Risk factors that predict future onset of restricting versus binge/purge anorexia nervosa in women: an exploratory study

Treatment of Eating Disorders in Children, Adolescents, and Young Adults

Anorexia Nervosa

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders.

Orthorexia nervosa (ON) is characterized as obsessional healthy eating that results in malnutrition and/or psychosocial impairment. Yet, ON shares theoretical overlap with eating disorders (EDs), especially anorexia nervosa (AN), as well as obsessive-compulsive disorder (OCD). This study aimed to further understand ON and its overlap with related disorders by assessing the ability of ON for detecting the presence/absence of threshold ED, AN, and OCD symptoms. An observational survey was completed by 197 participants recruited through eating disorder, dieting, and mental health support groups. Receiver operating characteristic (ROC) curve analyses determined the predictive ability of ON symptoms (assessed by Eating Habits Questionnaire [EHQ] orthorexia nervosa [OrNe] and healthy orthorexia [HeOr] subscales, and the Orthorexia Nervosa Inventory [ONI]) for detecting disordered eating symptoms (determined by Eating Disorder Examination Questionnaire [EDE-Q] global cut-scores), probable AN (determined by EDE-Q cut-scores and body mass index [BMI] <18.5), and OCD symptoms and obsessional thinking (assessed by the Revised Obsessive-Compulsive Inventory [OCI-R]). Results showed both the ONI and EHQ OrNe measures are able to adequately predict ED symptoms and AN; however, both were poor to moderate at detecting OCD symptoms and obsessional thinking. Healthy orthorexia was poor to moderate at detecting outcomes. These results suggest that ON, as it is currently operationalized, may be more closely related to EDs than OCD, and that ON may represent a subtype of AN. Results also support healthy orthorexia as a distinct construct to ON. While results are limited by the lack of definitive ON diagnostic criteria, findings suggest that treatments developed for EDs might be most suited to ON. ON has been proposed as a psychiatric disorder, and it shares theoretical overlap with several existing disorders. This study adopts a novel approach to assessing and exploring the overlap of ON with EDs, AN and OCD. Results suggest that ON shares more overlap with EDs and might best be understood as a subtype of EDs or AN.

Eating Disorders

ObjectiveThis review aimed to examine the validity of self‐report screening questionnaires for identifying eating disorder (ED) risk in adults and adolescents with overweight/obesity.MethodFive databases were searched from inception to September 2020 for studies assessing validation of self‐report ED screening questionnaires against diagnostic interviews in adolescents and adults with overweight/obesity. The review was registered with PROSPERO (https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=220013).ResultsTwenty‐seven papers examining 15 questionnaires were included. Most studies validated questionnaires for adults (22 of 27 studies), and most questionnaires (12 of 15) screened for binge eating or binge‐eating disorder (BED). The Eating Disorder Examination Questionnaire (sensitivity = .16–.88, specificity = .62–1.0) and Questionnaire on Eating and Weight Patterns (sensitivity = .07–1.0, specificity = .0–1.0) were most frequently validated (six studies each). Five studies of three questionnaires were in adolescents, with the Adolescent Binge‐Eating Disorder Questionnaire having highest sensitivity (1.0) but lower specificity (.27). Questionnaires designed to screen for BED generally had higher diagnostic accuracy than those screening for EDs in general.DiscussionQuestionnaires have been well validated to identify BED in adults with overweight/obesity. Validated screening tools to identify other EDs in adults and any ED in adolescents with overweight/obesity are lacking. Thus, clinical assessment should inform the identification of patients with co‐morbid EDs and overweight/obesity.Public SignificanceIndividuals with overweight/obesity are at increased risk of EDs. This review highlights literature gaps regarding screening for ED risk in this vulnerable group. This work presents possibilities for improving care of individuals with overweight/obesity by reinventing ED screening tools to be better suited to diverse populations.

The objective of this study was to characterize the temporal sequencing of symptom emergence for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and purging disorder (PD), as well as to test whether prodromal symptoms increase risk for future onset of each type of eating disorder and compare the predictive effects to those of established risk factors. Data from four prevention trials that targeted high-risk young women with body image concerns (N = 1,952; Mage = 19.7, SD = 5.7) and collected annual diagnostic interview data over 3-year follow-up were combined to address these aims. Regarding behavioral symptoms, compensatory weight control behaviors typically emerged first for AN, BN, and PD, whereas binge eating typically emerged first for BED. Regarding cognitive symptoms, for AN, weight/shape overvaluation typically emerged first, whereas for BN, BED, and PD, overvaluation typically emerged simultaneously with feeling fat and fear of weight gain. Binge eating, compensatory behaviors, weight/shape overvaluation, fear of weight gain, and feeling fat predicted BN, BED, and PD onset, whereas weight/shape overvaluation, fear of weight gain, and lower than expected body mass index predicted AN onset. Predictive effects of prodromal symptoms were similar in magnitude to those of established risk factors: Collectively, prodromal symptoms and risk factors predicted onset of specific eating disorders with 67-83% accuracy. Results suggest that compensatory weight control behaviors and cognitive symptoms are likely to emerge before binge eating in the various eating disorders and that offering indicated prevention programs to youth with prodromal symptoms may be an effective way to prevent eating disorders. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Binge eating and binge drinking commonly onset in adolescence and frequently co-occur with one another, especially among females. Understanding shared and unique risk factors for these behaviors can inform etiological models and elucidation of common and specific prevention/intervention targets. We analyzed self-report data from 1,994 participants of the Pittsburgh Girls Study, a population-based longitudinal study of behavioral and emotional development. We used path analysis to examine the impact of age 14 predictor variables on age 16 binge eating and drinking, adjusting for these behaviors at age 14. We hypothesized that greater negative emotionality, sensation-seeking, and impulsivity would be shared risk factors, whereas higher body mass index and thinness expectancies would be unique to binge eating, and positive alcohol expectancies would be unique to binge drinking. Results showed little comorbidity between binge eating and drinking (1.9% at age 14; 4.4% at age 16). Of the three hypothesized shared risks, only age 14 negative emotionality was associated with both binge eating and drinking at age 16; sensation-seeking was associated with binge drinking only and impulsivity was unrelated to either outcome. None of the hypothesized unique risk factors were associated with binge eating. Contrary to hypotheses, positive alcohol expectancies were related to both binge eating and drinking. While this study requires replication and extension to a greater spectrum of putative risk factors, findings suggest that negative emotionality and positive alcohol expectancies, but not impulse control or appearance-related factors, may be viable targets for unified prevention/treatment protocols delivered in community settings.

The aim of this study was to compare patients admitted to a specialized inpatient program for anorexia nervosa (AN) with and without a fear of weight gain in terms of specific eating disorder symptoms, general psychopathology, and treatment outcome. Measures of specific and general psychopathology were administered at admission to and discharge from the inpatient program. Of the 138 participants, 81% (n = 112) were categorized as having clinical levels of "fear of weight gain" and 19% (n = 26) were categorized as having subclinical levels of this feature. The subclinical-level group had lower scores on measures of eating disorder psychopathology, depression, general psychiatric disturbance, and obsessive-compulsive symptomatology, but higher self-esteem scores. There were no differences found in terms of age of onset of AN, duration of illness, AN subtype, body mass index, or treatment outcome. The current findings provide evidence that underweight patients who deny a fear of weight gain are less disturbed in terms of both eating disorder pathology and general psychopathology.

Males With Restrictive Eating Disorders: Barriers to Their Care

Eating Disorders: What Are the Risks?

Comorbidity among eating disorders, traumatic events, and posttraumatic stress disorder (PTSD) has been reported in several studies. The main objectives of this study were to describe the nature of traumatic events experienced and to explore the relationship between PTSD and anorexia nervosa (AN) in a sample of women. Eight hundred twenty-four participants from the National Institutes of Health-funded Genetics of Anorexia Nervosa Collaborative Study were assessed for eating disorders, PTSD, and personality characteristics. From a final sample of 753 women with AN, 13.7% (n = 103) met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for PTSD. The sample mean age was 29.5 (standard deviation = 11.1) years. In pairwise comparisons across AN subtypes, the odds of having a PTSD diagnosis were significantly lower in individuals with restricting AN than individuals with purging AN without binge eating (odds ratio = 0.49, 95% confidence interval = 0.30-0.80). Most participants with PTSD reported the first traumatic event before the onset of AN (64.1%, n = 66). The most common traumatic events reported by those with a PTSD diagnosis were sexually related traumas during childhood (40.8%) and during adulthood (35.0%). AN and PTSD do co-occur, and traumatic events tend to occur before the onset of AN. Clinically, these results underscore the importance of assessing trauma history and PTSD in individuals with AN and raise the question of whether specific modifications or augmentations to standard treatment for AN should be considered in a subgroup to address PTSD-related psychopathology.

This study prospectively investigated the course of bone mineral density (BMD) in patients with anorexia nervosa (AN) and bulimia nervosa (BN) over a 3.6-yr follow-up period. From an initial sample of 47 female patients with an eating disorder (T1), 38 (n = 24 AN; n = 14 BN) were reassessed at follow-up (T2) (participation rate, 80.1%). For nonrecovered AN patients at T2, prevalence rates of osteopenia (-1.0 SD > or = T-score > -2.5 SD) and osteoporosis (T-score < or = -2.5 SD) at the lumbar spine were 54.2 and 20.8%, respectively. Due to an annual loss of lumbar spine BMD (-3.7 +/- 4.9%) in the chronic AN patients and a slight but insignificant annual increase (0.7 +/- 1.7%) for those who recovered, the difference in BMD between both outcome groups was more pronounced at follow-up (0.93 +/- 0.13 vs. 1.14 +/- 0.13 g/cm2; P < 0.01). Nonrecovered AN patients with binge eating/purging type showed a significantly reduced BMD compared with patients with the restricting type (0.87 +/- 0.13 vs. 1.02 +/- 0.08 g/cm2; P = 0.02). Both at baseline and follow-up, AN patients had increased rates of bone resorption, as measured by urinary desoxypyridinoline, compared with a control group (n = 42) (11.4 +/- 4.4 vs. 10.4 +/- 7.8, P < 0.001, vs. 5.6 +/- 2.4 and 10.4 +/- 7.8 nM/mM creatinine, P < 0.05, respectively). The subtype of AN and body mass index were best predictors for BMD at the lumbar spine at follow-up (R2 = 0.576). With one exception, all bulimic patients had BMD and markers of bone turnover within the normal range. These results suggest that patients with chronic AN, particularly of the binge eating/purging type, are at high risk for osteoporosis and may need additional therapy to prevent bone loss.

Dynamic relationships among feeling fat, fear of weight gain, and eating disorder symptoms in an eating disorder sample

BackgroundDiabetic peripheral neuropathy (DPN) and lower extremity arterial disease (LEAD) are significant contributors to diabetic foot ulcers (DFUs), which severely affect patients’ quality of life. This study aimed to develop machine learning (ML) predictive models for DPN and LEAD and to identify both shared and distinct risk factors.MethodsThis retrospective study included 479 diabetic inpatients, of whom 215 were diagnosed with DPN and 69 with LEAD. Clinical data and laboratory results were collected for each patient. Feature selection was performed using three methods: mutual information (MI), random forest recursive feature elimination (RF-RFE), and the Boruta algorithm to identify the most important features. Predictive models were developed using logistic regression (LR), random forest (RF), and eXtreme Gradient Boosting (XGBoost), with particle swarm optimization (PSO) used to optimize their hyperparameters. The SHapley Additive exPlanation (SHAP) method was applied to determine the importance of risk factors in the top-performing models.ResultsFor diagnosing DPN, the XGBoost model was most effective, achieving a recall of 83.7%, specificity of 86.8%, accuracy of 85.4%, and an F1 score of 83.7%. On the other hand, the RF model excelled in diagnosing LEAD, with a recall of 85.7%, specificity of 92.9%, accuracy of 91.9%, and an F1 score of 82.8%. SHAP analysis revealed top five critical risk factors shared by DPN and LEAD, including increased urinary albumin-to-creatinine ratio (UACR), glycosylated hemoglobin (HbA1c), serum creatinine (Scr), older age, and carotid stenosis. Additionally, distinct risk factors were pinpointed: decreased serum albumin and lower lymphocyte count were linked to DPN, while elevated neutrophil-to-lymphocyte ratio (NLR) and higher D-dimer levels were associated with LEAD.ConclusionsThis study demonstrated the effectiveness of ML models in predicting DPN and LEAD in diabetic patients and identified significant risk factors. Focusing on shared risk factors may greatly reduce the prevalence of both conditions, thereby mitigating the risk of developing DFUs.