Monday, October 3, 2016

Defining Energy Deficiency in Sport: Beyond the Female Athlete Trials

By: Laura J Moretti, MS RD CSSD LDN
Drive, passion, and determination are characteristics that enable athletes to push themselves both mentally and physically to excel in their respective sport. Athletes, especially elite athletes, are well akin to the notions of sacrifice in their lives and working hard to achieve their goals. In such a population, particularly adolescents and young adults, it is essential to ensure that these athletes are providing their bodies with the adequate nutrition to support their high levels of training and overall health. Energy availability is calculated as the energy intake (EI) less the energy cost of exercise relative to fat-free mass (FFM), in other words a failure to intake enough calories to support exercise expenditures.  A decrease in EI, increase in exercise expenditure, or a combination of the two, can have a negative impact on an athlete’s performance and overall health.
Relative Energy Deficiency in Sport, otherwise known as RED-S, was first introduced by the International Olympic Committee (IOC) in 2014. RED-S is a syndrome that encompasses the myriad negative impacts of energy deficiency on both male and female athletes. Energy Deficiency in sport has often been thought to be a “female athlete only” problem known as the Female Athlete Triad (menstrual function, bone health, and energy availability). Although the components of the Triad are included in the RED-s model there is also a much broader range of symptoms that may be caused by energy deficiency in sport that do not discriminate between the sexes (figure 1). The RED-s model includes the negative impact that energy deficiency may have on gastrointestinal, immunological, endocrine, metabolic, hematological, and cardiovascular systems. RED-S can also have a psychological impact as well as cause a delay in growth and development, particularly in adolescent athletes. The negative impact of energy deficiency on bone development can cause stress injuries and some may be irreversible, potentially leading to osteoporosis.  The negative performance effects of energy deficiency include decreased endurance, increased recovery time, irritability, difficulty concentrating, and a decreased training response (figure 2).
Although disordered eating and/or eating disorders are sometimes the cause of energy deficiency, it is important to note that it may also be a lack of knowledge on the athlete’s part for the number of calories they need to support their expenditures. A Registered Sports Dietitian (RD CSSD) plays a valuable role in estimating the needs of an athlete while considering resting metabolism and caloric expenditures from training.  These professionals can also educate the athlete on exercise metabolism as well as fueling strategies for before, during, and after competition to meet elevated energy needs.
If an athlete is found to have a clinical eating disorder or disordered eating, a multidisciplinary approach is recommended. The treatment team should consist of a physician, psychologist or psychotherapist, registered dietitian, and in the case of an athlete, may also include a physical therapist, athletic trainer, and/or coach.  Throughout treatment it can be helpful to closely involve the athlete’s coach so that the individual feels supported by not just his/her family, but also his/her athletic family, which can lead to a better prognosis and cooperation with treatment recommendations. It is also very helpful to have a treatment contract to be shared with the athlete, members of the coaching staff, and any other necessary individuals to eliminate confusion around level of activity, return to play, and other recommendations from the clinical team.
The signs and symptoms of RED-S vary athlete to athlete. However, some common symptoms for low energy availability may include: excessive fatigue, muscle loss, frequent illness or injury, stress fractures, menstrual dysfunction, inability to recover, and decrease in performance.  It is important for coaches, trainers, and parents to be aware of these signs and symptoms to be able to intervene early. Early intervention is especially important for adolescent athletes since they are in their peak growth years.  Education of young athletes around proper fueling practices can help prevent injury, promote growth, and boost overall performance.
About the author:
Laura Moretti, MS, RD, CSSD, LDN, completed a Master’s Degree in clinical nutrition as well as her didactic program in clinical dietetics at New York University’s Steinhardt School of Education, Department of Nutrition and Food Studies. She completed her dietetic internship at New York-Presbyterian Hospital including intensive training at the Weill Cornell Medical Center inpatient eating disorder treatment program. Laura recently moved to Boston from New York City to join the Sports Medicine Team at Boston Children’s Hospital where she is also the Dietitian for the Female Athlete Program. She previously worked as the Primary Nutrition Therapist at Columbus Park Collaborative and Appleman Nutrition in New York City. She possesses a specialty in sports performance based nutrition as well as treating low energy availability, disordered eating, and eating disorders in athletes.  Laura has an extensive amount of experience in consulting and collaborating with local colleges, universities, professional sport, and dance facilities. She also is the consulting RD for the Boston Ballet Company. Laura is an active member of the Academy of Nutrition and Dietetics, International Academy of Eating Disorders, Massachusetts Dietetic Association, Collegiate and Professional Sports Dietitian Association, Co-Chair of the AED Sport and Exercise SIG, and the Sports, Cardiovascular, and Wellness Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics.  On a personal note, Laura is a competitive triathlete as well as a Boston Marathon Qualifier.
  1. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad– Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014 Apr;48(7):491-7. doi: 10.1136/bjsports-2014- 093502. PubMed PMID: 24620037.
  2. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. RED-S CAT. Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7):421-3. PubMed PMID: 25896450.

Athletes and Eating Disorders: Redefining an Injury and Expanding Identity in Treatment

By Riley Nickols, Ph.D.

In the Victory Program at McCallum Place, athlete-patients are regularly reminded that an eating disorder is an injury – a metabolic injury.  Similar to most physical injuries, eating disorders require proper treatment, rest, and rehabilitation to facilitate healing before it is safe and appropriate to return to sport.  If an eating disorder is conceptualized as an injury, it can help to best inform treatment considerations (e.g., how and when to integrate training during treatment).  Additionally, it is important to recognize that an eating disorder is an injury so that expectations during treatment and upon return to training or sport can be discussed and modified if needed.
Upon return to sport, a false sense of health and wellness can inappropriately be attributed to an athlete-patient by coaches, teammates, and sports medicine personnel due to the athlete-patient’s seemingly improved physical appearance after obtaining treatment to address complications from an eating disorder. Unlike a visible representation that can be apparent after an athlete sustains certain injuries (e.g., needing crutches after ACL surgery), a metabolic injury that results from an eating disorder is not always visible by the naked eye and, as a result, an athlete-patient may not appear as though he or she is still injured.  Although metabolic injuries, such as eating disorders, can sometimes be more covert and the implications might be less observable compared to musculoskeletal injuries, individuals are in significant danger of relapse if treatment, support, and parameters upon returning to sport are not appropriate and consistent.  Therefore, it is essential that coaches, athletic trainers, and sports medicine personnel are thoroughly informed by the athlete-patient’s treatment team about specific recommendations on how to best support an athlete-patient’s return to sport.
Similar to musculoskeletal injuries in sport, there are significant risks when sport training is incorporated too aggressively during eating disorder treatment as the athlete-patient remains physically and psychologically vulnerable.  Additionally, a heightened risk for re-injury or relapse exists if sport training is introduced in an inappropriate or unsupported manner during the eating disorder treatment process.   As such, it is imperative that a treatment team is sensitive and informed of how to best facilitate and support sport training into an athlete-patient’s treatment.  Eating disorder treatment providers should remain current on recent research addressing recommendations for incorporating exercise into treatment and, if needed, obtain consultation from other experienced providers.
A serious injury can be both physically and psychologically traumatic for an athlete.  A multitude of challenges are likely to follow after an athlete experiences an injury.  For athletes who devote an immense amount of time, energy, and emotion to their sport and define their self-worth by their performance and success in athletics, a serious injury can be psychologically devastating.  An athlete can experience a loss of identity as a result of needing to halt participation in sport due to an injury or eating disorder.  An athlete is likely to encounter significant difficulties, especially if identity is largely, or entirely, comprised of “being an athlete” when participation in sport is abruptly stopped due to an injury (including an eating disorder).  Specifically, if perceived value and worth are largely contingent on sport participation and accomplishments, an individual’s identity can be threatened when sport participation is disrupted by injury or when sport participation ends (e.g., retirement).
The need to abstain from sport training or competition can sometimes be similar to the stages of grief (i.e., denial, anger, bargaining, depression and acceptance; Kubler-Ross, 1969), therefore, providers must demonstrate sensitivity to the challenges the athlete-patient is likely to experience during treatment.  Before identity is explored in treatment, it is critical the athlete-patient is able to mourn the temporary (or permanent) loss of sport.  If an athlete-patient is not allowed to grieve the loss of sport, efforts to address his or her identity in treatment can inadvertently be interpreted as being dismissive of a distressing experience.  Individuals who are either temporarily or permanently not able to participate in sport can perceive their identity as “an athlete” to no longer exist since they are not currently competing in sport.  The factors that characterize an athlete are well-established, enduring traits that persist in the midst of an injury or after competitive sport participation ends.  Recognizing that “being an athlete” is a trait, rather than a state, can be powerful in treatment, especially when an athlete-patient is unable to compete in sport or is not performing up to expectations.
A treatment team should be supportive and sensitive to the important role of sport in an athlete-patient’s life.  In conjunction with supporting an athlete-patient’s identity as an athlete, an athlete-patient has a unique and important opportunity to develop a more expansive identity during treatment.    With the help of an attuned clinician, an athlete-patient can recognize and develop other parts of his or her identity (e.g., sibling, son/daughter, cousin, student, friend, volunteer) that might have previously been superseded by an all-encompassing athlete identity.
The ability to develop a more robust identity and self-representation can help an individual securely answer questions such as, “Who am I without my sport?” when continued sport participation is in jeopardy or ends.  This process is not intended to decrease the importance of sport in one’s life, but rather to increase the other parts of oneself that have been neglected or minimized in proportion to an individual’s athlete identity.  When an individual is able to cultivate a broader sense of self, they are more likely to experience the setbacks and success in sport more easily than if their identity is solely as an athlete.

Eating Disorders and Adolescent Athletes

By Dani Gonzales, Psy.D., Sarah Archer, L.M.F.T., and Sammi Montag R.D.

Conflicting and Concurrent Literature

Whether rooting for elite athletes in the Olympics, getting fantasy football roster line-ups, or watching little league sports on weekends, it is clear that sports and athletes surround our daily lives. The topic of eating disorders within athlete populations has received increased attention over the past several decades. What is confusing about this topic is that prevalence rates of eating disorders in athlete populations ranges from as low as 1% to 62% across a variety of sports (Byrne & McClean, 2001). Even more confusing is the fact that studies indicate a variety of risks for developing eating disorders and treatment recommendations. This article aims to discuss three topics: 1.) the conflicting literature in regards to athletes at risk or struggling with eating disorders, 2.) specialized dietary approach for athletes, 3.) treatment recommendations and family-based interventions for athletes.
A comprehensive review of current literature suggests that as a field full of effective treatment providers, we largely disagree on our recommendations for this specific demographic population especially in regards to return to play. One camp of the argument suggests that athletes are at greater risk for developing eating disorders when compared to nonathletes (Hausenblaus & Carron, 1999; Sundogt-Borgen, 1994; Zucker, Womble, Williamson, & Perrin, 1999). The other camp defends that sport serves to protect athletes from developing eating disorders (DiBartolo & Shaffer, 2002; Gutgesell, Moreau, & Thompson, 2003; Hausenblaus & McNally, 2004; Reinking & Alexander, 2005). What is agreed upon is that the qualities which make an athlete desirable are also traits found in individuals with eating disorders, such as excessive exercise, (over) compliance, perfectionism, denial of discomfort, working through the pain, commitment, and high achievement (Thompson and Sherman, 1999).
One of the most important areas of concern and motivation for athletes and their caregivers is the decision and clearance to return to play. Currently, there is no clear consensus regarding recovery criteria for athletes with eating disorders. For female athletes with eating disorders, the Female Athlete Triad and openness to fuel for additional exercise can generally be a good guideline to follow (Joy, Kussman, & Nattiv, 2016). Clinicians and their treatment team providers should also incorporate dietary recommendations, BMI, bone mineral density labs, medication compliance, and therapeutic feedback from the families involved, as well as coaches before a decision is reached. It is recommended that families and coaches also form a written agreement to implement before return to play is initiated. These return to play contracts have demonstrated specific guidelines in which the athlete is to meet with the appropriate treatment team providers, follow daily meal plan, agreement to weigh-in, and limitation of workout/play time.

Specialized Dietary Approach

An adolescent athlete entering treatment for an eating disorder is set apart by their desire to return to their sport for the enjoyment rather than a means of weight loss. We see many teens that identify as athletes, however, who began their sport in the context of the eating disorder as a way to facilitate weight loss. The primary target, upon entering treatment, for any of our athletes is medical stabilization and movement towards weight restoration (if applicable). Once medically cleared, the treatment team is able to develop a reintegration plan which ideally includes feedback and buy in from the coach. A primary distinguisher that the dietary staff at UC San Diego-Eating Disorder Center for Treatment and Research (UCSD-EDC) looks for in regard to the athlete’s readiness to transition back into their sport, is an understanding of increased caloric needs and the willingness to fuel nutritionally to meet the physical demands of their sport. In addition, it is imperative for the athlete to have a mentality orientated toward recovery in order to slowly rehabilitate from their metabolic injury. Transition back into their sport requires close observation by a primary care physician to oversee vitals and a registered dietitian to monitor weight trends and the quality and quantity of intake.
In an attempt to prevent relapse, many aspects of recovery must be taken into consideration with the treatment discharge of an adolescent athlete. Key components that need to be addressed include the continued growth of adolescents requiring a moving goal weight range, the necessity for continued nutritional fueling for the energy requirements of their sport, and identifying essential adjustments to nutritional intake with an increase in training and/or intensity. Each of these components is vital for continued recovery as well as optimal athletic performance.

Application of Treatment via Family-Based Interventions

As treatment providers for pediatric and adolescent programs, challenging patients with fear foods, restaurant outings, and coping ahead for the return to school is both commonplace and necessary to challenge the eating disorder and promote recovery. At the same time, due to the fears surrounding exercise and the impact on weight gain, medical and mental stability, many treatment programs are cautious about the right time to return patients to their sport or allow exercise as an integral treatment component.  However, following the current data that indicates exercise can not only promote our patient’s mental well-being but also increase recovery rates (Arthur-Cameselle & Quatromoni, 2014), we now recognize the importance of sport in our patient’s lives and when medically appropriate encourage its return.
While we know from research that athletes in lean sports are more at risk for developing an eating disorder (Cameselle & Quatromoni, 2014; Joy, Kussman, & Nattiv, 2016), it is evident that more and more athletes are at risk for developing an eating disorder. At UCSD-EDC we have also seen an increase in our overall student athlete admissions across multiple sports. These athletes range from water polo players, swimmers, runners, soccer players to dancers and with support from the parents, our athletes plan on returning to sport. Rather than being hesitant to have these middle and high school aged athletes return to their sport, the treatment team, comprised of parents and clinicians, now use it both as a motivator and goal at the onset of treatment.
To lay the ground work, we provide psychoeducation to the real experts on these patients: their parents. We discuss the impact of sport on the eating disorder, risk factors such as signs of overtraining and following the evidence based Family Based Treatment model, and allow the parents to decide if and when they feel their child is ready to return to their sport. With feedback from our medical, dietary, and therapeutic members of the treatment team, parents create a plan for return to sport and slowly increase their child’s participation while our team closely monitors their medical and psychiatric stability.
As our adolescent athletes are still in school and live at home with their parents, parent psychoeducation of Sport and Eating Disorders is paramount, in that they are the primary source of supervision of meals and exercise for these athletes. At UCSD-EDC, we firmly believe the parents are the key to not only the re-feeding process, supervision, and reduction of eating disorder behaviors, but additionally, the ones to oversee the return to exercise. While the treatment team provides expertise and focuses on medical stability, our goal is to continue to empower and charge the parents in the task of supervising their child’s healthy return to sport.
Similar to the model laid out at the Victory Program within McCallum Place, we also look to coaches, trainers, and athletes as having a role within the FBT “family” as they have direct access to the patient and are often highly respected by the student athlete. Whether it’s speaking to coaches directly or providing trainings to athletic directors and trainers, our aim is to provide our patient’s athletic “family” with knowledge and skills to effectively manage the athlete’s return to sport.
At the UCSD-EDC we take a unique approach. While we aim to empower parents and educate coaches, we also provide a curriculum for our athletes that is focused on the areas of psychoeducation, Body Image, Cognitive Behavior Therapy and Dialectical Behavior Therapy. Our primary goals include, challenging myths related to eating disorders and sports, openly discussing the athlete’s specific concerns related to body image while having our patient develop and utilize skills that help them more effectively regulate mood and anxiety. While medical stability is always the number one priority, we firmly believe both the physical and mental health benefits of our patient’s returning to their sport can outweigh the risks if carefully executed with the goal of maintaining the athlete’s health. While the return to sports can play a positive role in an adolescent’s life, we also know that building leadership skills, mastery, and increasing self-esteem assist in one’s long-term recovery. At UCSD-EDC we are dedicated to developing quality based programs founded on empirically supported research that help guide parents and the adolescent athlete by expanding their knowledge of healthy nutrition and positive sport performance.

Thursday, September 15, 2016

A 12-Item, Short-Form Questionnaire Results from the EDE-QS correlated well with those from the EDE-Q.

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP
The Eating Disorders Examination Questionnaire (EDE-Q), a 28-item self-report questionnaire, is very widely used and considered a good alternative to the Eating Disorder Examination (EDE). It offers a shorter version that is easy for patients to complete. Why, then, develop an even shorter version of the EDE-Q
Dr. Nichole Gideon and colleagues recently reported their development of the EDE-QS, a 12-item short form of the EDE-Q (PLOS ONE, May 3, 2016). The authors developed the shorter questionnaire to address two problems they identified with the EDE-Q. According to Dr. Gideon, some study populations have not supported the EDE-Q's four-factor structure (Restraint, Eating Concern, Shape Concern, and Weight Concern), and patients consistently score higher on the EDE-Q than on the EDE. And, according to the authors, other inconsistencies between the two measures have been observed in the self-report assessment of features such as objective binge eating behaviors, laxative use, and self-induced vomiting. Even though the administration time for the EDE-Q is markedly shorter than that of the EDE, they contend that it is not ideal for use as a session-by- session outcome measure. 

Two studies to evaluate the questionnaire

Two studies were used to compare the two questionnaires. The goal of the first study was to develop a psychometrically and conceptually sound short form of the EDE-Qthat could be used to measure session-by-session changes. Data from 489 patients attending three eating disorders services in the United Kingdom between April 2008 and January 2013 were included; all data were anonymous when analyzed. 
The second study tested the questionnaire in two study populations, those with and those without EDs. To obtain their study population, the authors sent out an email appeal providing a link to an online survey to all students at a London university. The same link was advertised on the website of Beat (Beating Eating Disorders; ), a charity supporting current and former ED patients. 
The survey included several online questionnaires, and was completed by 559 men and women. Of these, 54 (9%) currently had an eating disorder. Twenty-five had seen the study though the university email appeal and the rest were recruited through the Beat advertisement. All participants completed the EDE-QS, the EDE,and the Clinical Impairment Assessment (CIA), which analyzes impairment in psychosocial functioning secondary to an eating disorder. In addition they filled out the Short Evaluation of Eating Disorders (SEED), the SCOFF questionnaire, the Generalized Anxiety Disorder Questionnaire, the Patient Health Questionnaire, and the World Health Organization Quality of Life Questionnaire.

Was the shorter form effective?

Fewer men than women reported having an eating disorder, and those with an eating disorder reported lower levels of education. There also was a close correlation with the CIA because this questionnaire measures psychosocial impairment secondary to an eating disorder. The EDE-QS showed a positive association with other measures of eating disorder pathology in both groups, just as the authors had hypothesized. There was only a medium correlation between the EDE-QS and the SEED questionnaire.
The authors reported that the brevity and revised response categories on the EDE-QSbetter permit ongoing progressive monitoring, which has been shown to improve patient outcome. The availability of weekly session by session feedback data also may be more appropriate for mental health settings. One more bonus of the shorter instrument may be reduced burden on patients and staff.

The second study did have some limitations, including its small sample size and convenience sampling method. Also, the use of diagnostic assessment or interviews would have been preferable to the online method. The number of people who identified themselves as having eating disorders was relatively small. Finally, the authors noted that it would be a good step to establish clinically significant changes or cutoff points for the EDE-QS, to differentiate between nonclinical and clinical impairment in EDs.

Self-Control and its Connection to Disordered Eating Focusing on strict goals may miss deeper concerns.

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP
Hilde Bruch was among the pioneers who defined anorexia nervosa (AN) as a struggle for control and a sense of identity, greater competence, and effectiveness. To Dr. Bruch, the symptoms of AN were manifestations of an individual's attempts to compensate for an underlying sense of ineffectiveness and lack of control in other parts of his or her life. Control over eating becomes a focus in an individual's life because it is seen as a success in the context of perceived failures.

A study from Australia

Psychologist Franzisca V. Froreich and researchers at the University of Southwest Australia, Sydney, recently studied the role of self-control in a group of 175 females with AN, who completed self-report questionnaires that addressed measures of control, eating disorders pathology and obsessive-compulsive symptoms (J Eat Disord. 2016; 4:14). The focus of the Australian study was to determine which form of individual self-control was most strongly associated with disordered eating. Another part of the study was exploring the relationship between self- control and obsessive-compulsive symptoms.

Finding patients through the Internet

The authors found their study participants in a somewhat unique way, through Amazon Mechanical Turk l (MTurk), a crowdsourcing website. Females who were registered with MTurk and living in the US, and who were between 18 and 40 were eligible to participate. A final study group of 175 women aged 19 to 40 years signed up for the study. After reading an introductory information page and giving consent, participants completed questionnaires, beginning with control-related questionnaires, presented in randomized order. 

A positive connection between ED symptoms and fear of losing self-control 

Just as the authors had hypothesized, eating disorder symptoms and obsessive-compulsive symptom severity were positively associated with external locus of control, negative sense of control, feelings of ineffectiveness, and fear of losing self-control. All were negatively associated with sense of mastery.
The authors report that although a number of control dimensions are related to disordered eating behaviors, ineffectiveness and fear of losing self-control are the strongest predictors of eating pathology. They also noted that none of the items in any of the control scales administered in this study directly referred to eating or weight or shape. Thus, the underlying control beliefs are not disorder-specific but more general in nature; in addition, the direction of causality between control and eating disorders cannot be determined by the results of this study, according to the authors. Instead, the results of this study add some evidence that ineffectiveness and fear of losing self-control are important to consider in the maintenance and treatment of disordered eating behaviors. 
Thus, treatment that focuses on stringent behavioral goals, such as reducing control over eating, weight and shape, may not address the deeper problems that underlie and often maintain these very symptoms. A more successful approach may be to help the individual re-establish adaptive mechanisms of personal control and effectiveness, and thus reduce the need to rely on weight and shape control.

Loss of Control Eating Can Be a Problem for Teens Planning Bariatric Surgery Problematic eating behaviors may affect up to 25% of these young patients.

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP
Before undergoing bariatric surgery, severely obese teens may present with problematic disordered eating behaviors. Disordered eating is common among teens undergoing bariatric surgery; 20% to 48% report binge eating, eating faster than usual, and feeling guilty about eating, eating until uncomfortably full, eating without hunger, and preferring to eat alone (J Clin Psychiatry. 2012; 73:1351). Some may meet the diagnostic criteria for an eating disorder. 
Loss of control (LOC) eating is a subjective sense of being unable to stop or control eating, regardless of the food involved. According to members of the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Consortium, LOC eating may be more clinically relevant than binge eating among adolescents, and may also be a better marker of eating-related psychopathology in teens than are objective binge-eating episodes (OBEs). (The Teen-LABS study is an ongoing cohort study of teens aged 13 to 19 who were enrolled and underwent bariatric surgery from 2007 to 2012.)

A study to identify teens with LOC eating

Dr. Linsey M. Utzinger, of the Neuropsychiatric Research Institute, Fargo, ND, and her colleagues analyzed data from the Teen-LABS study to identify candidates for their study (Int J Eat Disord. 2016; E-pub before print). Teens completed baseline assessments within 30 days of their bariatric surgery date. They also completed the following questionnaires: Questionnaire of Eating and Weight Patterns-Revised(QEWP-R), the Night Eating Questionnaire (NEQ), the Beck Depression Inventory(BDI-II), and the Impact of Weight on Quality of Life-Kids (IWQOL-Kids).
Two-hundred and forty-two teens (mean age: 17.1 years) participated in the study. One-hundred and eighty-three were females, and 59 were males. The median body mass index (BMI, mg/kg2) was 50.5. (One of the requirements for adolescent bariatric surgery is a BMI above 40, or a BMI between 35 and 40 when there is a serious comorbidity.)

Nearly one-fourth had LOC eating problems

The most common problematic eating behavior reported among the 242 teens was LOC eating, which was reported by 65 teens, or nearly 24% of the study group. Before they underwent bariatric surgery, nearly 7% of the teens met current criteria for binge eating disorder, or BED. Two teens met the criteria for bulimia nervosa, and 12 met the criteria for night-eating syndrome.
Compared to teens without LOC eating, those with LOC eating showed greater impairment on almost all psychosocial variables. This included greater depression and more marked impairment in weight-related quality of life. Unlike earlier studies showing that LOC eating in youth is associated with maladaptive family function, this was not the case in this study. It is still unknown whether the high rates of disordered eating behaviors in teen candidates for bariatric surgery persist or develop after surgery.

Requirements for surgery

Before being considered for bariatric surgery, teens must meet a number of requirements, beginning with a BMI of 35 to 40. Both patient and parent/guardian must provide consent for the procedure; the patient, and a parent/guardian must undergo psychological evaluation to be certain he or she is prepared for pre- and post-surgery requirements, including a supportive family environment, willingness to commit to strict diet, exercise and weight loss support groups, and physician follow-up for the rest of their lives. They also must have reached physical and skeletal maturity (Tanner Scale IV or V). Teen girls must be willing to avoid pregnancy for at least 1 year, and preferably 2, after the weight-loss surgery. Finally, prospective patients must agree to participate in a clinically supervised weight loss program, and to fail to lose weight on such program for at least 6 months.

The authors point out that it is important for clinicians to identify LOC eating problems among teens scheduled for bariatric surgery, and to make appropriate treatment referrals for these young patients.

Predicting Relapse Risk with Weight Gain Patterns

Reprinted from Eating Disorders Review
September/October Volume 27, Number 5
©2016 IAEDP

Fewer than half of patients treated for anorexia nervosa (AN) maintain their initial recovery, and up to 63% relapse after treatment. By identifying individual patterns of weight gain during inpatient treatment, clinicians might better evaluate an anorexic patient's treatment response, noncompliance, and risk of relapse, according to researchers from the University of Maryland, Stanford University School of Medicine, and Johns Hopkins School of Medicine. At the recent International Conference on Eating Disorders (ICED) meeting in San Francisco, Saniha H. Makhzoumi and colleagues reported identifying 3 distinct weight gain patterns in their study of 211 female inpatients with AN or subthreshold AN. 
The women had a mean age of 28.5 years, mean admission body mass index (BMI, mg/kg2) of 16.14, and had been ill with AN for a mean of nearly 11 years. The researchers assessed frequency of ED behaviors, and clinical variables on admission, such as BMI, age, target weight, behavioral subtype and number of prior hospitalizations for ED treatment. They also administered the Eating Disorder Inventory, the Eating Disorder Recovery Self-Efficacy Questionnaire, and the NEO Five Factor Inventory. The research team identified 3 distinct patterns of weight gain and response to treatment. Women with the highest risk of relapse were more likely to have purging subtype AN, and to have higher lifetime BMIs (and higher weight suppression), along with past hospitalizations for AN treatment.