Prevalence and risk factors associated with low bone mineral density in Asian adolescents with anorexia nervosa and atypical anorexia nervosa

OBJECTIVE

This retrospective study aimed to evaluate the prevalence and risk factors for low bone mineral density (BMD) at diagnosis in Asian adolescent females with anorexia nervosa (AN) and atypical AN.

METHOD

We analyzed the BMD results for 213 patients between 10 and 18 years of age, with AN and atypical AN receiving care at a pediatric hospital in Singapore. We used linear regression analyses to determine if type of eating disorder, premorbid weight, and duration of amenorrhea were risk factors for low BMD. For a subset of patients with repeat BMD evaluation, we used paired t-tests to assess the impact of weight or menstrual restoration on the change in BMD.

RESULTS

The prevalence of BMD height-for-age Z-scores <-2 at presentation was higher in patients with AN (13.0%) than atypical AN (2.3%) (p = .034). In multivariate regression, a diagnosis of atypical AN was protective against low BMD at the lumbar spine (B = 0.394, p = .009) and total body less head (B = 0.774, p = .010). Duration of amenorrhea was not associated with BMD across all sites. For those with repeat BMD measures, there was significantly less deterioration in the BMD Z-scores for patients with weight or menstrual restoration (R = -0.22 ± 0.59, NR = -0.69 ± 0.43, p = .029).

CONCLUSIONS

Duration of amenorrhea was not associated with BMD in this sample. A diagnosis of AN was correlated with lower BMD than atypical AN. Further research is needed to better understand the relationship between amenorrhea, weight status, and bone health in Asian adolescents with eating disorders.

PUBLIC SIGNIFICANCE

In this sample, 13% of Asian adolescents with AN and 2.3% of Asian adolescents with atypical AN have low BMD. In our study population, duration of amenorrhea was not correlated with BMD. Among adolescents with AN, a history of being underweight at the highest pre-morbid BMI, is correlated with low BMD. It is important for physicians to take a thorough weight history in evaluating bone health in this population.

Munchausen syndrome by proxy: A narrative review and update for the dentist and other healthcare professionals

Munchausen syndrome by proxy (MSbP) is a form of abuse in which a caregiver with Factitious Disorder Imposed on Another (FDIA) fabricates or induces signs or symptoms in a person under their care to satisfy a self-serving psychological need. Unnecessary clinical evaluations, procedures, and treatments that are initiated based on falsification by the abuser inadvertently add to the trauma experienced by the victim. It is a form of abuse and the impact on victims can be severe, sometimes fatal, and far-reaching such as prolonged neglect and extension to affected siblings. The long-term exposure to MSbP may predispose the victim to eventually developing factitious disorder imposed on self (FDIS). While MSbP often involves child victims, elderly, adults, and pets have also been reported as victims. MSbP can be a diagnostic challenge, and the important keys to timely identification of MSbP include the ability to detect deception by caregivers through awareness, clinical suspicion, and careful review of available health records; it also involves collecting collaborative information from other relevant healthcare providers including dentists, schoolteachers, and social workers. To date, there are limited published cases of MSbP with oral findings. This paper provides a narrative review of the current understanding of MSbP with a section on cases with oral findings. This paper aims to increase awareness about the clinical presentations and management considerations for MSbP among dentists and other healthcare professionals.

Use of a Mobile Lifestyle Intervention App as an Early Intervention for Adolescents With Obesity: Single-Cohort Study

Background

Effective, resource-efficient treatment is urgently needed to address the high rates of pediatric and adolescent obesity. This need has been accelerated by the COVID-19 pandemic. The use of a mobile health tool as an early intervention before a clinic-based multidisciplinary weight management program could be an effective treatment strategy that is appropriate during a pandemic.

Objective

This study aims to assess the effectiveness of and adolescent engagement with a mobile app–based lifestyle intervention program as an early intervention before enrollment in a clinic-based multidisciplinary weight management program.

Methods

This prospective single-cohort study involved adolescents, aged 10-16 years, who were overweight and obese (defined as BMI percentile above the 85th percentile). Participants used the mobile Kurbo app as an early intervention before enrolling in a clinic-based multidisciplinary weight management program. Kurbo’s health coaches provided weekly individual coaching informed by a model of supportive accountability via video chat, and participants self-monitored their health behavior. The implementation of Kurbo as an early intervention was evaluated using the reach, effectiveness, adoption, implementation, and maintenance framework by reach (number who consented to participate out of all patients approached), implementation (Kurbo engagement and evaluation), and effectiveness as measured by the primary outcome of the BMI z-score at 3 months. Secondary outcome measures included changes in body fat percentage, nutrition and physical activity levels, and quality of life at 3 months. Maintenance was defined as the outcome measures at 6-month follow-up.

Results

Of the 73 adolescents who were approached for enrollment, 40 (55%) of adolescents were recruited. The mean age was 13.8 (SD 1.7) years, and the mean BMI z-score was 2.07 (SD 0.30). In the multiethnic Asian sample, 83% (33/40) of the participants had household incomes below the national median. Kurbo engagement was high, with 83% (33/40) of participants completing at least 7 coaching sessions. In total, 78% (18/23) of participants rated the app as good to excellent and 70% (16/23) stated that they would recommend it to others. There were no statistically significant changes in BMI z-scores at 3 months (P=.19) or 6 months (P=.27). Participants showed statistically significant improvements in measured body fat percentage, self-reported quality of life, and self-reported caloric intake from the 3-day food diaries at 3 and 6 months.

Conclusions

The use of Kurbo before enrollment in an outpatient multidisciplinary clinical care intervention is a feasible strategy to expand the reach of adolescent obesity management services to a low-income and racially diverse population. Although there was no significant change in BMI z-scores, the use of Kurbo as an early intervention could help to improve quality of life and reduce body fat percentage and total caloric intake.

Implementation of family-based treatment for Asian adolescents with anorexia nervosa: A consecutive cohort examination of outcomes

OBJECTIVE

This study describes the implementation of family-based treatment (FBT) in an eating disorder program in Asia as well as clinical outcomes of Asian adolescents with anorexia nervosa (AN) treated with FBT.

METHOD

This retrospective consecutive cohort study of 147 Asian adolescents with AN was compared between those in FBT (n = 65) versus treatment as usual (TAU) (n = 82). Variables associated with weight restoration were analyzed between groups.

RESULTS

Participants' mean age was 14.2 (SD = 1.5) years and 93% were female. Mean presenting %mBMI was 74.0 (SD = 7.8) and average illness duration was 7.7 (SD = 6.1) months. The two groups' baseline characteristics were not significantly different. Weight restoration rates in the FBT group were significantly higher than the TAU group at 6-, 12-, and 24-month time points. A linear mixed model showed the mean %mBMI was significantly higher at 0, 6, 12, and 24 months in the FBT group. The median time to weight restoration for patients on FBT was shorter (FBT: 7.0 months, TAU: 19.0 months; 95% CI [14.5, 23.5] χ² = 15.84, p < .001). Within the FBT group, those that completed ≥9 FBT sessions had significantly higher rates of weight restoration at 12 months. Across all participants, those with a lower starting %mBMI were less likely to achieve weight restoration by 12 months.

CONCLUSION

FBT can be effectively implemented in a multidisciplinary eating disorder program managing Asian adolescents with AN with improved rates of weight restoration. Further research is needed to understand the predictors and moderators of remission using FBT in Asian adolescents with AN.

Outcomes of a higher calorie inpatient refeeding protocol in Asian adolescents with anorexia nervosa

OBJECTIVE

This study aims to compare the outcomes of higher calorie refeeding (HCR) and a lower calorie refeeding (LCR) methods among a diverse sample of young Asian adolescents admitted to a tertiary institution in Asia for management of anorexia nervosa (AN).

METHOD

This is a retrospective case control study of Asian adolescents who were managed using an inpatient HCR protocol (2016-2017) and an LCR protocol (2010-2014). Baseline characteristics, daily change in percent median body mass index (%mBMI), and rates of refeeding hypophosphatemia were analyzed between groups.

RESULTS

A total of 125 adolescents with AN were analyzed with 61 (52%) patients in the HCR group. Mean age was 14.0 years (SD =1.5) and mean presenting %mBMI was 73.2 (SD =6.9) with mean length of stay of 11.9 days (SD = 6.6). Patients in the HCR group had significantly increased rate of change of %mBMI (M = 0.39, SD = 0.31) than patients in the LCR group (M = 0.12, SD = 0.43) (p < .001). There was an increased rate of mild hypophosphatemia in the HCR group (HCR: 46%, LCR: 22%, p = .007) but no difference in rates of moderate hypophosphatemia and no cases of severe hypophosphataemia. Lower presenting %mBMI significantly predicted the phosphate levels (p = .004).

DISCUSSION

In a sample of Asian adolescents with AN, use of an HCR protocol was associated with improved rate of inpatient weight gain. There was increased risk of mild hypophosphataemia, but not moderate to severe hypophosphataemia, suggesting that an HCR protocol can be used safely with close monitoring of phosphate levels.

First presentation of restrictive early onset eating disorders in Asian children

OBJECTIVE

This study aims to describe the spectrum of children with restrictive early onset eating disorders (EOEDs), defined as below 13 years of age, presenting to a tertiary institution in Asia and comparing them with older adolescents with eating disorders.

METHODS

This is a retrospective case review of Asian children who were treated in an eating disorder center. Baseline characteristics and inpatient management at first presentation of children younger than 13 years of age (EOED) were compared to those in older adolescents.

RESULTS

A total of 288 patients with restrictive eating disorders were analyzed with 53 (18%) patients having onset younger than age 13 at initial presentation. There were no significant differences in percentage weight loss and hospitalization rates between the two age groups. Patients with EOED presented with significantly shorter duration of symptoms, and lower rates of secondary amenorrhea. More patients with EOED required phosphate supplementation compared to those in older age group.

CONCLUSION

Despite having a shorter duration of illness, Asian children with EOED had similar percentage weight loss and rates of admission due to malnutrition as those in older Asian adolescent patients. This study underlined the severity of EOEDs and the need for early recognition and medical assessment.

Evaluation of a group family-based intervention programme for adolescent obesity: the LITE randomised controlled pilot trial

INTRODUCTION

This study aimed to evaluate the LITE (Lifestyle Intervention for TEenagers) group programme, a family-based behavioural lifestyle intervention for overweight and obese adolescents.

METHODS

We conducted a two-arm randomised controlled trial that recruited overweight and obese adolescents who attended a tertiary care weight management clinic. Participants were randomised to the LITE programme or usual care. The primary outcome assessed was body mass index (BMI) z-score. Secondary outcomes of anthropometric measurements, metabolic profile, parenting and adolescents' perception of family support were measured at baseline, three months and six months. Feasibility and acceptability of the LITE programme were also evaluated.

RESULTS

61 adolescents were enrolled, with 31 in the LITE programme and 30 in usual care. At three months, participants in the programme had a greater reduction in weight (-0.18 ± 2.40 kg vs. 1.48 ± 1.97 kg; p = 0.107), waist circumference (-1.0 ± 3.1 cm vs. 2.4 ± 2.7 cm; p = 0.016), waist-height ratio (-0.01 ± 0.02 vs. 0.01 ± 0.02; p = 0.040) and systolic blood pressure (-3.8 ± 13.7 vs. 5.7 ± 13.1; p = 0.119) compared to the usual care group. There was no significant difference in BMI z-score. At six months, there were significant improvements in adolescents' perception of family support for eating habits in the LITE group compared to the usual care group. The LITE programme had a good attendance rate of 67.7% and was well received.

CONCLUSION

The LITE programme showed feasibility and short-term clinical effectiveness in improving some clinical outcomes and improved adolescents' perception of family support.

Sexual matters among teenagers

In the complex developmental period of puberty, adolescents experience biophysical changes and adapt to societal and cultural expectations of adulthood. Development of their sexuality is an important biopsychosocial change during this period that, when neglected, may result in unmet sexual and reproductive health needs. Patterns of behaviour in adolescence have repercussions across the lifespan. HEADSSS (home, education/employment/eating, activities, drugs, sexuality, sleep, suicide/depression and safety) is a systematic clinical screening tool for use with adolescents. Adolescents may view risk-seeking lifestyle patterns as appropriate behaviours, and physicians can help them recognise the risks and develop less harmful alternatives and strategies. Personal biases should not affect healthcare providers' duty to respect the rights of adolescents and ability to provide developmentally appropriate care. Healthcare professionals should be familiar with the relevant legal statutes in Singapore and refer suspected sexual abuse or violence, risk of self-harm, teenage pregnancy, newly diagnosed sexual transmitted infections or multiple risk-seeking behaviours for further evaluation and help.

Caring for Children and Adolescents With Eating Disorders in the Current Coronavirus 19 Pandemic: A Singapore Perspective

Our public pediatric tertiary hospital in Singapore has been a part of a robust public health response to coronavirus 19 that has been calibrated in a timely manner to the evolving international situation. As of mid-March, Singapore remains in a containment mode with enhanced surveillance and limited community spread. Within this context, our service for pediatric eating disorder care has had to make significant adaptations to our models of service delivery as well as respond to the changing psychosocial needs of our patients. Given infection control requirements, we have instituted modular staffing for our inpatient and outpatient settings, necessitating task shifting and an increased use of technology for communication. Because of the reduced outpatient capacity and the need to minimize nonurgent trips to the hospital, we have implemented telemedicine and have leveraged on partnerships with school counselors and other community partners. "Coronaphobia" has influenced our patients' willingness to attend visits and worsened existing health anxiety for some. Responsiveness to families' and patients' health and financial concerns has been essential. As coronavirus 19 impacts more countries, our institution's experience can provide insight into challenges and possible adaptations to providing ongoing care for eating disorder patients in this environment.

Adolescent health in Asia: insights from Singapore

The introduction of adolescent medicine as a medical subspecialty in Singapore was a welcome in an evolving health care system that is unique in terms of both efficiency, in financing and the results achieved in community health outcomes. The Ministry of Health (MOH) already recognized the need to accommodate the health care concerns related to adolescent psychosocial health risk behaviors and an increased prevalence of young people living with chronic illness. The challenge for the pioneer team of physicians trained in adolescent medicine was to develop and sustain a model of care that integrated (i) core clinical services that include quality measures of care to adolescents; (ii) professional development and capacity building needing an expansive teaching agenda at every level of health education; (iii) strong inter-sectorial collaborations within hospital and community partners; and (iv) robust research and evaluation strategies that keep clinical practice relevant and evidence based.