Course and outcome in individuals with atypical anorexia nervosa: Findings from the Study of Refeeding to Optimize iNpatient Gains (StRONG)

OBJECTIVE

We previously reported that participants with atypical anorexia nervosa (atypical AN) had higher historical and admission weights, greater eating disorder psychopathology, but similar rates of amenorrhea and weight suppression at baseline as compared to anorexia nervosa (AN); here, we compare 1-year outcomes.

METHOD

Weight, % median body mass index (%mBMI), Eating Disorder Examination Questionnaire (EDE-Q) scores, resumption of menses, and rehospitalizations were examined at 3, 6, and 12 months post-discharge. Analyses (N = 111) compared changes in %mBMI, weight suppression, and EDE-Q scores over time between atypical AN and AN.

RESULTS

Among the participants (48 atypical AN, 63 AN), both groups gained weight but those with atypical AN had lower gains than those with AN in %mBMI (p = .02) and greater weight suppression (p = .002) over time. EDE-Q scores improved over time, independent of weight suppression, with no significant difference between atypical AN and AN. Groups did not differ by rates of resumption of menses (80% atypical AN, 76.9% AN) or rehospitalization (29.2% atypical AN, 37.9% AN). Greater weight suppression predicted longer time to restore menses and more days of rehospitalization.

DISCUSSION

Individuals with atypical AN regained a smaller proportion of body mass and were more weight suppressed over time. Change in eating disorder cognitions, resumption of menses, and rehospitalization rates at 1-year follow-up did not differ between groups. There was no significant difference in weight suppression between groups for those who were psychologically improved at 12 months. Findings highlight limitations in our understanding of weight recovery in atypical AN. New metrics for recovery are urgently needed.

PUBLIC SIGNIFICANCE

Little is known about outcome in atypical anorexia nervosa (atypical AN). We examined recovery metrics in young people with atypical AN and anorexia nervosa (AN) 1 year after medical hospitalization. Individuals with atypical AN showed slower weight gain and remained further from their pre-illness weight. There were no differences in the rates of psychological recovery, resumption of menses, or rehospitalization. New metrics are needed to assess recovery in atypical AN.

Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with atypical anorexia nervosa

OBJECTIVE

The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose.

METHOD

Patients were enrolled upon admission and randomized to meal-based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t-tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight).

RESULTS

Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p = .008, Cohen's d = -.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p < .001, Cohen's d = .51) and greater hypomagnesemia (29% vs. 11%, p = .03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p < .001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p < .001), weight gain was 1.6%mBMI (.8, 2.4) greater (p < .001), and hypomagnesemia odds were 70% (12, 128) lower (p = .02).

DISCUSSION

Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group.

PUBLIC SIGNIFICANCE

The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital.

Clinical characteristics of hospitalized male adolescents and young adults with atypical anorexia nervosa

OBJECTIVE

To describe the clinical characteristics of male adolescents and young adults hospitalized for medical complications of atypical anorexia nervosa (atypical AN) and to compare their clinical characteristics with females with atypical AN and males with anorexia nervosa (AN).

METHOD

A retrospective review of electronic medical records for patients with atypical AN and AN aged 9-25 admitted to the UCSF Eating Disorders Program from May 2012 to August 2020 was conducted.

RESULTS

Among 21 males with atypical AN (mean age 15.1 ± 2.7, mean %mBMI 102.0 ± 11.8), medical complications evidenced by admission laboratory values included anemia (52.9%), vitamin D insufficiency/deficiency (52.6%), and zinc deficiency (31.6%). Compared with females with atypical AN (n = 69), males with atypical AN had longer length of stay (11.4 vs 8.4 days, p = .004), higher prescribed kcal at discharge (4114 vs 3045 kcal, p < .001), lower heart rate nadir (40.0 vs 45.8, p = .038), higher aspartate transaminase (AST, 37.9 vs 26.2 U/L, p = .032), higher alanine transaminase (ALT, 30.6 vs 18.3 U/L, p = .005), and higher rates of anemia (52.9% vs 19.4%, p = .005), with no differences in vitamin D, zinc, and vital signs. Compared with males with AN (n = 40), males with atypical AN had no significant differences in vital signs or laboratory assessments during the hospitalization.

DISCUSSION

Atypical AN in males leads to significant medical comorbidity, and males with atypical AN require longer hospital stays compared to females with atypical AN. Rates of abnormal vital signs and abnormal serum laboratory values during hospital admissions do not differ in males with atypical AN compared to AN.

PUBLIC SIGNIFICANCE

Adolescent and young adult males with atypical anorexia nervosa experience significant medical complications. Males with atypical anorexia nervosa had longer hospitalizations and higher prescribed nutrition at discharge than females. Medical complications of atypical anorexia nervosa in male adolescents and young adults were generally equal to those of male adolescents and young adults with anorexia nervosa. Clinicians should be aware of unique medical complications of males with atypical anorexia nervosa.

Predictors of visceral and subcutaneous adipose tissue and muscle density: The ShapeUp! Kids study

BACKGROUND AND AIMS

Body fat distribution, i.e., visceral (VAT), subcutaneous adipose tissue (SAT) and intramuscular fat, is important for disease prevention, but sex and ethnic differences are not well understood. Our aim was to identify anthropometric, demographic, and lifestyle predictors for these outcomes.

METHODS AND RESULTS

The cross-sectional ShapeUp!Kids study was conducted among five ethnic groups aged 5-18 years. All participants completed questionnaires, anthropometric measurements, and abdominal MRI scans. VAT and SAT areas at four lumbar levels and muscle density were assessed manually. General linear models were applied to estimate coefficients of determination (R2) and to compare the fit of VAT and SAT prediction models. After exclusions, the study population had 133 male and 170 female participants. Girls had higher BMI-z scores, waist circumference (WC), and SAT than boys but lower VAT/SAT and muscle density. SAT, VAT, and VAT/SAT but not muscle density differed significantly by ethnicity. R2 values were higher for SAT than VAT across groups and improved slightly after adding WC. For SAT, R2 increased from 0.85 to 0.88 (girls) and 0.62 to 0.71 (boys) when WC was added while VAT models improved from 0.62 to 0.65 (girls) and 0.57 to 0.62 (boys). VAT values were significantly lower among Blacks than Whites with little difference for the other groups.

CONCLUSION

This analysis in a multiethnic population identified BMI-z scores and WC as the major predictors of MRI-derived SAT and VAT and highlights the important ethnic differences that need to be considered in diverse populations.

Associations of Contemporary Screen Time Modalities With Early Adolescent Nutrition

OBJECTIVE

To determine the associations between screen time across several contemporary screen modalities (eg, television, video games, text, video chat, social media) and adherence to the Mediterranean-DASH (dietary approaches to stop hypertension) intervention for neurodegenerative delay (MIND) diet in early adolescents.

METHODS

We analyzed data from the Adolescent Brain Cognitive Development study of 9 to 12-year-old adolescents in the United States. Multiple linear regression analyses examined the relationship between self-reported screen time measures at baseline (year 0) and the 1-year follow-up (year 1) and caregiver-reported nutrition assessments at year 1, providing a prospective and cross-sectional analysis. Cross-sectional marginal predicted probabilities were calculated.

RESULTS

In a sample of 8267 adolescents (49.0% female, 56.9% white), mean age 10 years, total screen time increased from 3.80 h/d at year 0 to 4.61 h/d at year 1. Change in total screen time from year 0 and year 1 was associated with lower nutrition scores at year 1.

PROSPECTIVE

Screen time spent on television, video games, and videos at year 0 was associated with lower nutrition scores at year 1. Cross-sectional: Screen time spent on television, video games, videos, texting, and social media at year 1 was associated with lower MIND diet scores at year 1.

CONCLUSIONS

Both traditional (television) and several contemporary modalities of screen time are associated, prospectively and cross-sectionally, with lower overall diet quality, measured by the MIND diet nutrition score, in early adolescents. Future studies should further explore the effect of rising digital platforms and media on overall adolescent nutrition.

What medical providers need to elevate outpatient care for adolescents and young adults with binge-eating disorder: A novel protocol

PURPOSE

Binge-eating disorder (BED) in adolescents and young adults is underrecognized and understudied and no standardized guidelines exist for medical providers caring for this population. To highlight the lack of extant evidence, we examine the demographic characteristics of youth with BED in an academic eating disorders (EDs) program and primary care clinic and describe the needs of their medical care providers.

METHOD

A retrospective chart review was conducted for patients who met criteria for BED from July 2021 to June 2022. We surveyed their medical providers to understand their needs in caring for this population. A multidisciplinary team with expertise in the care of youth with EDs amalgamated current evidence in caring for youth with BED into a protocolized care schema designed for implementation in the outpatient medical setting.

RESULTS

Eighteen youth with BED were reviewed, 14 identified as female, 3 as male, and 1 as "Other." Average age was 15.4 (2.7) years old, and mean body mass index was 35.90 (8.25). 33.3% (6) patients identified as White/Caucasian, followed by 22.2% (4) Hispanic/Latinx. Eleven of 18 were privately insured. The most common medical recommendations were for regular meals and snacks and for individual psychotherapy. Medical providers desired more education about identification and management of youth with BED.

CONCLUSIONS

To address the lack of medical care guidelines for youth with BED, recommendations in this Forum include: increased education for medical providers, standardized medical monitoring, an emphasis on psychotherapy, and a weight-inclusive orientation.

PUBLIC SIGNIFICANCE

Adolescents and young adults with BED are underrecognized and undertreated. Little is known about the characteristics of these patients and the medical care these patients receive within academic EDs program. For the first time, preliminary recommendations for medical care are provided.

Sex differences in cholesterol and triglyceride levels among hospitalized adolescents and young adults with eating disorders

OBJECTIVE

To determine sex differences in cholesterol and triglyceride levels among adolescents and young adults hospitalized for medical complications of eating disorders.

METHODS

A retrospective electronic medical record review of patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical stabilization, between 2012 and 2020, was conducted. Non-fasting total cholesterol and triglycerides were collected; however, LDL and HDL levels were not available.

RESULTS

Among 83 males and 441 females, mean ± SD age was 15.5 ± 2.8 years, 64.1% had anorexia nervosa, and admission percent median body mass index was 87.3 ± 13.9. The proportion of males and females with high total cholesterol (13.3% vs. 18.1%, Cramer's V = 0.05, p = .28) and high triglyceride levels (9.6% vs. 8.1%, Cramer's V = 0.02, p = .63) did not differ. Mean total cholesterol levels were higher in females compared to males (F 169.6 ± 41.1 mg/dL vs. M 154.5 ± 45.1 mg/dL, Cohen's d = 0.36, p = .003), although a majority were within the normal range. In adjusted linear regression models, male (compared to female) sex (B = -14.40, 95% CI -24.54, -4.27) and higher percent median body mass index (B = -0.33, 95% CI -0.60, -0.06) were associated with lower total cholesterol levels in adjusted models (R2  = 0.04).

DISCUSSION

Building on prior work showing equally severe complications of eating disorders in males compared to females, we did not find sex differences in those presenting with high total cholesterol or triglycerides. Future research is needed to understand the pathophysiology and role of dyslipidemia in acute malnutrition, and the impact of nutritional rehabilitation and weight restoration.

PUBLIC SIGNIFICANCE

We found that the proportion of male and female adolescents and young adults hospitalized for medical complications of an eating disorder with high total cholesterol did not significantly differ. Although average total cholesterol levels were higher in female compared to male patients with eating disorders, a majority of these levels remained within the normal range. Patients with more severe malnutrition had a higher risk of elevated total cholesterol levels. Clinicians should consider monitoring cholesterol levels in young people hospitalized for restrictive eating disorders.

Social epidemiology of the Mediterranean-dietary approaches to stop hypertension intervention for neurodegenerative delay (MIND) diet among early adolescents: the Adolescent Brain Cognitive Development Study

BACKGROUND

The purpose of our study was to understand the relationship between sociodemographic factors and adherence to the MIND (Mediterranean-DASH [Dietary Approaches to Stop Hypertension] Intervention for Neurodegenerative Delay) diet in a demographically diverse national population-based sample of 9-12-year-olds in the US.

METHODS

We analyzed data from the Adolescent Brain and Cognitive Development (ABCD) Study (Year 1, N = 8333). Multivariable linear regression analysis was used to identify associations between MIND diet score and sociodemographic factors, including race/ethnicity, household income, parent education level, age, sex, and sexual minority status.

RESULTS

Compared to White adolescents, Latino adolescents showed the greatest adherence to the MIND diet. Boys had lower adherence to the MIND diet than girls. Lower household income was associated with lower adherence to the MIND diet. Older age was associated with lower adherence to the MIND diet. Sexual minorities had a lower adherence to the MIND diet when compared to their heterosexual counterparts.

DISCUSSION

Female sex, Latino ethnicity, Asian and Black race, high household income, heterosexual sexual orientation, and younger age were associated with higher adherence to the MIND diet. These sociodemographic differences can inform targeted screening and counseling for clinicians and public health organizations among diverse adolescent populations.

IMPACT STATEMENT

Sociodemographic disparities in diet quality have been documented, but none have explored adherence to the MIND (Mediterranean-DASH [Dietary Approaches to Stop Hypertension] Intervention for Neurodegenerative Delay) diet in early adolescence. In this demographically diverse sample of 9-12-year-old early adolescents in the U.S., we found notable and nuanced sociodemographic disparities in adherence to the MIND diet. Sociodemographic factors associated with higher adherence to the MIND diet included female sex, Latino ethnicity, high household income, heterosexual sexual orientation, and younger age.

Cross-sectional assessment of body composition and detection of malnutrition risk in participants with low body mass index and eating disorders using 3D optical surface scans

BACKGROUND

New recommendations for the assessment of malnutrition and sarcopenia include body composition, specifically reduced muscle mass. Three-dimensional optical imaging (3DO) is a validated, accessible, and affordable alternative to dual X-ray absorptiometry (DXA).

OBJECTIVE

Identify strengths and weaknesses of 3DO for identification of malnutrition in participants with low body mass index (BMI) and eating disorders.

DESIGN

Participants were enrolled in the cross-sectional Shape Up! Adults and Kids studies of body shape, metabolic risk, and functional assessment and had BMI of <20 kg/m2 in adults or <85% of median BMI (mBMI) in children and adolescents. A subset was referred for eating disorders evaluation. Anthropometrics, scans, strength testing, and questionnaires were completed in clinical research centers. Lin's Concordance Correlation Coefficient (CCC) assessed agreement between 3DO and DXA; multivariate linear regression analysis examined associations between weight history and body composition.

RESULTS

Among 95 participants, mean ± SD BMI was 18.3 ± 1.4 kg/m2 in adult women (N = 56), 19.0 ± 0.6 in men (N = 14), and 84.2% ± 4.1% mBMI in children (N = 25). Concordance was excellent for fat-free mass (FFM, CCC = 0.97) and strong for appendicular lean mass (ALM, CCC = 0.86) and fat mass (FM, CCC = 0.87). By DXA, 80% of adults met the low FFM index criterion for malnutrition, and 44% met low ALM for sarcopenia; 52% of children and adolescents were <-2 z-score for FM. 3DO identified 95% of these cases. In the subset, greater weight loss predicted lower FFM, FM, and ALM by both methods; a greater percentage of weight regained predicted a higher percentage of body fat.

CONCLUSIONS

3DO can accurately estimate body composition in participants with low BMI and identify criteria for malnutrition and sarcopenia. In a subset, 3DO detected changes in body composition expected with weight loss and regain secondary to eating disorders. These findings support the utility of 3DO for body composition assessment in patients with low BMI, including those with eating disorders. This trial was registered at clinicaltrials.gov as NCT03637855.

Accuracy and Precision of 3-dimensional Optical Imaging for Body Composition by Age, BMI, and Ethnicity

BACKGROUND

The obesity epidemic brought a need for accessible methods to monitor body composition, as excess adiposity has been associated with cardiovascular disease, metabolic disorders, and some cancers. Recent 3-dimensional optical (3DO) imaging advancements have provided opportunities for assessing body composition. However, the accuracy and precision of an overall 3DO body composition model in specific subgroups are unknown.

OBJECTIVES

This study aimed to evaluate 3DO's accuracy and precision by subgroups of age, body mass index, and ethnicity.

METHODS

A cross-sectional analysis was performed using data from the Shape Up! Adults study. Each participant received duplicate 3DO and dual-energy X-ray absorptiometry (DXA) scans. 3DO meshes were digitally registered and reposed using Meshcapade. Principal component analysis was performed on 3DO meshes. The resulting principal components estimated DXA whole-body and regional body composition using stepwise forward linear regression with 5-fold cross-validation. Duplicate 3DO and DXA scans were used for test-retest precision. Student's t tests were performed between 3DO and DXA by subgroup to determine significant differences.

RESULTS

Six hundred thirty-four participants (females = 346) had completed the study at the time of the analysis. 3DO total fat mass in the entire sample achieved R2 of 0.94 with root mean squared error (RMSE) of 2.91 kg compared to DXA in females and similarly in males. 3DO total fat mass achieved a % coefficient of variation (RMSE) of 1.76% (0.44 kg), whereas DXA was 0.98% (0.24 kg) in females and similarly in males. There were no mean differences for total fat, fat-free, percent fat, or visceral adipose tissue by age group (P > 0.068). However, there were mean differences for underweight, Asian, and Black females as well as Native Hawaiian or other Pacific Islanders (P < 0.038).

CONCLUSIONS

A single 3DO body composition model produced accurate and precise body composition estimates that can be used on diverse populations. However, adjustments to specific subgroups may be warranted to improve the accuracy in those that had significant differences. This trial was registered at clinicaltrials.gov as NCT03637855 (Shape Up! Adults).

Parental self-efficacy: Longitudinal impact on clinical outcomes across levels of care in adolescent anorexia nervosa

OBJECTIVE

Parental self-efficacy in the domain of weight restoration for adolescents with restrictive eating disorders is central to success in family-based interventions. We sought to characterize this parental self-efficacy during a brief hospitalization for medical stabilization and follow-up among patients with anorexia nervosa (AN) or atypical AN (AAN) enrolled in the StRONG clinical trial to understand the potential impact of inpatient treatment on caregiver empowerment.

METHODS

Patients were enrolled upon hospital admission and refed per protocol. We examined correlates of the Parents Versus Anorexia (PVA) scale, a measure of parental self-efficacy in the domain of weight restoration, at admission, discharge, 10-days, 1-month, and 3-months post-discharge. Multi-level models evaluated associations among PVA scores and change in %median BMI and Eating Disorder Examination-Questionnaire (EDE-Q) global scores over 3-months post-discharge.

RESULTS

Parents of N = 67 adolescents and young adults M(SD) age 15.79 (2.20) years and 85.00 (11.86) %median BMI participated. PVA scores did not change significantly during hospitalization (p = .053), which lasted on average 10.7 ± 4.5 days. PVA scores increased post-discharge (p = .009), with significant increase between discharge and 1-month post-discharge (p = .045). PVA scores were not associated with subsequent clinical outcomes. Rather, a main effect of time significantly predicted higher %median BMI and improved EDE-Q scores (p < .001).

DISCUSSION

The finding that parental self-efficacy did not deteriorate during the inpatient stay is promising given the medical necessity of hospitalization to ensure short-term safety in some cases and the importance of parental self-efficacy to support long-term recovery.

PUBLIC SIGNIFICANCE

Family-based treatment is the recommended treatment for young people with AN and AAN, serious psychiatric illnesses that may require inpatient medical stabilization. Prior evidence suggests that parental self-efficacy in the outpatient setting is a key component of treatment success. The current study suggests that parental self-efficacy and longer-term treatment outcomes are not undermined by a brief inpatient hospitalization.

Automated body composition estimation from device-agnostic 3D optical scans in pediatric populations

BACKGROUND

Excess adiposity in children is strongly correlated with obesity-related metabolic disease in adulthood, including diabetes, cardiovascular disease, and 13 types of cancer. Despite the many long-term health risks of childhood obesity, body mass index (BMI) Z-score is typically the only adiposity marker used in pediatric studies and clinical applications. The effects of regional adiposity are not captured in a single scalar measurement, and their effects on short- and long-term metabolic health are largely unknown. However, clinicians and researchers rarely deploy gold-standard methods for measuring compartmental fat such as magnetic resonance imaging (MRI) and dual X-ray absorptiometry (DXA) on children and adolescents due to cost or radiation concerns. Three-dimensional optical (3DO) scans are relatively inexpensive to obtain and use non-invasive and radiation-free imaging techniques to capture the external surface geometry of a patient's body. This 3D shape contains cues about the body composition that can be learned from a structured correlation between 3D body shape parameters and reference DXA scans obtained on a sample population.

STUDY AIM

This study seeks to introduce a radiation-free, automated 3D optical imaging solution for monitoring body shape and composition in children aged 5-17.

METHODS

We introduce an automated, linear learning method to predict total and regional body composition of children aged 5-17 from 3DO scans. We collected 145 male and 206 female 3DO scans on children between the ages of 5 and 17 with three scanners from independent manufacturers. We used an automated shape templating method first introduced on an adult population to fit a topologically consistent 60,000 vertex (60 k) mesh to 3DO scans of arbitrary scanning source and mesh topology. We constructed a parameterized body shape space using principal component analysis (PCA) and estimated a regression matrix between the shape parameters and their associated DXA measurements. We automatically fit scans of 30 male and 38 female participants from a held-out test set and predicted 12 body composition measurements.

RESULTS

The coefficient of determination (R2) between 3DO predicted body composition and DXA measurements was at least 0.85 for all measurements with the exception of visceral fat on 3D scan predictions. Precision error was 1-4 times larger than that of DXA. No predicted variable was significantly different from DXA measurement except for male trunk lean mass.

CONCLUSION

Optical imaging can quickly, safely, and inexpensively estimate regional body composition in children aged 5-17. Frequent repeat measurements can be taken to chart changes in body adiposity over time without risk of radiation overexposure.

An exploration of the association between premorbid weight status on patient and caregiver factors at pre and post-treatment among youth with anorexia nervosa/atypical anorexia nervosa

Patients with atypical anorexia nervosa (AAN) or anorexia nervosa (AN) with premorbid history of higher weight (PHW; median BMI ≥ 85th %ile) may report greater eating disorder (ED) pathology, anxiety, and depression, than patients with premorbid history of lower weight (PLW; mBMI <85th %ile). Less is known about caregiver attitudes or treatment outcome related to premorbid weight history. The current study examined associations between premorbid weight history and patient/caregiver factors at presentation, during treatment, and end of treatment among adolescents (N = 138) diagnosed with AN/AAN and their caregivers who received interdisciplinary ED treatment. The sample comprised adolescents with PHW (n = 58, 40.6 %) or PLW (n = 82, 59.4 %). Adolescents with PHW did not differ with regard to patient- or caregiver-reported ED symptoms, comorbid psychopathology, rates of treatment completion, and attainment of estimated body weight compared to PLW (ps > .05). Adolescents with PHW (vs. PLW) were more likely to be diagnosed with AAN (67.9 %, p < .001), identify as cisgender male (p < .001) and to have lost more weight prior to presentation (p < .001). Perceived caregiver burden was lower among adolescents with PHW vs. PLW (p < .001). Further research should expand on this preliminary study exploring associations between premorbid weight history on patient and caregiver factors at treatment presentation and conclusion to enhance the efficacy of evidence-based treatment across the weight-spectrum.

Monitoring body composition change for intervention studies with advancing 3D optical imaging technology in comparison to dual-energy X-ray absorptiometry

BACKGROUND

Recent 3-dimensional optical (3DO) imaging advancements have provided more accessible, affordable, and self-operating opportunities for assessing body composition. 3DO is accurate and precise in clinical measures made by DXA. However, the sensitivity for monitoring body composition change over time with 3DO body shape imaging is unknown.

OBJECTIVES

This study aimed to evaluate the ability of 3DO in monitoring body composition changes across multiple intervention studies.

METHODS

A retrospective analysis was performed using intervention studies on healthy adults that were complimentary to the cross-sectional study, Shape Up! Adults. Each participant received a DXA (Hologic Discovery/A system) and 3DO (Fit3D ProScanner) scan at the baseline and follow-up. 3DO meshes were digitally registered and reposed using Meshcapade to standardize the vertices and pose. Using an established statistical shape model, each 3DO mesh was transformed into principal components, which were used to predict whole-body and regional body composition values using published equations. Body composition changes (follow-up minus the baseline) were compared with those of DXA using a linear regression analysis.

RESULTS

The analysis included 133 participants (45 females) in 6 studies. The mean (SD) length of follow-up was 13 (5) wk (range: 3-23 wk). Agreement between 3DO and DXA (R2) for changes in total FM, total FFM, and appendicular lean mass were 0.86, 0.73, and 0.70, with root mean squared errors (RMSEs) of 1.98 kg, 1.58 kg, and 0.37 kg, in females and 0.75, 0.75, and 0.52 with RMSEs of 2.31 kg, 1.77 kg, and 0.52 kg, in males, respectively. Further adjustment with demographic descriptors improved the 3DO change agreement to changes observed with DXA.

CONCLUSIONS

Compared with DXA, 3DO was highly sensitive in detecting body shape changes over time. The 3DO method was sensitive enough to detect even small changes in body composition during intervention studies. The safety and accessibility of 3DO allows users to self-monitor on a frequent basis throughout interventions. This trial was registered at clinicaltrials.gov as NCT03637855 (Shape Up! Adults; https://clinicaltrials.gov/ct2/show/NCT03637855); NCT03394664 (Macronutrients and Body Fat Accumulation: A Mechanistic Feeding Study; https://clinicaltrials.gov/ct2/show/NCT03394664); NCT03771417 (Resistance Exercise and Low-Intensity Physical Activity Breaks in Sedentary Time to Improve Muscle and Cardiometabolic Health; https://clinicaltrials.gov/ct2/show/NCT03771417); NCT03393195 (Time Restricted Eating on Weight Loss; https://clinicaltrials.gov/ct2/show/NCT03393195), and NCT04120363 (Trial of Testosterone Undecanoate for Optimizing Performance During Military Operations; https://clinicaltrials.gov/ct2/show/NCT04120363).

Hospital-based higher calorie refeeding and mealtime distress in adolescents and young adults with anorexia nervosa or atypical anorexia nervosa

OBJECTIVE

The StRONG study demonstrated that higher calorie refeeding (HCR) restored medical stability faster in patients hospitalized with anorexia nervosa (AN) and atypical AN (AAN), with no increased safety events compared with standard-of-care lower calorie refeeding (LCR). However, some clinicians have expressed concern about potential unintended consequences of HCR (e.g., greater mealtime distress). The purpose of this study was to examine patient treatment preference and compare mealtime distress, food refusal, and affective states between treatments.

METHOD

Participants (N = 111) in this multisite randomized clinical trial were ages 12-24 years, with AN or AAN, admitted to hospital with medical instability who received assigned study treatment (HCR or LCR). Treatment preference was assessed prior to randomization in the full sample. In a subset of participants (n = 45), linear mixed effect models were used to analyze momentary ratings of mealtime distress (pre, during, and post-meals) and daily affective state during the hospitalization.

RESULTS

About half (55%) of participants reported a preference for LCR. Treatment assignment was not associated with food refusal, mealtime distress, or affective states in the subsample. Food refusal increased significantly over the course of refeeding (p = .018). Individuals with greater depression experienced more negative affect (p = .033), with worsening negative affect over time for individuals with higher eating disorder psychopathology (p = .023).

DISCUSSION

Despite understandable concerns about potential unintended consequences of HCR, we found no evidence that treatment acceptability for HCR differed from LCR for adolescents and young adults with AN and AAN.

PUBLIC SIGNIFICANCE

The efficacy and safety of higher calorie refeeding in hospitalized patients with anorexia nervosa has been demonstrated. However, it is not known whether higher calorie refeeding (HCR) increases meal-time distress. This study demonstrated that HCR was not associated with increased mealtime distress, food refusal, or affective states, as compared with lower calorie refeeding. These data support HCR treatment acceptability for adolescents/young adults with anorexia nervosa and atypical anorexia nervosa.

Eating disorders in sexual minority adolescents and young adults: examining clinical characteristics and psychiatric co-morbidities in an inpatient medical setting

BACKGROUND

Sexual minority adolescents and young adults are at higher risk of eating disorders compared to heterosexual peers. However, little is known about the clinical and psychiatric presentation of this population requiring inpatient medical stabilization. Given the increased risk for eating disorder behaviors in sexual minority individuals amidst increased rates of medical hospitalizations secondary to eating disorders, it is important to understand presenting characteristics of this population. The objectives of this study were to (1) describe the clinical characteristics of sexual minority adolescents and young adults with eating disorders admitted for medical instability and (2) compare psychiatric co-morbidities and suicidality of sexual minority adolescents and young adults to heterosexual peers.

METHODS

A retrospective chart review was conducted of 601 patients admitted to a large inpatient eating disorders medical stabilization unit between 2012 and 2020. Data collected included demographics, medical data including vital signs, and psychiatric characteristics. Chi square or t-tests were used to examine potential differences in clinical characteristics and psychiatric co-morbidities between groups. Modified Poisson regression was used to assess associations between sexual orientation and psychiatric co-morbidities.

RESULTS

Over one fifth (21.1%, n = 103) of our inpatient sample identified as a sexual minority individual. The average age of participants was 15.6 years (2.7). Sexual minority adolescents and young adults had higher percent median body mass index compared to heterosexual peers and yet equally severe vital sign instability on admission. Sexual minority adolescents and young adults were almost 1.5 times more likely to have a psychiatric comorbidity with higher rates of depression, anxiety, and post-traumatic stress disorder. Sexual minority adolescents and young adults were approximately two times more likely to have a history of self-injurious behaviors and/or suicidality.

CONCLUSIONS

Sexual minority adolescents and young adults with eating disorders have equally severe vital sign instability despite higher percent median body mass index on admission for medical stabilization. Sexual minority adolescents and young adults hospitalized for medical complications of eating disorders are far more likely to have an additional mental health disorder and a history of self-harm and/or suicidality, which may portend a less favorable long-term prognosis.

Contemporary screen time modalities and disruptive behavior disorders in children: a prospective cohort study

BACKGROUND

Cross-sectional studies have demonstrated associations between screen time and disruptive behavior disorders (conduct disorder and oppositional defiant disorder); however, prospective associations remain unknown. This study's objective was to determine the prospective associations of contemporary screen time modalities with conduct and oppositional defiant disorder in a national cohort of 9-11-year-old children.

METHODS

We analyzed data from the Adolescent Brain Cognitive Development (ABCD) Study (N = 11,875). Modified Poisson regression analyses were conducted to estimate the associations between baseline child-reported screen time (total and by modality) and parent-reported conduct or oppositional defiant disorder based on the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5) at 1-year follow-up, adjusting for potential confounders.

RESULTS

Participants reported an average of 4 hr of total screen time per day at baseline. Each hour of total screen time per day was prospectively associated with a 7% higher prevalence of conduct disorder (95% CI 1.03-1.11) and a 5% higher prevalence of oppositional defiant disorder (95% CI 1.03-1.08) at 1-year follow-up. Each hour of social media per day was associated with a 62% higher prevalence of conduct disorder (95% CI 1.39-1.87). Each hour of video chat (prevalence ratio [PR] 1.21, 95% CI 1.06-1.37), texting (PR 1.19, 95% CI 1.07-1.33), television/movies (PR 1.17, 95% CI 1.10-1.25), and video games (PR 1.14, 95% CI 1.07-1.21) per day was associated with a higher prevalence of the oppositional defiant disorder. When examining thresholds, exposure to >4 hr of total screen time per day was associated with a higher prevalence of conduct disorder (69%) and oppositional defiant disorder (46%).

CONCLUSIONS

Higher screen time was prospectively associated with a higher prevalence of new-onset disruptive behavior disorders. The strongest association was between social media and conduct disorder, indicating that future research and interventions may focus on social media platforms to prevent conduct disorder.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization

BACKGROUND

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.

METHODS

A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.

RESULTS

Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).

CONCLUSIONS

Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

A device-agnostic shape model for automated body composition estimates from 3D optical scans

BACKGROUND

Many predictors of morbidity caused by metabolic disease are associated with body shape. 3D optical (3DO) scanning captures body shape and has been shown to accurately and precisely predict body composition variables associated with mortality risk. 3DO is safer, less expensive, and more accessible than criterion body composition assessment methods such as dual-energy X-ray absorptiometry (DXA). However, 3DO scanning has not been standardized across manufacturers for pose, mesh resolution, and post processing methods.

PURPOSE

We introduce a scanner-agnostic algorithm that automatically fits a topologically consistent human mesh to 3DO scanned point clouds and predicts clinically important body metrics using a standardized body shape model. Our models transform raw scans captured by any 3DO scanner into fixed topology meshes with anatomical consistency, standardizing the outputs of 3DO scans across manufacturers and allowing for the use of common prediction models across scanning devices.

METHODS

A fixed-topology body mesh template was automatically registered to 848 training scans from three different 3DO systems. Participants were between 18 and 89 years old with body mass index ranging from 14 to 52 kg/m2 . Scans were registered by first performing a coarse nearest neighbor alignment between the template and the input scan with an anatomically constrained principal component analysis (PCA) domain deformation using a device and gender specific bootstrap basis trained on 70 seed scans each. The template mesh was then optimized to fit the target with a smooth per-vertex surface-to-surface deformation. A combined unified PCA model was created from the superset of all automatically fit training scans including all three devices. Body composition predictions to DXA measurements were learned from the training mesh PCA coefficients using linear regression. Using this final unified model, we tested the accuracy of our body composition models on a withheld sample of 562 scans by fitting a PCA parameterized template mesh to each raw scan and predicting the expected body composition metrics from the principal components using the learned regression model.

RESULTS

We achieved coefficients of determination (R2 ) above 0.8 on all nine fat and lean predictions except female visceral fat (0.77). R2 was as high as 0.94 (total fat and lean, trunk fat), and all root-mean-squared errors were below 3.0 kg. All predicted body composition variables were not significantly different from reference DXA measurements except for visceral fat and female trunk fat. Repeatability precision as measured by the coefficient of variation (%CV) was around 2-3x worse than DXA precision, with visceral fat %CV below 2x DXA %CV and female total fat mass at 5x.

CONCLUSIONS

Our method provides an accurate, automated, and scanner agnostic framework for standardizing 3DO scans and a low cost, radiation-free alternative to criterion radiology imaging for body composition analysis. We published a web-app version of this work at https://shapeup.shepherdresearchlab.org/3do-bodycomp-analyzer/ that accepts mesh file uploads and returns templated meshes with body composition predictions for demo purposes.

Sex differences and associations between zinc deficiency and anemia among hospitalized adolescents and young adults with eating disorders

PURPOSE

To determine sex differences in and associations between zinc deficiency and anemia among adolescents and young adults hospitalized for medical complications of eating disorders.

METHODS

We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Descriptive statistics, crude, and adjusted logistic regression models were used to assess the association between zinc deficiency (< 55 mcg/dL) and anemia (< 13.6 g/dL in males [M] and < 11.8 g/dL in females [F]).

RESULTS

A total of 87 males and 450 females met eligibility criteria (age 15.98 ± 2.81, 59.4% anorexia nervosa; admission body mass index 17.49 ± 2.82). In unadjusted comparisons, plasma zinc in males and females were not statistically different (M 64.88 ± 14.89 mcg/dL vs F 63.81 ± 13.96 mcg/dL, p = 0.517); moreover, there were no differences in the percentage of males and females with zinc deficiency (M 24.14% vs F 24.89%). However, a greater percentage of males than females were anemic (M 50.00% vs F 17.61%, p < 0.001), with similar findings in the subgroup with anorexia nervosa. In logistic regression models stratified by sex and eating disorder diagnosis, zinc deficiency was significantly associated with anemia in males (AOR 3.43, 95% CI 1.16, 10.13), but not females (AOR 1.47, 95% CI 0.86, 2.54).

CONCLUSIONS

For the first time, we demonstrate that zinc deficiency is equally severe in males compared to females hospitalized with medical complications from eating disorders, with nearly a quarter of inpatients experiencing zinc deficiency. Anemia is more common in males than females hospitalized with eating disorders.

LEVEL OF EVIDENCE

Level V: descriptive cross-sectional study.

Renal Function in Patients Hospitalized With Anorexia Nervosa Undergoing Refeeding: Findings From the Study of Refeeding to Optimize Inpatient Gains

PURPOSE

Among complications of malnutrition secondary to anorexia nervosa (AN) or atypical anorexia nervosa (AAN), renal impairment remains poorly elucidated. Evaluating renal function in hospitalized pediatric patients with AN and AAN undergoing refeeding will yield important information to guide clinicians in screening and managing renal dysfunction in this population.

METHODS

This is a secondary analysis of data from the Study of Refeeding to Optimize Inpatient Gains trial, a multicenter randomized clinical trial comparing higher calorie refeeding versus lower calorie refeeding in 120 adolescents and young adults hospitalized with medical instability secondary to AN or AAN. Baseline disease characteristics were obtained. Vital sign measurements, weight, electrolytes, and fluid status were evaluated daily to ascertain medical stability. Renal function on admission and throughout hospitalization was quantified using daily creatinine measurement and calculation of the estimated glomerular filtration rate (eGFR) using the modified Schwartz equation. Regression analysis and mixed linear models were utilized to evaluate factors associated with eGFR.

RESULTS

Of the 111 participants who completed treatment protocol, 33% had a baseline eGFR less than 90, suggesting renal impairment. Patients who experienced more rapid weight loss and more severe bradycardia were more likely to have low admission eGFR. While eGFR improved during refeeding, eGFR change by day based on refeeding treatment assignment did not reach statistical significance (95% confidence interval, -1.61, 0.15]; p = .095).

DISCUSSION

Renal impairment is evident on admission in a significant number of adolescents and young adults hospitalized with AN and AAN. We demonstrate that short-term medical refeeding yields improvement in renal function.

Physical activity from young adulthood to middle age and premature cardiovascular disease events: a 30-year population-based cohort study

Background

Although physical activity is generally protective of cardiovascular disease (CVD), less is known about how young adult physical activity relates to premature CVD events. The objective of this study was to determine the association between level and change in physical activity from young adulthood to middle age and incidence of premature CVD events before age 60.

Methods

We analyzed data collected across four urban sites from nine visits over 30 years of follow-up (1985–2016) from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective community-based cohort study of 5115 Black and White women and men aged 18–30 years at baseline (1985–1986). Linear mixed models were used to develop individualized moderate-to-vigorous intensity self-reported physical activity trajectories per participant. Fatal and nonfatal coronary heart disease (CHD), heart failure, and stroke outcomes were analyzed separately and as a combined CVD event outcome.

Results

Overall, physical activity declined in young adults as they progressed through middle age. Lower physical activity scores (per 100 exercise units) in 18 year-olds were associated with higher odds of premature CHD (AOR 1.14, 95% CI 1.02–1.28), heart failure (AOR 1.21, 95% CI 1.05–1.38), stroke (AOR 1.20, 95% CI 1.04–1.39), and any CVD (AOR 1.15, 95% CI 1.06–1.24) events. Each additional annual 1-unit reduction in the physical activity score was associated with a higher annual odds of incident heart failure (1.07, 95% CI 1.02–1.13), stroke (1.06, 95% CI 1.00–1.13), and CVD (1.04, 95% CI 1.01–1.07) events. Meeting the minimum (AOR 0.74, 95% CI 0.0.57–0.96) and twice the minimum (AOR 0.55, 95% CI 0.34–0.91) Department of Health and Human Services physical activity guidelines through follow up was protective of premature CVD events.

Conclusions

Given recent trends in declining physical activity with age and associated premature CVD events, the transition from young adult to midlife is an important time period to promote physical activity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01357-2.

Moderate-to-vigorous intensity physical activity from young adulthood to middle age and metabolic disease: a 30-year population-based cohort study

OBJECTIVES

To determine the association between moderate-to-vigorous intensity physical activity (MVPA) trajectories (course over age and time) through the adult life course and onset of metabolic disease (diabetes and dyslipidaemia).

METHODS

We analysed prospective community-based cohort data of 5115 participants in the Coronary Artery Risk Development in Young Adults study, who were black and white men and women aged 18-30 years at baseline (1985-1986) at four urban sites, collected through 30 years of follow-up. Individualised MVPA trajectories were developed for each participant using linear mixed models.

RESULTS

Lower estimated MVPA score at age 18 was associated with a 12% (95% CI 6% to 18%) higher odds of incident diabetes, a 4% (95% CI 1% to 7%) higher odds of incident low high-density lipoprotein (HDL) and a 6% (95% CI 2% to 11%) higher odds of incident high triglycerides. Each additional annual 1-unit reduction in the MVPA score was associated with a 6% (95% CI 4% to 9%) higher annual odds of diabetes incidence and a 4% (95% CI 2% to 6%) higher annual odds of high triglyceride incidence. Analysing various MVPA trajectory groups, participants who were in the most active group at age 18 (over 300 min/week), but with sharp declines in midlife, had higher odds of high low-density lipoprotein and low HDL incidence, compared with those in the most active group at age 18 with subsequent gains.

CONCLUSION

Given recent trends in declining MVPA across the life course and associated metabolic disease risk, young adulthood is an important time period for interventions to increase and begin the maintenance of MVPA.

Three-dimensional optical body shape and features improve prediction of metabolic disease risk in a diverse sample of adults

OBJECTIVE

This study examined whether body shape and composition obtained by three-dimensional optical (3DO) scanning improved the prediction of metabolic syndrome (MetS) prevalence compared with BMI and demographics.

METHODS

A diverse ambulatory adult population underwent whole-body 3DO scanning, blood tests, manual anthropometrics, and blood pressure assessment in the Shape Up! Adults study. MetS prevalence was evaluated based on 2005 National Cholesterol Education Program criteria, and prediction of MetS involved logistic regression to assess (1) BMI, (2) demographics-adjusted BMI, (3) 85 3DO anthropometry and body composition measures, and (4) BMI + 3DO + demographics models. Receiver operating characteristic area under the curve (AUC) values were generated for each predictive model.

RESULTS

A total of 501 participants (280 female) were recruited, with 87 meeting the criteria for MetS. Compared with the BMI model (AUC = 0.819), inclusion of age, sex, and race increased the AUC to 0.861, and inclusion of 3DO measures further increased the AUC to 0.917. The overall integrated discrimination improvement between the 3DO + demographics and the BMI model was 0.290 (p < 0.0001) with a net reclassification improvement of 0.214 (p < 0.0001).

CONCLUSIONS

Body shape measures from an accessible 3DO scan, adjusted for demographics, predicted MetS better than demographics and/or BMI alone. Risk classification in this population increased by 29% when using 3DO scanning.

Assessment of vitamin D among male adolescents and young adults hospitalized with eating disorders

PURPOSE

Medical complications of eating disorders in males are understudied compared to females, as is the case of vitamin D deficiency. The aim of this study was to assess vitamin D levels among male and female adolescents and young adults hospitalized for medical complications of eating disorders.

METHODS

We retrospectively reviewed electronic medical records of patients aged 9-25 years (N = 565) admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Serum vitamin D (25-hydroxy) level was assessed at admission as was history of prior calcium, vitamin D, or multivitamin supplementation. Linear regression was used to assess factors associated with vitamin D levels.

RESULTS

A total of 93 males and 472 females met eligibility criteria (age 15.5 ± 2.8, 58.8% anorexia nervosa; admission body mass index 17.6 ± 2.91). Among male participants, 44.1% had 25-hydroxyvitamin D levels < 30 ng/mL, 18.3% had 25-hydroxyvitamin D levels < 20 ng/mL, and 8.6% had 25-hydroxyvitamin D levels < 12 ng/mL. There were no significant differences in 25-hydroxyvitamin D levels in males compared to females, except that a lower proportion (1.9%) of female participants had 25-hydroxyvitamin D levels < 12 ng/mL (p = 0.001). Only 3.2% of males reported calcium or vitamin D-specific supplementation prior to hospital admission, while 8.6% reported taking multivitamins. White race, prior calcium/vitamin D supplementation, and higher calcium levels were associated with higher vitamin D levels on admission.

CONCLUSIONS

Nearly half of patients admitted to the hospital for malnutrition secondary to eating disorders presented with low 25-hydroxyvitamin D levels; males were more likely than females to have severe vitamin D deficiency. These findings support vitamin D assessment as part of the routine medical/nutritional evaluation for hospitalized eating disorder patients, with particular attention on male populations.

Outcomes of a Standardized, High-Caloric, Inpatient Re-Alimentation Treatment Protocol in 120 Severely Malnourished Adolescents with Anorexia Nervosa

Evidence accumulates that, with close medical monitoring and phosphate supplementation, higher-caloric re-alimentation protocols beginning at 2000 kcal/day (HCR) are not associated with an increased incidence of electrolyte abnormalities in patients with anorexia nervosa (AN) but rather result in faster weight gain. These studies are still scant and have largely been performed in adults or moderately malnourished adolescents. Methods: A retrospective chart review of patients with AN aged 12−20 years and with a body mass index (BMI) < 15 kg/m2 alimented according to a standardized treatment protocol in a German clinic specialized in AN was conducted. All patients received 2000 kcal/day from day one. The effect of HCR was examined with respect to laboratory changes and weight development over 4 weeks. Results: In 120 youth (119 (99.2%) females and 1 (0.8%) male, the mean BMI was 13.1 ± 1.1 (range = 10.2−15.0), %mBMI was 62.1 ± 6.0% and weight gain was 0.76 ± 0.22 kg per week, with the highest rate of weight gain during week 1 (1.25 ± 1.28 kg/week). Over 4 weeks, the total weight gain was 3.00 ± 1.92 kg. Nine patients (7.5%) developed mild hypophosphatemia, and none developed refeeding syndrome. Conclusions: Starting re-alimentation with 2000 kcal/d under close medical surveillance, severely malnourished youth with AN met the recommended weight gain targets between 0.5 and 1 kg/week according to current treatment guidelines, without anyone developing refeeding syndrome.

Sex differences in refeeding among hospitalized adolescents and young adults with eating disorders

OBJECTIVE

To determine sex differences in refeeding (i.e., short-term nutritional rehabilitation) outcomes among hospitalized adolescents and young adults with eating disorders.

METHODS

We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical and nutritional management between May 2012 and August 2020. Descriptive statistics, crude, and adjusted linear regression models were used to assess the association between sex and nutritional outcomes and predictors of length of stay.

RESULTS

A total of 588 adolescents and young adults met eligibility criteria (16% male, mean [SD] age 15.96  [2.75], 71.6% anorexia nervosa, admission percent median body mass index [%mBMI] 87.1 ± 14.1). In unadjusted comparisons, there were no significant sex differences in prescribed kilocalories (kcal) per day at admission (2013 vs. 1980, p = .188); however, males had higher estimated energy requirements (EER, kcal) (3,694 vs. 2,925, p < .001). In linear regression models adjusting for potential confounders, male sex was associated with higher prescribed kcals at discharge (B = 835 kcal, p < .001), greater weight change (B = 0.47 kg, p = .021), and longer length of stay (B = 1.94 days, p = .001) than females. Older age, lower admission weight, lower prescribed kcal at admission, higher EER, and lower heart rate at admission were factors associated with longer length of stay in a linear regression model.

DISCUSSION

These findings support the development of individualized approaches for males with eating disorders to improve quality of care and health care efficiency among an underserved population.

Assessment of clinical measures of total and regional body composition from a commercial 3-dimensional optical body scanner

BACKGROUND

The accurate assessment of total body and regional body circumferences, volumes, and compositions are critical to monitor physical activity and dietary interventions, as well as accurate disease classifications including obesity, metabolic syndrome, sarcopenia, and lymphedema. We assessed body composition and anthropometry estimates provided by a commercial 3-dimensional optical (3DO) imaging system compared to criterion measures.

METHODS

Participants of the Shape Up! Adults study were recruited for similar sized stratifications by sex, age (18-40, 40-60, >60 years), BMI (under, normal, overweight, obese), and across five ethnicities (non-Hispanic [NH] Black, NH White, Hispanic, Asian, Native Hawaiian/Pacific Islander). All participants received manual anthropometry assessments, duplicate whole-body 3DO (Styku S100), and dual-energy X-ray absorptiometry (DXA) scans. 3DO estimates provided by the manufacturer for anthropometry and body composition were compared to the criterion measures using concordance correlation coefficient (CCC) and Bland-Altman analysis. Test-retest precision was assessed by root mean square error (RMSE) and coefficient of variation.

RESULTS

A total of 188 (102 female) participants were included. The overall fat free mass (FFM) as measured by DXA (54.1 ± 15.2 kg) and 3DO (55.3 ± 15.0 kg) showed a small mean difference of 1.2 ± 3.4 kg (95% limits of agreement -7.0 to +5.6) and the CCC was 0.97 (95% CI: 0.96-0.98). The CCC for FM was 0.95 (95% CI: 0.94-0.97) and the mean difference of 1.3 ± 3.4 kg (95% CI: -5.5 to +8.1) reflected the difference in FFM measures. 3DO anthropometry and body composition measurements showed high test-retest precision for whole body volume (1.1 L), fat mass (0.41 kg), percent fat (0.60%), arm and leg volumes, (0.11 and 0.21 L, respectively), and waist and hip circumferences (all <0.60 cm). No group differences were observed when stratified by body mass index, sex, or race/ethnicity.

CONCLUSIONS

The anthropometric and body composition estimates provided by the 3DO scanner are precise and accurate to criterion methods if offsets are considered. This method offers a rapid, broadly available, and automated method of body composition assessment regardless of body size. Further studies are recommended to examine the relationship between measurements obtained by 3DO scans and metabolic health in healthy and clinical populations.

Sociodemographic Correlates of Contemporary Screen Time Use among 9- and 10-Year-Old Children

OBJECTIVE

To determine sociodemographic correlates of contemporary screen time use among a diverse population-based sample of 9- and 10-year-old children.

STUDY DESIGN

In 2021, we analyzed cross-sectional baseline (2016-2018) data from the Adolescent Brain Cognitive Development study (n = 10 755). Multiple linear regression analyses were conducted to estimate associations between sociodemographic factors (sex, race/ethnicity, country of birth, household income, parental education) and 6 contemporary forms of screen time (television, videos [eg, YouTube], video games, social networking, texting, and video chat).

RESULTS

On average, children reported 3.99 hours of screen time per day across 6 modalities, with the most time spent watching/streaming television shows/movies (1.31 hours), playing video games (1.06 hours), and watching/streaming videos (1.05 hours). On average, Black children reported 1.58 more hours of screen time per day and Asian children reported 0.35 less hours of screen time per day compared with White children (mean 3.46 hours per day), and these trends persisted across most modalities. Boys reported higher overall screen time (0.75 hours more) than girls, which was primarily attributed to video games and videos. Girls reported more time texting, social networking, and video chatting than boys. Higher income was associated with lower screen time usage across all modalities except video chat. However, in high-income households, Latinx children reported 0.65 more hours of screen time per day than White children.

CONCLUSIONS

Given the sociodemographic differences in child screen use, guideline implementation strategies can focus on key populations, encourage targeted counseling by pediatricians, and adapt Family Media Use Plans for diverse backgrounds.

Contemporary screen time usage among children 9-10-years-old is associated with higher body mass index percentile at 1-year follow-up: A prospective cohort study

OBJECTIVE

There is a paucity of prospective research exploring the relationship among contemporary screen time modalities (e.g., video streaming, video chatting, texting and social networking) and body mass index (BMI) percentile. The objective of this study was to determine the prospective associations between screen time behaviours in a large and demographically diverse population-based cohort of 9-10-year-old children and BMI percentile at 1-year follow-up.

METHODS

We analyzed prospective cohort data from the Adolescent Brain Cognitive Development (ABCD) Study (N = 11 066). Multiple linear regression analyses were conducted to estimate associations between baseline screen time behaviours (exposure) and BMI percentile at 1-year follow-up, adjusting for race/ethnicity, sex, household income, parent education, depression, binge-eating disorder and baseline BMI percentile.

RESULTS

Each additional hour of total screen time per day was prospectively associated with a 0.22 higher BMI percentile at 1-year follow-up (95% CI 0.10-0.34) after adjusting for covariates. When examining specific screen time behaviours, each additional hour of texting (B = 0.92, 95% CI 0.29-1.55), video chat (B = 0.72, 95% CI 0.09-1.36) and video games (B = 0.42, 95% CI 0.06-0.78) was significantly prospectively associated with higher BMI percentile.

CONCLUSIONS

Screen time is prospectively associated with a higher BMI percentile 1 year later among children 9-10 years old.

A pose-independent method for accurate and precise body composition from 3D optical scans

OBJECTIVE

The aim of this study was to investigate whether digitally re-posing three-dimensional optical (3DO) whole-body scans to a standardized pose would improve body composition accuracy and precision regardless of the initial pose.

METHODS

Healthy adults (n = 540), stratified by sex, BMI, and age, completed whole-body 3DO and dual-energy X-ray absorptiometry (DXA) scans in the Shape Up! Adults study. The 3DO mesh vertices were represented with standardized templates and a low-dimensional space by principal component analysis (stratified by sex). The total sample was split into a training (80%) and test (20%) set for both males and females. Stepwise linear regression was used to build prediction models for body composition and anthropometry outputs using 3DO principal components (PCs).

RESULTS

The analysis included 472 participants after exclusions. After re-posing, three PCs described 95% of the shape variance in the male and female training sets. 3DO body composition accuracy compared with DXA was as follows: fat mass R2 = 0.91 male, 0.94 female; fat-free mass R2 = 0.95 male, 0.92 female; visceral fat mass R2 = 0.77 male, 0.79 female.

CONCLUSIONS

Re-posed 3DO body shape PCs produced more accurate and precise body composition models that may be used in clinical or nonclinical settings when DXA is unavailable or when frequent ionizing radiation exposure is unwanted.

Factors associated with refeeding hypophosphatemia in adolescents and young adults hospitalized with anorexia nervosa

BACKGROUND

Refeeding hypophosphatemia (RH) in individuals with anorexia nervosa (AN) is a potentially fatal complication of nutrition restoration; yet, little is known about risk. This retrospective cohort study examined factors found in hospitalized youth with AN that may contribute to RH.

METHODS

We reviewed medical records of 300 individuals diagnosed with AN admitted between the years of 2010 and 2016. Logistic regression examined factors associated with RH. Multivariate regression examined factors associated with phosphorus nadir.

RESULTS

For 300 participants, the mean (SD) age was 15.5 (2.5) years, 88.3% were White, and 88.3% were female. Participants lost an average of 11.3 (9.7) kg of body weight and were 82% (12.1) of median body mass index (BMI). Age (P = .022), nasogastric (NG) tube feeding (P = .054), weight gain (P = .003), potassium level (P = .001), and magnesium level (P = .024) were contributors to RH. Odds of RH were 13.7 times higher for each unit reduction in magnesium, 9.2 times higher for each unit reduction in potassium, three times higher in those who received NG feeding, 1.5 times higher for each kg of weight gain, and 1.2 times higher for each year of age. Regarding phosphorus nadir, serum magnesium level (P < .001) and admission BMI (P = .002) contributed significantly.

CONCLUSION

The results indicate that age, NG feeding, weight gain, electrolyte abnormalities, and BMI on admission are potential indicators of the development of RH in youth. This study identifies clinical risk factors associated with RH and may guide further investigation.

Physical Activity and Hypertension From Young Adulthood to Middle Age

INTRODUCTION

The optimum physical activity dose to achieve during young adulthood to prevent hypertension using the 2017 American College of Cardiology/American Heart Association guidelines remains undefined. This study aims to determine the association between level and change in physical activity through the adult life course and the onset of hypertension using these 2017 definitions.

METHODS

In 2020, prospective community-based cohort data of 5,115 Coronary Artery Risk Development in Young Adults study participants were analyzed. The cohort included Black and White men and women aged 18-30 years at baseline (1985-1986) at 4 urban sites, collected through 30 years of follow-up (2015-2016). Individualized physical activity trajectories were developed for each participant using linear mixed models.

RESULTS

Black women reported the lowest physical activity levels from young adulthood through middle age. Lower physical activity score (per 100 units) at age 18 years was associated with 4% (95% CI=1%, 7%, p=0.002) higher odds of hypertension incidence. Each additional 1-unit reduction per year in physical activity score was associated with 2% (95% CI=1%, 3%, p=0.001) higher annual odds of hypertension incidence. Meeting approximately the current minimum physical activity guideline levels at age 18 years and through follow-up was not protective of hypertension incidence; however, meeting approximately twice the current minimum physical activity guideline level at age 18 years and through follow-up was protective of hypertension incidence.

CONCLUSIONS

Moderate physical activity levels may need to exceed current minimum guidelines to prevent hypertension onset using 2017 American College of Cardiology/American Heart Association definitions.

Contemporary screen time modalities among children 9-10 years old and binge-eating disorder at one-year follow-up: A prospective cohort study

OBJECTIVE

To determine the prospective associations between contemporary screen time modalities in a nationally representative cohort of 9-10-year-old children and binge-eating disorder at one-year follow-up.

METHOD

We analyzed prospective cohort data from the Adolescent Brain Cognitive Development (ABCD) Study (N = 11,025). Logistic regression analyses were conducted to estimate associations between baseline child-reported screen time (exposure) and parent-reported binge-eating disorder based on the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5, outcome) at one-year follow-up, adjusting for race/ethnicity, sex, household income, parent education, BMI percentile, site, and baseline binge-eating disorder.

RESULTS

Each additional hour of total screen time per day was prospectively associated with 1.11 higher odds of binge-eating disorder at 1-year follow-up (95% CI 1.05-1.18) after adjusting for covariates. In particular, each additional hour of social networking (aOR 1.62, 95% CI 1.18-2.22), texting (aOR 1.40, 95% CI 1.08-1.82), and watching/streaming television shows/movies (aOR 1.39, 95% CI 1.14-1.69) was significantly associated with binge-eating disorder.

DISCUSSION

Clinicians should assess screen time usage and binge eating in children and adolescents and advise parents about the potential risks associated with excessive screen time.

Practice-Based Evidence and Clinical Guidance to Support Accelerated Re-Nutrition of Patients With Anorexia Nervosa

Anorexia nervosa (AN) is characterized by underweight, and the primary goal of treatment is weight restoration. Treatment approaches (ie, hospitalization for weight recovery vs for medical stabilization) and settings (ie, medical/pediatric or psychiatric units) for patients with AN vary between and also within countries. Several specialized eating disorder units worldwide have established high-caloric refeeding (HCR) protocols for patients with AN. In observational studies, HCR shortens hospital stays and increases initial weight gain, the latter being associated with a favorable long-term prognosis. However, clinicians may still remain reluctant to accept this approach for fear of medical complications of HCR, including the risk of refeeding syndrome (RS).1 Research is building toward the development of evidence-based recommendations for safe and effective re-nutrition of underweight patients with AN. This focused review was based on clinical experience and describes 3 different protocols for nutritional management devised by experts from 3 different parts of the world (Australia, Germany, and the United States), in medical refeeding of patients with AN who have established HCR in their clinical units. In addition, and in order to understand energy requirements, empirical data on energy turnover of patients with AN from former metabolic studies are presented. To the best of our knowledge, there is no study reporting on HCR in a cohort of severely malnourished adolescents with AN (ie, with a mean body mass index [BMI] of <15 kg/m2). Therefore, to provide information about the treatment of extremely malnourished patients with AN, we included a recently published HCR protocol for adults with a BMI of <13 kg/m2.2.

Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

We recently reported the short-term results of this trial revealing that higher-calorie refeeding (HCR) restored medical stability earlier, with no increase in safety events and significant savings associated with shorter length of stay, in comparison with lower-calorie refeeding (LCR) in hospitalized adolescents with anorexia nervosa. Here, we report the 1-year outcomes, including rates of clinical remission and rehospitalizations.

METHODS

In this multicenter, randomized controlled trial, eligible patients admitted for medical instability to 2 tertiary care eating disorder programs were randomly assigned to HCR (2000 kcals per day, increasing by 200 kcals per day) or LCR (1400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and 12 months post discharge. Clinical remission at 12 months post discharge was defined as weight restoration (≥95% median BMI) plus psychological recovery. With generalized linear mixed effect models, we examined differences in clinical remission over time.

RESULTS

Of 120 enrollees, 111 were included in modified intent-to-treat analyses, 60 received HCR, and 51 received LCR. Clinical remission rates changed over time in both groups, with no evidence of significant group differences (P = .42). Medical rehospitalization rates within 1-year post discharge (32.8% [19 of 58] vs 35.4% [17 of 48], P = .84), number of rehospitalizations (2.4 [SD: 2.2] vs 2.0 [SD: 1.6]; P = .52), and total number of days rehospitalized (6.0 [SD: 14.8] vs 5.1 [SD: 10.3] days; P = .81) did not differ by HCR versus LCR.

CONCLUSIONS

The finding that clinical remission and medical rehospitalization did not differ over 1-year, in conjunction with the end-of-treatment outcomes, support the superior efficacy of HCR as compared with LCR.

Food Insecurity, Sexual Risk, and Substance Use in Young Adults

PURPOSE

The aim of the study was to determine the association between food insecurity, sexual risk behaviors, sexually transmitted infections (STIs), and substance use in a nationally representative sample of U.S. young adults.

METHODS

Cross-sectional nationally representative data of U.S. young adults aged 24-32 years from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health were analyzed. Multiple logistic and linear regression analyses were conducted with food insecurity as the independent variable and self-reported STIs, sexual risk behaviors, and substance use as the dependent variables, adjusting for covariates and stratifying by sex.

RESULTS

Of the 14,786 young adults in the sample, 14% of young women and 9% of young men were food insecure. Food-insecure young women had greater odds of any STI, HIV, chlamydia, exchanging sex for money, and multiple concurrent sex partners in the past 12 months compared to young women reporting food security, adjusting for covariates. Food insecurity was associated with higher odds of any STI, chlamydia, and exchanging sex for money among young men who identify as gay or bisexual, but not in the general population of young men. Food insecurity was associated with greater odds of marijuana use, methamphetamine use, and nonmedical use of prescription opioids, sedatives, and stimulants in both young men and women.

CONCLUSIONS

Food insecurity is associated with risk behaviors and self-reported STIs, including HIV, in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate.

Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial

IMPORTANCE

The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome.

OBJECTIVE

To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach.

INTERVENTIONS

Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day.

MAIN OUTCOMES AND MEASURES

Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay.

RESULTS

Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant.

CONCLUSIONS AND RELEVANCE

In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02488109.

Predictors of liver fat among children and adolescents from five different ethnic groups

Objectives

As rates of obesity around the world have increased, so has the detection of high level of liver fat in children and adolescents. This may put them at risk for cardiovascular disease later in life. This analysis of a cross‐sectional population‐based study of children and adolescents evaluated demographic and lifestyle determinants of percent liver fat.

Methods

Healthy participants (123 girls and 99 boys aged 5–17 years) recruited by convenience sampling in three locations completed questionnaires, anthropometric measurements, and dual X‐ray absorptiometry and magnetic resonance imaging (MRI) assessment. General linear models were applied to estimate the association of demographic, anthropometric, and dietary factors as well as physical activity with MRI‐based percent liver fat.

Results

The strongest predictor of liver fat was body mass index (BMI; p < 0.0001); overweight and obesity were associated with 0.5% and 1% higher liver fat levels. The respective adjusted mean percent values were 2.9 (95% CI 2.7, 3.1) and 3.4 (95% CI 3.2, 3.6) as compared to normal weight (2.4; 95% CI 2.3, 2.6). Mean percent liver fat was highest in Whites and African Americans, intermediate in Hispanic, and lowest among Asians and Native Hawaiians/Pacific Islanders (p < 0.0001). Age (p = 0.67), sex (p = 0.28), physical activity (p = 0.74), and diet quality (p = 0.70) were not significantly related with liver fat.

Conclusions

This study in multiethnic children and adolescents confirms the strong relationship of BMI with percent liver fat even in a population with low liver fat levels without detecting an association with age, sex, and dietary or physical activity patterns.

Predicting 3D body shape and body composition from conventional 2D photography

PURPOSE

Total and regional body composition are important indicators of health and mortality risk, but their measurement is usually restricted to controlled environments in clinical settings with expensive and specialized equipment. A method that approaches the accuracy of the current gold standard method, dual-energy x-ray absorptiometry (DXA), while only requiring input from widely available consumer grade equipment, would enable the measurement of these important biometrics in the wild, enabling data collection at a scale that would have previously been prohibitive in time and expense. We describe an algorithm for predicting three-dimensional (3D) body shape and composition from a single frontal 2-dimensional image acquired with a digital consumer camera.

METHODS

Duplicate 3D optical scans, two-dimensional (2D) optical images, and DXA whole-body scans were available for 183 men and 233 women from the Shape Up! Adults Study. A principal component analysis vector basis was fit to 3D point clouds of a training subset of 152 men and 194 women. The relationship between this vector space and DXA-derived body composition was modeled with linear regression. The principal component 3D shape was then fitted to match a silhouette extracted from a 2D photograph of a novel body. Body composition was predicted from the resulting 3D shape match using the linear mapping between the principal component parameters and the DXA metrics. Accuracy of body composition estimates from the silhouette method was evaluated against a simple model using height and weight as a baseline, and against DXA measurements as ground truth. Test-retest precision of the silhouette method was evaluated using the duplicate 2D optical images and compared against precision of the duplicate DXA scans. Paired t-tests were performed to detect significant differences between the sets.

RESULTS

Results were reported on a held-out set. Body composition prediction achieved R² s of 0.81 and 0.74 for percent fat prediction of males and females, respectively, on a held-out test set consisting of 31 males and 39 females. Precision estimates for fat mass were 2.31% and 2.06% for males and females, respectively, compared to 1.26% and 0.68% for DXA scans. The t-tests revealed no statistically significant differences between the silhouette method measurements and DXA measurements, or between retests.

CONCLUSION

Total and regional body composition measures can be estimated from a single frontal photograph of a human body. Body composition prediction using consumer level photography can enable early screening and monitoring of possible physiological indicators of metabolic disease in regions where medical imagery or clinical assessment is inaccessible.

Prevalence and correlates of muscle-enhancing behaviors among adolescents and young adults in the United States

OBJECTIVES

To determine the prevalence of muscle-enhancing behaviors in adolescents and young adults using a nationally representative sample in the USA and to examine differences by sex, race/ethnicity, age, socioeconomic status, body mass index, and participation in team sports.

METHODS

Prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves I through III (1994-2002) were analyzed. Engagement in muscle-enhancing behaviors including dietary changes, exercise and weightlifting, supplement use, performance-enhancing substances, and anabolic androgenic steroids were recorded. Multiple logistic regression models using generalized estimating equations, incorporating robust standard errors with clustering by school and within persons, and using national sample weighting, were used to determine associations with muscle-enhancing behaviors across three data collection waves.

RESULTS

Of the 18,924 adolescents at baseline, 29.2% of males and 7.0% of females reported weight gain attempts, while 25.2% of males and 3.8% of females reported any muscle-enhancing behavior. All muscle-enhancing behaviors were more common in males compared to females (p<0.001). Among young men 18-26 years old, 15.6% reported using legal performance enhancing substances and 2.7% reported using androgenic anabolic steroids. Factors that were associated with muscle-enhancing behaviors in males across three data collection waves included Black or Hispanic/Latino race/ethnicity, age over 14 years, higher parental education, lower body mass index, and participation in team sports.

CONCLUSIONS

Muscle-enhancing behaviors ranging from dietary changes to supplement and androgenic anabolic steroid use are common among adolescent and young adult males. Clinicians should consider screening for muscle-enhancing behaviors in these populations.

Food Insecurity and Chronic Disease in US Young Adults: Findings from the National Longitudinal Study of Adolescent to Adult Health

BACKGROUND

Food insecurity, or the limited or uncertain access to food resulting from inadequate financial resources, is associated with a higher prevalence of chronic disease in adulthood. Little is known about these relationships specifically in young adulthood, an important time for the development of chronic disease.

OBJECTIVE

To determine the association between food insecurity and chronic disease including diabetes, hypertension, obesity, and obstructive airway disease in a nationally representative sample of US young adults.

DESIGN

Cross-sectional nationally representative data collected from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health was analyzed using multiple logistic regression models.

PARTICIPANTS

US young adults ages 24-32 years old MAIN MEASURES: Food insecurity and general health; self-reported diabetes, hypertension, hyperlipidemia, "very overweight," and obstructive airway disease; measured obesity derived from body mass index; and inadequate disease control (hemoglobin A1c ≥ 7.0%, blood pressure ≥ 140/90 mmHg) among those with reported diabetes and hypertension.

KEY RESULTS

Of the 14,786 young adults in the sample, 11% were food insecure. Food-insecure young adults had greater odds of self-reported poor health (2.63, 95% confidence interval (CI) 1.63-4.24), diabetes (1.67, 95% CI 1.18-2.37), hypertension (1.40, 95% CI 1.14-1.72), being "very overweight" (1.30, 95% CI 1.08-1.57), and obstructive airway disease (1.48, 95% CI 1.22-1.80) in adjusted models compared with young adults who were food secure. Food insecurity was not associated with inadequate disease control among those with diabetes or hypertension.

CONCLUSIONS

Food insecurity is associated with several self-reported chronic diseases and obesity in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate. Future research should evaluate the impact of early interventions to combat food insecurity on the prevention of downstream health effects in later adulthood.

Predictors of muscularity-oriented disordered eating behaviors in U.S. young adults: A prospective cohort study

OBJECTIVE

To determine adolescent predictors of muscularity-oriented disordered eating behaviors in young men and women using a nationally representative longitudinal sample in the United States and to examine differences by sex.

METHOD

We used nationally representative longitudinal cohort data collected from baseline (11-18 years old, 1994-1995) and 7-year follow-up (18-24 years old, 2001-2002) of the National Longitudinal Study of Adolescent to Adult Health. We examined adolescent demographic, behavioral, and mental health predictors of young adult muscularity-oriented disordered eating behaviors defined as eating more or differently to gain weight or bulk up, supplements to gain weight or bulk up, or androgenic anabolic steroid use at 7-year follow-up.

RESULTS

Of the 14,891 included participants, 22% of males and 5% of females reported any muscularity-oriented disordered eating behavior at follow-up in young adulthood. Factors recorded at adolescence that were prospectively associated with higher odds of muscularity-oriented disordered eating in both sexes included black race, exercising to gain weight, self-perception of being underweight, and lower body mass index z-score. In addition, participation in weightlifting; roller-blading, roller-skating, skate-boarding, or bicycling; and alcohol among males and depressive symptoms among females during adolescence were associated with higher odds of muscularity-oriented disordered eating in young adulthood.

CONCLUSIONS

Interventions to prevent muscularity-oriented disordered eating behaviors may target at-risk youth, particularly those of black race or who engage in exercise to gain weight. Future research should examine longitudinal health outcomes associated with muscularity-oriented disordered eating behaviors.

Weight Loss and Illness Severity in Adolescents With Atypical Anorexia Nervosa

BACKGROUND

Lower weight has historically been equated with more severe illness in anorexia nervosa (AN). Reliance on admission weight to guide clinical concern is challenged by the rise in patients with atypical anorexia nervosa (AAN) requiring hospitalization at normal weight.

METHODS

We examined weight history and illness severity in 12- to 24-year-olds with AN (n = 66) and AAN (n = 50) in a randomized clinical trial, the Study of Refeeding to Optimize Inpatient Gains (www.clinicaltrials.gov; NCT02488109). Amount of weight loss was the difference between the highest historical percentage median BMI and admission; rate was the amount divided by duration (months). Unpaired t tests compared AAN and AN; multiple variable regressions examined associations between weight history variables and markers of illness severity at admission. Stepwise regression examined the explanatory value of weight and menstrual history on selected markers.

RESULTS

Participants were 16.5 ± 2.6 years old, and 91% were of female sex. Groups did not differ by weight history or admission heart rate (HR). Eating Disorder Examination Questionnaire global scores were higher in AAN (mean 3.80 [SD 1.66] vs mean 3.00 [SD 1.66]; P = .02). Independent of admission weight, lower HR (β = -0.492 [confidence interval (CI) -0.883 to -0.100]; P = .01) was associated with faster loss; lower serum phosphorus was associated with a greater amount (β = -0.005 [CI -0.010 to 0.000]; P = .04) and longer duration (β = -0.011 [CI -0.017 to 0.005]; P = .001). Weight and menstrual history explained 28% of the variance in HR and 36% of the variance in serum phosphorus.

CONCLUSIONS

Weight history was independently associated with markers of malnutrition in inpatients with restrictive eating disorders across a range of body weights and should be considered when assessing illness severity on hospital admission.

Food Insecurity Is Associated With Poorer Mental Health and Sleep Outcomes in Young Adults

PURPOSE

The aim of the study was to determine the association between food insecurity, mental health, and sleep outcomes among young adults. Young adulthood represents an important developmental period when educational and economic transitions may increase the risk for food insecurity; however, little is known about associations between food insecurity and health outcomes in this period.

METHODS

Cross-sectional nationally representative data of U.S. young adults aged 24-32 years from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health were analyzed in 2018. Multiple logistic regression analysis was conducted with food insecurity as the independent variable and self-reported mental health (depression, anxiety, and suicidality) and sleep (trouble falling and staying asleep) outcomes as the dependent variables.

RESULTS

Of the 14,786 young adults in the sample, 11% were food insecure. Food-insecure young adults had greater odds of mental health problems including a depression diagnosis (1.67, 95% confidence interval [CI] 1.39-2.01), anxiety or panic disorder diagnosis (1.47, 95% CI 1.16-1.87), and suicidal ideation in the past 12 months (2.76, 95% CI 2.14-3.55). Food insecurity was also associated with poorer sleep outcomes including trouble falling (adjusted odds ratio 1.78, 95% CI 1.52-2.08) and staying (adjusted odds ratio 1.67, 95% CI 1.42-1.97) asleep.

CONCLUSIONS

Food insecurity is associated with poorer mental and sleep health in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate. Future research should test interventions to simultaneously combat food insecurity and mental health problems in young adulthood.

Detailed 3-dimensional body shape features predict body composition, blood metabolites, and functional strength: the Shape Up! studies

BACKGROUND

Three-dimensional optical (3DO) body scanning has been proposed for automatic anthropometry. However, conventional measurements fail to capture detailed body shape. More sophisticated shape features could better indicate health status.

OBJECTIVES

The objectives were to predict DXA total and regional body composition, serum lipid and diabetes markers, and functional strength from 3DO body scans using statistical shape modeling.

METHODS

Healthy adults underwent whole-body 3DO and DXA scans, blood tests, and strength assessments in the Shape Up! Adults cross-sectional observational study. Principal component analysis was performed on registered 3DO scans. Stepwise linear regressions were performed to estimate body composition, serum biomarkers, and strength using 3DO principal components (PCs). 3DO model accuracy was compared with simple anthropometric models and precision was compared with DXA.

RESULTS

This analysis included 407 subjects. Eleven PCs for each sex captured 95% of body shape variance. 3DO body composition accuracy to DXA was: fat mass R2 = 0.88 male, 0.93 female; visceral fat mass R2 = 0.67 male, 0.75 female. 3DO body fat test-retest precision was: root mean squared error = 0.81 kg male, 0.66 kg female. 3DO visceral fat was as precise (%CV = 7.4 for males, 6.8 for females) as DXA (%CV = 6.8 for males, 7.4 for females). Multiple 3DO PCs were significantly correlated with serum HDL cholesterol, triglycerides, glucose, insulin, and HOMA-IR, independent of simple anthropometrics. 3DO PCs improved prediction of isometric knee strength (combined model R2 = 0.67 male, 0.59 female; anthropometrics-only model R2 = 0.34 male, 0.24 female).

CONCLUSIONS

3DO body shape PCs predict body composition with good accuracy and precision comparable to existing methods. 3DO PCs improve prediction of serum lipid and diabetes markers, and functional strength measurements. The safety and accessibility of 3DO scanning make it appropriate for monitoring individual body composition, and metabolic health and functional strength in epidemiological settings.This trial was registered at clinicaltrials.gov as NCT03637855.

Children and Adolescents' Anthropometrics Body Composition from 3-D Optical Surface Scans

OBJECTIVE

This study aimed to explore the accuracy and precision of three-dimensional optical (3DO) whole-body scanning for automated anthropometry and estimating total and regional body composition.

METHODS

Healthy children and adolescents (n = 181, ages 5-17 years) were recruited for the Shape Up! Kids study. Each participant underwent whole-body dual-energy x-ray absorptiometry and 3DO scans; multisite conventional tape measurements served as the anthropometric criterion measure. 3DO body shape was described using automated body circumference, length, and volume measures. 3DO estimates were compared with criterion measures using simple linear regression by the stepwise selection method.

RESULTS

Of the 181 participants, 112 were used for the training set, 49 were used for the test set, and 20 were excluded for technical reasons. 3DO body composition estimates were strongly associated with dual-energy x-ray absorptiometry measures for percent body fat, fat mass, and fat-free mass (R² : 0.83, 0.96, and 0.98, respectively). 3DO provided reliable measurements of fat mass (coefficient of variation, 3.30; root mean square error [RMSE], 0.53), fat-free mass (coefficient of variation, 1.34; RMSE, 0.53 kg), and percent body fat (RMSE = 1.2%).

CONCLUSIONS

3DO surface scanning provides accurate and precise anthropometric and body composition estimates in children and adolescents with high precision. 3DO is a safe, accessible, and practical method for evaluating body shape and composition in research and clinical settings.

Genetic risk, body mass index, and weight control behaviors: Unlocking the triad

BACKGROUND

The relationship between genetic risk for body mass index (BMI) and weight control behaviors remains unknown. The objectives of this study were to determine the association between genetic risk for BMI and weight control behaviors in young adults, and to examine actual measured BMI as a potential mediator variable.

METHOD

We analyzed data from three data collection waves of the National Longitudinal Study of Adolescent to Adult Health. The BMI polygenic score (PGS) was based on published genome-wide association studies for BMI. BMI was collected at 11-18 years and 18-26 years. Weight control behaviors included self-reported: (a) weight loss behaviors (dieting, vomiting, fasting/skipping meals, diet pills, laxatives, or diuretic use to lose weight) and (b) weight gain behaviors (eating more or different foods than normal, taking supplements to gain weight).

RESULTS

Among 4,397 participants, the BMI PGS was associated with higher odds of weight loss behaviors in females (OR 1.24, 95% CI 1.14-1.35) and males (OR 1.43, 95% CI 1.26-1.62), and this association was mediated by BMI (indirect effect 0.04, 95% CI 0.03-0.05 in females and 0.03, 95% CI 0.03-0.04 in males). The BMI PGS was associated with lower odds of weight gain behaviors in females and males, which was also mediated by actual BMI.

CONCLUSIONS

The BMI PGS was associated with weight loss behaviors in both males and females, and this association was mediated by actual measured BMI. Clinical interventions to prevent high BMI, particularly for individuals with genetic risk, may also prevent subsequent development of potentially unhealthy weight loss behaviors.