transitions in AN.

Potential Triggers for Risking the Development of Eating Disorders in Non-Clinical Higher-Education Students in Emerging Adulthood

Nowadays, eating disorders (ED) among individuals during emerging adulthood have become a crucial challenge to public health, taking into account the fact that the global prevalence of the ED risk in student-aged populations already stands at 10.4% and has been sharply increasing during the COVID-19 pandemic. In all, from 50% to 80% of all the ED cases go undetected or are not correctly diagnosed; moreover, these individuals do not receive specialized treatment. Therefore, early diagnosis detected via screening questionnaires for ED is highly recommended. This study aimed to identify the triggers for ED risk development in emerging-adulthood individuals and to reveal the factors significant not only for ED prevention but also for assessing individuals with subthreshold symptoms. This cross-sectional study provides the results for the ED symptom screening in 1716 Lithuanian higher-education students aged 21.2 ± 3.9, during emerging adulthood. According to the results of this study, 19.2% of students were at risk for ED. Potential risk factors such as sex (odds ratio (OR): 3.1, 95% CI: 1.9–4.9), body weight (self-reported body mass index) (adjusted (A) OR: 1.4; 95% CI: 1.2–1.7) and comorbidities such as smoking (AOR: 2.1; 95% CI: 1.6–2.8), and perceived stress during the pandemic (AOR: 1.4; 95% CI: 1.1–1.8) are involved in anticipating the symptomatology of ED during emerging adulthood. Regular initial screenings with universally adopted questionnaires and further referral to a psychiatrist must be applied to promote both the diagnosis of early-onset symptomatology and the treatment of these ED in student-aged populations. Preventive programs for reducing the prevalence of overweight or obesity among students during emerging adulthood should focus on integration directions for the development of a positive body image.

The powerful effect of body image inflexibility on the explanation of eating psychopathology severity

PURPOSE

Feelings of shame and social comparison focused on physical appearance have been identified as important risk factors for the engagement in disordered eating behaviours. Further, recent studies have emphasized the role of body-image psychological (in)flexibility in the association between several risk factors and eating psychopathology. The current study intended to explore, in two different path models, the effects of external shame, physical appearance-related social comparison, and body image inflexibility on the explanation of eating psychopathology severity.

METHODS

This study follows a cross-sectional design and was conducted in a sample of 776 emerging-adult women, aged between 18 and 28, who completed an online battery of self-report measures. Path analyses were conducted using a structural equation modeling.

RESULTS

Model 1's results showed that external shame and unfavourable social comparison based on physical appearance directly accounts for 26% of the variance in disordered eating. In turn, when body image inflexibility is introduced as a mediator in the relationship presented in Model 1, variance in disordered eating increases to 60% (Model 2). These results suggest that both external shame and unfavourable physical appearance-related social comparison have an impact on disordered eating behaviours. However, when body image inflexibility is introduced, the mentioned relationships change and reveal that psychological inflexibility is a significant mediator of these associations.

CONCLUSION

These findings seem to demonstrate that body image inflexibility is a key process for the engagement in disordered eating, so the promotion of psychological flexibility focused on one's body is crucial for the prevention and treatment of disordered eating behaviours and attitudes.

LEVEL OF EVIDENCE

Level IV: Cross-sectional study.

The role of positive self-compassion, distress tolerance, and social problem-solving in the relationship between perfectionism and disordered eating among racially and ethnically diverse college students

Eating disorders (EDs) are associated with high levels of distress, functional impairment, and morbidity. Perfectionism has been consistently identified as an important factor in the etiology and maintenance of disordered eating, and as a promising target for treatment efforts. To address the detrimental effects of perfectionism on disordered eating, further research is needed to better understand what mechanisms may influence the relationship between these variables. In the present research, we examined three constructs related to self-regulation as potential mediators of the relationship between perfectionism and disordered eating: positive self-compassion, distress tolerance, and social problem-solving. We collected data from a sample of racially and ethnically diverse undergraduate students (N = 280) using an online questionnaire battery. Using structural equation modeling (SEM), we developed measurement and structural models to meet criteria for good fit and tested the hypothesized relationships. Distress tolerance emerged as a robust, statistically significant mediator of the relationship between perfectionism and disordered eating. Social problem-solving and self-compassion did not mediate this relationship. Distress tolerance may counterbalance the cognitive load associated with perfectionism; freeing up mental resources to focus on resisting urges for immediate relief through engagement in maladaptive disordered eating.

The light and the dark side of social media use: Depression, anxiety, and eating attitudes among adolescents

In the current study, we explored the links between social networking activity, eating attitudes (EA), anxiety, and depression among adolescents. We used a cross-sectional design. Our sample consisted of 532 males and females, aged 12 to 15 (M = 13.55, SD = 0.90), from the Eastern side of Romania. We analyzed our data using three different pathways to explore these relationships on the overall sample, as well as the at-risk for eating disorders (ED) group (n = 134), and the non-ED-risk (n = 398) samples. The results suggested that depressive and anxiety symptoms partially mediated the relationship between social networking and eating attitudes in the overall group and in the not-at-risk for ED group, but not in the at-risk for ED sample. When controlling for gender, social networking use partially mediated the relationship between anxiety and depressive symptoms and eating attitudes in the overall group and the not-at-risk for ED group, and a total mediating effect within this relationship in the at-risk ED sample was also found. In adolescents with symptoms of potential ED, social networking use seemed to have a protective role compared to the not-at-risk sample. The present study suggested that social networking use might increase the chances of developing unhealthy eating attitudes in adolescents who are not-at risk to develop an eating disorder, but, at the same time, it might play a protective role (instead of a harmful one) for adolescents who already developed such symptoms. Results are discussed concerning their clinical and practical implication for adolescents? physical and mental health, especially during the COVID?19 pandemic, and the potential protective role of social media use for adolescents with ED symptoms.

Predictors of non-completion of a day treatment program for adults with eating disorders

Although treatment dropout is common among patients with eating disorders, very few studies have examined predictors of non-completion in day treatment. We investigated various potential predictors of dropout from adult day treatment. Participants were 295 adult patients with a diagnosis of Anorexia Nervosa (restricting or binge-eating/purging subtype), Bulimia Nervosa (BN), Other Specified Feeding or Eating Disorder, or Avoidant Restrictive Food Intake Disorder. Predictors included eating-disorder characteristics, motivation at the commencement of treatment, Body Mass Index (BMI), time spent in treatment and personality dimensions. Logistic regression analyses showed that for patients with a BMI of less than 20 at the start of treatment, low BMI was a significant predictor of staff-initiated termination due to not meeting weight gain goals. Furthermore, completing less than 6 weeks of treatment was associated with staff-initiated termination. For the whole sample, those with higher changes in weight over the course of treatment were less likely to terminate prematurely. None of the other predictor variables yielded significant results. Results of the current study highlight characteristics of patients who are more likely not to complete day treatment and can help identify patients who may be at risk for not succeeding in multi-diagnostic day treatment programs.

Students' perceptions of an online mental health intervention: a qualitative interview study

BACKGROUND

University students are at a heightened risk of developing mental health disorders. Online interventions are becoming increasingly popular in this target group, both to prevent the development of mental health disorders and to treat existing ones. The PLUS (Personality and Living of University Students) programme is a web-based targeted prevention intervention which has been tested across two European countries. Completion of this programme has been relatively poor. Understanding university students' opinions, experiences and perceptions of the PLUS programme can lead to future improvements in intervention design, engagement and dissemination.

METHODS

Semistructured interviews were conducted with university students from the UK (n = 10) and Austria (n = 14) who had previously had access to PLUS. Students were asked about their perception and experiences of the programme, and how it could be improved. Results were analysed using thematic analysis.

RESULTS

Experience of online prevention programmes in general were limited and as a result of this, few had specific expectations of the PLUS programme before signing up. The lack of guidance and accountability due to the online nature of the programme made engagement challenging for many, however, frequent reminder emails helped mitigate this. In terms of positives of the programme, participants found the flexibility suitable for students and many noticed that the programme created change in how they thought or behaved.

CONCLUSION

Overall, the PLUS programme was well received by students, despite study retention being poor. Although PLUS was viewed as a useful tool to integrate into the university setting, several improvements were suggested to increase engagement. By considering this feedback, uptake and intervention completion can be improved for future preventative interventions.

Adverse childhood experiences in relation to mood-, weight-, and eating-related outcomes in emerging adulthood: Does self-compassion play a buffering role?

BACKGROUND

Adverse childhood experiences (ACEs) are associated with a range of health problems, yet protective factors such as self-compassion may help buffer these associations.

OBJECTIVE

This study examined associations of distinct patterns of ACEs with depressive symptoms, body mass index (BMI), and disordered eating symptoms and investigated self-compassion as a potential protective factor.

PARTICIPANTS AND SETTING

Data from a diverse sample of 1440 emerging adults (M_age = 22.2 years; 53.7% female; 80.3% with race/ethnicity other than non-Hispanic white) came from the population-based EAT 2018 (Eating and Activity over Time) study.

METHODS

Seven types of ACEs were retrospectively self-reported and used as model indicators in latent class analysis to identify patterns of ACEs. Self-compassion, depressive symptoms, height and weight (to calculate BMI), and disordered eating symptoms were also assessed. Demographic-adjusted regression models were conducted.

RESULTS

Three latent classes emerged: "low ACEs" (66.5% of the sample), "household dysfunction" (24.3%), and "household dysfunction and abuse" (9.1%). Compared to participants in the "low ACEs" class, participants in either latent class involving household dysfunction demonstrated higher levels of depressive and disordered eating symptoms. Participants in the "household dysfunction and abuse" class also had higher BMI. Associations differed by self-compassion for depressive symptoms (p_interaction = 0.01), BMI (p_interaction = 0.03), and disordered eating symptoms (p_interaction = 0.005), such that associations for latent classes characterized by ACEs were weaker with higher levels of self-compassion.

CONCLUSIONS

These findings suggest self-compassion may act as a buffer against adverse mood-, weight-, and eating-related outcomes in the face of adversity and therefore may be an important intervention target.

Orthorexia Nervosa: differences between clinical and non-clinical samples

BACKGROUND

Orthorexia Nervosa (ON) is a construct characterized by behaviors, emotions, and beliefs on eating healthy food and excessive attention to diet; moreover, dieting has been considered a risk factor in ON symptoms development. The principal aim of this study was to investigate the differences in clinical and non-clinical groups most at risk of ON. Aspects that could be associated with ON (Eating Disorders [EDs], obsessive-compulsive symptomatology, perfectionistic traits, anxiety, depression, Body Mass Index [BMI]) were investigated in all groups.

METHODS

The sample consisted of 329 adults belonging to four different groups. Three were on a diet: Anorexia/Bulimia Nervosa group (N = 90), Obesity/Binge Eating Disorder group (N = 54), Diet group (N = 91). The Control group consisted of people who were not following a diet (N = 94). Participants completed several self-administered questionnaires (EHQ-21, EDI-3, OCI-R, MPS, BAI, BDI-II) to assess ON-related features in different groups.

RESULTS

Analyses highlighted higher orthorexic tendencies in Anorexia/Bulimia Nervosa, Obesity/BED, and Diet groups than in the Control group. Moreover, results have shown that in the AN/BN group, eating disorders symptomatology and a lower BMI were related to ON and that in Obesity/Binge Eating Disorder and Diet groups, perfectionism traits are associated with ON.

CONCLUSION

Individuals who pursue a diet share some similarities with those who have an eating disorder regarding emotions, behaviors, and problems associated with orthorexic tendencies. Moreover, perfectionistic traits seem to predispose to higher ON tendencies. In general, these results confirm the ON as an aspect of the main eating disorders category.

Exploring alternatives for adolescent anorexia nervosa: adolescent and parent treatment (APT) as a novel intervention prospect

Recovery and remission rates of adolescent anorexia nervosa (AN) following Family Based Treatment (FBT) have seen a relative decline over recent years. While reasonably successful in achieving physical recovery (i.e. weight restoration), both empirical and anecdotal accounts highlight a lack of attention to the psychological recovery of the adolescent within manualised FBT. As such, there is a need for innovation to explore treatment variations and alternatives for the proportion of adolescents with AN who do not respond favourably to this first-line treatment. This paper introduces a new treatment framework to the field for clinical consideration and empirical assessment. Adolescent and Parent Treatment (APT) for adolescent AN draws from both family-based and individual treatment models, applying a developmental lens. APT attends to physical and psychological recovery simultaneously and from the start of treatment, with capacity to tailor individual psychological modules to the adolescent formulation. While clearly in its infancy, APT provides an exciting new avenue for exploration within the field, as we seek new avenues to support young people and their families to effectively combat this deadly illness.

Can you find the right support for children, adolescents and young adults with anorexia nervosa: Access to age-appropriate care systems in various healthcare systems

OBJECTIVE

Anorexia nervosa (AN) often has its onset in childhood or adolescence. However, there is insufficient knowledge regarding access to and utilisation of age-specific clinical diagnostics and treatment.

METHODS

A literature review covering the last 10 years was conducted to provide a narrative review of the current state of research on the detection and treatment of young patients with AN in primary and secondary care.

RESULTS

Most articles were of Western European or US origin. Timely diagnosis of the eating disorder (ED) and treatment options more often depend on the structure and quality of the national health care system than on scientific evidence. Regular paediatric health check-ups and age-appropriate eating disorder services appear to facilitate early diagnosis. Age-specific treatment that also involves the carers is often associated with a higher continuity of care and a better outcome. Although many adolescents require an extension of treatment into young adulthood, individual and health care system-related obstacles in many countries prevent a smooth transition.

CONCLUSION

To improve outcomes in childhood and adolescent AN, age-specific and timely diagnostic and therapeutic procedures are urgently needed.

"I'm truly free from my eating disorder": Emerging adults' experiences of FREED, an early intervention service model and care pathway for eating disorders

BACKGROUND

Eating disorders (EDs) typically start during adolescence or emerging adulthood, periods of intense biopsychosocial development. FREED (First Episode Rapid Early Intervention for EDs) is a service model and care pathway providing rapid access to developmentally-informed care for emerging adults with EDs. FREED is associated with reduced duration of untreated eating disorder and improved clinical outcomes, but patients' experiences of treatment have yet to be assessed.

OBJECTIVE

This study aimed to assess emerging adults' experiences of receiving treatment through FREED.

METHOD

This study triangulated qualitative data on participants' experiences of FREED treatment from questionnaires and semi-structured interviews. Participants were 106 emerging adults (aged 16-25; illness duration < 3 yrs) (questionnaire only = 92; interview only = 6; both = 8). Data were analysed thematically.

RESULTS

Most participants reported psychological and behavioural changes over the course of treatment (e.g. reduction in symptoms; increased acceptance and understanding of difficulties). Participants identified five beneficial characteristics of FREED treatment: i) rapid access to treatment; ii) knowledgeable and concerned clinicians; iii) focusing on life beyond the eating disorder; iv) building a support network; v) becoming your own therapist.

CONCLUSION

This study provides further supports for the implementation of early intervention and developmentally-informed care for EDs. Future service model development should include efforts to increase early help-seeking.

Impending Transition From Pediatric to Adult Health Services: A Qualitative Study of the Experiences of Adolescents With Eating Disorders and Their Caregivers

Background: There is a dearth of research that identifies pediatric to adult health care transition practices that yield positive outcomes for young people with eating disorders (EDs). Further, adolescent and caregiver perspectives are poorly understood and underrepresented in the literature. The purpose of this study, focused on the impending transition from pediatric to adult health services, was twofold: (a) to identify adolescent and caregiver perspectives of barriers and facilitators of a successful transition for adolescents with EDs; and (b) to understand adolescent and caregiver suggestions of interventions for a successful transition. Design/Method: We recruited five adolescents with EDs who were about to be transferred out of pediatric care as well as their caregivers. We conducted a qualitative study in accordance with the principles of interpretive description. Through conducting semi-structured, in-depth interviews with adolescents and caregivers, we investigated their knowledge about health system transitions and anticipated experiences. We identified participants' perceptions of barriers and facilitators regarding a successful transition, as well as their recommendations to improve the transfer of care. Results: Participants possessed a limited understanding of transition processes despite the fact that they were about to be transferred to adult care. From our analyses, the following themes were identified as barriers during the transition process: re-explaining information to adult healthcare providers, lack of professional support while waiting for uptake into the adult health system, and late timing of transition of care discussions. Both adolescents and caregivers expressed that involvement of parents and the pediatric healthcare team helped to facilitate a successful transfer of care. In addition, participants expressed that the implementation of a Transition Coordinator and Transition Passport would be helpful in facilitating a seamless transfer between systems of care. Discussion: These findings demonstrate a significant gap in the system and highlight the importance of developing interventions that facilitate a successful transition. The themes that emerged from this study can inform the development of interventions to facilitate a coordinated transition from pediatric to adult health services for adolescents with EDs.

Assessing the impact of First Episode Rapid Early Intervention for Eating Disorders on duration of untreated eating disorder: A multi-centre quasi-experimental study

BACKGROUND

Duration of untreated eating disorder (DUED), that is, the time between illness onset and start of first evidence-based treatment, is a key outcome for early intervention. Internationally, reported DUED ranges from 2.5 to 6 years for different eating disorders (EDs). To shorten DUED, we developed FREED (First Episode Rapid Early Intervention for EDs), a service model and care pathway for emerging adults with EDs. Here, we assess the impact of FREED on DUED in a multi-centre study using a quasi-experimental design.

METHODS

Two hundred and seventy-eight patients aged 16-25, with first episode illness of less than 3 years duration, were recruited from specialist ED services and offered treatment via FREED. These were compared to 224 patients, of similar age and illness duration, seen previously in participating services (treatment as usual [TAU]) on DUED, waiting times and treatment uptake.

RESULTS

FREED patients had significantly shorter DUED and waiting times than TAU patients. On average, DUED was reduced by ∼4 months when systemic delays were minimal. Furthermore, 97.8% of FREED patients took up treatment, versus 75.4% of TAU.

DISCUSSION

Findings indicate that FREED significantly improves access to treatment for emerging adults with first episode ED. FREED may reduce distress, prevent deterioration and facilitate recovery.

Facilitators and barriers to supporting young people with eating disorders during their transition to, and time at, university: An exploration of clinicians' perspectives

BACKGROUND

Eating disorders (EDs) are common in student populations and present formidable challenges as to how best to treat and support these young people, especially at points of transition. Yet research exploring these challenges is lacking, particularly from the perspective of those providing treatment and support.

METHODS

A qualitative design was used to explore clinicians' perspectives of supporting students with EDs. Twelve clinicians from a large ED service in the United Kingdom participated in one-to-one semi-structured interviews. Data were analysed using thematic analysis.

RESULTS

Facilitators and barriers to supporting students with EDs fell into four overarching themes: Health System, University, Patient and Carer Factors. Reported facilitators were; ED service awareness, flexibility and resources, university as a motivator, and carer support. Reported barriers were; poor links and communication between institutions, the primary care system, poor university provision for and awareness of EDs, young people's denial and ambivalence, inconsistent implementation of guidelines, and carer anxiety.

CONCLUSIONS

The findings revealed challenges unique to the university transition, including the need for more collaborative working between healthcare and education institutions, improved training of non-specialised ED professionals, and the benefits of a flexible, adapted ED treatment approach specifically tailored to the unique needs of students with EDs.

"I'm not a teenager, I'm 22. Why can't I snap out of it?": a qualitative exploration of seeking help for a first-episode eating disorder during emerging adulthood

BACKGROUND

Eating disorders (EDs) typically have their onset during adolescence or the transition to adulthood. Emerging adulthood (~ 18-25 years) is a developmental phase which conceptually overlaps with adolescence but also has unique characteristics (e.g. increased independence). Emerging adults tend to come to ED services later in illness than adolescents, and emerging adulthood's unique characteristics may contribute to such delays.

OBJECTIVE

This study aimed to explore attitudes towards ED symptoms, and their implications for help-seeking, amongst emerging adults receiving ED treatment through FREED, an early intervention care pathway.

METHOD

Participants were 14 emerging adults (mean age 20.9 years; SD = 2.0), all currently receiving specialist treatment for a first-episode, recent-onset (< 3 years) ED. Semi-structured interviews relating to experiences of help-seeking were conducted, and data were analysed thematically.

RESULTS

Symptom egosyntonicity, gradual reappraisal and feelings of exclusion from ED discourse were key attitudinal phases prior to help-seeking, each of which had distinct implications for help-seeking.

CONCLUSIONS

Emerging adults with first-episode EDs show a distinct set of help-seeking-related challenges and opportunities (e.g. help-seeking for others; help-seeking at transitions; self-sufficiency). This research might be used to inform the development and evaluation of interventions which aim to facilitate help-seeking amongst emerging adults with first-episode recent-onset EDs.

Eating Disorders among College Students in France: Characteristics, Help-and Care-Seeking

The aim of this paper was to identify the characteristics of broader categories of eating disorders (ED) and help- and care-seeking among college students. An online cross-sectional study was conducted among students of the University of Rouen-Normandy, France. The Expali-validated algorithmic tool, combining SCOFF test (Sick, Control, One stone, Fat, Food) and body mass index, was used to screen eating disorders into three diagnostic categories: restrictive eating disorders, bulimic eating disorders, and hyperphagic eating disorders. A total of 1493 college students were included; mean age was 20.1 years (SD = 1.9). The prevalence of likely cases of eating disorder was 24.8% (95% CI, 22.6-27.0). Percentage distributions of bulimic eating disorders, hyperphagic eating disorders, and restrictive eating disorders were 13.3%, 8.6%, and 2.9%, respectively. The two main resources for help-seeking in emotional stress situations were friends and family, whatever the ED. Students with eating disorders consulted their general practitioner more often for stress or anxiety than students without eating disorders: hyperphagic eating disorders (44.9%), restrictive eating disorders (35.1%), bulimic eating disorders (30.2%), and no eating disorder (20.4%) (p < 0.0001). The prevalence of healthcare renunciation was 21.9%, with a higher risk among students with bulimic eating disorders (AOR CI 95% 1.91 (1.34-2.72). The findings show one quarter of students screened positive for an eating disorder. Stress management was not necessarily different between students with eating disorders and students without eating disorders, but the former had a greater risk of renouncing treatment, especially related to a fear of seeing a general practitioner.

What prevents young adults from seeking help? Barriers toward help-seeking for eating disorder symptomatology

OBJECTIVES

The aim of this study was to investigate help-seeking attitudes, intentions, and behaviors, and to systematically explore perceived barriers to help-seeking for eating, weight, or shape concerns among young adults. Differences in perceived barriers as a function of type of eating disorder symptomatology were also examined.

METHOD

Data were collected using an online survey among individuals (aged 18-25 years) in Australia. Overall, 291 young adults with varying levels of eating disorder symptoms completed measures of disordered eating, weight or shape concerns, help-seeking barriers, attitudes, intentions, and behaviors. According to their self-reported symptoms, participants were classified into four subgroups (i.e., anorexia nervosa [AN] symptoms, bulimia nervosa [BN] symptoms, binge-eating disorder [BED] symptoms, and other eating disorder symptoms).

RESULTS

Despite the belief that help-seeking is useful, only a minority of participants with elevated symptoms, namely those with AN, BN, and BED symptoms, believed they needed help. Across the sample, the most frequently cited barriers to seeking help for eating disorder symptoms were: concern for others, self-sufficiency, fear of losing control, denial and failure to perceive the severity of the illness, and stigma and shame.

DISCUSSION

The findings highlight the need to educate young adults about the severity of eating disorders and the importance of seeking help, and to increase the awareness of help-seeking barriers among those designing public health interventions as well as clinicians. Our findings suggest that help-seeking barriers may differ depending on the type of eating disorder symptomology.