Tuesday, February 26, 2019

Launch of the National Center of Excellence for Eating Disorders

Launch of the National Center of Excellence for Eating Disorders
The National Center of Excellence for Eating Disorders (NCEED) is dedicated to educating and training healthcare providers on the evidence-based management of eating disorders and improving eating disorder awareness among the public. NCEED’s mission is closely tied to the Anna Westin Act provisions within 21st Century Cures and Mental Health Reform Act and is thus poised to have meaningful and lasting impact on the ability for individuals with eating disorders to be detected and provided with evidence-based treatment. This week’s launch is the first in a series of programming phases for NCEED and will offer an initial set of resources for healthcare providers and the public as well as information on upcoming events of interest. Subsequent phases will provide online trainings, interactive webinars, and a mechanism for submitting technical assistance requests. Learn more at their website, https://www.nceedus.org/.

Disordered Eating in Middle-aged and Older Women

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A large Norwegian sample highlights a sometimes overlooked community health problem.
Disordered eating, emerging from body dissatisfaction, weight preoccupation, and dysfunctional eating patterns, has generally been described as a problem of younger patients. However, the fact that disordered eating can occur at any age, from childhood to advanced years, has been reinforced in a cross-sectional study of more than 90,000 middle-aged Norwegian women (PLoS ONE oi.org/10.1371/journal.pone.0211056).
When Dr. Marie Sigstad Lande and colleagues at the Arctic University of Norway, Tromo, analyzed disordered eating among 90, 592 women 46 and 76 years of age (median age: 55 years) who had completed questionnaires from the Norwegian Women and Cancer study from 2002 to 2005, they found the prevalence of disordered eating was 0.28%, and this was highest among women older than 66 years of age. Disordered eating was strongly associated with a history of depression, being unemployed, and single. In this study, depression was he strongest correlate of disordered eating: women with disordered eating had three-fold higher odds of also  being diagnosed with depression. Women with disordered eating were also more likely to report low energy intake, and less likely to be   moderately physically active. Just as in earlier studies, Dr. Lande and colleagues’ finding that the oldest age group—women 66 to 76 years of age—had the highest prevalence of disordered eating.
This large-scale study confirms the findings of earlier smaller studies showing that disordered eating can arise in mid-life and older age. The authors feel that their study “underscores a somewhat under-communicated community health problem that needs attention in terms of age-specific treatment and prevention.”

BED and Food Addiction

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Nearly all participants in one study had at least a mild food addiction.
It’s unclear how binge eating disorder (BED) and the newer concept of food addiction are related. BED is very commonly assessed by eating disorder professionals; food addiction, somewhat less often. A new tool, the Yale Food Addiction Scale, has been developed to assess for food addiction (Gearhardt and colleagues, 2011). This scale measures addictive qualities of eating behavior. It was recently revised to become the YFAS 2.0, adjusted for changes to the diagnostic criteria from DSM 5. Carter and colleagues (Appetite. 2019; 133:362) recently described the results of measuring food addiction using the YFAS 2.0in a group of people with BED (n=71) and controls (n=79). In this study, participants completed the YFAS 2.0,as well as an Eating Disorders Examination(EDE) interview to establish an eating disorder diagnosis.
Interestingly, nearly all the BED participants in this study (overall, 92%)   scored positive for at least mild food addiction, while very few of the controls who did not have an eating disorder endorsed food addiction symptoms (only 6%). Among those with BED and at least moderate food addiction scores, higher EDEsubscale scores were seen (except for the Restraint Subscale), and indications of greater levels of depression and anxiety were seen as well.
These interesting findings highlight the frequency with which food addiction may be present in individuals seen in eating disorder settings. This should stimulate further interest in the use of such screenings to increase awareness about food addiction, and as we learn more about how food addiction, this may influence treatment approaches.

Links Between Binge Eating Disorder and Suicide

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New information in a largely unexplored area
Binge eating disorder (BED) is still the most common eating disorder in the US, with a lifetime prevalence of 3.5% for women and 2.0% for men. Despite this, much of its course and correlation to other factors remain relatively unknown, compared to other eating disorders such as anorexia nervosa and bulimia nervosa, for example. A collaborative study found that both binge eating behaviors and body mass index (BMI) are independently related to suicidal ideation and suicide attempts among US adults (BMC Psychiatry. 2018; 18:196).
Dr. Kristal Lyn Brown of Virginia Commonwealth University School of Medicine, Richmond, and colleges at the University of Michigan School of Public Health, Ann Arbor, reported that one impetus for their study was that the relationship between BED and suicidality had not yet been examined in a population-based study of adults in the US. In addition, unlike other eating disorders, patients with BED do not use compensatory or restorative behaviors such as excessive exercise or laxative abuse, and thus are at higher risk for gaining weight and becoming obese. The authors examined three hypotheses: BED is linked to an elevated likelihood of suicidality; 2) BMI is associated with likelihood of suicidality in a nonlinear manner, and 3) the relationship between BED and suicidality is exacerbated by BMI, and any differences by gender.
One-third of adults were affected
The study results were based on the 2001-2003 Collaborative Psychiatric Epidemiologic Surveys, a set of three nationally representative cross-sectional household surveys. (The data used for the analysis are available at https://www.icpsr.umich.edu/icpsrweb/ICPSR Studies/20240.)   The data were limited to persons with complete data on BMI, BED, and suicidality and the initial sample included 14,497 individuals. While BMI did not substantially explain the association between binge eating and suicidal behavior, there was evidence that suicidality was exacerbated by high BMI.
A third of the adults with BED had a history of suicidality, compared to 19% of those without BED. BMI was associated with suicidality in a curvilinear manner and this relationship was exacerbated by binge eating/ BED.
Finding that binge eating/BED  is associated with suicidality echoes the broader literature on eating disorders and associated psychiatric comorbidities: nearly a third of women with BED report a lifetime history of suicidal ideation and 15% reported having attempted suicide (Arch Gen Psychiatry.2011; 68:714). Several studies have shown a link between binge eating and mood disorders, novelty seeking, and impulsiveness, all of which have been linked to suicidal behaviors.  The researchers found that the relationship between BMI and suicidal thoughts did not differ by gender, unlike earlier reports. As for depression, there was an inverse relationship between BMI and suicide attempts among men regardless of depression history and a curvilinear relationship among women, with a higher incidence of attempts among those with low BMIs compared to normal-weight women without histories of depression.
Dr. Brown and colleagues hope that their findings lead to thoughtful integration of psychiatric care into weight loss programs for adults with a history of binge eating behavior.

Finding a Better Definition for Severe and Enduring Anorexia Nervosa

Vol. 30 / No. 1  

Many patient variables make the definition challenging. 
As the 11thedition of the International Classification of Diseases(ICD-11) is nearing pre-release this spring, Drs. Phillipa Hay and Stephen Touyz have commented on the lack of clear definitions for severe and enduring anorexia nervosa (AN). In an editorial in the Journal of Eating Disorders(2018; 6:41), the two well-known eating disorders experts lament the lack of consensus or clear-cut definitions for recovery or definitions of severe AN. (ICD-11will be presented at the World Health Assembly in May, for adoption by member states, and will officially come into effect on January 1, 2022).
The authors point out three components of severe and enduring AN (Table 1): a decade or more years of a body mass index above the DSM-5severe range; marked morbidity from chronic starvation and longstanding illness; years of experiencing diagnostic level eating disorder symptoms with previous failed treatment attempts; and 3 to 10 years of illness; and treatment resistance. The criteria they propose are based on such factors as the clinically significant functional impact of the disorder ( for example, poor quality of life and unrelenting symptoms, the duration of disease of several years of AN, and exposure to at least two evidence-based treatments delivered by an appropriate clinician or treatment facility, with a diagnostic assessment and formulation that incorporates an assessment of the person’s eating disorder health literacy with an assessment of the patient’s stage of change.
Both authors point out some of the problems with the term, “treatment resistant,” which they are reluctant to use in the eating disorders field because it is viewed as pejorative and places blame on the physician and patient. Treatment resistance is also not well understood, according to the authors, and there is no real consensus on the definition—for example, how many attempts have been made at re-feeding or how many treatment sessions are felt to be enough before they are discarded?

Loss of Control Eating Among Teens Linked to Perceived Family Function

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Poor family function was linked with obesity in adolescent girls.
Loss of control (LOC) eating, a feeling that one cannot stop or control what or how much he or she consumes, affects approximately a third of children who are overweight or obese. It has also been linked to the development of partial or full-syndrome binge eating disorder, or BED (J Abnorm Psychol. 2011. 120:108;J Abnorm Psychol. 2013. 122:684).
Dr. Manuela Jaramillo, from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health, Bethesda, MD, and her collaborators recently concluded that among girls with LOC eating and high body mass indexes, poor family function plays a role in greater consumption of obesity-producing macronutrients during binge episodes (Nutrients. 2018. 10:1869). The researchers reported the connection after studying the relationship between perceived family functioning and energy intake during a laboratory test meal designed to model a binge episode. The team had hypothesized that lower levels of adaptability and cohesion would lead to greater total energy consumption, a larger percentage of energy consumed from fat and carbohydrates, with lower percentage of energy from protein.
The study group
The study group included 108 adolescent girls 12 to 17 years of age who were at high risk for developing eating disorders and excess weight gain, and who had experienced at least one LOC eating episode during the prior month. All were between the75th and 97thpercentile for body mass index (BMI, kg/m2). Then, family functioning was defined as the teen’s perceived level of adaptability and cohesion of her family; this was assessed by the researchers with the Family Adaptation and Cohesion Scale III, a 20-iem self-report that measures perceived levels of family adaptability. A sample item would be, “Family members like to spend time with each other.” Higher scores equal greater adaptability and cohesion.
The test method used included analysis of energy intake, pre-meal hunger, depressive symptoms, and post-meal subjective evaluation of LOC eating. At 11 am participants were presented with a 9835-kcal buffet test meal with a wide assortment of foods, and were advised via a tape recording to “Let yourself go and eat as much as you want.” Participants were left alone in the room until they signaled that they were finished eating. The test foods were then weighed and compared after the meal. A single item was used to measure pre-meal hunger with a question, “How hungry do you feel right now?” The Brunel Mood Scale was used to measure depressive symptoms, and a single-item assessment was used to measure post-meal evaluation of LOC eating.
The authors concluded that adolescent girls with diagnoses of LOC eating who perceived their families as being relatively less adaptable consumed significantly more carbohydrates and less protein from the test meal, which was designed to model an LOC episode.  They also noted that the study findings underscored the importance of addressing family function in a clinical setting and, when possible, to include family members in interventions that may help modify adolescent girls’ eating behaviors.

Update: Another Possible Cause Linked to BED and Obesity

Vol. 30 / No. 1  
Two seemingly polar opposites, food insecurity, or lack of food, often due to poverty, and binge-eating disorder, or BED, are associated, according to a recent report by Janet Lydecker, PhD, of the Department of Psychiatry Yale School of Public Health, New Haven, CT. She and her colleagues reported their findings in the International Journal of Eating Disorders, published online December 19, 2018.
The study recruited 1,2651 participants using Amazon’s Mechanical Turk, a web-based recruitment platform; participants then reported their weight and height, and the researchers calculated body mass index (kg/m2) for each.  After this, the study participants were divided into three groups. More than half (56.8%; n=710) were classified as having a healthy weight with no eating disorder; 85 participants (6.8%) Had diagnoses of BED, and 456 patients (36.5%) were obese but had no eating disorder.
The researchers defined food security in three categories (1) if the individuals were able to afford regular nutritious meals, (2) low food insecurity if they modified food quality, variety, or desire to satisfy hunger, and (3) very low food security if they reduced their food intake or quality to the point of having physiological hunger. One-third (33.7%; n=422) were found to have food insecurity; 18,5% (n=231) had low food security; and 15.3% (n=191) had very low food security.  Compared with persons who had healthy weights, those deemed to have low food security were 2.5 times more likely to have BED. The same pattern was associated with an increased likelihood of being obese. Other researchers, such as Tomoko Udo, PhD, of the School of Public Health at SUNY University at Albany, NY, have noted that the dietary restraint model of binge eating suggests that when a person engages in dietary restriction as a way to control calories or due to lack of access to food, he or she is more likely to engage in binge eating due to deprivation.
Dr. Lydecker noted that clinician s traditionally associate self-imposed dieting, seen as skipping meals or cutting back on calories to lose weight, as one of the causes of binge eating. However, she added, externally imposed restrictions on food, skipping meals or cutting back on intake because food isn’t available is also related to binge eating.  “Food insecurity could be a factor making it more difficult for patients to get better if they cannot address it. By addressing it, clinicians and patients with BED can collaborate more effectively to treating binge eating,” she said.