Wednesday, March 18, 2020

Self-Screening Tools for Detecting Eating Disorders among College Students

Vol. 31 / No. 1  

 Disappointing results from a large study.
Since the peak time of the onset of an eating disorder is usually between adolescence and early adulthood, a self-screening questionnaire targeted at this age group would have obvious benefits.  But screening in a way that identifies those with an eating disorder while not mis-identifying those without may be a challenge. Selecting the correct screening instrument may be the key. However, when Japanese researchers recently studied the screening accuracy of the Eating Attitudes Test(EAT-26) and self-reported body frame, followed by a semi-structured interview with the  Structured Clinical Interview for DSM-IV Axis 1 Disorders(SCID)  among new college students, the test results were disappointing (BMC Res Notes. 2019; 12:613).
Earlier studies in Japan using the EAT-26to detect eating disorders and abnormal eating behaviors among high school and college students have yielded inconsistent results. Dr. Norika Hayakawa and four colleagues at Nagoya University designed a larger-scale anonymous study of new college students from 2012 to 2015; the survey was administered during the students’ college entrance medical checkup. The 5275 students who agreed to participate provided self-reported body weight and height and completed the EAT-26. Then, the SCID ED module was conducted among 131 students to provide an eating disorder diagnosis.
Among the 131 students who completed the semi-structured interview, no student with a high EAT-26 score was diagnosed as having an eating disorder based on the SCID. Conversely, 3 students were diagnosed with an eating disorder but none had an elevated EAT-26 score.  One limitation of the study was that only 1.7% of new students were included in the semi-structured interviews, and it is unclear if these were randomly selected.
After assessing their results, the authors concluded that when the EAT-26 alone is used, it is not possible to identify individuals with an eating disorder. Another interpretation of the findings is that a measure such as the EAT-26 is best used for identifying disordered eating attitudes or behaviors, but not to make diagnoses.

Knowledge of Nutrition Needs Can Be Lacking among Those with Eating Disorders

Vol. 31 / No. 1  

Two studies point to a need for improvement.
Recently, Polish nutritionists wondered, how much do people with eating disorders know about nutrition? Do age, education, type of eating disorder, or body mass index (BMI, kg/m2) play a role? (Rocz Panstw Zaki Hig. 2019; 70:41).
Dr. Beata Calyniuk and colleagues at the Medical University of Silesia, Kantowice, Poland, assessed knowledge of nutrition using a survey questionnaire designed by Dr. Calyniuk. The 33-question instrument was published on the Internet in one of the social media portals in the “Eating disorders-tackling” group, which includes people with all types of eating disorders.
The authors found that the least-informed group were people younger than 20 years of age, and those who lived in medium-sized cities with populations between 20,000 and 100,000. Respondents with a vocational education were least informed about nutrition, and those with normal body mass indexes scored highest on knowledge of nutrition in eating disorders. Overall, the authors reported, their study showed that nutrition knowledge was selective and not enough to provide appropriate food choices to meet nutritional needs.
Their findings echoed those of an earlier 6-month study of 182 adolescents with and without eating disorders and their parents (Int J Adolesc Med Health2015; 27:11). The study was conducted in a suburban adolescent medicine office. Eighteen basic questions about nutrition were presented to the teens and their parents. Neither teens with or without an ED correctly answered more than 50% of the questions. Also, fewer than 16% of respondents in either group correctly answered questions about appropriate intake of fats, carbohydrates, and proteins.
Both studies findings underscored the importance of teaching patients about healthy lifestyles and nutrition and thoroughly discussing all nutrients, their functions, and effects on the body.

Musicians and Eating Disorders

Vol. 31 / No. 1  

A recent study shows perfectionism is one underlying factor.
Karen Carpenter is one of the best-known pop singers to have been overcome by longtime anorexia nervosa, and her death at age 32, in 1983, shocked most fans worldwide. Other well-known actresses and singers, such as Jane Fonda, Britney Spears, Elton John, and Lady Gaga, are just a few of the many celebrities who report having dealt with bulimia nervosa.
A recent report from London has shown that eating disorders are surprisingly common among musicians. The key elements increasing risk could be: perfectionism, stress, anxiety, and depression—all components of performing before a live audience (Eat Weight Disord. 2019; 24:54).
Drs. Marianna E. Kapsetaki and Charlie Easmon of Imperial College London and University College London investigated eating disorders among 303 musicians.  The authors had noted that eating disorders are not uncommon among performing artists and hypothesized that eating disorders would have a high prevalence among musicians. The authors sought to pinpoint factors that might be involved, including the type of music, the musician’s income, the stage in his or her career, the time of year, their age, gender, and risk factors, such as parental or peer pressure, social isolation, and perfectionism. They wanted to see if musicians believed eating disorders affected performance and diet, and if the musicians used any particular foods or substances to enhance their performance.
The participants were females and males 18 years of age or older, at all stages in their musical careers. They were asked about any eating disorders in the past, and current eating disorders. General mental health was assessed with the Depression Anxiety Stress Scale(DASS-21).  Body mass index was calculated from self-reported height and weight. All the questions were uploaded on UCL Opinio 7.3online survey software in English, and the survey was then sent worldwide to the musicians.
Musicians in every type of music were affected
A total of 119 males and 182 females participated, and the median age was 27 years. All types of music were represented, from classical to pop, folk, and rock.  Of the participants, 83% were instrumentalists, 31% were singers, 5% were composers, 2% were musicologists, 2% were conductors; and 2% described themselves as “other.” The EDE-Q Global Score (EDE-QGS)showed pathological values in 19% of the musicians, and when asked about lifetime history of an eating disorder, 32% of the participants answered positively. EDE-Q subscale scores were in the pathologic range in 13% to 35% of participants, with the highest percentage being seen on the shape concern subscale.
The authors noted that most of the participants spent much time traveling within one country (85%) versus traveling overseas. Most reported that their eating habits did not affect either their career or their performance; however, some reported that their career affected their eating habits—many reported that they would change their diet if they had higher incomes and about 20% were dependent on or addicted to certain food or drinks, usually caffeine-containing drinks.                      
Pinpointing possible risk factors
Music students, professional musicians, soloists and musicians who traveled overseas had a higher percentage of pathological scores on the EDE-QGSand there was a positive correlation between scores on the EDE-QGSand risk factors of perfectionism, depression, anxiety, stress, peer pressure, and social isolation. There was added stress when an individual was a soloist compared to singing or playing in a small or large group.
The authors note that an increased prevalence of eating disorders among musicians could be due to increased levels of perfectionism (especially in classical or professional musicians) because their goal is to perform perfectly.  The authors also suggest that one reason singers report more eating disorders than do instrumentalists is that there is an ambivalent association with their primary instrument, that is, their bodies make the music.
It is common to think that certain groups are at high risk for eating disorders; endurance athletes or dancers come to mind.  This study suggests that musicians are at similarly elevated risk.

Access to Treatment, and Mortality in Eating Disorders

Vol. 31 / No. 1  

The study model also showed a high prevalence of eating disorders in the general population.
Having a better understanding of the prevalence of eating disorders over the lifetime “could help decision-makers and clinicians better target policies and programs,” according to a team of public health  researchers led by Zachary J. Ward, MPH, of Harvard’s Center for Health Decision Science, Boston (JAMA Network Open. 2019; 2[10]:e1912925).
Given the effort that studies providing data on prevalence across the lifespan would entail, the team designed an analytical model study to simulate clinical and epidemiologic eating disorders data, using a simulated nationally representative cohort of 100,000 individuals (50% male) modeled from birth to age 40 for anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified feeding and eating disorders (OSFED). The authors also sought to estimate how increasing access to treatment for eating disorders might diminish mortality. Estimates of prevalence, remission and relapse rates as well as excess mortality were drawn from the existing literature.
Eating disorders by age
The study results showed that the estimated prevalence of eating disorders was high: the highest estimated mean annual prevalence of eating disorders overall occurred at approximately 21 years of age for both males and females. The mean lifetime prevalence increased to approximately 1 in 7 males and approximately 1 in 5 females by age 40. The types of eating disorders followed a similar pattern, peaking in the late 20s and then decreasing slowly in later adulthood; in this study, most cases involved OSFED. In the model, 95% of those developing an ED did so by 25 years of age.
Treatment prevented approximately 41.7 deaths per 100,000 persons; however, increasing coverage to provide treatment to all with EDs would prevent 70.5 deaths per 100,000. Of note: total prevention of all EDs was estimated to prevent 213 deaths per 100,000.
This modeling highlights the prevalence of EDs and the mortality burden associated with ED and underscores the potential benefits of improved access to treatment.

Problematic Internet Use and Prediction of Eating Disorders

Vol. 31 / No. 1  
A new link between Internet use and eating disorders
According to Statista, the German online portal for statistics, in 2018, the average American spent 24 hours a week online. Smartphones and social networks have increased the level of Internet addiction and eating disorders among university students, according to a recent study by researchers at the University of Granada (Nutrients. 2019; 11:2151).
Problematic Internet Use is one reflection of uncontrolled use of technology, and recent studies are showing a link between Internet addiction and eating disorders.  Problematic Internet Use is categorized as a “behavioral addiction” (Comput Hum Behav. 2016; 55:76). Dr. Francisco-Javier Hinojo-Lucena and colleagues in Granada, Spain, conducted a meta-analysis of the literature on Problematic Internet Use and EDs using two databases, Scopusand Web of Science. The researchers included journal articles, empirical research, papers written in either English or Spanish, to study the association of  Problematic Internet Use with an eating disorder among students. They excluded proceeding of meetings and congresses, book chapters, books, or non-peer-reviewed publications, theoretical papers or reviews, Problematic Internet Use not associated with a particular eating disorder, and non-student populations. The researchers identified 12 articles in the systemic analysis and 10 in the meta-analysis. Seventy-five percent of the articles were published since 2014; the first articles on Problematic Internet Use and eating disorders were published in 2009.
Some conclusions were made
The authors evaluated articles and documents that included 16,520 students from different countries. A number of eating disorders were associated with Problematic Internet Use: AN, BN, BED, food preoccupation, loss of control eating, and dieting. Most cases involved BN (92% of cases) and highlighted the interest in AN (50%), food preoccupation and loss of control eating (both 42%), and BED (17%). Overall, those with Problematic Internet Use were more likely to have an ED or disordered eating. The authors also noted that most studies involved university students, the group at highest risk. Problematic Internet Use presents many challenges because it may encourage sedentary behavior and may facilitate ordering food online. An additional danger from the social networks is the risk of social comparisons, which can also lead to the development of eating disorders such as AN or BN.
Finally, the authors suggest that since university students are at the greatest risk, preventive measures should be introduced earlier, at lower educational levels.

The Importance of Restoring Body Fat Mass in the Treatment of Anorexia Nervosa: An Expert Commentary.

The Eating Disorder Journal
(February 2020, Vol. 21, No.2)
Anorexia nervosa is a severe mental disorder that is characterised by dietary restriction, low weight and widespread endocrine abnormalities. Whilst the importance of weight restoration has been recognised in recent guidelines, the significance of normalising body fat mass has received less attention. A recent systematic review and meta-analysis found that a minimum of 20.5% body fat mass is necessary for regular menses in women with anorexia nervosa of reproductive age. This has significant implications for both treatment and research. It is important to help the patient and carers understand that a certain level of body fat percentage is essential for optimal health, such as the return of menstruation. Further research is needed into how best to use this information to help motivation to change as part of treatment. The benefit of the return of menstruation goes beyond improved fertility: it signals the normalisation of sexual hormones, which have a widespread impact on the body and multiple pathways in the brain. Given the complex functions of adipocytes in various organs of the body, the metabolic effects of the normal body fat tissue should not be underestimated. Further research is needed to elucidate the mechanisms behind the link between minimum body fat mass, menstruation, bone and brain health in anorexia nervosa. J Popul Ther Clin Pharmacol. 2019 Sep 4;26(3):e9-e13. doi: 10.15586/jptcp.v26i3.629.

Physical and psychological aspects of anorexia nervosa based on duration of illness: a cross-sectional study.

The Eating Disorder Journal
(February 2020, Vol. 21, No.2)
BACKGROUND: We evaluated physical and psychological features of patients with anorexia nervosa (AN) who differed by duration of illness. METHODS: Data were obtained from 204 female patients with AN, divided into two groups based on illness duration: short-term illness duration (less than 5 years; n = 118); and long-term duration (5 years or more; n = 86). Physical parameters were measured using blood serum testing and psychological aspects were assessed using various instruments. RESULTS: A significantly higher proportion of restricting type AN was observed in the short-term group while the proportion of binge eating/purging type AN was higher in the long-term group. There was no difference in body mass index (BMI) between the groups. Serum total protein, albumin, potassium, chloride, and calcium in the long-term group were significantly lower than in the short-term group. Overall scores on the Eating Disorder Inventory as well as most of the subscales, except maturity fears, were higher in the long-term group than in the short-term group. The care subscale of the Parental Bonding Instrument (PBI) was lower in the long-term group than in the short-term group, while the overprotection subscale of the PBI was higher in the long-term group than in the short-term group. Results of a multiple regression analysis indicated that the overprotection subscale of the PBI was the only significant predictor of duration of illness. CONCLUSIONS: Duration of illness may be associated with physical and psychological features of AN; thus, adapting therapeutic approaches to illness duration might be necessary. Biopsychosoc Med. 2019 Dec 23;13:32. doi: 10.1186/s13030-019-0173-0. eCollection 2019.