Wednesday, December 13, 2017

Television and Dysfunctional Eating in Teens

Vol. 28 / No. 6  

One gender-related difference emerged in a study in southern Italy.
Adolescence can be a wondrous time of physical growth and exposure to new ideas and experiences, but it may also bring social aspects of everyday life that negatively affect body image. Environmental factors such as teasing by peers and family members and exposure to unattainable ideals of thinness are good examples.
Dr. Barbara Barcaccia and researchers at the University of Sapienza, Rome, and Boston College explored the possible influence of models portrayed on TV on adolescents. The authors sought to examine body image, uneasiness with one’s body, eating-disordered behavior, depression, and anxiety among a group of teens and young adults (Revista Brasileira de Psiquiatria. 2017; doi:10.1590/1516-4446-2016-2200, published online before print). The Italian researchers studied 301 teens 14-19 years of age who were recruited from 13 high schools in southern Italy. The teens filled out a series of questionnaires, including The Body Uneasiness Test (BUT) and the Eating Disorders Inventory-2. The BUT contains 71 questions about weight phobia, body image concerns, and worries about specific bodily parts and functions (Eat Weight Disord. 2006; 11:1). Sample statements include “I avoid mirrors” and “I compare my appearance with others.”
Responses differed by gender
One trend that emerged from the study was gender-based responses to media exposure, highlighting differences in susceptibility to body misperceptions among males and females. Just as reported in previous studies, drive for thinness was impacted more by media exposure in females than males. Perhaps sensitivity to media images helps explain differences in ED prevalence by gender. The authors noted that women do watch more entertainment and image-focused television programs than do men (Eat Behav. 2013. 14:441). They also pointed out that objectification theory states that in Western culture women are specifically objectified and their bodies used to measure self-worth. This then leads to a subconscious tendency for women to compare their body image to others to a greater extent than do men (Psychol Women Q. 1997. 21:173).
Another interesting finding in this study was that the extent to which males’ friends wished to physically resemble TV characters; this was the only statistically significant finding for the males in the study. The authors pondered various possible causes for this trend. While males and females are sensitive to the influence of their friends, in the Italian culture, according to the authors, boys and men interact socially to a greater extent than in other parts of the world.
The results also showed that women were more susceptible to ED behaviors, distorted perceptions of their bodies, and development of depression after exposure to mass media. In contrast, males were more susceptible to distorted perception of their bodies, state and trait anxiety, and depression through indirect comparisons to the mass media through their friends.

A Promising Agent for ED Patients with Severe Behavioral Problems

Vol. 28 / No. 6  

A pilot study used an agent originally designed for patients with epilepsy.
Studies of medications such as SSRIs for individuals with eating disorders have focused on the ED, but many people have co-occurring pervasive severe affective and behavioral problems. A recent trial has offered hope for this subgroup of ED patients.
Some patients with bulimia nervosa (BN) and binge-purge type anorexia nervosa (ANbp) can have many bouts with loss of control eating and compensatory behaviors, such as self-induced vomiting, often with severe medical morbidity. Other comorbid behaviors can include substance abuse, impulsive behaviors such as shoplifting, and self-injury.
Dr. Mary Ellen Trunko and colleagues at the University of California, San Diego, recently reported the results of their pilot study evaluating use of the mood-stabilizing drug lamotrignine (Lamactal®) in a group of patients with ANbp and BN with a range of dysregulated behaviors who had not responded to antidepressants (BPD and Emotion Regulation. 2017; 4:21). The small study group included 9 women with AN or BN-spectrum eating disorders (14 started the trial but 5 did not complete 2 months, for various reasons). All the women were participating in dialectical behavior therapy (DBT) in partial hospital or intensive outpatient treatment settings. Their treatment included 10 hours per day, 6 days per week. As the women improved, they were able to step down to 6 hours of treatment a day and ultimately to 4 hours a day. All participants received a routine lamotrigine titration until a target dose of 100 to 300 mg per day was reached.
Their DBT program included weekly individual sessions, twice-weekly skills training groups using the DBT Skills Manual (Linehan M. DBT Skills Manual, second ed. Guilford Press, New York, 2008), group sessions, and skills coaching via telephone contact or text-messaging outside program hours. The women also underwent emotional and behavior assessments and were studied with a number of questionnaires, including the Eating Disorder Examination Questionnaire (EDEQ). All the DBT therapists met as a team once a week.
An improvement in symptoms was noted
All 9 women who completed the study reported reductions in dysregulated emotions and problems with impulse control. In general BEST and ZAN BPD ratings improved and lamotrignine was said to well-tolerated. One of the women stopped the medication because of a possible rash, a rare but potentially very serious side effect of lamotrigine.
The authors argued for a large-scale rigorous investigation of the drug, with and without DBT or other therapies. This would differ from most med trials in ED in that an inclusive rather than exclusive set of criteria would be used, resulting in a highly comorbid group (of the sort we often see in routine clinical care).

Some Surprising Genetic Findings for Individuals with Anorexia Nervosa

Vol. 28 / No. 6  
One discovery was a genetic basis for greater educational achievement.
We know there is an important genetic component to anorexia nervosa, but a recent study points in some surprising directions. This large study by Laramie Duncan, PhD, and colleagues (Am J Psychiatry. 2017; 174:850) not only suggests that AN can be partially heritable, but also that metabolic, weight-related, and inflammatory factors may be some of these inherited components.
A scan of the entire genome for links
In all, 3,495 participants with AN and 10,982 controls took part in this remarkably large study. A genome-wide associate scan was conducted to search the entire genome for links between AN and genetic markers. At least three major findings emerged. First, confirming results from previous studies, AN was shown to be partially inherited, with genes accounting for about 20% of the chance of developing the disorder. Second, there was a strong association between AN and the area on a chromosome near genes for diabetes mellitus and some autoimmune diseases. Third, people with AN had lower body mass indexes, lower insulin and glucose levels, and higher high-density lipid cholesterol levels than those without the disorder. Finally, individuals with AN had higher educational achievement. This is an interesting finding because in the past such accomplishments were assumed to be primarily related to family environment. This study suggests that higher achievements may in fact have a genetic basis.
These findings, if replicated, will greatly broaden our understanding of the phenomenon of AN, to include both metabolic and behavioral components of the disorder.

Self-Admission for Inpatient Treatment

Vol. 28 / No. 6  

A small study found areas that needed improvement for ED patients.
For more than a decade, selected patients with severe psychiatric illnesses, including eating disorders, have been able to admit themselves for inpatient treatment in several European countries (which differs markedly from practice in the US).
Eligible patients can typically admit themselves at will for 3 to 7 days, and may leave the service at any time. To be eligible, patients must maintain constant contact with the adult outpatient unit or day treatment unit. Another requirement is that they must have been treated at least one time in the adult inpatient ward during the past 3 years, and know the framework of and the routines and rules of the specific ward.
Swedish researcher Dr. Mattias Strand and colleagues wanted to examine patient experiences with self-admission during the process of starting a new self-admission program in an eating disorders service at the Stockholm Centre for Eating Disorders (BMC Psychiatry. 2017; 17:343). The Swedish researchers interviewed 16 patients in a self-admission program after 6 months, to learn about their experiences and to get suggestions for improving the program.
Some room for improvement
Most patients were generally satisfied with their experience, but they also had suggestions for improvements. One overarching issue was maintaining the balance between the positive effects of the patient’s sense of autonomy and the difficulties handling the freedom and responsibility involving in self-admission. Some patients were not always confident that they could use the increased accountability in a constructive way. An example of this was problems that arose during the process of reserving a bed in the inpatient center. Although the patient is responsible for checking on the availability of a bed and calling back to check on the status of a bed before admission, this was stressful and proved discouraging to some. Establishing a separate waiting list for the self-admission beds (usually 2 to a unit) was the solution. Other patients found staff rotations unsettling. Because their stay in the hospital was usually brief, they did not always work with the same staff members, and had no single regular contact person. Some felt there was not enough emphasis on long-term goals. One patient summed it up well by saying, “This thing about deciding a lot for yourself—perhaps you need to be a little careful about that because if you get to decide for yourself, very often it will be the illness talking.”
Some changes were made
The authors implemented several changes, including providing more thorough information about the rationale of self-admission and patient accountability. They also provided a single contact staff member for each self-admitted patient. Another very important addition was a thorough discussion of one major drawback of the program: the brief time of admission makes it unlikely that a patient can achieve any long-term treatment goals during a single stay. Instead, the authors stress that self-admissions should be viewed as booster opportunities or brief respites. Finally, according to the authors, patients with an eating disorder may be even more reluctant to seek help than other patients, and this needs to be addressed in the design of future self-admission programs.
This is an intriguing approach. For those with ED, one wonders if it will be highly effective in interrupting symptoms of binge eating and purging, or restricting, or if ultimately it will be too small a dose to be helpful.

A Better Way to Measure Body Composition?

Vol. 28 / No. 6  

Measuring free fatty mass with BIA equations
Body weight and body mass index (BMI, kg/m2) are two major measurements used to establish body composition and degree of underweight or overweight. However, according to a group of Italian researchers, these gold standards turn to tin with severely malnourished patients, such as those with anorexia nervosa (AN). Dual energy x-ray absorptiometry (DXA) represents a gold standard but is not always available; BIA is more available but seen a less valid. Could better equations to calculate BIAS results help? (Nutr Clin. 2017; clnu.2017.07.016, published online).
One such technique uses DXA. Dr. Maurizio Marra and colleagues at Frederico II University, Naples, Italy, evaluated several BIA equations to determine how accurately they could estimate body composition among patients with AN. Their study group included 82 AN patients with restrictive-type disease (ANr) who were attending the outpatient clinic at the authors’ university. All underwent whole-body DXA scans with two x-ray beams at different energy levels to measure free fatty mass (FFM, or lean body mass plus bone mineral content) and fat mass (FM). BIA was performed and then various approaches to analyzing the results were examined.
Results: BIA measurements underestimated FFM
On average, all the BIA equations significantly underestimated DXA-derived FFM values. Overall, DXA was more accurate than BIA, which in turn gave a more accurate picture than BMI.   The authors underscore the need to develop disease specific methods for analyzing BIA results as a way to make them more useful.

Web-Based Aftercare for Women with Bulimia Nervosa

Vol. 28 / No. 6  
Early results were promising, but dropouts were a problem.
Response to treatment for BN is modest, but an important factor is that relapse is common (Psychosom Med. 2011; 73:270). To combat this, a group in Germany recently designed a 9-month manualized CBT Web-based aftercare program for women with BN (J Med Internet Res 2017; 19:e321, published online before print). This is one of the first studies designed to evaluate the efficacy of programs targeting maintenance or improvement of treatment gains achieved during inpatient treatment for BN.
Web-based interventions have several advantages over face-to-face interventions, according to Dr. Corinna Jacobi and her colleagues. Patients’ access to the Internet reduces barriers such as cost, availability of services, waiting time, transportation challenges, and stigma about having an eating disorder. The increased anonymity may also encourage individuals to seek help.
Dr. Jacobi and her fellow researchers conducted a randomized controlled trial of 253 women with DSM-IV diagnoses of BN. Over more than 4 years, patients were screened and recruited from 13 hospitals throughout Germany that offer inpatient treatment for eating disorders. Patients were eligible for the study if they were at least 17 years old and had reduced their binge-eating and compensatory behaviors by at least 50% compared to their levels at hospital admission. Participants were then randomized to treatment with the Internet program, “IN@,” or to treatment as usual.
The Web-based intervention, IN@, included information on eating behaviors and core bulimic symptoms, and advice about healthy exercise, body image, and self-esteem. In addition, the IN@ program included a monitoring log for bulimic symptoms and a personal diary. Three clinical psychologists specially trained in behavior therapy for EDs also provided individualized email feedback and up to 9 monthly real-time individual personal chats of about 1 hour per participant. Women in the treatment-as-usual group were also assessed at all follow-up points, and had the option to take part in any outpatient treatment programs offered by the individual hospitals. Assessments were made at admission, at discharge from the hospital, 9 months after admission, 9 months after the intervention, and 9 months after this. Because the study hospitals were scattered throughout Germany, and the patients returned home to different parts of the country, all interview assessments were done by telephone by trained assessors blinded to patient group assignments.
The authors reported that 15% of the women in the intervention program never logged onto the Internet site after being discharged. The remaining 107 women accessed at least half of the intervention content. Forty-seven women (37%) participated in at least one live chat.
Symptoms and program adherence at study’s end
In general, results were numerically better in the IN@ group, but many othercomparisons were not statistically significant. Binge-eating episodes increased significantly in both groups after discharge from the hospital. However, at the post-intervention follow-up, binge-eating episodes were 27% lower in the intervention group than in the treatment-as-usual group. At follow-up there was no difference between the two groups. At the post-intervention assessment, about 1 in 5 patients reported abstinence from binge eating and lack of compensatory behaviors during the prior 2 months, but the difference between the treatment groups was not significant.
As for the incidence of vomiting at the post-intervention point, it was 46% lower in the intervention group, a statistically significant difference. At follow-up, the frequency of episodes of all compensatory behaviors was 41% lower but the difference was no longer significant. The authors note that even though the intervention did not significantly affect abstinence, the results may have important clinical implications, namely that rates of vomiting in the intervention group were almost half of those among the treatment-as-usual group.
What could improve adherence to a Web-based CBT program? The authors suggest that future programs be directed at adapting interventions to help increase adherence and reduce dropouts because use of the website and live chats was modest.

Perspectives: Teaching New Math for EDs

By Sandra Wartski, PsyD, CEDS
At the height of their illness, clients with eating disorders are often engaged in ongoing mental math torture. There is usually an exhausting focus on various mathematical calculations, including calories consumed, calorie expenditure, restrictive meal planning, exhaustive menu examination, weight analysis, clothing size scrutiny, and a myriad of other mental gymnastics that undermine concentration and focus upon joyful life activities.
Some of this over-focus on numbers can represent an OCD (Obsessive Compulsive Disorder) and ED overlap; however, unlike some of the other non-ED-OCD behaviors, such as door-tapping or handwashing, the ED numbers focus ends up being much more deeply rooted in meaning, entrenched “stuckness,” and trepidation.   The gold standard of treatment for OCD is more formally known as Exposure Response Prevention (ERP) therapy, and generally involves refraining from giving in to the OCD commands. ERP requires an individual to be exposed to the thoughts, images, and objects that trigger anxiety and then preventing usual responses to this anxiety with compulsions and/or rituals.
ED treatment involves a healthy dose of the ERP approach (even when not labeled as such), because keeping up with food and eating is a daily requirement (unlike some of the pure OCD “pulls” that can be more easily avoided, such as airplanes or cracks in the sidewalk), and is at the core of recovery. But the extra layers of ED meaning imbued upon the numbers means that clinicians may also need to pull in additional skills.
ED treatment is already multifaceted. Part of treatment does involve teaching a new approach involving facing calories, weight, size, and food. We wish for less negative obsession about amounts and numbers but, paradoxically, we also need a reasonable focus on some of this at the start of recovery. We are generally aiming at intuitive eating eventually, where we would hope that selection of a particular snack is based more on availability and taste preference rather than fat grams or calories. Unfortunately, most clients are far from this in the beginning. The majority need guidance in general structure, outlines, and minimums to begin the process of resetting in this confusing process of attending mindfully to hunger and fullness signals.
When negative number crunching or mental math torture is a significant symptom, sometimes creating a surprising or novel approach can help to break rigid routines. Some clients are willing to engage in straightforwardly breaking habits with a more basic exercise such as deliberately creating number confusion. This might involve repeatedly reciting random numbers or counting backwards in Roman numerals when the ED counting commences, but sometimes teaching a more comprehensive “New Math” is what might be needed.
New Math Subtraction
Clients are generally well versed with skills that enable them to cut out or avoid foods. Sneaky subtraction tactics are presented by the ED as logical and necessary but are really duplicitous and devious. New Math Subtraction might involve helping a client to find other things to cut out of his or her current routines instead. We can help clients to consider other things to subtract from their current life. Aside from aiming to diminish the continual math calculations, we can encourage them to consider other, broader-range issues that deserve to get cut out of their lives. We might propose questions about what else needs to be subtracted from current thinking patterns, behavioral interactions, relationships, and life routines in general that would substantially enhance current health and happiness. When ED subtraction begins to take hold, can we stop and switch gears to figure out what else might be subtracted instead? Perhaps this involves cutting out time spent on certain social media sites or with certain competitive friends. Maybe this involves getting out of an old routine of not eating at family dinners and instead cutting out the habit of not speaking up. Rather than avoiding certain taboo foods, is there perchance a need to cut out a false assumption or negative association?   Subtracting and deleting that which truly needs to be deleted is freeing.
New Math Addition
Individuals with EDs also add in ED-inspired behaviors fairly regularly, such as calculated water-loading to manage hunger pangs or secretive over-exercise to undo the anxiety of having added in a snack. Addition anxiety lurks around every bend, allowing the ED to attempt to prevent or “make right” any perceived failing. With New Math Addition, there are multiple add-ins to consider. We might aim to help clients to creatively consider what they need more of in their lives. This requires a broader perspective than the usual ED narrow focus, moving away from “needing” more torment and instead finding ways to add in more joy, fun, and relaxation. What else would they like to be included in their lives? What else has needed to be said or revealed that has been missing from conversations for far too long? What has been absent since the ED took residence and could be added back in? Looking for those add-ins that truly enhance day-to-day living from the inside out creates a whole new dimension of living.
New Math Multiplication
ED multiplication misery comes in various forms, such as repeatedly rounding up calorie estimations, distorted message cycling, and falling into mirror distortion trickery. New Math Multiplication focuses on more authentic ways of maximizing enjoyment.   Helping clients orient to ways of capitalizing on and actively seeking out more of the good is complex at the beginning but becomes increasingly easier as new routines are established. Like learning the times tables, there is effort needed at first but then the calculations become second nature. Can we help clients find a way to practice reviewing the positive experiences and moments of gratitude twice as often as the negative? Are there activities that would be double the fun with a good friend? Can we orient to how the delight of a meal or the comfort of an outfit might be quadrupled? Multiplier effects can create an explosion of positive experiences.
New Math Division
Grapes cut in half, sandwiches into quarters, or brownies into sixths are not uncommon partitioning practices for those struggling with an ED. There is often the concern about how much is too much, and then the derogatory division begins. Instead of cutting the serving in half, can we explore ways of cutting the stress in half? Can divide up the unrealistic work load instead of the next snack? Helping a client to stay in treatment and to feel the support of their treatment team and their support system is likely to be the most essential new math concept in the domain of division. Any workload, fear, anxiety, and confusion are generally reduced significantly when shared with others. Clients have often spent so much time operating secretly and calculating cunningly that this notion of sharing and letting in others will be hard, but ultimately distributes the difficulty so much more effectively. Dividing the things that truly need sharing and balance rather than the nutritional intake needs allows more stable and settled focus overall.
Privileging the Practice
Just as with any new skill, New Math requires practice and repetition. Once we are used to approaching situations in one way, shifting to a new way of thinking takes time and patience. Sometimes, however, a little bit of surprise and lightheartedness can disrupt even the most rigid of routines.

Update: Improved Sexual Function May Be One Marker of Recovery from AN

Vol. 28 / No. 6  

Young women with AN who resume menstruation after recovery have better psychological and physiological health than those who do not, according to new research from the University of Florence, Italy. Dr. Giovanni Castellini and colleagues reported the results of their study of sexual function among anorexia nervosa (AN) patients at the 30th European College of Neuropsychopharmacology Congress in Paris in September. The researchers’ results challenge the usual idea of recovery from AN based on weight restoration or behavioral changes. In addition to these well-known markers of successful recovery, the authors recommend that factors such as concern over body image, as well as sexual function, poor overall quality of life, and patients’ subjective experiences be taken into account when measuring recovery from AN.
Dr. Castellini and his fellow researchers studied 39 patients with AN and 40 with BN to see how sexual functioning moderates recovery, and to identify factors associated with restoration of regular menstrual periods and healthy sexual function. All patients underwent individualized cognitive behavioral therapy (CBT) for one year and then were revaluated at the end of treatment and 2 years later (3-year follow-up). When CBT was completed, 56.4% (22) of AN patients and 57.5% (23) of BN patient were thought to have recovered from the disorder. At the 3-year follow-up evaluation, 48.7% of AN patients and 60.0% of BN patients were considered recovered.
The pattern of recovery at the end of CBT differed between those with and without amenorrhea. Those who had resumed menstruation had greater reductions in EDE-Q total score and in the restraint subscale score, and greater increases in body mass index, Female Sexual Functioning Index (FSFI) total score, and triglyceride levels at the end of CBT. These differences remained at the 3-year follow-up.
Dr. Castellini advised that that assessing patients’ sexual functioning could help determine the need and direction of ongoing treatment for AN. When patients remain amenorrheic after treatment, another cycle of psychotherapy may be warranted, or another psychotherapeutic evaluation may be necessary, particularly when there is no improvement after the first year of psychotherapy.

More from ICED 2017: A New Look at the Many Facets of Binge Eating Disorder

Vol. 28 / No. 6  
With the publication of the DSM-5, binge eating disorder (BED) finally became an official diagnosis. Although BED is the most common eating disorder with a 2.4% prevalence rate, it is still being defined, as was evident in several presentations at the International Conference on Eating Disorders (ICED) meeting in Prague. In workshops and paper presentations, clinicians from around the world presented their original BED research and reviews.
New Research and Questions about Current Criteria
James E. Mitchell, MD, Chester Fritz Distinguished University Professor at the University of North Dakota School of Medicine and Health Sciences (and emeritus EDR Editorial Board member) set the stage with four-part training presentation on BED during the ICED Clinical Research and Training Day. One intriguing area of research includes new studies of gut microbiomes. One finding is that individuals who consume a diet rich in lipids and carbohydrates have a distinctly different set of gut bacteria compared to those who consume a low-lipid/low-carbohydrate diet. As for treatment, CBT is a well-established treatment for BED and most patients improve substantially and these improvements are generally maintained at 1-year follow-up. Integrative Cognitive-Affective Therapy (ICAT), which helps patients with BN and BED improve their eating behaviors, diffuse bulimic triggers, and better regulate thoughts and emotions, is among the newer treatment approaches. CBT is more effective than other therapies, with the possible exception of Interpersonal Psychotherapy, Dialectical Behavior Therapy, and supervised self-help, he said.
With all the advances, many questions remain, Dr. Mitchell noted. For example, are current criteria for BED correct? Is BED a distinct form of psychopathology or a member of an outlier group meriting its own diagnosis? What is “a large amount of food”? Patients who have had bariatric surgery can’t eat large amounts but develop loss of control over eating. Is this a matter of loss of control or of merely eating a large amount of food?
Six paper sessions on BED sought to answer a few of these many questions.
Are DSM-5 Indicators of Binge-Eating Episodes Valid in Obese Adults? 
Thus far, studies of the validity of DSM-5 signs of episodes of binge-eating episodes indicating loss of control have produced mixed results, and there is no naturalistic evidence about whether the indicators are characteristic of binge eating at the time it occurs.
Dr. Andrea Goldschmidt of Brown University, Providence, RI, and her colleagues designed a study using ecological momentary assessment (EMA) to examine whether eating episodes were actual binge-eating episodes or non-binge-eating events. The study participants were 50 obese adults (mean age: 40.3 years; mean BMI: 40.3 mg/kg2). The EMA procedure involved carrying a handheld computer for 2 weeks. The participants used the computer in several ways: (1) to record symptoms before and after eating episodes; (2) for signal-contingent recordings based on 6 semi-random prompts sent to them each day; and (3) to record symptoms each night before bedtime. Participants received $75 per week for completing the assessments, and a $50 bonus for responding within 45 minutes of receiving the random signals. Dr. Goldschmidt reported that participants responded to more than 90% of the random signals they received.
After Dr. Goldschmidt and colleagues recorded 1689 eating events across binge-eating episodes and non-binge-eating episodes, they found that eating alone and eating rapidly were not significant predictors of binge-eating episodes. Dr. Goldschmidt added that it is unclear whether “eating rapidly” is a defining feature of BED. She added that her group’s results need to be replicated in persons with a diagnosis of BED, and that indicators from EMA testing might also be useful for diagnoses outside of BED.
Is a Taste for Sweet Foods a Signal of Binge Eating?
Erica L. Goodman reported the results of a recent study she and her colleagues performed at the University of North Dakota, Fargo, and the University of North Carolina, Chapel Hill. The team was searching for a possible link between a preference for sweet-tasting foods and binge eating. If they could show this connection, this subgroup of patients might be at higher-than-normal risk for developing diabetes mellitus, metabolic syndrome, hypertension, psychological stress and impaired blood glucose levels, among others. In turn, the group would have greater degree of food cravings and would consume more calories overall as well as more calories from fat and carbohydrates. This would lead to greater postprandial changes in in insulin and glucose levels than among participants without a preference for sweet foods and carbohydrates, or “sweet dislikers” (SDL).
The authors’ study group included 41 persons with BED; 85% were female; 82.9% were White, 12.2% were African American, and 4.9% were categorized as “Other.” The mean BMI was 34.5 mg/kg2. All participants participated in a Sweet Taste Test, where they tasted 5 concentrations of sucrose, and indicated their liking of the concentration and judged the intensity of the solution.
Those in the sweet-liking (SL) group reported eating nearly 3,000 kcal per day compared to the SDL group, who consumed an average of 2,100 kcal per day. Individuals in the SL group had a smaller change in insulin levels in response to high blood glucose levels than did those in the SDL group. Goodman told the audience that this may be an indication that patients in the SL group have greater glucose dysregulation than do those in the SDL group. Patients who were in the SL group also tended to have less glucose regulation than did those in the SDL group.
Patients with a combination of BED and who are sweet-likers may be at an even higher risk for such dysregulation, she noted. This may, in turn, place individuals of this specific phenotype at a heightened risk for developing diabetes or metabolic syndrome.
The authors’ results provided evidence that individuals with BED who prefer sweet-tasting foods may have elevated risk for increased binge eating, craving/intake of high-fat foods and carbohydrates, and for developing glucose intolerance, as seen by limited response in insulin to high blood glucose as well as less of a change in glucose regulation. These individuals may be at greater risk for obesity and related conditions such as diabetes and metabolic syndrome.
What Are the Best Treatments for BED?
A host of treatments have been proposed for BED, including therapist-led cognitive behavioral therapy (CBT), pharmacologic therapy with a host of products, including second-generation antidepressants or lisdexamfetamine dimesylate (LDX ®), and behavioral weight loss treatment. Dr. Christine M. Peat, from the University of North Carolina, Chapel Hill, and her colleagues recently performed a review of the literature to determine the effectiveness of treatments for BED. They found that a definitive answer was elusive.
Dr. Peat noted that numerous agents are used off-label for treating BED but currently only one agent, LDX, an amphetamine originally designed to treat attention deficit hyperactivity disorder (ADHD) in children, has FDA approval for treatment of BED. When LDX was compared with second-generation antidepressants in 11 different trials, the differences in efficacy were nonsignificant. When variants of CBT and behavioral weight loss were analyzed, there also was no definitive difference.
The authors concluded that BED treatment includes a variety of effective choices, but more head-to-head trials of active interventions are needed. In addition, the group suggests that stepped-care models are needed to better tailor interventions to individual groups.
How Does Food Addiction Differ from BED?
Ariana Chao, PhD, of the Pennsylvania State University School of Nursing, told audience members that food addiction is a popular but controversial concept that is often described using criteria borrowed from the DSM. Food addiction affects from 1%-9% of the general population and 15% to 57% of obese individuals. Food addiction also occurs in from 42% to 57% of BED patients. Some researchers have suggested that food allergy and BED be treated before weight loss programs are started.
She also described results of The Penn Weight Healthy Eating, Exercise, Lorcasein (WHEEL) study. This 14-week weight loss intervention followed and analyzed rates of attrition and percentage of weight loss among 178 individuals. Of the 178 participants, 2% had food addiction plus BED, 8% had BED alone, and 5% had food addiction alone. Limitations of their study, according to the authors, were that all participants had sought treatment and all were Black females.
In a two-phase program, Phase 1 included weekly 90-minute group lifestyle modification sessions, a structured diet of 1000-1200 kcal/day, daily self-monitoring, and recommendations for physical exercise. Phase 2 included group lifestyle modifications. In addition, the patients were randomized to receive lorcaserin (Belviq®), a selective 5-HT2c serotonin receptor agonist, or placebo.
At the end of the 14 weeks, the authors concluded that neither food addiction nor BED is likely to be a mechanism for obesity. There was no short-term attrition, and having a diagnosis of BED was not a contraindication to joining a behavioral weight loss program. Also, patients with food addiction, like those with EDs, may need additional support during weight loss treatment, advised Dr. Chao.
The Effects of Weight Regain on Bariatric Surgery Patients
According to the American Society for Metabolic and Bariatric Surgery, the number of bariatric surgeries performed annually is quickly approaching 200,000. Thirty percent of bariatric surgery patients experience suboptimal postsurgical outcomes such as losing only half of their excess weight. And, among patients with suboptimal weight loss, 56% need a second surgical procedure. High attrition rates are seen at follow-up.
Two paper presentations reported studies that examined the role of weight regain after bariatric surgery with gastric bypass and gastric sleeve surgery and psychiatric comorbidity, and the validity of an instrument for selecting patients for bariatric surgery.
Stanford Bariatric Integrated Psychosocial Assessment for Surgery (BIPAS)
Lianne Salcido, MS, of Stanford University, reported on the Stanford Bariatric Integrated Psychosocial Assessment for Surgery, or BIPAS, an 18-point screening instrument her group developed to establish guidelines for a standard definition of weight regain after bariatric surgery. The goal was to provide more effective screening tool for patients undergoing bariatric surgery. The group hoped to establish a standardized definition for what is significant weight regain and to provide a natural point of intervention. The BIPAS covers 4 psychosocial domains associated with poor post-surgical outcomes from gastric surgery. Salcido said the instrument was adapted from an empirically validated and reliable screening tool originally developed to predict adverse outcomes in transplantation patients
Salcido noted that many presurgical psychosocial evaluations and self-report measures cannot adequately predict which patients are most at risk for poor results. Part of this is due to insufficient characterization of psychosocial or behavioral variables as well as lack of standardization for assessing bariatric surgery candidates.
The BIPAS features four domains: coping, understanding readiness for surgery, psychopathology, and social support. Domain III contains questions specifically involving ED psychopathology, including binge eating, purging, night eating, and emotional eating. Of interest, when the Stanford team used a multiple linear regression calculated to predict 2-year weight outcome based on Domains I, II, III, and IV BIPAS scores, they found Domains III and IV were predictive of weight regain after surgery.
What Is a Healthy Cutoff for Weight Regain after Bariatric Surgery?
Maria Francisca Mauro, MD, and her coworkers in the Obesity and Eating Disorders group at the Federal University of Rio de Janeiro, Brazil, reported that there is a clear lack of standardization or a healthy cutoff point for weight regain after bariatric surgery. “Weight regain” was defined differently in 11 of 13 articles the group reviewed.
Dr. Mauro noted that the general prevalence of weight regain after bariatric surgery ranges from 14% to 77%, and, importantly, the researchers’ review showed no clear evidence of preoperative general or eating psychopathology or an impact on weight regain after surgery. However, in contrast to earlier studies, their findings agreed with previous systematic reviews showing that postoperative eating psychopathology, including BED, loss of control eating, substance use (especially alcohol abuse), and “grazing” may have an impact in weight regain after bariatric surgery.
Dr. Mauro said that the lack of a standard definition for weight regain has had an impact on how the outcome of gastric surgery has been reported in the literature and in the analysis and interpretation of the current literature in the field.

Thursday, October 12, 2017

Q&A: Endocrine Problems Among Men with AN

Vol. 28 / No. 5  

Q: I’ve read a lot about the endocrine problems among women with AN, but not much about hormonal dysfunction among men with AN. How common are these effects in male patients? (G.V., Los Altos, CA)
A: An article by Dr. Aren Skolnick from Long Island Jewish Medical Center, New Hyde Park, NY, and fellow endocrinologists at the Carl Icahn School of Medicine, St Luke’s Hospital, NY, NY, adds some helpful perspectives on this very subject. The authors reported four cases of young men with hormonal dysfunction (AACE Clin Case Rep. 2016;2:e351) due to underlying AN; these cases lay out the variety of problems that can be seen in men severely ill with AN.
The first was a 24-year-old man with AN hospitalized for bradycardia and a hospital course who developed abnormal liver tests, pancreatitis, pneumomediastinum, and refeeding syndrome. Over the past year his weight had dropped from 220 lb to 79 lb as he took the product Hydroxycut®, drastically cut back his food intake, and took up a rigorous exercise program, including running 10 miles each day. On examination, he was found to have bradycardia and low blood pressure. His BMI was 12. Endocrine studies showed a TSH level of 1.28 µIU/mL (normal range: 0.34 to 5.60), free T4 level of 0.7 ng/dL (normal: 0.6 to 1.1), and free T3 of 1.1 pg/mL (normal: 2.5 to 3.9), and a total T3 reading of 31 ng/dL (normal: 8 to 178). Two-dimensional echocardiography showed an ejection fraction of only 19%, indicating significant heart dysfunction. He had a complicated hospital course that lasted 7 months and he was referred to a rehabilitation facility.
The second patient was a 20-year-old with a BMI of 12.9. He first sought help for erectile dysfunction and was started on testosterone replacement therapy. Worsening fatigue and constipation were more recent complaints. When he was seen again, he seemed severely cachectic with sarcopenia. He was arousable but could not speak. Like the first patient, he had bradycardia. His lab workup showed a capillary blood glucose level of 50 mg/dL, and abnormal liver function tests. The repeat finger-stick glucose level was 15 mg/dL, and his TSH level was 2.6 µIU/mL (normal: 0.34 to 5.60). His T4 level was 0.8 ng/dL (normal:0.6 to 1.1), and the total T3 level was 20 ng/dL (normal: 87 to 178).
The third patient, a 23-year-old, presented after losing 35 lb over the prior 2 months. His pulse and blood pressure were low, and his BMI was 13. He was hypoglycemic (50 mg/dL) and had bradycardia and hypothermia. Endocrine lab studies showed a TSH of 0.82 IU/mL (normal: 0.34 to 5.60), a low testosterone level of 198 ng/dL (normal: 249 to 836), and extremely low follicle- stimulating hormone levels and thyroid levels.
The last patient was a 20-year-old male who had lost 130 lb over the prior 6 months. His BMI was 18. His lab tests showed severe hypokalemia, 2 mmol/L (normal: 3.1 to 5.1) hypochloremia, and elevated bicarbonate. He developed bradycardia (pulse 39 to 49 beats/minute) hypothermia, and hypotension. His endocrine workup showed TSH at 2.0 µIU/mL, freeT4 at 1.72 µIU/mL (normal: 0.8-1.8), hemoglobin A1c 5.5%, among other findings.
All four of these young men had protein-calorie malnutrition, hypothermia, hypotension, and bradycardia and then were found to have multiple endocrinopathies. Three of the young men had no previous diagnoses of AN or another ED and thus AN was not considered early on. Three of the four also has some signs of elevated cortisol levels, hypothyroidism and hypogonadism.
These four cases point out that various endocrine disturbances can occur in men with AN. That three of the four had not been previously diagnosed with AN despite having fairly severe symptoms underscores the challenges with case finding in AN. -SC

Does Teasing Lead to Disordered Eating?

Vol. 28 / No. 5  

Results differed in two studies; one added changes over time.
Teasing about weight and bullying in adolescence is believed to influence the development of abnormal eating behaviors and attitudes. However, Spanish researchers recently reported finding no significant or independent effects from teasing on eating behaviors (Rev Psquiatr Salud Ment. 2017; Aug 14. doi:10.1016/j.rpsm.2017; Epub ahead of print).
The two-year prospective study of 7167 adolescent females and males between 13 and 15 years of age used the Perception of Teasing Scale, or POTS, questionnaire to measure the effects of teasing about weight and general abilities. The association of teasing to eating psychopathology 2 years later was analyzed, controlling for body mass index (BMI), and measures of body dissatisfaction, drive to thinness, perfectionism (Eating Disorders Inventory), emotional symptoms, and hyperactivity, measured at the first assessment.
Teasing about weight or teasing about abilities did not impact onset of later eating psychopathology. The results were similar for boys and girls, with one exception. In girls, but not in boys, controlling BMI was enough to make any earlier effect of teasing disappear, according to the authors.
A different result in a second, larger study
The results from the Spanish study contrasted with those from a longitudinal cohort study (Project EAT) that followed a diverse sample of 1830 adolescents from 1999 to follow-up in 2015 (Prev Med.2017; Jul;100:173. doi: 10.1016/j.ypmed.2017.04.023. Epub 2017 Apr 24). The relationship of weight-based teasing at baseline was examined as a predictor of weight status, binge eating, dieting, eating as a coping strategy, unhealthy weight control methods, and body image 15 years later. Dr. Rebecca M. Puhl of the University of Connecticut, Hartford, and colleagues wanted to identify whether weight-based teasing during adolescence would predict adverse eating and weight-related outcomes, and to differentiate which source of teasing (by peers or family members) had an impact on the outcome.
Teasing about weight did have later repercussions
Teasing about weight during adolescence predicted higher BMI and obesity 15 years later. For women, these long-term associations occurred across peer and family-based teasing; in contrast, only teasing by peer members predicted higher BMIs among men at long-term follow-up.
Weight-based teasing from peers and family during the teen years also predicted subsequent binge eating, unhealthy weight control methods, eating to cope, poor body image, and recent dieting in women 15 years later.
In some ways these findings contradict, but taken into consideration with other work in this area, the impact of teasing remains a major concern.

Purging Behaviors and Sleep Disturbances

Vol. 28 / No. 5  

In a study from Japan, disturbed sleep was dramatically different in those with purge-type AN.
Disturbed sleep is a common complaint among patients with mood or anxiety disorders and is also common among those with EDs. For example, in one earlier study of 549 college women, 30% of those with an eating disorder (AN, BN, or BED) complained of insomnia, compared to 5% of participants without an eating disorder (Eat Behav. 2014; 15:686).
In the first study to focus on the effects of purging behaviors among patients with EDs and how this affects sleep quality, Dr. Tokusei Tanahashi and his team studied a group of female inpatients with a primary diagnosis of AN (BioPsychoSocial Med. 2017; 11:22). The team wanted to understand how purging behaviors relate to sleep quality and patterns, and which disordered eating behaviors, such as binge-eating, vomiting, or laxative abuse, might affect global sleep quality among female patients with AN. Their study group included 20 consecutive female inpatients with a primary diagnosis of AN who were admitted to the Department of Psychosomatic Medicine at Kohnodai Hospital, Chiba, Japan, during a 6-month span.
The study participants completed the Japanese version of the Pittsburgh Sleep Quality Index, which assesses the quality and disruption of sleep. Then, using the raw data provided by the questionnaire, the authors recorded each individual’s sleep-onset time, wake-up time, and sleep duration. The team also administered the Center for Epidemiologic Studies Depression scale (CES-D) to assess depression. Of the initial group of 86 patients with eating disorders, 23 diagnosed with AN were found to be eligible for further study. Three women with binge eating-purging type AN (AN-BP) did not consent to entering the study, so the final group included 20 women from 15 to 58 years of age (8 with AN-R, 12 with AN-BP), and the mean duration of illness was 7.2 years in those with AN-BP, 2.6 years among those with AN-R. BMI was 13.7 mg/k2 in the AN-BP group and 12.6 in the AN-R group
One group had poorer quality of sleep
The authors found that patients with AN-BP had dramatically worse global sleep quality and more disrupted circadian rhythm and abnormal sleep duration than did patients with AN-R. Impaired sleep patterns ( a score of 5 or more on the PSQI) were reported in 2 of 8 participants with AN-R (25%), compared with 9 or 12 patients with AN-BP (75%). Although the team did not specifically evaluate the night-eating syndrome, their results showed that 67% of those with AN-BP had disturbed circadian rhythm, potentially relevant to the night-eating syndrome.
Although the sample size was small, the results highlight the possible impact of vomiting and the duration of AN on impaired sleep quality.

What Can An Avatar Reveal About Body Image in AN?

Vol. 28 / No. 5  
In a German study, beauty was in the attitude, not the eye, of the beholder.
Although viewed as central to AN, body image disturbance is still not that well understood. A team of researchers in Germany and Switzerland have turned to three-dimension (3D) technology to better define the effects of image disorders by studying 24 women in AN and 24 control patients (Psychol Med. 2017. doi:10.1017/S00332917172008).
The researchers sought to examine whether women with AN overestimate their weight or are merely more sensitive to weight changes compared to normal controls. Next, they wanted answer the question, how do women with AN and controls differ in regard to their desired bodies? A third question was whether an individual’s estimated body size or desired body size correlated with eating disorder symptoms or actual body size? The researchers also invited the study participants back for a repeat of the experiment– but now in 2D–to evaluate how robust individuals’ answer another question, “How robust are our findings on own body size estimation and body size?”
The research team then used 3D body scans to create virtual reality 3D bodies (avatars) for each study participant. The avatars were varied through a range of ±20% of the participants’ weights. They also used a stereoscopic virtual reality life-size stereo display that allowed for realistic weight manipulations of the photo-realistic avatars.
At the start of the experimental session, each woman was informed that based on her body scan, an exact model and more or less manipulated models of her body had been generated. The process was described to participants as akin to inflating, then deflating a balloon. When the subject saw different versions of her body she was asked to decide whether the version was exactly her body or if it had been manipulated. In the first experiment, participants estimated the size of their own body and indicated their desired body size. In the second experiment, participants estimated the size of the weight and shape of an avatar that was altered to have a different identity but the same size and shape.
Distorted attitudes, not visual distortions, were the key
The authors’ results were interesting in that they contradict a widespread assumption that patients with AN overestimate their body weight because of visual distortions. Instead, based on their results, the authors feel attitudinal components are distorted in AN; in reality, the data suggest that if anything people with AN underestimated their weights. Thus, affected individuals feel underweight bodies are desirable and attractive. As a result, the authors recommend that clinical interventions be aimed at helping patients with AN change their attitude about “desired” weight and accept their bodies at a healthy weight.

Orthorexia Nervosa and Anorexia Nervosa: Similar, But Distinctly Different

Vol. 28 / No. 5  

A focus on food but differences by culture, and quality and quantity of food.
An individual with orthorexia nervosa (ON) is nearly religious about eating only healthy and “pure” foods, and is fixated upon healthy eating behavior. He or she may not be obsessed with “the perfect diet,” but with achieving an ideal weight. This might mean avoiding fats, sugar, or salt, or any foods suspected of containing artificial colors, flavors, or preservatives. While orthorexia is neithert officially an eating disorder nor recognized in the DSM-5, it does share some features with anorexia nervosa.
Dr. Anna Brytec-Matera and her colleagues at the SWPS University of Social Sciences and Humanities, Katowice, Poland (BMC Psychiatry. 2017; 15:252) recently designed a study to assess orthorexic behaviors, eating disorder pathology, and body image attitudes to find possible evidence of orthorexia among 52 women with eating disorders. The authors’ assessment included using the Eating Attitudes Test-26 (EAT-26) to identify ED symptoms, and the Polish version of the ORTO-15. The ORTO-15 is designed to assess AN symptoms, including obsessive attitudes toward choosing, buying, preparing, and consuming “healthy” foods. Attitudes toward body image were measured with the Polish version of the Multidimensional Body-Self Relations Questionnaire, or MBSRQ. The MBSRQ uses 8 subscales to measure factors such as feelings of attractiveness, fat anxiety, dieting and eating restraint, for example.
Two distinct groups were identified
Latent class analysis (LCA) identified two groups of eating disorders patients. The first group had a lower level of disordered eating and more orthorexic symptoms, while in the second group, who reported higher levels of eating disorders, orthorexic behaviors were less common. The authors noted that eating-related disturbances are suggested to be risk factors for orthorexia, and that the reverse is also true. One unexpected result, according to the authors, was identifying a group of clinically diagnosed ED patients without typical ED symptoms assessed by the EAT-26. One possible explanation for this might be related to the fact that the EAT-26 is a self-report questionnaire, and ED patients might have chosen to omit information. The authors hypothesized that some patients may have low scores on the EAT-26 and high scores on the ORTO-15 because they may “mistake” their symptoms for healthy behaviors.
Dr. Brytek-Matera and colleagues noted that their study was a small pilot trial, and it was smaller than usually recommended for LCA, which might limit the reproducibility of results. Also, they did not gather information about any comorbid psychiatric diagnoses. Nonetheless, results suggest interesting and complex relationships between ARFID, orthorexia, and EDs.