Monday, May 1, 2017
Courtesy of Eating Disorders Review
Shedding New Light on Eating Disorders at Midlife
Even the researchers were surprised when their study of 5,655 women in their 40s and 50s revealed that more than 15% of the women met criteria for a lifetime eating disorder. Another surprise: 3.6% of the women reported their eating disorders had been diagnosed only within the past year. The participants were drawn from the UK Avon Longitudinal Study of Parents and Children, a prospective study of pregnant women who expected to deliver their babies between April 1, 1991, and December 31, 1992.This was the first study of the prevalence, risk factors and healthcare use by middle-aged women with eating disorders. It is also the first study to investigate childhood and personality risk factors for full threshold and sub-threshold eating disorders. Nadia Micali, MD, PhD, and her colleagues at the Eating and Weight Disorders Program at Mt Sinai Hospital, New York City, reported that the number of women who had an eating disorder in the past was slightly higher than anticipated, and some women had first been diagnosed with an eating disorder at midlife. Childhood sexual abuse was prospectively associated with all binge/purge type disorders and an external locus of control was associated with binge eating disorder. Better maternal care was protective for bulimia nervosa. Childhood life events and interpersonal sensitivity were associated with all eating disorders.The study was first published online January 17, 2017, in BMC Medicine, an open-access journal.
Courtesy of Eating Disorders Review
Two studies examine how individual perceptions can be altered.
Body perception problems are among the most striking manifestations of anorexia nervosa (AN). In two recent studies, researchers in Australia and the US used different approaches to determine the origins of distorted body image among AN patients.
Visual adaptations after exposure
Dr. Kevin R. Brooks and colleagues at Macquarie University, Sydney, Australia, designed a unique study to test the effect of manipulated images on a group of female undergraduates (Frontiers in Neuroscience 2016; doi:10.3389/fnins.2016.00334). This is one of the few studies designed to explore how neural mechanisms affect body perception.
Dr. Brooks’ group chose 24 Caucasian female undergraduate psychology students for the experiment. First, full-body digital photos were taken of each participant. The women were photographed while standing and wearing bicycle shorts and a form-fitting top, with feet shoulder-width apart and arms straight at their sides. Then, the original photographs were manipulated in Adobe Photoshop to produce 7 final images depicting the subjects at from -30% to +30% of their original size. Weight and height were recorded to establish body mass index (BMI, kg/m2) for each participant.
Next, each student was shown a photograph of the face of another individual whose BMI and age closed matched hers. Each participant was then tested to see whether she thought the individual in the image was larger or smaller than non-manipulated images viewed at an earlier stage of the experiment. Looking at the digitally manipulated images for as little as 1 minute was enough to change the perception of images seen afterward. For example, after a student looked at images that had been manipulated to make a person appear thinner, people in non-manipulated images seemed heavier than normal.
Neural differences in self-perception during and after weight recovery
In healthy populations, several brain areas, including the medial prefrontal cortex, the posterior cingulate cortex, and the temporal parietal junction, are connected to self-perception and evaluation. Neural activations during self-perception are thought to be altered in AN patients (J Science and Neuroscience 2014; 39:178). But, does this factor normalize with recovery or do the neural activations persist?
To answer this question, Dr. Carrie J. McAdams and colleagues traced neural pathways that they theorized affected self-perception during illness and after weight recovery among women with AN (Social Cognitive and Affective Neuroscience 2016; 1825-1851.) Dr. McAdams and her colleagues used the Social Identity V2 task (McAdams and Krawak, 2014) and the Faces task to evaluate three groups: 19 healthy women, 22 women with AN, and 18 women in long-term weight recovery after AN. The Social Identity Task involves the subject in different interactions with images of themselves, friends, and reflected images personalized with the name of a female friend. The subjects then responded to 48 statements that related to social interactions, presented three times. In the Faces task, each subject viewed 15 images of her face and 15 images of a stranger. The stranger’s images closely matched those of the subject except that the head was tilted differently in each image. Both ill and weight- recovered AN participants had substantially different medial prefrontal cortex activation as compared to controls. Compared with controls, those with AN had different performance on the Faces task. The reactions were very similar among those with restored weight and controls.
Thus, successful weight recovery from AN seems to be associated with some aspects of self-perception, but not to others. Much more needs to be learned, but both studies add hope for possible ways to better understand the complexities of and treatment for patients with AN.
Courtesy of Eating Disorders Review
Diminished bone density is a common complication that needs much more thorough investigation.
Diminished bone mineral density (BMD) is a common medical complication of anorexia nervosa (AN). Since AN often begins in the teen years, causing bone mineral loss at a time when BMD normally rapidly increases, the long-term implications are significant.
Dr. Marwan El Ghoch, an expert in bone health and eating disorders, and his colleagues recently conducted a systematic review of the association between weight gain/weight restoration and BMD in adolescents with AN (Nutrients. 2016; 8:769). Noting that nearly 85% of females with AN have very low BMD and a 7-fold increased risk of spontaneous fractures compared to healthy controls, Dr. El Ghoch and his team conducted a systematic literature review of the association between weight gain/weight restoration and BMD in teens with AN.
Only 19 of the 1156 articles the authors initially reviewed met inclusion criteria for the study. Further, a review of these studies produced only 2 clear findings. First, weight restoration was associated with stabilization of BMD in 6 of 8 teens with AN after one year. Second, 7 studies with follow-up periods longer than a year showed the same trend to stabilization of BMD, followed by significant improvements in BMD. Only one study found that improved BMD can be achieved 30 months after weight restoration. Finally, another single study showed that teenage males with AN who remain underweight may have continued BMD loss.
The authors caution that these seemingly encouraging results must be viewed in light of the fact that weight restoration was achieved only in 9 of the 19 studies. The studies also offered varied definitions of normal weight cutoff points; for example, the cutoff points ranged from 17.5 kg/m2 to more than 19 kg/m2, and 15 of the studies were uncontrolled. And, none of the studies took into account the rate of weight gain or specific eating disorder behaviors than might have had an effect on BMD gain and weight restoration.
Still needed: guidelines for management of bone loss in teens
This represents a large body of work, but the authors point out that much more research is needed. For example, there is a need for full clarity on the extent of repair of bone that can occur with weight restoration. And, when BMD is not adequately restored with weight gain, adequate treatment is needed. Finally, much more research may help clarify how the existing findings about weight gain and bone health applies to teenage males with AN.
Courtesy of Eating Disorders Review
A Swedish study applies the case management approach for enduring eating disorders.
Some patients with severe eating disorders just don’t get better despite long-term treatment, and may go on to develop severe and enduring eating disorders (SEED). An eating disorders center in Stockholm is currently testing a case management system to help such patients (J Eat Disord. 2016; 4:24).
In 2014, the Stockholm Centre for Eating Disorders at the Karolinska Institute designed a new treatment unit, Eira, especially designed for SEED patients. A team at the Karolinksa Institute recently described their ongoing study investigating whether an individualized case management program approach could improve SEED patients’ quality of life, help control their healthcare costs, reduce eating disorder symptoms, and improve access to and voluntary use of available health care.
Patients who are candidates for case management often are seriously ill and in distress because of physical and financial strain, social problems, combined with anxiety, depression and compulsive behaviors. Ironically, some SEED patients appear to be well and thus are ambivalent about treatment. For some clinicians, a patient who has “tried everything” without a positive result may appear “unmotivated” and subsequently dismissed from treatment.
Case management systems
In the past, case management approaches have been aimed at adult patients with severe mental disabilities such as schizophrenia, severe addictive disorders, and psychoses. The case management method offers individualized care, which may last a few months to several years, and there is no time limit for the intervention.
The Eira unit accepts patients who have had an ED for at least 10 years and who have failed at least three treatment programs. All patients undergo a semi-structured diagnostic interview, a qualitative interview, and then complete several self-report questionnaires. Data from medical records are also collected. The program is designed so that the diagnostic interview and self-report assessments are done at follow-ups after 1, 2, and 3 years in the program.
The program can manage up to 30 patients simultaneously. The main activity involves clinical contact with a clinical case manager through supportive conversations. The case manager also has a role in treatment, for example, by providing social training, ways to control symptoms, and family support. According to the authors, the individual patient’s needs and references drive the frequency, setting, and form of the meetings. With the patient’s consent, relatives are invited to participate in the intervention, and special lectures for family members (without the patient) are offered twice a year. According to the authors, clinical outcome and cost-effectiveness will be carefully analyzed at the end of the current study.
The authors also note that the program offers an alternative to more traditional treatment, which is aimed at reducing the patient’s symptoms; instead, the case management approach prioritizes function and quality of life. It will be of great interest to see the final outcomes of this study.