Early intervention for eating disorders: a call to action for inclusion of minoritized groups

BackgroundPrimary care electronic health records (EHR) are widely used to study long-term conditions in epidemiological and health services research. Therefore, it is important to understand how well the recorded prevalence of these conditions in EHRs, compares to other reliable sources overall, and varies by socio-demographic characteristics. We aimed to describe the prevalence and socio-demographic variation of cardiovascular, renal, and metabolic (CRM) and mental health (MH) conditions in a large, nationally representative, English primary care database and compare with prevalence estimates from other population-based studies.MethodsThis was a cross-sectional study using the Clinical Practice Research Datalink (CPRD) Aurum primary care database. We calculated prevalence of 18 conditions and used logistic regression to assess how this varied by age, sex, ethnicity, and socio-economic status. We searched the literature for population prevalence estimates from other sources for comparison with the prevalences in CPRD Aurum.ResultsDepression (16.0%, 95%CI 16.0–16.0%) and hypertension (15.3%, 95%CI 15.2–15.3%) were the most prevalent conditions among 12.4 million patients. Prevalence of most conditions increased with socio-economic deprivation and age. CRM conditions, schizophrenia and substance misuse were higher in men, whilst anxiety, depression, bipolar and eating disorders were more common in women. Cardiovascular risk factors (hypertension and diabetes) were more prevalent in black and Asian patients compared with white, but the trends in prevalence of cardiovascular diseases by ethnicity were more variable. The recorded prevalences of mental health conditions were typically twice as high in white patients compared with other ethnic groups. However, PTSD and schizophrenia were more prevalent in black patients. The prevalence of most conditions was similar or higher in the primary care database than diagnosed disease prevalence reported in national health surveys. However, screening studies typically reported higher prevalence estimates than primary care data, especially for PTSD, bipolar disorder and eating disorders.ConclusionsThe prevalence of many clinically diagnosed conditions in primary care records closely matched that of other sources. However, we found important variations by sex and ethnicity, which may reflect true variation in prevalence or systematic differences in clinical presentation and practice. Primary care data may underrepresent the prevalence of undiagnosed conditions, particularly in mental health.

The ethics of exercise in eating disorders: Can an ethical principles approach guide the next generation of research and clinical practice?

Creative art therapies in the treatment of adolescents with eating disorders: An integrative review and thematic network analysis

A survey of Registered Dietitian Nutritionists who provide care to clients with eating disorders: Implications for education, training and clinical practice

ObjectiveQualitative studies report that autistic women have poor experiences when being treated for an eating disorder (ED) and express that ED services are not appropriately tailored to meet their needs. It is unclear whether their experience differs to other women accessing ED services. The aim of the current study was to compare autistic and non‐autistic women's ED illness history and experiences in ED services.MethodAn online survey about ED illness history and their experience with ED treatment was completed by 46 autistic women with a restrictive ED and 110 non‐autistic women with a restrictive ED.ResultsDespite some similarities, there were three key differences in the experiences reported by autistic and non‐autistic women. First, autistic women reported a longer duration of ED and being diagnosed with an ED at a younger age than non‐autistic women. Second, autistic women reported accessing a broader range of healthcare settings and ED treatments than non‐autistic women when being treated for an ED. Finally, autistic women rated their experiences of inpatient care, dietetic input, and cognitive behavioural therapy (CBT) as significantly less beneficial than non‐autistic women when being treated for an ED.ConclusionThese findings increase understanding of autistic women's ED experience and can help to shape ED services and treatments to better accommodate the needs of their autistic clients.

Eating disorders (EDs) pose significant challenges to mental and physical health, particularly among adolescents and young adults, with the COVID-19 pandemic exacerbating risk factors. Despite advancements in psychosocial and pharmacological treatments, improvements remain limited. Early intervention in EDs, inspired by the model developed for psychosis, emphasizes the importance of timely identification and treatment initiation to improve prognosis. Challenges in identifying prodromal phases and measuring the duration of untreated illness highlight the complexity of early intervention efforts in EDs. Current research focuses on reducing the duration of untreated eating disorder (DUED) and understanding the cognitive and behavioral symptoms preceding ED onset. However, current early intervention programs for EDs showed mixed results, necessitating further investigation. We introduce here the chronopathogram, a tool that may aid in precisely investigating the role of development in EDs. A chronopathogram is a graphical representation of pathological events as they unfold over time. Understanding the neurodevelopmental aspects of EDs and utilizing tools like the chronopathogram can aid in tracking the unfolding of symptoms over time, facilitating early detection and intervention efforts. Overall, addressing the key factors influencing the onset and course of EDs is essential for effective early intervention in these conditions.Level of evidence: Level V narrative review.

Introduction and purpose: Eating disorders belong to the group of mental diseases characterized by significant somatic complications and high mortality. There is a common opinion that these disorders mainly affect women. Such assumptions may result in limited knowledge of the diagnosis and treatment of an eating disorder in the male population. The aim of this study is to summarize the current knowledge about eating disorders among men, including binge eating disorder (BED), anorexia nervosa (AN) and bulimia nervosa (BN). Description of the state of knowledge: It turns out that the problem of eating disorders among the male sex is not so rare- it is estimated that approximately 10 million US men will experience an eating disorder at some point in their lives. The most common eating disorder among men appears to be binge eating disorder (BED). Men are also more likely to report binge eating than women. AN and BN occur much less frequently than BED in the male population. The symptoms of anorexia nervosa and bulimia nervosa may differ between men and women. More and more often we observe a development of a certain type of muscle dysmorphia among men, the so-called “reverse anorexia". Eating disorders carry a number of medical complications such as cardiac disorders, electrolyte disturbances, digestive problems and skeletal disturbances. Therapeutic interventions in the treatment of male eating disorders should take into account gender-specific problems. Conclusions: The real number of men suffering from eating disorders may be underestimated due to the neglect of the problem in the context of the male gender. It also results in poorly developed diagnostic and support schemes for men struggling with this problem. More research is needed on the topic of eating disorders in this group of patients as it will help to develop better diagnostic and therapeutic regimens adapted to the male gender.

Anhedonia, a transdiagnostic symptom referring to the loss of ability to experience pleasure, is heightened across eating disorder (ED) diagnoses. This study aimed to assess whether anhedonia changes during ED treatment and explore how changes in anhedonia relate to treatment outcome. Adults and adolescents in a partial hospitalization program for EDs (N=499) completed the Eating Disorders Examination Questionnaire (EDE-Q) and the anhedonia subscale of the Beck Depression Inventory (BDI) at admission and discharge. Anhedonia scores significantly decreased from admission to discharge. Anhedonia at admission was also significantly different across ED diagnostic groups. To examine how study variables related to discharge EDE-Q scores, a hierarchical linear regression was conducted with demographic, diagnostic, and medication variables in the first step, anhedonia and EDE-Q scores at admission added to the second step, and anhedonia at discharge added to the final step. Greater anhedonia at discharge was related to higher EDE-Q scores at discharge. Our findings suggest that anhedonia changes significantly over the course of intensive treatment and changes in anhedonia relate to ED symptoms at discharge. Future research is needed to determine whether specifically targeting anhedonia in ED treatment may influence treatment outcomes. The findings from this study suggest that anhedonia may decrease during eating disorder (ED) treatment, and greater anhedonia may relate to elevated ED symptoms. These results provide support for the continued study of anhedonia in ED samples and indicate that anhedonia should be explored as a potential target for novel ED treatments.

Background and AimsAll eating disorders (EDs) lead to a significant decrease of health status, psychosocial functioning and quality of life (QoL). Individuals with untreated binge eating disorder (BED) tend to gain weight over time, which may contribute to serious health issues. In somatic hospital departments, some outpatients have reduced compliance with lifestyle changes. This may, to some extent, be due to patients with an undiagnosed ED receiving the incorrect treatment. In this cross-sectional study, we aimed to investigate the prevalence of EDs among patients referred to lifestyle courses.ResultsA total of 136 patients referred from somatic hospital departments to lifestyle changes in a specialized hospital unit were included in the study. The response rate was 69.4%. Self-reported ED or sub-clinical symptoms of ED according to the Eating Disorder Examination Questionnaire (EDE-Q) were found in 17.65%. Of these, 11.03% fulfilled the self-reported criteria for an ED (BED, 7.35%; bulimia nervosa, 3.68%). Patients with an ED or subclinical ED symptoms had elevated grazing behaviour compared to those without ED symptomatology. A statistically significant difference in QoL was also found.Discussion and ConclusionsThe prevalence of self-reported ED or subclinical ED symptoms in patients referred to a lifestyle course is substantial. This ED group had reduced QoL and larger grazing behaviour compared to patients without ED symptomatology. Thus, the prevalence of undiagnosed EDs among patients within somatic hospital departments may be substantial, underlining the importance of screening and further research within this topic.Level of EvidenceLevel III, well-designed cohort study.SignificanceWhat is already known on this subject? In a review including populations from Scandinavia, the USA and South America, the estimated BED prevalence in individuals with higher body weight seeking help to lose weight is 13–27% [22]. Dawes et al. (2016) conducted a meta-analysis investigating the prevalence of mental health conditions among bariatric surgery candidates and recipients. They included 25 studies with a total of 13,769 patients and found that the prevalence of BED was 17% (13–21%) [10]. What this study adds? We have identified a group of patients who may be receiving inappropriate treatment with weight loss intervention instead of specialized ED intervention. It appears that this issue is valid in various somatic hospital departments. Thus, this is a field that requires further attention and investigation.

This chapter includes a review of literature on eating disorder (ED) assessment and treatment in athletes to identify the best practices for clinical sport psychologists. First, the authors (a licensed psychologist who is a certified mental performance consultant and a registered dietitian nutritionist with expertise treating athletes with EDs) describe a multidisciplinary ED treatment approach and identify core treatment providers for athletes’ best practice care. Next, a comprehensive review of screening and assessment tools to detect ED risk, low energy availability, and other relevant psychological and behavioral factors is presented. The authors endorse specific assessment tools that are reliable, valid, and appropriate for athletes, along with guidance on who and when to screen. In addition, the limited but emerging athlete-specific ED treatment research is reviewed, with a focus on sport-specific factors that influence athletes’ ED recovery. Common concerns that arise during competitive athletes’ ED treatment are discussed such as the need to reduce practice or competition, the role of exercise during treatment, and return-to-play decisions. Athlete-specific treatment recommendations and resources to locate qualified multidisciplinary treatment team members are provided. Finally, the authors articulate limitations of the existing literature, identifying future directions for research on ED screening and treatment for athletes.

There is a growing call to identify specific outcome predictors in real-world eating disorder (ED) treatment settings. Studies have implicated several ED treatment outcome predictors [rapid response (RR), weight suppression, illness duration, ED diagnosis, and psychiatric comorbidity] in inpatient settings or randomized controlled trials of individual outpatient therapy. However, research has not yet examined outcome predictors in intensive outpatient programs (IOP). The current study aimed to replicate findings from randomized controlled research trials and inpatient samples, identifying treatment outcome predictors in a transdiagnostic ED IOP sample. The current sample comprised 210 consecutive unique IOP patient admissions who received evidence-based ED treatment, M(SD)Duration = 15.82 (13.38) weeks. Weekly patient measures of ED symptoms and global functioning were obtained from patients' medical charts. In relative weight analysis, RR was the only significant predictor of ED symptoms post treatment, uniquely accounting for 45.6% of the predicted variance in ED symptoms. In contrast, baseline ED pathology was the strongest unique predictor of end-of-treatment global functioning, accounting for 15.89% of predicted variance. Baseline factors did not differentiate patients who made RR from those who did not. Consistent with findings in more controlled treatment settings, RR remains a robust predictor of outcome for patients receiving IOP-level treatment for EDs. Future work should evaluate factors that mediate and moderate RR, incorporating these findings into ED treatment design and implementation. Level IV, uncontrolled intervention.

Having both an eating disorder (ED) and borderline personality disorder (BPD) is associated with heightened clinical complexity, high levels of distress, and challenges in treatment. This study sought to qualitatively investigate the experiences of women with an ED and comorbid BPD as they undergo ED treatment, aiming to better understand factors that shape their perceptions of care. Fourteen women with both an ED and BPD in treatment at a public-sector ED clinic were recruited to participate in an open-ended qualitative interview about their lived treatment experiences. Five overarching themes (with seven subthemes) emerged from the qualitative analysis: (1) Difficulties with emotions as a key factor underlying both ED and BPD; (2) Perceptions of BPD in ED maintenance and treatment; (3) Relational dynamics in treatment; (4) Treatment is "never enough"; and (5) The importance of treating the ED and BPD together. This study highlights the lived experiences of women with both an ED and BPD. Patients expressed the need for ED treatment to target emotion dysregulation, interpersonal difficulties, and their attachment to their therapists and to treatment. This study provides insights into the experiences of patients with BPD of ED treatment that may help guide the approach to care in such individuals.

What Is the Problem? How Might Early Intervention Help Fix the Problem?
 
 The number of adolescents and young adults living with eating disorders is on the rise. This increase was especially noticeable during the height of the COVID-19 pandemic, with more than a 50% increase in the number of young women being hospitalized with an eating disorder.
 Early intervention programs are those delivered by community or health care–based organizations that offer interventions to treat adolescents and young adults living with eating disorders within the first 3 years of diagnosable disorder, with the intention of providing earlier access and preventing disease progression.
 
 What Did We Do?
 
 Advisors with lived experience of eating disorders shared their perspectives and priorities to help reviewers contextualize the evidence and interpret the findings in the literature. Advisors highlighted their treatment experiences and priorities for early intervention, highlighting equity considerations and challenges.
 We conducted a literature search to identify, gather, synthesize, and summarize relevant evidence to inform our understanding of the clinical effectiveness and clinical harms of early intervention programs.
 A search of the economic literature was conducted to identify economic evaluations of early intervention programs to treat adolescents and young adults living with eating disorders. Based on an assessment of the clinical evidence, the uncertainty and heterogeneity of the information precluded a de novo cost-effectiveness analysis (CEA). As such, a narrative summary of the health care resources required to implement an early intervention program for adolescents and young adults living with eating disorders was conducted.
 
 What Did We Find?
 
 Advisors with lived experience of eating disorders described a need for greater access to specialized services focused on eating disorder treatment, equity, capacity building, and culture change. Specific treatment approaches mentioned included family-based treatment, cognitive behavioural therapy, peer support, and group therapy.
 We identified 14 studies related to the clinical effectiveness of early intervention programs. We did not identify any studies evaluating clinical harms.
 The findings from included studies suggest that earlier engagement and access to eating disorder support could have clinical benefits; however, interpretation of these findings are uncertain due to various factors.
 No evidence was identified in the search for information on the cost-effectiveness of early intervention programs for the treatment of adolescents and young adults living with an eating disorder.
 The resources needed to run early intervention programs (or other similar interventional programs) to treat eating disorders may include administration, staffing, training, IT support and infrastructure, and other overhead costs related to the location in which the service is provided.
 
 What Does This Mean?
 
 The clinical evidence suggests that investment of health care resources into early intervention programs shows potential for overall benefit and may help address challenges with access to treatment, which was identified as an issue by those with lived experience.
 The human and financial resources required to implement early intervention programs will vary depending on the treatment options and treatment frequency chosen.
 The demands on an already limited pool of specialized health care resources in eating disorder care are important considerations when choosing whether to implement any new eating disorder treatment programs. Training and recruiting of specialized health care providers will be a key implementation consideration for any new early intervention program for the treatment of eating disorders.
 Further consultation with a diverse group of adolescents and young adults with lived experience with eating disorders might be beneficial to inform implementation of early intervention programs within the Canadian context.

Anxiety and Disordered Eating

1. Richard E. Kreipe, MD* 2. Carolyn P. Dukarm, MD† 1. 2. *Professor of Pediatrics and Chief, Division of Adolescent Medicine. 3. 4. †Senior Instructor in Pediatrics, Division of Adolescent Medicine, The University of Rochester School of Medicine, Rochester, NY. After completing this article, readers should be able to: 1. List the common features that eating disorders share. 2. Describe the hallmark of bulimia nervosa, including binge eating and its aftermath. 3. List diagnostic laboratory studies for eating disorders. 4. Describe the early treatment of anorexia nervosa. 5. Delineate the role of selective serotonin reuptake inhibitors in the treatment of eating disorders. Eating disorders are potentially life-threatening conditions experienced with increasing frequency by older children and adolescents, especially females. These conditions share several features, including dysfunctional eating habits (frequently related to underlying psychosocial issues such as depression, low self-esteem, family dynamics, or environmental problems), disturbance in body image, and change in weight (ranging from extreme loss of weight in anorexia nervosa to fluctuation around a normal to moderately high weight in bulimia nervosa). The feeding patterns may extend from voluntary restriction of food intake to episodic binge eating (often with a compulsive quality) that may be associated with compensatory behaviors ranging from ritualistic exercise to self-induced vomiting. Excessive concerns about negative body image drive many of the daily behaviors exhibited by young people who have eating disorders, who also have few alternative coping mechanisms for various developmental concerns. Once these dysfunctional patterns are established, they can be very difficult to alter because they serve as coping mechanisms and have their own addictive qualities. The pediatric practitioner has a primary role in the early identification and treatment of mild eating disorders and a collaborative role with appropriate colleagues in adolescent medicine, developmental-behavioral pediatrics, psychology, psychiatry, nutrition, and physical therapy to help patients who have established or severe eating disorders. The often extreme weight loss seen in anorexia nervosa (AN) in combination with the associated medical complications facilitates recognition and the early initiation of treatment. Bulimia nervosa (BM) and binge eating disorder (BED) are more likely to …