Is More Aggressive Refeeding Safe for Severely Malnourished Inpatients?

Vol. 28 / No. 2 — Eating Disorders Review

More evidence on this controversial question.

Recently there has been increased interest in the rate of refeeding people with AN. A new article from University of California, San Diego researchers suggests that more aggressive refeeding may be appropriate in selected young patients hospitalized with restricting eating disorders, including AN,  avoidant/restrictive food intake disorder (ARFID), or other specified eating disorders (J Eat Disord. 2017; 5:1, published online before print). The study group of 87 patients 8 to 20 years of age included a subgroup of severely malnourished patients who presented at less than 75% of expected body weight (%EBW).

On admission, most patients were started on an oral nutritional rehabilitation diet, and the initial caloric level was based on the patient’s recent dietary history. Typically the patients received from 1500 to 1800 kcal/day, but lower-calorie diets (such as 1200 kcal/day) were used if the patient had been using extreme dietary restriction, for example, fewer than 500 kcal/day over several weeks. Daily caloric intake was titrated to achieve 2 kg weight gain per week. If the daily target weight wasn’t achieved for 2 days in a row, the caloric intake was increased; this was also the case for those with persistent or severe cardiac complications, such as bradycardia overnight, symptomatic postural changes in heart rate or blood pressure, or arrhythmias.

Nasogastric or nasojejunal tubes were used if needed until the patient could consume 100% of daily nutritional and fluid needs by mouth for at least 24 hours. Intravenous fluids were reserved for dehydrated patients unable to tolerate oral fluids.

On admission, all patients were screened with complete blood counts and complete metabolic panels, urinalysis, and electrocardiograms. Refeeding laboratory findings were assessed daily, concentrating on serum magnesium and phosphorus levels, and urinalysis. Continuous cardiac monitoring was used throughout the patient’s entire hospital stay.

According to Dr. R. Tamara Maginot and colleagues, %EBW was determined through evaluation of several clinical factors. Although the conventional approach uses the 50th percentile body mass index (BMI, or kg/m2) to calculate expected body weight for children and adolescents, the San Diego researchers customized %EBW to return each child or teen to the growth trajectory in which he or she was healthy. For example, if the patient’s premorbid BMI was greater than the 85th percentile, and the patient was otherwise healthy, the initial %EBW was selected to restore the patient to a BMI at the 75th percentile level. If the premorbid growth patterns were unknown, the authors used the conventional 50th percentile for sex and age.

Most of the study group had been diagnosed with AN-restrictive subtype (66.7%), while 16.1% had diagnoses of AN-binge-purge subtype, 5.7% were diagnosed with Other Specified Eating Disorders, and 11.5% were diagnosed with ARFID. Fifteen patients required the use of nasogastric/nasojejunal feeding tubes during hospitalization. About 75% of patients were assigned to a higher-calorie diet on admission (66 patients; range: 1500 to 3000 kcal/ day). The lower-calorie group (21 patients) was given a mean of 1185 kcal/day, and had significantly longer hospital stays than other patients (38.3 days versus 31.9 days, respectively).

The authors note that just as in previous studies, the incidence of electrolyte abnormalities in their sample was not linked to the rate of caloric increase or initial calorie level. Instead, low phosphorus levels were more common among patients who had a lower %EBW on admission. This suggested that the degree of body depletion may be a more important predictor of electrolyte abnormalities than caloric levels. In this study, with every 1% decrease in %EBW on admission, the odds of hypophosphatemia increased by 6%. However, starting severely malnourished patients at on a higher-calorie regimen was not associated with a higher risk of hypophosphatemia, hypomagnesemia, or hypokalemia.

An important caveat to this study is that refeeding occurred on a medical unit with continuous cardiac monitoring. Although the regimen was well tolerated in this sample, this degree of monitoring would not be available in most ED treatment settings. Future studies of larger patient populations will be needed to help define the safety of administering higher-calorie diets, especially to severely malnourished patients. It is important to define rates that are safe, but also as effective and promptly delivered as possible.

Tracking Recovery from AN and BN over the Long Term

Vol. 28 / No. 2 — Eating Disorders Review

Encouraging results for most, but not all, patients over more than 2 decades.

Gaining weight is a major worry among people with EDs. The Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa has once more provided valuable information about the long-term effects of AN and BN. Dr. Kamryn T. Eddy and colleagues recently reported the results of their 22-year follow-up of women with AN and BN (J Clin Psychiatry. 2017. 78:184). At follow-up, two-thirds of the women had recovered. The Longitudinal Study was begun in 1987 with 246 women, all of who were seeking treatment for AN or BN. As part of the study, the women were interviewed every 6 months for a median time of 9.5 years to assess weekly symptoms, comorbidities, participation in treatment, and psychosocial functioning. Subsequently, 22-year follow-up was completed.

Dr. Eddy and coworkers reported that one of the indictors of long-term recovery was early recovery. At 22-year follow-up, 62.8% of women with AN and 68.2% of those with BN had recovered. This was vastly improved over the 9-year follow-up evaluation, which showed 31.4% of women with AN and 68.2% of those with BN had recovered.

Notably, about half of the women who were still ill at the 9-year point had recovered from their ED by the 22-year point. Recovery happened earlier for the women with BN, while recovery for AN patients was slower and continued over the long term.

A second study shows mortality trends 

An earlier study by Debra L. Franko, PhD, and her coworkers at Massachusetts General Hospital identified risk factors for mortality in people with AN and BN over time (Am J Psychiatry. 2013. 170:917). These researchers found that a long duration of illness, substance abuse, low weight and/or poor social functioning all raised the risk for death from AN. Among the 246 women who participated, 16 deaths (6.5%) were reported; among the 186 women with a lifetime history of AN, 14 (7.5%) died. Four of the deaths were from suicide Among the 60 women with BN and no history of AN, 2 (3.3%) had died. The authors also reported that the majority of women who had been initially diagnosed with AN experienced crossover from AN to BN, while crossover from those with an initial diagnosis of BN to AN was much less common.

A return to normal weights for most in a third study

H.B Murray and colleagues recently published very valuable long-term weight outcome results from a well-described cohort of people with AN and BN (Int J Eat Disord. 2017. Feb 11. doi: 10.1002/eat.22690).

The authors described the results of their 22-year longitudinal study of an original group of 225 patients with AN and BN. Two hundred and twenty-five were followed for 10 years and 177 were still in the study at the 22-year follow-up point. Over the course of this long study, most weight gain occurred within the first 2 years, and this lessened between years 2 and 5. Thereafter, the subjects’ weight remained relatively stable. Body mass index increased most rapidly during the early years of the study for those with lower weights at baseline (i.e., AN) and plateaued over time, settling in the normal range for most. At the 22-year follow-up point, 69% of participants were in the “normal weight range.” Seventeen percent were overweight or obese, and 14% were underweight.

Clinically, it seems as though people with AN or BN have various fears related to weight; these include the fear of ending up overweight or obese, but also the fear of gaining any weight. These results will be helpful for addressing the former fear.

As the longitudinal study continues, we will undoubtedly learn much more, and there is always the hope that recovery rates will move upward.

Tracing the Path of Disordered Eating Over Time

Vol. 28 / No. 2 — Eating Disorders Review

Four risk factors emerged in a community sample followed over 10 years. 

Little is known about how disordered eating behaviors and symptoms that appear in early adolescence may change over time. Results of a recent study gives us new information about this trajectory over time, including the fact that there is a 75% chance that those who had disordered eating would continue to have symptoms a decade later.

Carolyn M. Pearson, PhD, and collaborators at the University of Minnesota and Columbia University studied a community sample of teens over 10 years to see how risks of ED change throughout young adulthood (Int J Eat Disord. 2017. doi: 10:1002/eat.22692, published online before print). The team studied data from 2,287 participants in Project EAT, a valuable longitudinal study that has assessed eating-related, anthropomorphic, and psychological factors using surveys of male and female middle and high schools students, who are now young adults living in and around Minneapolis/St. Paul, MN. The EAT I survey analyzed teens 11 to 18 years of age and then revisited them as young adults 10 years later (EAT III).

Stability and transitions

The researchers found that those who had no symptoms in EAT I tended to remain in the same group 10 years later. For those identified in the dieting group in EAT I, dieting usually persisted. There was a 75% that chance that those with disordered eating symptoms during adolescence would continue to have disordered eating or to transition to the dieting group over the 10-year follow-up period.

Lower self-esteem, depressive symptoms, and substance use were important predictors of transition to disordered eating, and female respondents had greater odds than males of transitioning to increased symptoms a decade later. Family weight teasing also increased the odds of a teen transitioning to disordered eating; this was nearly statistically significant, and was a more powerful element than peer teasing.

Two factors were protective: higher self-esteem and family communication/caring. Some positive findings also emerged. One was that most teens who were asymptomatic at the first survey had not developed disordered eating behaviors by the 10-year follow-up. And, 1 in 4 of those with ED behaviors at the first survey was asymptomatic at the 10-year follow-up point. This suggested that some young adolescents with disordered eating do get better over time.

Screening for and intercepting risk factors early on

The study underscores the value of early detection and intervention for teens with disordered eating. Screening for psychological and socio-environmental risk factors, particularly low self-esteem, depressive symptoms, substance use, and poor family communication/caring, especially among adolescent girls, may help interrupt transition to EDs in young adulthood.

Transcranial Direct Stimulation for Bulimia Nervosa: Early Encouraging Results

Vol. 28 / No. 2 — Eating Disorders Review

A new treatment shows benefits over electroconvulsive therapy.

Neuromodulation is currently an area of great interest in the field of mental health treatment. One example of a neuromodulation technique is transcranial direct current stimulation (tDCS). Like electroconvulsive therapy (ECT), this method involves application of current to the scalp, but tDCS is quite different from ECT. In tDCS, patients are awake, there are few side effects, a very low level of current is supplied to the scalp, and no seizures follow the application of the currents. In most studies, the targeted site has been the dorsolateral prefrontal cortex (DLPFC). This region is part of the dorsal cognitive frontostriatal circuitry and is the major neural structure involved in executive functions, including self-regulatory control. It is also implicated in reward processing.

tDCS affects behavior in many different domains when applied precisely to the correct area of the scalp. In fact, previous evidence has shown some changes in eating behavior after even a single session of tDCS (Biol Psychiatry. 2010. 67:793). To further evaluate the potential of tDCS in eating disorder treatment, Dr. Maria Kekic and colleagues at Kings College, London recently conducted a study of tDCS in 39 patients (37 females and 2 males) with bulimia nervosa (PLoS One. 2017. 12: e0167606).

In this study, the subjects received either tDCS or sham application of tDCS in a double-blind fashion for 3 sessions. The results showed when a particular scalp electrode configuration was used (with the anode on the right and the cathode on the left), eating disorder cognitions were diminished, and mood was improved.

It seems likely that tDCS could ultimately be used as an eating disorder treatment that augments other treatments, rather than as a single modality. The authors are correct that this work is encouraging, and further study of tDCS is definitely needed.

Fear of Weight Gain and Dieting Affect Many Women throughout Life

Vol. 28 / No. 2 — Eating Disorders Review

A large Dutch study highlights distinctly different attitudes between men and women. 

Dieting and fear of gaining weight are common all across the lifespan for women, while a much smaller but still sizable number of men also have the same fears. These were a few findings from a recent study conducted in the Netherlands (Int J Public Health. 2017; published online February 20 before print). Dr. Margarita C. T. Slof-Op ‘t Landt and colleagues in Leiden and Amsterdam wanted to explore factors that might lead to the fear of weight gain throughout life, including gender, exercise habits, education, and lifestyle. This study is noteworthy in that it describes dieting and fear of weight gain in both men and women from adolescence to older age.

The researchers evaluated data from the Young or Adult Netherlands Twin Register, two national registers that compile information on health, lifestyle, personality and/or behavioral problems in twins and their family members. Each survey covers a 2- to 3-year period. In the youth-oriented register, twins and infants from multiple births (such as triplets) are registered at birth by their parents, and surveys are then repeated at fixed ages. At 14, 16, and 18 years of age, twins, triplets, and additional siblings complete self-report surveys with their parents’ consent. For those who completed several surveys, the most recent assessment was used. The adult cohort is made up of adult twins and multiple-birth adults born between 1909 and 1996, as well as their parents, non-twin siblings, spouses, and offspring. The authors invited 47,122 subjects to participate in their study, and data were available for 31,636 participants.

Women had the greatest weight-related concerns

Across all ages, the distribution of fear of weight gain was significantly different between men and women. Most men (up to 74%) reported not being afraid of gaining weight or of becoming “fat”; in contrast, up to 46% of women had no such concerns. Most women who responded had been on a diet at some point in their lives. A fear of gaining weight or becoming fat peaked among women between 16 and 25 years of age, and these concerns continued throughout their lives. A particularly troubling finding was that many women in the 16- to 25-year age group were very or extremely afraid of weight gain despite the fact that only 12% to 14% were actually overweight.

Most respondents were female (60.2%) and twins (61.9%). More than a third of the participants lived in densely populated areas; men and women 25 to 35 years of age were most likely to live in urban settings. More than half of the study participants reported having a high education level. Underweight or normal weight was most common among 13- to 16-year-olds. Overweight was most common among men between 55 and 65 years of age and in women older than 65. The level of exercise (determined by metabolic equivalents, or METs) was highest in 13- to 16-year old females and 16- to 18-year old males, and the lowest METs scores were found in men and women over 65 years of age

The study did have a few limitations: twin samples may differ from non-twins in various ways, including the fact that 62% of birth weights are usually lower in twins than in single births, and these body mass index differences continue into adulthood (Twin Res. 2001. 4:464). Still, the results stress that weight and diet concerns continue across the lifespan.

Some Good News for Eating Disorders Patients Concerned About Weight Gain

A return to normal weights for most in a long-term study.

Gaining weight is a major worry among people with eating disorders. H.B Murray and colleagues recently published very valuable long-term weight outcome results from a well-described cohort of people with anorexia nervosa (AN) and bulimia nervosa (BN) (Int J Eat Disord. 2017. Feb 11. doi: 10.1002/eat.22690).

The authors described their 22-year longitudinal study of an original group of 225 patients with AN and BN. Two hundred and twenty-five were followed for 10 years and 177 were still in the study at the 22-year follow-up point. Over the course of this long study, most weight gain occurred in the first 2 years, and this lessened between years 2 and 5. Thereafter, the subjects’ weight remained relatively stable. Body mass index increased most rapidly during the early years of the study for those with lower weights at baseline (i.e., AN) and plateaued over time, settling in the normal range for most. At the 22-year follow-up point, 69% of participants were in the “normal weight range.” Seventeen percent were overweight or obese, and 14% were underweight.

These results will certainly be useful in helping to address and help reduce some of the fears about weight gain that people with anorexia and bulimia have. Clinically, it seems as though people with AN or BN have various fears related to weight; these include the fear of ending up overweight or obese, but also the fear of gaining any weight. These results will be helpful for addressing the former fear.

The Positive Effects of Early Treatment Response

Vol. 28 / No. 2 — Eating Disorders Review

For many patients, early response can predict remission.

Early response to treatment for an eating disorder is often linked to a positive outcome, and to remission. Changes in behavior in the first weeks of treatment, such as a reduction in binge- eating and purging behaviors, or early weight gain in anorexic patients, can predict remission after a variety of treatments, regardless of the type or duration (Appetite. 2009. 52:805). This factor also enables clinicians to personalize treatment to improve outcome.

A group from King’s College, the University of Palermo, Italy, and the Federal University of Rio de Janeiro, Brazil, conducted a systematic review and meta-analysis of the literature to see how predictive early response actually is for patients with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) or eating disorders not otherwise specified (Eur Eat Disord Rev. 2017. 25:67).

Early responses were keyed to the disorder

One of the initial findings reported by Dr. Bruno Palazzo Nazar and his colleagues was how the definition of “early response” varied according to the individual eating disorder. For patients with AN, the main outcome was attaining 95% of ideal body weight (IBW). In contrast, for patients with BN, it was a percentage reduction in binge eating and/or purging over a variable time period. For AN patients, early weight gains by outpatient adolescents with AN were predictive of remission in studies that used family-based therapy (Psychothotherapy, Chicago IL. 2016. 53:251) and cognitive behavioral therapy. This pattern was the same for inpatient AN treatment, where early weight gains at different time points during the first 6 weeks of therapy could predict remission (Psychother Res. 2007. 17:218; J Eat Disord Assoc. 2016. 10:1002/erv.2443). In contrast, for BN patients, the predictive pattern was far weaker, and early response was only moderately linked to better outcome. In BED studies, early response had only a fair capacity to predict good outcome.

Clinical implications of the findings

The study results indicated that failure to respond to outpatient psychological treatment during the early phase of treatment is linked to persistent symptoms in patients with AN at one year. The authors also reported there is a 77% chance that a patient who responds early will have a remission of symptoms at the end of treatment.

Among patients with BED, early response to treatment showed a high specificity and low sensitivity in predicting remission—there was an approximately 30% increase in the chances of remission in a patient with BED with an early response, and these individuals were 5 times more likely to achieve remission than were patients with slower responses (Clin Psychol Rev. 2012. 32:292).

In contrast to the positive effects of early response among patients with AN and BED, early response among BN patients did not strongly predict remission. In fact, an early response to treatment by patients with BN increased their chances of remission only by 15%.

These results should spur interest in identifying modifications to existing treatments to increase the likelihood of early response.

An Option for Those with Severe Anorexia Nervosa: Deep Brain Stimulation

Vol. 28 / No. 2 — Eating Disorders Review

After 1 year, AN patients had weight gains and improved mood.

Deep brain stimulation, or DBS, has been helpful for a number of neurological disorders, including Parkinson’s disease, and has been studied for the treatment of refractory psychiatric disorders, including major depression and obsessive-compulsive disease (OCD). Similar to a cardiac pacemaker, DBS uses implanted electrodes to send low-level electrical currents to specific structures deep within the brain. Implantation of the electrodes into the brain requires precise surgery and careful brain mapping for each individual.

Nir Lipsman, MD, and a team at the University of Toronto recently reported that DBS of the subcallosal cingulate, deep in the brain’s white matter, can significantly improve anxiety and depression, along with affective regulation, and can help increase body weight for patients with extreme treatment-resistant AN. This is the largest study thus far of DBS used for patients with long-term treatment-resistant AN (Lancet Psychiatry 2017; Feb 23, published online before print). All the 16 women in the pilot study were markedly underweight at the beginning of the study and had AN for a mean of 18 years. Most (88%) of the women also had comorbid mood and anxiety disorders.

Analyzing the effects one year after surgery

The Canadian researchers reported that DBS can affect the brain circuitry that might maintain anorexia, making the disorder so resistant to treatment. In their pilot trial of 16 women with severe, highly treatment-refractive and chronic AN (mean age: 34 years), one year after the surgery, DBS of the subcallosal cingulate was found to be safe. The procedure also improved mood and, over time, BMI as well. The implants provided continuous stimulation of the subcallosal cingulate for 12 months.

Even though most of the women tolerated the procedure and implants well, nearly half had adverse effects. Two women asked that the devices be removed or deactivated. The most common adverse effect was pain related to the surgical implantation itself or to positioning of the electrodes. Seven, or 44%, of the subjects had serious adverse effects, including electrolyte disturbances, but most appear to have been related to AN itself (all patients had severe and unrelenting symptoms). One woman had an unexplained seizure several months after her electrodes were implanted.  Importantly, the overall tolerability of the procedure seemed similar to what has been previously observed in depression and OCD, despite the precarious physical state of people with severe AN.

Eleven of the 14 women who completed the study had an increase of at least 1 BMI unit after 12 months of DBS, and the average BMI after 12 months was 17.34 kg/m2, vs 13.83 kg/m2 at the beginning of the study. DBS also improved depression and anxiety and emotional dysfunction scores. The mean Hamilton Depression Rating Scale score was 8.79 at the end of the 12 months, vs 19.4 at baseline. The mean Beck Anxiety Inventory score was 38.0, compared to 27.14 at baseline, and mean dysfunction in emotional regulation score was 131.8 vs 104.4 at baseline.

At the end of the 12 months, positron emission tomographic images showed significant changes in cerebral glucose metabolism in key brain structures, suggesting that DBS can directly affect AN-related brain circuitry. The authors noted that a longer-term study will help determine how long the positive effects of DBS last in AN patients with such severe disease.

Challenges for Autistic Individuals Who Also Binge-Eat

Vol. 28 / No. 2 — Eating Disorders Review

Even though binge eating is widespread among those with autism spectrum disease (ASD), current diagnostic criteria make it nearly impossible to assess binge eating among autistic patients, according to Janice Goldschmidt, MS, RD, LDN, Director of Nutrition Services at Community Support Services, Gaithersburg, MD. Goldschmidt discussed her current research and findings on binge eating and ASD during a poster session at the 2017 iaedp Symposium in Las Vegas. She also noted that although cognitive behavioral therapy (CBT) has strong support in the treatment of BED, it may not be effective for many ASD patients. And, DSM-5 criteria stipulate that if an ED co-occurs with ASD or another mental disorder, then the condition is secondary and a stand-alone diagnosis isn’t warranted. Goldschmidt also noted that the current practice of denying a stand-alone diagnosis of BED or any eating disorder for those with ASD and other mental disorders needs to be addressed. Without a stand-alone diagnosis, binge eating on the autism spectrum is much less likely to draw the interest of ED specialists.

Obesity Stigma

by Jenny Ellison, Ph.D.

Obesity has been considered problematic for a long time. Medical, philosophical, and religious scholars, in texts dating back over two thousand years, suggest that fatness is a sign of physical or moral imbalance. Over time body fat has retained this negative cultural baggage. While the problems understood to result from having a larger body have shifted from religious, to moral, to health concerns, what remains is a deeply ingrained cultural belief that being fat is bad. Research shows that in the historical and contemporary context, obesity represents danger, an excess of desire, lack of control, laziness, and ignorance of nutrition (Farrell 2011). Health practitioners need to understand the depth of historical and contemporary bias against fat people. People experience their health, fat or thin, not with discreet dividing lines between medical and social settings, but immersed in a culture that is fascinated with controlling body weight.

What is obesity stigma?

Obesity stigma is the idea that a person’s weight is a reflection of their character (Farrell 2011). It can be experienced individually, through negative comments about weight, unsolicited advice about dieting, and assumptions about a person’s physical fitness or food consumption. But obesity stigma is also a social problem. Obesity stigma shapes not only how people think and talk about weight, but also how larger people are treated. Studies indicate that obese people face discrimination in employment (Kirkland 2003; Rothblum 1992; Solovay 2000). In the United States, people have been denied health insurance based on weight alone (Kirkland 2008; Wann 2009). In Canada, obesity stigma has resulted in discrimination in the healthcare system (Ellison, McPhail, Mitchinson 2016). The “obesity epidemic” identified in the 1990s may have increased instances of stigma in Canada and the United States. Some evidence suggests an uptick in eating disorders among children in the wake of the anti-obesity public health messaging of the 2000s (CTV News 2013). Messaging aimed at eliciting shame from fat people has been described as a “pedagogy of disgust” by Deborah Lupton, because of their stigmatizing representations of larger bodies (2013).

Obesity stigma is experienced by people who are fat, but it impacts all people (Wooley 1970). Negative attitudes toward obesity targets women, racialized people, the working class, rural people, and children in different ways (Beauboeuf-Lafontant 2003; Ellison, McPhail and Mitchinson 2016). Obesity sigma overlaps with racial discrimination, class privilege, sexism, and ableism (Farrell 2011). Starting in the 1800s, American popular culture began to reflect the idea that there is a connection between civilization and slenderness. At sights like the Chicago World’s Fair, exhibits and newspapers suggest that “primitive people” have a preference for large bodies, whereas civilized people control their appetites (Farrell 2011). These ideas, embedded in western culture, shape contemporary approaches to obesity reduction and food systems (McPhail 2016). For example, health research about Canadian Indigenous peoples has repeated the false idea that they are genetically predisposed to storing body fat (Poudrier 2016). Assumptions about class, ethnicity, and knowledge of nutrition also spill over into the way health professionals treat patients, and students are treated by teachers (Rothblum 1992; Petherick 2016).

Responding to Obesity Stigma

People have reacted to obesity stigma in different ways, often informally. This includes internalizing negative messaging, dieting, feeling angry, and lashing out at family or peers (Joannise 1999). Since the 1960s fat activist groups have formed in response to negative social messaging about obesity. Fat activism was not just about obesity stigma but about transforming the way that weight is understood in western societies. Fat activism has taken on many different forms – some of it looks like other types of advocacy for civil and human “rights” of the 1960s. More commonly, however, activists see fatness in terms of social and cultural “rights”: the right to participate, the right to social inclusion, and the right to clothing that fits (Ellison 2016). Thousands of people have participated in fat activist groups, online communities, and social events. While the majority of obese people are not fat activists, the movement offers insight into how it feels to be fat, and how fat people themselves would like to deal with stigma. Activists ask that health professionals:

• Foster a culture of empathy and not shame. Don’t talk about weight if it isn’t the presenting issue.

• Promote exercise for physical fitness and happiness, not weight loss.

• See food as nourishment and not “good/bad.”

Fat activism shows us the potential for carving out safe spaces for people that acknowledge their specific physical and gendered needs (Ellison 2013).

Experts increasingly recognize that stigma itself can cause health problems. In Canada, the Canadian Obesity Network, dedicated to reducing obesity, has also recognized stigma is a major barrier to health promotion. Health at Every Size researchers suggest promoting exercise, a balanced diet, and intuitive eating has better health outcomes than anti-obesity messaging (Farrell 2011). Focusing on environmental changes, rather than targeting particular populations, is also an important facet of health promotion (Abel, Leslie and Yancey 2000). Shifting the way people think about weight is not easy. It can begin by recognizing that obesity stigma is a social problem, rooted in culture, and not in a person’s character.

Ramadan: The Battle of Fasting for God or Eating Disorders?

By Malak Saddy, RDN, LD

As an apprehensive and self-conscious youth, Ramadan posed a bit of an inconvenience for me as I tried to manage my daily life, as well as a platform to advertise my variance to the community in which I lived. I knew I was different and unique, my name, Malak, stuck out like a wrong note in a serenade of Lisas and Megans. My frizzy, curly, unruly, brown hair and garlicky packed lunch of hummus and pita all screamed I was different.  Add to that, once a year for a month, I would go sit and hide myself in the school library during lunch, patiently waiting for the bell to ring to join my friends again. I would sit quietly away from the cafeteria aromas and constant questions of why I wasn’t eating. It was a part of my life that I practiced and celebrated with all my being. As I grew older and continued practicing Ramadan I became more confident and vulnerable. I didn’t shield myself in the school library. I began to embrace the holy month and with that I was bombarded with questions and statements of, “How much weight do you lose?” “You can’t have water?!” “That’s a great diet, I bet you get so skinny at the end of the month.” I would cringe at these comments and respond that Ramadan wasn’t about weight loss or dieting, it was about being grateful for all the blessings that one has in life like health, food, water, and shelter, as well as friends and family that cared for you.

That special time for Muslims around the world is soon approaching. For those who have an eating disorder, Ramadan can pose a whole set of difficulties and internal battles such as fasting for my eating disorder or for God? It is during this month that so many eating disorders go under the radar.

Since the Muslim calendar is lunar, the times and dates of Ramadan change and this year it begins at the end of May. It is a month of fasting and spirituality, for all able bodied, and sound minded Muslims. According to tradition, it is the month of mercy and forgiveness. During this holy month, Muslims must fast daily from predawn to sunset. Depending on the moons sighting the number of days Muslims fast varies from 29 to 30 days. This time of year, while we are fasting between 18 to 19 hours in various parts of the Northern hemisphere, Muslims in the Southern hemisphere are fulfilling their religious duties during short winter days which last about 10 to11 hours.

Fasting does not only entail abstaining from all food and drink, but also from any bad behaviors and habits, and sexual intimacy during the fast. It is a month of divine and physical cleansing, with extra special prayers and supplications. A time of hiatus from our daily material lives. A month of reflection and contemplation. A practice of willpower, empathy, humanitarian servitude, and patience. A month of training for the body and soul, to seek redemption and to continue the journey of righteousness throughout the year.

The barrier we may face as clinicians when treating a Muslim client is that culturally many refer to “illness” as physical diseases like cancer or diabetes and disregard eating disorders, depression, and anxiety. These beliefs encourage the feelings of continued shame, guilt, and comparison. These are some of the hurdles that our clients must overcome empowering them into recovery.

As a clinician when the subject of not fasting has been discussed, I have been met with both acceptance and rejection by both clients and families. There are multiple aspects and guidelines that you can reflect to those who come into your practice debating that necessity. When counseling clients, I have found the following to be helpful in reflecting back to them:

1. Contacting a local mosque and involve an Imam who is well versed in mental health and social issues and who can explain to the client that fasting is only for those healthy individuals.
2. He/she can participate in the of holy month without fasting, but rather through other acts of worship as well. Perhaps they can connect with their faith and God through abstaining from using social media, serving the community, restraining from anger, doing good deeds, or preforming charities to those in need.
3. In the Quran, the Book of Islam, God (Allah in Arabic) revealed, “Fast the prescribed number of days; except if any of you is ill or on a journey, let him fast a similar number of days later. For those who cannot endure it for medical reasons, there is a ransom: the feeding of the one poor person for each missed day” [chapter 2 verse 183].
4. It also states in the Quran that one can pay Fidyah, in which a donation of food or money is used to help those in need. When one is not able to fast, paying this compensation still deems one practicing Islam and participating in Ramadan.

In my years of practice, I have learned in general that when approaching the topic of religion and culture with a client, to always treat this with sensitivity, respect, and compassion, for culture and religion are integral parts of the human frame work. Begin to have the conversation with your client before Ramadan starts and gain a better understanding of what the holiday means to them. By approaching the topic with knowledge and alternatives it can lead to a more supportive and recovery minded discussion.

Malak, in her own words, has offered, “should anyone have a Muslim client and would like to speak to me further to contact me via email. I would love to help out in anyway that I can.” Malak can be reached by emailing malak.saddy@centerfordiscovery.com

Making Your Body an Ally in the Treatment and Recovery of Binge Eating Disorder

By Kari Anderson, DBH, LCMHC, CEDS with Shiri Macri, MA, LCMHC

Like other eating disorders, body shame is at the root of binge eating disorder. This shame can spring from many places: an internalization of society’s “thin ideal,” trauma, or simply from a long history of dieting. But unlike the restricting or purging involved in other eating disorders, the act of bingeing is an egodystonic behavior, meaning it leads one away from his or her value of thinness. That only compounds the shame. Add to that the trauma of living in a plus size body in our culture and many come to feel that they are unworthy—and, worse, that it’s their own fault.

Being present in a body that harbors so much shame is intolerable. As a protective measure, many sufferers binge eat to disconnect from painful thoughts and feelings. The mind of someone with binge eating disorder includes a borage of judgment and shame—judgment about the food, the body, the person themselves. People can get so caught up in these narratives that escape through binge eating seems to be the only possibility. But shame and self-loathing peak in the aftermath of a binge, further perpetuating the cycle. As a counter measure, many with binge eating try and restrict, but in an attempt to regulate the arousal system, the body “takes over” and this eating behavior becomes compulsive and reactive, leaving people feeling out of control.

Reconnection to the body is part of the healing process, which is why mindfulness—bringing awareness to the present moment without judgment—is an ideal intervention for binge eating disorder. Our western diet culture teaches us not to trust our decision making around food and to hate our bodies, forcing us to turn to outside “experts” for the answers. A mindful practice helps to reverse this, allowing us to notice what truly feels good—instead of a focusing on being good or looking good. In the practice of mindful meditation, we gain the ability to simply observe our thoughts and feelings. That, in turn, empowers us to take charge of our responses and disengage from automatic reactivity.

Third-wave cognitive behavioral interventions that are infused with mindfulness, such as dialectical behavior therapy, help shift someone from dichotomous, all-or-nothing thinking to a more flexible perspective, and encourage a more self-compassionate inner dialogue.

Mindful movement also plays an important role for those recovering from binge eating, helping them to gently and gradually reconnect with their physical bodies. In a preliminary study, Dr. Shane McIver, at Deakin University in Melbourne, Australia found a 12-week yoga program decreased binge eating and improved other health measures. Numerous studies by D. Vancampfort have found that combining physical activity and cognitive behavioral therapy improves outcomes for those with mental disorders including those with binge eating disorder. Body-based interventions can be very effective in healing underlying trauma, extensive work by Dr. Bessel Van Der Kolk has found. When the arousal system is overactivated as a result of trauma, the body enters a fight-flight mode and a person can become hypervigilant to “threats,” real or imagined. Body-based treatments such as yoga allow a person to literally move through the hyper-aroused state and into healing.

Intentional focus on merging the mind and body, healing one’s relationship with body through acceptance and forgiveness techniques, and ongoing self-care can help shift someone suffering from binge eating disorder from body shame to a functional focus on his or her body, therefore, neutralizing the shame that has so far kept them locked in the disordered behavior.

About the authors:

Dr. Kari Anderson has been treating eating disorders for 25 years, with particular emphasis on Binge Eating Disorder. She has served in several clinical and administrative roles for inpatient treatment centers, The Rader Institute and Remuda Ranch Programs. She currently is Executive Director for Green Mountain at Fox Run and President of their Women’s Center for Binge and Emotional Eating in Ludlow, Vermont.

She earned her Doctorate in Behavioral Health at Arizona State University in 2012. Kari is faculty for the Eating Disorder Institute at Plymouth State University in New Hampshire. She also serves on the Eating Disorder Specialist Certification Committee for the International Association of Eating Disorder Professionals.

Co-creator of the Am I Hungry?® Mindful Eating for Binge Eating Program, Kari also co-authored the award-winning book, Eat What You Love, Love What You Eat for Binge Eating: A Mindful Eating Program for Healing Your Relationship with Food and Your Body.

Shedding New Light on Eating Disorders at Midlife

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.

Tracking Down Body Image Distortions

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.                                                                                                                                                                             

The Effect of Weight Gain/Restoration on Bone Mineral Density in Anorexia Nervosa

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.

Help for Patients Who Just Can’t Recover

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.

Child Abuse and Development of EDs

Courtesy of Eating Disorders Review

The type of abuse had later effects on individual disorders.

A history of trauma during childhood is more common among patients with eating disorders than among the general population, and this relationship has been extensively studied. Results from a recent study at the University of Montpellier in southern France, add new information about early abuse and its effect on EDs (Scientific Reports; published online before print, doi: 10:1038/srep35761).

Dr. S. Guillaume and his colleagues report that while many studies of child abuse have focused upon sexual or physical abuse, far fewer have examined the effects of emotional abuse and neglect during childhood. The authors’ results indicate that more severe eating disorder symptoms may be related to specific types of childhood trauma. In their study, emotional abuse during childhood independently predicted higher Eating Disorders Examination Questionnaire (EDE-Q) scores for eating, weight, and shape concerns, along with poorer daily functioning. In contrast, sexual and physical abuse predicted greater EDE-Q eating concerns.

In their study, the researchers examined 192 consecutive young adult female patients admitted to an outpatient treatment unit (102 with anorexia nervosa, 64 with bulimia nervosa, and 26 with binge-eating disorder). For the clinical assessment, the psychiatrists administered the EDE-Q, and the Functioning Assessment Short Test (FAST). The FAST’s 24-item questionnaire assesses impairment or disability in 6 specific areas of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships and leisure time (Clin Pract Epidemiol Ment Health. 2007; 3:5). Childhood trauma was evaluated with the French version of the Childhood Trauma Questionnaire, which retrospectively examines 5 types of trauma through self-reports: sexual abuse, physical abuse, physical neglect, emotional abuse, and emotional neglect (J Am Acad Child Adolesc Psychiatry. 1997; 36:340).

Depression was the most common comorbidity

The most common lifetime comorbidities were major depressive disorders (77%) and anxiety disorders (42%). More than three-fourths of patients were college educated, and the mean age was 25 years. When evaluated for childhood trauma, 42% reported none, while 21% of the subjects had experienced at least 3 types of trauma. Emotional neglect was most common, reported by 36% of the women. Moderate-to-severe trauma was more common among patients with BN than among those with AN. The proportion of patients with physical and sexual trauma did not differ among the three groups. However, those found to have high scores for EDE-Q restraint had more psychiatric disorders, such as major depressive illness, bipolar disorder or substance abuse disorder, and were more likely to have had a lifetime history of suicide attempts than were patients with lower restraint scores.

One goal of the study was to scrutinize the impact of psychiatric comorbidities on the relationship between trauma during childhood and the subsequent severity of ED symptoms. The authors concluded that not all subtypes of abuse have the same impact upon patients. Instead, different types of abuse act additively to exacerbate “the severity of a wide range of ED features, including clinical and neuropsychological dimensions and daily functions.”