Search

Weight-centric health practices are based on the principle that excess weight predicts chronic disease, informing a growing sociopolitical movement to address an "obesity epidemic." This hyper-focus on preventing obesity may contribute to weight stigma (i.e., the devaluation and discrimination of individuals based on body size) and other iatrogenic outcomes for youth, including the development and maintenance of eating disorders (EDs). Current evidence-based treatments for EDs include language and practices that may reinforce fears of fatness, body shame, and unhealthy dietary restriction without guidance on addressing weight stigma. Here, we present case examples from three adolescent patients across ED presentations and body sizes to (1) elucidate the role of weight stigma in ED development, (2) highlight the ubiquity and harms of weight stigma within ED treatments, and (3) outline thoughtful protocol adaptations to avoid further harm and facilitate recovery. We conclude with a call for immediate action to advance research characterizing the harms of weight-centric approaches in existing ED interventions to reduce the risk of iatrogenic effects on youth with EDs and advance weight-inclusive approaches to ED treatment.

ObjectiveParental 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.MethodsPatients 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.ResultsParents 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

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  .05). Adolescents with PHW (vs. PLW) were more likely to be diagnosed with AAN (67.9 %, p

ObjectiveThe 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.MethodParticipants (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.ResultsAbout 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).DiscussionDespite 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 significanceThe 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 (EDs) are complex psychiatric diagnoses requiring specialized care. Family-based treatment (FBT) is the first-line treatment for adolescent anorexia nervosa and is also efficacious for other EDs. This study describes practice changes due to the implementation of an integrated interdisciplinary FBT-aligned treatment program for EDs at a large tertiary care hospital in the United States. We examined the feasibility and acceptability of implementation, barriers to implementation, and impact on providers' roles over a one-year period. Practice changes came with shifts in roles, and were largely experienced as acceptable with good suitability. Barriers identified may inform future interdisciplinary implementation efforts.

Populations at high risk for COVID-19- including Spanish speakers-may face additional barriers to obtaining COVID-19 vaccinations; by understanding their challenges, we can create more equitable vaccine interventions. In this study, we used interviews to identify barriers and enablers to COVID-19 vaccine uptake among participants in the San Francisco Department of Public Health contact tracing program. Data analysis employed Capability, Opportunity, Motivation Behavior model (COM-B) and the Behavior Change Wheel framework as guides to target barriers with interventions and supporting policies. This paper presents data from interviews focused on COVID-19 vaccine uptake that was part of a project to improve COVID-19 preventive behaviors in San Francisco. We completed seventeen interviews between February and May 2021; six (35%) were completed in English and 11 (65%) in Spanish. Barriers to vaccine uptake included an unprepared health system, fear of side effects, limited knowledge, and conflicting information. Behavioral factors influencing vaccine uptake were mainly related to physical opportunity, automatic motivation, and psychological capability. Interventions that could address the most significant number of barriers included education, enablement, and environmental restructuring. Finally, communication and marketing policies that use diverse multi-lingual social media and environmental planning that includes accessible vaccine sites for people with disabilities, literacy barriers, and limited English proficiency could significantly increase vaccination. Public health departments should tailor interventions to high-risk populations by understanding the specific barriers they face. This exploratory study suggests how implementation science can provide frameworks to achieve this.

BackgroundEating disorders are associated with substantial morbidity and mortality that can be minimized by timely access to evidence-based treatment. However, disparate access to eating disorders treatment may contribute to significant health disparities amongst marginalized groups. This study examined the association between insurance type (public vs. private) and receipt of recommended mental health treatment in a sample of racially/ethnically diverse youth who presented to an adolescent medicine clinic with malnutrition secondary to disordered eating.MethodsA retrospective chart review was conducted for youth ages 11-25 years (N = 1060) who presented to an urban adolescent medicine specialty program between June 1, 2012 and December 31, 2019 for malnutrition secondary to disordered eating. Bivariate and logistic regression analyses examined the association between insurance type (public vs. private) and other demographic/clinical factors on receipt of recommended treatment within six months of the initial evaluation.ResultsPatients with public insurance were one third as likely to receive recommended treatment as patients with private insurance (AOR = 3.23; 95% CI = 1.99, 4.52), after adjusting for demographic and clinical factors. Latinx (AOR = 0.49; 95% CI = 0.31, 0.77) and Asian (AOR = 0.55; 95% CI = 0.32, 0.94) patients were half as likely to receive recommended treatment as White patients.ConclusionsAccess to evidence-based mental health treatment is a necessary first step towards health equity for individuals with eating disorders. Additional work is needed to dismantle systemic inequities that contribute to disparities in care for youth of color and those with public insurance.

Over the course of the COVID-19 pandemic, rates of eating disorders have increased, further straining systems of care that were already overburdened. The current paper describes novel interventions, largely informed by Family-Based Treatment (FBT), that were implemented by a tertiary specialist adolescent eating disorders service. In response to the pandemic, programming was designed to bridge access to care while waiting for availability of evidence-based therapy. The Brief Psychology Consultation Clinic provides several sessions to patients and families, focused on psychoeducation and problem-solving informed by FBT and other evidence-based therapies. Two groups, the FBT Caregiver Workshop Series and FBT Caregiver Support Group, provide psychoeducation and support for caregivers of youth with eating disorders. Perceived strengths and benefits of these services, as well as barriers to implementation and future research directions are discussed.

Introduction: Emerging data suggest that the COVID-19 pandemic has disproportionately impacted women in academic medicine, potentially eliminating recent gains that have been made toward gender equity. This study examined possible pandemic-related gender disparities in research grant submissions, one of the most important criteria for academic promotion and tenure evaluations. Methods: Data were collected from two major academic institutions (one private and one public) on the gender and academic rank of faculty principal investigators who submitted new grants to the National Institutes of Health (NIH) during COVID-19 (March 1st, 2020, through August 31, 2020) compared with a matched period in 2019 (March 1st, 2019, through August 31, 2019). t-Tests and chi-square analyses compared the gender distribution of individuals who submitted grants during the two periods of examination. Results: In 2019 (prepandemic), there was no significant difference in the average number of grants submitted by women compared with men faculty. In contrast, women faculty submitted significantly fewer grants in 2020 (during the pandemic) than men. Men were also significantly more likely than women to submit grants in both 2019 and 2020 compared with submitting in 2019 only, suggesting men faculty may have been more likely than their women colleagues to sustain their productivity in grant submissions during the pandemic. Discussion: Women's loss of extramural funding may compound over time, as it impedes new data collection, research progress, and academic advancement. Efforts to support women's research productivity and career trajectories are urgently needed in the following years of pandemic recovery.

In the USA, family-based treatment (FBT) with inpatient medical stabilization as needed is the leading evidence-based treatment for youth with anorexia nervosa (AN). In continental Europe, typically inpatient multimodal treatment targeting weight recovery followed by outpatient care (IMT) is standard care, if prior outpatient treatment was not sufficient. Our aim was to compare weekly weight gain and hospital days over six months for adolescents receiving FBT (USA) versus IMT (Germany) using naturalistic treatment data. To yield similar subgroups of youth aged 12−18 years, inclusion criteria were a percent median BMI (%mBMI) between 70−85 and the restrictive AN subtype. Weight gain and hospital days were compared, adjusted further in a multiple linear regression analysis (MLRA) for baseline group differences. Samples differed on baseline %mBMI (FBT [n = 71], 90.5 ± 12.8; IMT [n = 29], 78.3 ± 9.1, p < 0.05). In subgroups with comparable baseline %mBMI, the weekly weight gain over 6 months was similar (FBT [n = 21]: 0.35 ± 0.18 kg/week; IMT [n = 20]: 0.30 ± 0.18, p = 0.390, p = 0.166 after MLRA), but achieved fewer hospital days in FBT (FBT [n = 7]: 4 ± 6 days, IMT [n = 20]: 121 ± 42 days, p < 0.0001 before and after MLRA). FBT may be effective for a subgroup of adolescents with AN currently receiving IMT, but head-to-head studies in the same healthcare system are needed.

BackgroundEating disorders have serious psychological and physical consequences. Current evidence-based treatments for adolescents with eating disorders have modest effects, underscoring the need to improve current treatment approaches. Cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) have been proposed as alternative treatment options, with burgeoning research in this area. This review aims to summarize and critically analyze the current literature on the feasibility, acceptability, effectiveness, and efficacy of CBT and DBT for adolescent eating disorders, and then proposes areas of future research.MethodsPsycINFO and PubMed were searched using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify studies examining the feasibility, acceptability, effectiveness and/or efficacy of CBT or DBT for adolescent eating disorders.ResultsEligible studies (N = 50; CBT: n = 40, DBT: n = 10) indicated that both treatments are reasonably feasible, acceptable, and possibly effective for adolescent eating disorders across diagnoses and levels of care, though efficacy trials are lacking.ConclusionsCBT and DBT demonstrate promise as alternatives to family-based approaches for adolescent eating disorders. Adequately powered trials to establish the effectiveness and efficacy of CBT and DBT are needed, particularly ones that compare these treatments against other leading approaches. Despite high rates of relapse and likelihood for severe and enduring illness, there is a dearth of evidence-based treatment options for adolescents with eating disorders. Potentially viable but less well-studied treatments for adolescents with eating disorders include cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). This systematic review of CBT and DBT for adolescent eating disorders focuses on feasibility (i.e., how easy it was to implement the treatment), acceptability (i.e., how well the intervention was received by patients and therapists), effectiveness (i.e., how well the intervention performed under routine, real-world circumstances), and efficacy (i.e., how well the intervention performed in highly-controlled research settings). This review concludes that research supports the feasibility and acceptability of these approaches, as well as preliminary evidence of their effectiveness. However, the field is lacking studies that systematically compare CBT and DBT to other evidence-based approaches. Recommendations to advance research on CBT and DBT for adolescent eating disorders are provided, including a call for efficacy studies that clarify their performance compared to other leading approaches.

BackgroundFamily-based treatment (FBT) for anorexia nervosa is an evidence-based treatment, but its effectiveness is untested among socioeconomically disadvantaged and racially diverse youth. Adapting FBT may facilitate "scale-out" for Medicaid-insured youth served in publicly-funded settings and potentially improve outcomes for more diverse populations.MethodsThis mixed methods effectiveness-implementation Hybrid Type 3 pilot study protocol included a planning period in collaboration with the San Francisco Department of Public Health, culminating in a two-day in-person FBT training for 25 therapists in the county, followed by the opportunity to engage in one year of weekly supervision. The training incorporated FBT adaptations intended to improve fit for low-income families within community-based settings. Treatment appropriateness and acceptability will be measured immediately post-training. Following the training, cases referred for FBT will only be assigned to the trained clinicians who voluntarily opted into long-term group supervision. Clinicians treating at least one FBT case during the supervision period will report on implementation, adaptations, and patient weight gain. Finally, semi-structured interviews with clinician participants will be conducted, focused on implementation challenges and facilitators, local treatment adaptations, and overall satisfaction with FBT.DiscussionLearning about clinician adaptations will advance knowledge about treatment of eating disorders in publicly-funded community clinics, which serve a racially/ethnically and socioeconomically diverse group of youth. This project is designed to accelerate FBT implementation in publicly-funded mental health systems, and inform service improvements for underserved youth with eating disorders.

ObjectiveOutcome measurement in youth with eating disorders relies heavily on self-report, which is problematic in a population that may deny or minimize symptoms. Caregiver-report measures are lacking. This study examined the psychometric and clinical properties of a newly-developed measure designed to assess short-term change in eating disorder symptomatology as observed by caregivers-the Eating Disorder-15 for Parents/Caregivers (ED-15-P).MethodAt initial presentation to an outpatient eating disorders assessment, 206 families (primary caregiver and their child up to 18 years old) completed psychological measures.ResultsThe ED-15-P demonstrated excellent reliability, preliminary evidence of discriminant and concurrent validity, and good sensitivity to change early in treatment (first 8 weeks). Agreement between primary caregivers and children on eating disorder psychopathology was moderate, while agreement between pairs of caregivers was relatively strong. Level of agreement varied across behaviors and informants, with poorer caregiver-child agreement on dieting and driven exercise.DiscussionAgreement was stronger within caregiver pairs than caregiver-child pairs, indicating that caregivers and their children have related but unique perspectives on eating disorder symptoms, highlighting the importance of multi-informant assessment. The ED-15-P complements a parallel youth report measure to more comprehensively assess eating disorder psychopathology, with high utility for measuring change over time.

Background and objectivesWe 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.MethodsIn 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.ResultsOf 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.ConclusionsThe 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.

ObjectiveDespite evidence supporting the use of measures to track ongoing progress and outcome in treatment, there is a relative absence of measures that are appropriate for this purpose in youth with eating disorders. This study examined the psychometric properties of the Eating Disorder-15 for Youth (ED-15-Y) scale, including its ability to detect short-term change in symptomatology.MethodYouth (N = 203) ages 8-18 years completed self-report questionnaires and semi-structured diagnostic interviews upon initial presentation for an outpatient eating disorders assessment at an academic medical center.ResultsThe ED-15-Y demonstrated excellent reliability (internal consistency, split-half reliability) and high sensitivity to change early in treatment (change from sessions 1 to 8, adjusting for baseline score). Further, these data demonstrate that the ED-15-Y has excellent convergent validity, being highly correlated with a well-tested, longer measure of eating disorders psychopathology-the Eating Disorders Examination-Questionnaire (EDE-Q). These data also support good discriminant and concurrent validity, differentiating between youth without an eating disorder or with ARFID and youth with eating disorders involving weight and shape concerns (e.g., anorexia nervosa, bulimia nervosa).DiscussionThe ED-15-Y may be a useful tool to briefly assess eating disorder psychopathology in youth as young as 8 years old. Its sensitivity to change very early in treatment suggests that it has the potential to be used as a routine outcome measure in the context of treatment.

ObjectivePsychotropic medication use in youth with eating disorders (EDs) is poorly understood despite high co-occurrence of psychiatric disorders. This study examined characteristics associated with medication use in treatment-seeking youth with EDs.MethodYouth up to age 18 reported on medication use when presenting to an academic medical center outpatient ED service in the United States. Data presented were collected between 1998-2015.ResultsThe sample (N = 604) was predominantly female (90.6%) with a mean age of 15.3 years (SD = 2.3). Approximately one-third (30%, n = 173) were taking psychotropic medications (40%, n = 70, were taking multiple medications). Antidepressant use was most common (26%, n = 152), followed by atypical antipsychotics (8%, n = 43). Adjusting for co-occurring psychiatric disorders, non-Hispanic Whites who had received prior treatment (psychotherapy, hospitalization) were significantly more likely to be using medication. Longer illness duration and prior treatment were associated with greater antidepressant use. For atypical antipsychotics, prior hospitalization was associated with greater use.ConclusionsFindings confirm moderate psychotropic medication use among young patients with EDs despite a lack of clarity regarding optimally effective pharmacologic interventions in this population. Pharmacological trials examining the efficacy of medications for young patients with EDs are warranted to inform future prescribing practice.

ObjectiveThis study used mixed methods to evaluate caregiver perspectives on recovery from an eating disorder.MethodCaregivers (N = 387) completed an online survey about their child's weight history, treatment history, illness trajectory, and recovery.ResultsChildren were predominantly females with adolescent onset anorexia nervosa and currently 18.4 years old on average. Qualitative analysis of caregivers' open-ended definitions of recovery revealed seven distinct recovery domains, including (a) weight (45%); (b) body image, eating disorder cognitions, and related emotions (54%); (c) eating behavior (71%); (d) independence and responsibility in eating disorder management (28%); (e) physical health (21%); (f) psychological well-being (31%); and (g) life worth living (27%). Most (72%) reported that their child had achieved partial or full recovery at some point in their lifetime. Only 20% reported that their child had ever achieved full recovery, but 93% of those had sustained recovery over time (i.e., no relapses since achieving recovery). Physical recovery occurred on average 2.7 years after eating disorder onset, followed shortly by social and emotional recovery (2.9 years), and finally behavioral (3.4 years) and cognitive (3.9 years) recovery, which occurred at weights 6-7 pounds higher than those at which physical recovery was achieved.DiscussionFindings suggest that caregivers hold a multifaceted view of recovery that includes not only weight restoration and symptom reduction, but also full engagement in social and occupational activities, establishment of a meaningful life, cognitive flexibility, and emotional well-being. These data support clinical observations that physical and behavioral recovery precede cognitive recovery.

Comparing evidence-based psychotherapy (EBP) to usual care typically demonstrates the superiority of EBPs, although this has not been studied for eating disorders EBPs such as family-based treatment (FBT). The current study set out to examine weight outcomes for adolescents with anorexia nervosa who received FBT through a randomized clinical research trial (RCT, n = 54) or non-research specialty care (n = 56) at the same specialist pediatric eating disorder service. Weight was recorded throughout outpatient treatment (up to 18 sessions over 6 months), as well as at 6- and 12-month follow-up. Survival curves were used to examine time to weight restoration [greater than 95% median body mass index (mBMI)] as predicted by type of care (RCT vs. non-research specialty care), baseline clinical and demographic characteristics, and their potential interaction. Results did not indicate a significant main effect for type of care, but there was a significant effect for baseline weight (p = .03), such that weight restoration was achieved faster across both treatment types for those with a higher initial %mBMI. These data suggest that weight restoration achieved in non-research specialty care FBT was largely similar to that achieved in a controlled research trial.Clinical trial registrationhttp://www.anzctr.org.au/, identifier ACTRN12610000216011.

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.

ObjectiveEarly response, as indicated by early weight gain, in family-based treatment (FBT) for adolescent anorexia nervosa (AN) predicts remission at end of treatment. However, little is known about what factors contribute to early response. Further, no previous studies have examined early response to separated forms of FBT.MethodData from a randomised clinical trial of conjoint FBT and separated FBT (parent-focused treatment, PFT) were analysed to examine the timing and amount of early weight gain that predicted remission and identify factors associated with early response.ResultsWeight gain of at least 2.80 kg in FBT (N = 55) and 2.28 kg in PFT (N = 51), by Session 5, were the best predictors of remission at end of treatment. Early response in FBT was predicted by greater paternal therapeutic alliance and lower paternal criticism. Early response in PFT was predicted by less severe eating-disorder symptoms and negative affect at baseline, lower maternal criticism, and greater adolescent therapeutic alliance.ConclusionsThe results confirm that early weight gain is an important prognostic indicator in both conjoint FBT and PFT and suggest that addressing negative emotion, parental criticism, and therapeutic alliance early in treatment could improve remission rates.

Comparing evidence-based psychotherapy (EBP) to usual care typically demonstrates the superiority of EBPs, although this has not been studied for eating disorders EBPs such as family-based treatment (FBT). The current study set out to examine weight outcomes for adolescents with anorexia nervosa who received FBT through a randomized clinical research trial (RCT, n = 54) or non-research specialty care (n = 56) at the same specialist pediatric eating disorder service. Weight was recorded throughout outpatient treatment (up to 18 sessions over 6 months), as well as at 6- and 12-month follow-up. Survival curves were used to examine time to weight restoration [greater than 95% median body mass index (mBMI)] as predicted by type of care (RCT vs. non-research specialty care), baseline clinical and demographic characteristics, and their potential interaction. Results did not indicate a significant main effect for type of care, but there was a significant effect for baseline weight (p = .03), such that weight restoration was achieved faster across both treatment types for those with a higher initial %mBMI. These data suggest that weight restoration achieved in non-research specialty care FBT was largely similar to that achieved in a controlled research trial. Clinical Trial Registration:http://www.anzctr.org.au/, identifier ACTRN12610000216011.

ABSTRACT Objective Method Results Discussion This study describes the current management of patients with eating disorders (EDs) served by publicly–funded Medicaid behavioral health systems.Behavioral health leaders across nine counties in California met on a quarterly basis to share experiences, challenges, and lessons in the management of EDs within publicly–funded service systems. Detailed notes were taken, and a qualitative content analysis was undertaken to identify key themes.County leadership noted insufficient outpatient capacity and difficulty building capacity for ED treatment, in addition to extraordinary challenges when facilitating admission to out‐of‐network higher level of care programs, at significant expense. Several challenges were identified in building an internal ED workforce, including the fact that many providers weren't eager to treat EDs due to training burden, patient complexity, and high levels of clinician burnout. When a higher level of care was required due to lack of outpatient resources or patient symptom severity or complexity, leaders dedicated significant resources to identify and contract with an appropriate program and secure the necessary funds.Our study supports the need for specialized ED treatment and case management, as well as standardized processes and centralized resources, in Medicaid‐managed care. Findings also indicate the importance of protecting against clinician burnout, possibly through reduced caseload expectations, financial incentives, or increased support. Future policy change could reduce administrative burden and clinician burnout by facilitating admission to and reimbursement for higher levels of care. [ABSTRACT FROM AUTHOR]

Given that weight gain patterns in adolescents receiving outpatient Family-Based Treatment (FBT) have not been characterized, the purpose of this study was to examine trajectories of weight gain in a group of adolescent patients with a restrictive eating disorder [e.g., anorexia nervosa (AN) and atypical AN] receiving FBT. This study also examined the association of patient characteristics with weight gain trajectories, including age, diagnosis, weight suppression, presenting BMI-for-age percentile, and eating pathology. Latent growth mixture modeling was used to identify distinct weight trajectories, as defined by change in BMI-for-age percentile, for 153 adolescents with AN or atypical AN, receiving FBT. There were five distinct weight gain trajectory profiles for adolescents receiving FBT for a restrictive eating disorder. Younger age and greater weight suppression were associated with more rapid weight gain trajectories. A pattern of slow and consistent weight gain was associated with older age and less eating pathology. There was considerable variability in weight gain trajectories in youth receiving outpatient FBT for a restrictive eating disorder. This suggests that patients' presenting information can be used to inform expectations regarding weight gain trajectories.

OBJECTIVE:Family-based treatment (FBT) is an efficacious treatment for adolescent eating disorders, yet it is not routinely implemented in clinical practice. Given that consumers play a role in treatment selection, this study sought to examine families' perspectives on FBT and remission markers associated with increased treatment satisfaction across families. METHOD:Participants were 40 adolescents and 43 caregivers who received outpatient FBT. FBT helpfulness was assessed using a treatment follow-up questionnaire, and eating disorder symptomatology was assessed using percent expected body weight (%EBW) and the eating disorder examination (EDE). Regression analyses were used to assess whether changes in symptoms from baseline to end-of-treatment (EOT) were significantly associated with helpfulness reports. RESULTS:On average, patients and their parents perceived FBT as "quite helpful" and "extremely helpful," respectively. Improvements in all EDE subscales, with the exception of restraint, were significantly associated with adolescent report of helpfulness (all p

Although family-based therapy (FBT) is a well-established treatment for anorexia nervosa, its implementation and effectiveness in clinical settings has been neglected. A group of seven therapists at a community-based eating disorders clinic were trained in skills-enhanced FBT and provided treatment to 11 youth with anorexia nervosa. Family-based skills training, which borrowed heavily from dialectical behavior therapy, was introduced in four additional sessions and then integrated throughout the remainder of FBT. FBT was perceived as appropriate and acceptable by all participants. Therapists reported high treatment fidelity. There was a large improvement in weight and moderate improvement in caregiver-reported eating disorder psychopathology but no clinically significant change by youth report. This study provides preliminary data on the implementation and effectiveness of FBT in the community.

This study characterizes variations in duration, salary support, policy clarity, and constraints or prerequisites for childbearing and family leave policies at 12 top-tier US medical schools.

Classifying eating disorders in youth is challenging in light of developmental considerations and high rates of diagnostic migration. Understanding the transactional relationships among eating disorder symptoms, both across the transdiagnostic spectrum and within specific diagnostic categories, may clarify which core eating disorder symptoms contribute to, and maintain, eating-related psychopathology in youth. We utilized network analysis to investigate interrelationships among eating disorder symptoms in 636 treatment-seeking children and adolescents (90.3% female) ages 6-18 years (M age = 15.4 ± 2.2). An undirected, weighted network of eating disorder symptoms was created using behavioral and attitudinal items from the Eating Disorder Examination. Across diagnostic groups, symptoms reflecting appearance-related concerns (e.g., dissatisfaction with shape and weight) and dietary restraint (e.g., a desire to have an empty stomach) were most strongly associated with other eating disorder symptoms in the network. Binge eating and compensatory behaviors (e.g., self-induced vomiting) were strongly connected to one another but not to other symptoms in the network. Network connectivity was similar across anorexia nervosa, bulimia nervosa, and otherwise specified feeding or eating disorder subgroups. Among treatment-seeking children and adolescents, dietary restraint and shape- and weight-related concerns appear to play key roles in the psychopathology of eating disorders, supporting cognitive-behavioral theories of onset and maintenance. Similarities across diagnostic categories provide support for a transdiagnostic classification scheme. Clinical interventions should seek to disrupt these symptoms early in treatment to achieve maximal outcomes. (PsycINFO Database Record

While many studies have explored the relationship between different eating disorder diagnoses and the familial social environment, current evidence does not support associations between distinct family interaction patterns (e.g. high enmeshment) and particular diagnoses (e.g. anorexia nervosa). The current study seeks to move beyond the current literature to explore whether empirically derived subtypes of family environment are associated with clinical features within a transdiagnostic sample of youth seeking treatment for eating disorders (n = 123). Latent class modelling of the Family Environment Scale identified three classes (i.e. different Family Environment Scale profiles): (1) Control-Oriented; (2) System Maintenance-Oriented; and (3) Conflict-Oriented. Data are presented to characterize the classes (e.g. age, gender, rates of different eating disorders, severity of eating disorder pathology and rates of comorbid disorders). These preliminary results suggest that family interaction types may help personalize treatment for eating disorders and encourage future research to guide such efforts. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

ObjectiveIndividuals with eating disorders (ED), particularly anorexia nervosa (AN), and bulimia nervosa (BN), often wish to reduce their body weight in pursuit of a thin ideal, but no study has examined the relation between desired weight and ED pathology in a clinical population of youth. Given the potential impact of desired weight on normalization of eating patterns and weight restoration, we examined the relation between desired weight and ED pathology in youth with AN or BN.MethodsParticipants were 340 youth presenting to an outpatient ED clinical research program. Height and weight were measured, and youth completed the Eating Disorder Examination. Desired weight was operationalized as "desired weight percentage" (calculated as a percentage of expected body weight [EBW]) and "weight difference percentage" (actual weight minus desired weight, divided by actual weight and multiplied by 100).ResultsYouth with AN desired to be a lower percentage of their EBW than youth with BN (p

ObjectiveThis study examined physician residents' and fellows' knowledge of eating disorders and their attitudes toward patients with eating disorders.MethodsEighty physicians across disciplines completed a survey. The response rate for this survey across disciplines was 64.5 %.ResultsParticipants demonstrated limited knowledge of eating disorders and reported minimal comfort levels treating patients with eating disorders. Psychiatry discipline (p = 0.002), eating disorder experience (p = 0.010), and having ≥4 eating disorder-continuing medical education credits (p = 0.037) predicted better knowledge of anorexia nervosa but not bulimia nervosa. Psychiatry residents (p = 0.041), and those who had treated at least one eating disorder patient (p = 0.006), reported significantly greater comfort treating patients with eating disorders.ConclusionThese results suggest that residents and fellows from this sample may benefit from training to increase awareness and confidence necessary to treat patients with eating disorders. Sufficient knowledge and comfort are critical since physicians are often the first health care provider to have contact with patients who have undiagnosed eating disorders.

ObjectiveThe purpose of this investigation was to examine the indirect effects of Integrative Cognitive-Affective Therapy (ICAT-BN) and Cognitive-Behavioral Therapy-Enhanced (CBT-E) on bulimia nervosa (BN) treatment outcome through three hypothesized maintenance variables: emotion regulation, self-directed behavior, and self-discrepancy.MethodEighty adults with BN were randomized to 21 sessions of ICAT-BN or CBT-E. A regression-based bootstrapping approach was used to test the indirect effects of treatment on outcome at end of treatment through emotion regulation and self-directed behavior measured at mid-treatment, as well as the indirect effects of treatment at follow-up through emotion regulation, self-directed behavior, and self-discrepancy measured at end of treatment.ResultsNo significant differences in outcome between treatment conditions were observed, and no significant direct or indirect effects were found. Examination of the individual paths within the indirect effects models revealed comparable treatment effects. Across treatments, improvements in emotion regulation and self-directed behavior between baseline and mid-treatment predicted improvements in global eating disorder scores but not binge eating and purging frequency at end of treatment. Baseline to end of treatment improvements in emotion regulation and self-directed behavior also predicted improvements in global eating disorder scores at follow-up. Baseline to end of treatment improvements in emotion regulation predicted improvements in binge eating and baseline to end of treatment increases in positive self-directed behavior predicted improvements in purging at follow-up.DiscussionThese findings suggest that emotion regulation and self-directed behavior are important treatment targets and that ICAT-BN and CBT-E are comparable in modifying these psychological processes among individuals with BN.

ObjectiveEating disorder diagnostic criteria were revised from the fourth to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and -5, respectively). This study examines the impact of these revisions on rates of eating disorder diagnoses in treatment-seeking youth.MethodParticipants were 651 youth, ages 7-18 years, presenting to an outpatient eating disorders program who met criteria for a DSM-IV eating disorder diagnosis on intake. Patients completed well-validated semi-structured interviews to assess eating disorder psychopathology and psychiatric comorbidity.ResultsParticipants were predominantly female (n = 588; 90.3%) with an average age of 15.28 years (SD = 2.21), mean percent of median Body Mass Index (mBMI) of 101.91 (SD = 31.73), and average duration of illness of 16.74 months (SD = 17.63). Cases of DSM-IV Eating Disorder Not Otherwise Specified (EDNOS), now most consistent with DSM-5 Other Specified Feeding or Eating Disorder, decreased from 47.6% to 39.0%, Anorexia Nervosa increased from 29.6% to 33.5%, and Bulimia Nervosa increased from 22.7% to 24.7%.DiscussionConsistent with previous studies, and in keeping with the aims of the DSM-5 for eating disorders, the revised diagnostic criteria reduced cases of DSM-IV EDNOS and increased cases of specified eating disorders. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:578-581).

Background: Family-based treatment (FBT) is the leading intervention for adolescents with anorexia nervosa (AN); however, it is under researched in socioeconomically disadvantaged and racially diverse youth. Methods: Semi-structured interviews were completed with ten FBT clinicians who practice in publicly-funded settings. Interview questions were focused on implementation challenges, overall acceptability and appropriateness of FBT, and naturally-occurring treatment adaptations. Results: Content analysis revealed common themes relating to the implementation of FBT in publicly-funded, community-based settings: acceptability and appropriateness, complexity and learnability, perceived core components of FBT, cultural adaptations, socioeconomic factors, logistical considerations, organizational and systemic barriers, training acceptability, participant's self-efficacy, and telehealth accommodations. Conclusion: The discussed themes offer insights into the implementation of FBT for settings with limited resources, aligning with prior research on clinical adaptations for multicultural patients. Recognizing these themes can guide clinical adjustments and refine the adapted treatment model in real-world settings for patients facing systemic barriers. [ABSTRACT FROM AUTHOR]

Although loss of control (LOC) while eating is a core construct of bulimia nervosa (BN), questions remain regarding its validity and prognostic significance independent of overeating. We examined trajectories of objective and subjective binge eating (OBE and SBE, respectively; i.e., LOC eating episodes involving an objectively or subjectively large amount of food) among adults participating in psychological treatments for BN-spectrum disorders (n = 80). We also explored whether changes in the frequency of these eating episodes differentially predicted changes in eating-related and general psychopathology and, conversely, whether changes in eating-related and general psychopathology predicted differential changes in the frequency of these eating episodes. Linear mixed models with repeated measures revealed that OBE decreased twice as rapidly as SBE throughout treatment and 4-month follow-up. Generalized linear models revealed that baseline to end-of-treatment reductions in SBE frequency predicted baseline to 4-month follow-up changes in eating-related psychopathology, depression, and anxiety, while changes in OBE frequency were not predictive of psychopathology at 4-month follow-up. Zero-inflation models indicated that baseline to end-of-treatment changes in eating-related psychopathology and depression symptoms predicted baseline to 4-month follow-up changes in OBE frequency, while changes in anxiety and self-esteem did not. Baseline to end-of-treatment changes in eating-related psychopathology, self-esteem, and anxiety predicted baseline to 4-month follow-up changes in SBE frequency, while baseline to end-of-treatment changes in depression did not. Based on these findings, LOC accompanied by objective overeating may reflect distress at having consumed an objectively large amount of food, whereas LOC accompanied by subjective overeating may reflect more generalized distress related to one's eating- and mood-related psychopathology. BN treatments should comprehensively target LOC eating and related psychopathology, particularly in the context of subjectively large episodes, to improve global outcomes.

BackgroundWeight suppression (WS), which is the difference between a patient's highest and current weight, has been associated with bulimic symptom severity in adults with bulimia nervosa (BN). However, the impact of WS on eating disorder psychopathology in youth with BN is unknown.MethodsParticipants included 85 youth with DSM-5 BN who presented for outpatient treatment. Current WS was calculated as the difference between highest and current body mass index z-score (BMIz), while greatest WS was the difference between highest and lowest BMIz, both assessed at participants' current height. Separate multivariable linear regressions were conducted to determine if current or greatest WS was significantly associated with frequency of binge eating, compensatory behaviors, or dietary restraint. A secondary analysis was conducted on youth ages 16 and older, given the limitation of assessing WS at current height in younger participants with greater height instability.ResultsYouth with higher levels of greatest WS (but not current WS) were older, had a longer duration of illness, and reported greater weight and shape concern. When adjusting for BMIz, neither current nor greatest WS was significantly associated with bulimic behaviors or dietary restraint in the full sample. However, in the subset of youth ages 16 and older, current WS moderated the effect of BMIz on binge eating and compensatory behaviors. For youth with high WS, those with a high current BMIz engaged in more frequent binge eating than those with low current BMIz, and the negative impact of BMIz on compensatory behaviors became weaker.ConclusionsOur findings suggest that WS is clinically relevant in the presentation of youth with BN, and that it may need to be addressed as one important factor in BN psychopathology. Future studies using growth charts to determine historically highest and lowest BMIz may help to further elucidate the link (or lack thereof) between WS and BN psychopathology in youth.

ObjectiveAlthough many individuals with purging disorder (PD) report loss of control (LOC) eating, it is unclear whether they differ from those who do not, or from other eating disorders involving purging and/or LOC.MethodWe compared PD with LOC (PD-LOC), PD without LOC (PD-noLOC), bulimia nervosa (BN), and anorexia nervosa-binge/purge subtype (AN-B/P) on measures of eating-related and general psychopathology in treatment-seeking adolescents.ResultsPD-LOC comprised ∼30% of PD diagnoses. PD-LOC and PD-noLOC did not differ from one another, or from BN and AN-B/P, on most measures of psychopathology, with some exceptions. PD-noLOC was similar to AN-B/P (p = 0.99) and significantly different from BN on eating concerns (p

PurposeEating disorders (EDs) impact both males and females, but little is known about sex differences in ED psychopathology and overall clinical presentation. This study compared demographic and clinical characteristics of child and adolescent males and females who presented for ED treatment.MethodsParticipants included 619 youth (59 males and 560 females) ages 6-18 years who presented for treatment between 1999 and 2011.ResultsMales presented for ED treatment at a significantly younger age (p < .001), earlier age of onset (p = .004), and were more likely to be nonwhite (p = .023). Females showed more severe ED pathology across the Eating Disorder Examination subscales (weight concern: p < .001; eating concern: p < .001; restraint: p = .001; and shape concern: p = .019) and global score (p < .001). Males were more likely to present with an ED other than anorexia nervosa or bulimia nervosa (p = .002). Females presented with significantly higher rates of mood disorders (p = .027) and had a lower average percent of expected body weight (p = .020). Males and females did not differ in duration of illness, prior hospitalization or treatment, binging and purging episodes, anxiety disorders, behavioral disorders, or self-esteem. All analyses were controlled for age.ConclusionsResults indicate that further exploration into why the sexes present differently may be warranted. Developing ED psychopathology assessments that better capture nuances particular to males and reevaluating criteria to better categorize male ED diagnoses may allow for more targeted treatment.