Binge Eating: How the Health at Every Size Approach Can Transform Treatm

Binge Eating: How the Health at Every Size Approach Can Transform Treatment

By Jennie J. Kramer, LCSW-R, Executive Director of Metro Behavioral Health Associates and Ashley Seruya, Social Work graduate intern and HAES Educator and Content Specialist

How can clinicians, clients experiencing eating disorders, and loved ones of those struggling all contribute to the changing culture of eating disorders? At our centers, we believe it starts with tackling the weight stigma that is so embedded within the diagnosis and treatment of BED and the entire eating disorder diagnostic category.

So let’s start with some simple definitions: what is a binge?

Compulsive Overeating is akin to what some call “grazing”. It is often eating all day, perhaps not too mindfully, almost by rote and certainly not in response to intuitive hunger cues. An example is someone who keeps a supply of a food in a desk drawer at work and eats from it rather frequently all day long. One is often not aware that she/he/they is doing it.

Emotional Eating is also not in response to intuitive hunger cues but much more episodic in nature. It is most often in response to or in anticipation of some emotions or events that cause anxiety, worry, upset or any other unpleasant feelings. There’s also usually a great awareness that it is happening but one feels helpless to do anything else in the moment in an attempt to self soothe.

These are not binges per se. Bingeing certainly has components of emotional and compulsive overeating but it is most often much more copious amounts of food in one sitting, stopped only by either physical discomfort, pain or falling asleep. It is most often alone and accompanied by a sense of great personal shame.

It is also important to note that all categories are quite fluid. Many who struggle actually utilize multiple behaviors across the spectrum, including bingeing, restricting, and purging. Though an individual may lean more heavily on one behavior or another, it is important to acknowledge that these categories are not as black and white as clinical procedure might suggest. With BED specifically, it is unusual to experience bingeing without also engaging in restrictive behavior of some kind, though this is not always acknowledged diagnostically.

There is inherent weight bias within the DSM-5 or Diagnostic Statistical Manual, the present standard for all psychiatric diagnoses, including those related to one’s relationship to food and body. For example, the diagnosis of Anorexia Nervosa (AN) requires an individual to be of low weight while those with BED are often assumed to be of higher weight. These general weight class assumptions are rooted in weight stigma. In truth, many individuals struggling with anorexia are in average-sized or larger bodies.

As a result, many individuals have a difficult time being properly diagnosed, especially those in higher-weight bodies exhibiting restrictive symptoms. Their experience may not be taken as seriously, despite existing research that indicates that how much weight is lost in short period of time is much more indicative of the severity of a restrictive eating disorder than weight itself. Someone who, for example, is of a higher weight and loses a large amount of weight in a short period of time via restriction but is still considered “overweight” or “obese” by the BMI scale will likely be misdiagnosed and their restrictive behaviors are likely to not be believed by providers because of the stereotypes surrounding eating disorders and the ways in which the DMS-5 perpetuates these stereotypes. Furthermore, insurance reimbursement often relies on DSM-5 diagnoses. Being diagnosed improperly can lead to improper treatment and an inability to pay for that treatment.

In terms of treatment, this means embracing a Health at Every Size (HAES) approach to recovery for all eating disorders. HAES, a body of work that began in the 60s and has been popularized by Dr. Linda Bacon, is an approach to health and wellbeing that is weight inclusive rather than weight centric. Instead of pathologizing larger bodies, HAES proposes that all people are deserving of respect and quality of care, no matter their size. HAES proponents believe all people in all bodies should be able to pursue health if that is something they desire and are committed to creating a world in which we divorce health status from weight.

Let’s say that again – divorcing health status from weight. Quite the task when we are all steeped in diet culture at every turn.

Here are some statistics to ponder:

• Often referred to as the “obesity paradox,” people in the “overweight” and “obese” categories on the BMI scale have a lower morbidity rate than those in the “normal” and “underweight” BMI categories;
• No current research can show sustained intentional weight loss on a long-term basis;
• Health gains are maintained with or without maintaining weight loss when health behaviors are maintained;
• Those who do engage in intentional weight loss are more likely to end up heavier than when they initially began attempting to lose weight;
• Weight cycling, the most likely result of attempts at intentional weight loss, may be more metabolically dangerous than remaining at a stable higher weight.

With all of this information in mind, it becomes clear that what we think we know about weight isn’t quite as black and white as previously believed. For eating disorders, this becomes an important factor in diagnosing and treating those in higher-weight bodies. Too many well intended treatment models continue to pathologize larger bodies, not believing people when they report their experiences of restriction simply because they are not “underweight.” Many then get wrongly treated via weight loss clinics, highlighting the misunderstanding of how BED functions.

Instead, let’s start by acknowledging bingeing behavior as one of several coping mechanisms meant to self soothe. We also need to begin acknowledging the role that restriction plays in BED, and the role of internalized fat-phobia in all eating disorder development and maintenance. Understanding more about the society in which we live and how it continues to treat larger-bodied individuals as second-class citizens (hiring managers are less likely to hire someone who is “overweight;” it is legal to fire someone for being in a larger body in the majority of states; peer-to-peer bullying related to weight is a pervasive problem in our schools; stereotypes about larger people persist, including beliefs about laziness and poor personal hygiene), is essential to understanding how eating disorders function and some of the barriers individuals face when attempting to recover. How can we truly expect people to let go of their eating disorder behaviors when we live within a world that tells us that in order to be valuable, we must be thin? How can we expect people to even understand their behavior is disordered when we don’t recognize the restriction that takes place in bingeing-type eating disorders? These are important questions to be asking ourselves as professionals, sufferers and those who support loved ones who suffer.

The Power of What We See: An Examination of Weight Bias in Television Programming

The Power of What We See: An Examination of Weight Bias in Television Programming

By Kristine Vazzano, PhD

The human brain processes images 60,000 times faster than words.

This data is not only powerful, but pivotal in illustrating the many ways the media can impact how we see and feel about our bodies as well as those around us. Living in our culture, we are exposed to numerous images each day dictating how we “should” look. Inherent in these messages can be the notion that fat is bad and thin is good. Although these messages are prevalent in countless media streams, television continues to be a primary media outlet. When we look closely at how body shapes and sizes are characterized in television, several trends and patterns of weight stigma become apparent.

These trends include:

• Reality shows focusing on weight loss, featuring weight loss as a game and something solely in someone’s control. These shows ignore the harmful consequences of dieting and reinforce the dangerous idea that becoming thinner means positive things for someone’s overall happiness, health, and appearance.
• Mischaracterizing people based on their size. Television shows commonly depict certain characters in a negative light, appearing unintelligent, unhappy, or mean. In fact, in 40% of children’s movies, a character of a higher weight is disliked as a part of the story line.
• Featuring characters in larger bodies as the sources of humor or someone to make fun of. These trends are particularly evident in children’s movies and video games.
• Misrepresenting size diversity by showing more women that are underweight and fewer women in higher weight bodies.

What are the implications?

The messages in television programming misrepresenting size diversity and people in higher weight bodies contributes to harmful and inaccurate stereotypes. These patterns imply that a person’s character or personality is negatively linked to their body shape and size.  Laughing at individuals in higher weight bodies and casting them in a negative light reinforces weight bias that is already common in our culture. It perpetuates weight-based stigma, the harmful notion that it is acceptable to make fun of those in a larger body.

Furthermore, by stigmatizing individuals with a higher body weight in these ways, TV programming is reinforcing the thin ideal making it seem as though thinner bodies are something we must strive for in order to be happier, healthier, well liked, and successful.

Much of the programming is geared toward a younger audience, one particularly vulnerable to developing attitudes and beliefs about others and their own bodies as well.

What can we do?

• Be aware and critical of what you see. Challenge messages reinforcing weight stigma. Educate yourself and those around you about the importance of treating all people with respect.
• We have the power to choose some of what we consume. Turn off the shows that reinforce weight bias. Seek out shows, social media accounts and other media that challenges the thin ideal and provides healthier, flexible messages.
• Speak out about weight bias. Stand up to the discriminatory messages you see and hear. Reinforce the message that size does not demonstrate someone’s worth, personality or health.

Network Analysis of Males and Eating Disorder Symptoms

Network Analysis of Males and Eating Disorder Symptoms

By Lauren Forrest, MA

When you think of the term “eating disorder”, what words come to mind? Perhaps you think of descriptors like girls, women, thin, body image, and lean. If you read a case description of someone with an eating disorder, how often would you guess the case description described a female vs. a male? It’s likely your mind would have a stronger association between eating disorder + girls/women/female, as compared to eating disorder + boys/men/male. And it’s true: girls and women are more likely to be affected by eating disorders than boys and men. However, the gender gap of eating disorder prevalence is closer than you may think—males account for roughly 20–25% of affected individuals (Hudson et al., 2007; Mohler-Kuo et al., 2016; Udo & Grilo, 2018). Importantly, one reason why male eating disorders are lesser known than female eating disorders may be because of differences in core eating disorder symptoms (for a thorough review, see Murray et al., 2017). In collaboration with a team of excellent colleagues (Natalie Perkins, Jason Lavender, and April Smith), I led a study that identified core eating disorder symptoms among men, and I’m excited to tell you more about it.

This study used something called network analysis to identify core eating disorder symptoms. Network analysis is a statistical technique that identifies how individual symptoms interact with one another. Through empirical methods, network analysis specifically identifies the symptom(s) that have the strongest connections to other symptoms in the network, which is important because these highly-connected symptoms may be those that cause the development of several other symptoms in the network. For example, network analysis findings among women indicate that eating disorder symptoms like shape and weight overvaluation—where people feel like their shape or weight is extremely important to how they judge themselves as people—are highly related to several other symptoms, like fearing weight gain and dieting.

Even though network analysis shows promise to better understand core symptoms of eating disorders, males have been very under-represented in eating disorder network studies. Without including boys and men in our research studies, we can’t know whether the symptom-level interactions identified among women are operating similarly for boys and men. Our study identified specific eating disorder symptoms that may be the main drivers of eating disorders in men. To do this, our symptom network included items that are typically used to assess eating disorders, while also including items that capture experiences that seem to be important to men’s experiences, such as items related to male (vs. female) body ideals.

In western society, the male body ideal is muscular and lean. This is in contrast to the female body ideal, which is thin and marked by having a low weight. To achieve these different body ideals, males and females may engage in specific eating disorder behaviors. Dietary restriction and purging may be used to lose weight and achieve a thin body ideal, whereas eating large quantities of specific foods (e.g., those high in protein), lifting weights, and exercising intensely may be used to gain muscle mass and achieve a muscular body ideal. Most of the measures that are commonly used to assess eating disorders do an excellent job of assessing attitudes and behaviors associated with achieving a thin body ideal, but few incorporate items that assess attitudes and behaviors associated with achieving a muscular body ideal (please see the great work of Dr. Kelsie Forbush for an exception). In our study, we used a “both–and” approach, where we included items in the network that are commonly used in eating disorder research (but lack male/muscularity specificity) while also including items that capture muscularity-related body ideals, dissatisfaction, and behaviors.

The results of our study were quite interesting. We found the items with the greatest importance in the network—i.e., items that were most strongly associated with all other items—were shape overvaluation (believing a person’s body shape is one of their most important qualities), wanting to lose weight, fearing losing control over eating, feeling guilty for missing a weight training session, and using dietary supplements. The first three symptoms (shape overvaluation, wanting to lose weight, and fear of losing control over eating) were expected to be important, based on previous research. But the most interesting part of the results was that the last two symptoms (feeling guilty for missing weight training and using dietary supplements) came from measures assessing male/muscularity-specific eating disorder symptoms. This may mean that to most accurately diagnose, understand, and treat eating disorders among males, we need to be paying attention to some of the things we already pay attention to for female eating disorders (e.g., shape overvaluation, valuing weight loss) while also increasing the attention we pay to things like dissatisfaction about one’s body not being “muscular enough” or “lean enough” and the behaviors that may arise from this dissatisfaction (e.g., intense and strict weight lifting schedules, supplement use).

More broadly, one implication of these results is that as a field we may need to expand our theoretical models of eating disorders. Rather than our models specifying that pursuit of a thin body is the driver of all eating disorder symptoms (which is a belief ranging from implicit to explicit in current theoretical models of eating disorders), we may better conceptualize male and female symptoms by specifying that pursuit of any body ideal (thin, muscular, lean, etc.) could lead people to engage in specific eating and exercise behaviors to achieve that ideal. For some people, these experiences may result in clinically significant eating pathology. Such an expansion could bring necessary growth and diversity to our field, and ultimately help us impact more people through more accurately assessing, diagnosing, treating, and preventing eating disorders.

To my mind, one of the most problematic stereotypes about eating disorders is that they are “female diseases.” There is a kernel of truth to this stereotype, as eating disorders do affect more females than males. However, the fact that a sex difference exists doesn’t mean that males don’t develop eating disorders, and it also doesn’t mean that eating disorders present exactly the same in men and women. My hope is that by conducting research like what my colleagues and I did here, we can help the eating disorders field better recognize the similarities and differences between male and female eating disorders, so that we can make sure that we’re providing the most thorough and effective assessment and treatment for all affected individuals. 

Eating Disorders Coalition Celebrates Latest Federal Guidance on Implementation of Mental Health Parity to Promote Compliance and Enforce Eating Disorders Coverage

WASHINGTON, D.C. (October 28, 2019) – The US Department of Labor, US Department of Health and Humans Services, and the US Department of the Treasury released guidance last month entitled, “FAQs About Mental Health and Substance Use Disorder Parity Implementation and the 21st Century Cures Act Part 39,” providing additional direction to insurance plans, issuers, and outside stakeholders in an effort to promote compliance with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The Eating Disorders Coalition for Research, Policy & Action (EDC) applauds the Departments additional guidance, including new clarifications that will enhance insurance coverage for eating disorders as a result of the Anna Westin Act provisions included within the 21st Century Cures Act (P.L. 114-255).  The EDC has worked tirelessly to educate federal agencies on the barriers to care for individuals and families with eating disorders. This work has included submission of public comments on previous federal guidance documents in September 2017 and June 2018; Congressional letters of support in 2017 (House/Senate) and 2018 (House/Senate); and participation in a July 2018 and a January 2019 federally hosted forums with stakeholders and federal agencies to discuss MHPAEA implementation. The most recent guidance from the Departments includes victories for our community regarding the following:  Coverage of Sub-group Disorders: When a plan or issuer provides benefits for a mental health condition/substance use disorder, benefits for that condition or disorder must be provided in every classification in which medical/surgical benefits are provided. Insurance plans are in violation of MHPAEA if coverage for eating disorders does not extend to all sub-types including, anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, and other specified feeding or eating disorders (OSFED).  Shifting the Burden of Proof for Fail-First Policies to Payers: It is incumbent upon the insurance company, not the patient, to prove they’re in compliance with step therapy protocols and are able to demonstrate evidentiary standards were utilized comparably to develop step therapy requirements between mental health/substance use disorder benefits and medical/surgical benefits.  Residential Care Classified as Inpatient, Covered Benefit: Residential eating disorders treatment is classified as a sub-category of inpatient care to ensure the patient receives their inpatient covered benefit just as skilled nursing facilities, nursing home care, and hospice are considered sub-categories of inpatient care.  Rights to Receive Medical Necessity and Denial Information: Insurance plans must provide current/potential patients and contracted providers with free of charge information regarding claim denials and related documents on medical necessity requirements to file within 30 days of a participant’s request.  “The recent guidance from the Departments provides further clarity to individuals and families with eating disorders, treatment providers, and insurance companies to fully comply with the Mental Health Parity and Addiction Equity Act as intended,” said EDC Board President Chase Bannister, MDIV, MSW, LCSW, CEDS. “Our coalition has worked diligently to fight for equitable treatment under the law. We will remain steadfast in our mission to continue having a seat at the table as we educate the Departments on MHPAEA violations and work together to drive change for those in need of treatment.”  The EDC recognizes that parity enforcement and compliance both remain a work in progress, therefore we will continue to use our collective voice to provide expertise to the Departments as they release additional implementation guidance on a rolling basis.  The Eating Disorders Coalition for Research, Policy & Action (EDC) is a Washington, DC-based, federal advocacy organization comprised of advocacy organizations, academics, treatment providers, family/loved ones of children with eating disorders and people experiencing eating disorders nationwide. The EDC advances the recognition of eating disorders as a public health priority throughout the United States. Additional resources can also be found at www.eatingdisorderscoalition.org.

When People with Anorexia Injure Themselves

Vol. 29 / No. 6 — Eating Disorders Review

Difficulty regulating emotions is a common component of an eating disorder, and self-injury  may act as a coping mechanism for dealing with overwhelming emotions. This was one finding from a recent study of patients with anorexia nervosa or eating disorders not otherwise specified (J Eat Disord. 2018; 6:26).

Dr. Linda Smithius and colleagues at Parnassus Psychiatric Institute, Rotterdam, used a cross-sectional design and a self-report questionnaire to measure the prevalence and characteristics of self-harm behavior among 136 patients with eating disorders. The authors found that 41% of their study subjects had injured themselves during the previous 30 days. Those who injured themselves had been in treatment longer and were more likely to have a secondary psychiatric diagnosis, suggesting more severe illness than those who did not injure themselves. These patients also stated they a reduction in negative feelings and increased relief after hurting themselves. Afterwards they also could articulate the emotions that led them to injure themselves. The Dutch researchers were also able to isolate the intensity of two emotions in particular, “feeling angry at myself” and “feeling angry at others.”

The authors noted that emotion regulation appears to differ between subtypes of anorexia nervosa, so that patients with the purging subtype have reported greater difficulty regulating their emotions than do patients with restrictive-type anorexia nervosa (J Eat Disord. 2016; 4:17). The findings replicate work using intensive self-monitoring strategies such as ecological momentary assessment to measure the impact of self-injury on emotion regulation

EATING DISORDERS Large Study Analyzes Compulsive Exercise and Eating Disorders

Vol. 29 / No. 6 — Eating Disorders Review

One finding: Nearly half of eating disorders patients were compulsive exercisers.

In the largest study to date of compulsive exercise in adults with eating disorders, more than 9,000 female and male patients were examined for tell-tale symptoms (J Eat Disord. 2018; 6:11). Dr. Elin Monell and colleagues at the Karolinska Institute and the Stockholm Health Care Services, both in Stockholm, Sweden, gathered their data from the Stockholm database, a clinical database for specialized eating disorders treatment centers throughout Sweden. The database includes all treatment modalities, including medical, psychosocial and nutritional data and records the length and intensity of treatment.

In Sweden, about 60% of treatment is given as outpatient care; approximately 25% of patients receive day treatment and residential care. Records of patients registered from March 2005 to October 2017, were identified, and 9,117 patients with histories of eating disorders were included in the final study. All participants were studied with semi-structured interviews and questionnaires, including the Structured Eating Disorder Interview, the Eating Disorder Examination questionnaire(EDE-Q), The Structural Analysis of Social Behavior,and the Structural Clinical Interview for DSM-IV-Axis 1 Disorders(SCID-1).

Compulsive exercise at admission

Of the total sample of 9,117 patients, 96.3% were female, and the patients’ ages ranged between 18 and 81 years. Compulsive exercise was noted in 48.2% of female patients at admission and in 45.5% of male patients, where it was most often linked to eating disorders not otherwise specified or to bulimia nervosa. Both males and females who compulsively exercised had more general eating disorders pathology and restraint than did those who did not compulsively exercise. Females with compulsive exercise diagnoses were slightly younger, had a fairly shorter duration of eating disorders, and a slightly lower body mass index than did non-compulsive exercisers.

Compulsive exercise predicted a slightly lower remission rate in men, and women who had never engaged in compulsive exercise or had ceased using it remitted twice as quickly as those who continued to use compulsive exercise during treatment.

The authors noted that compulsive exercise was a transdiagnostic symptom in their study. Their results are similar to those of a prior study of adolescents with eating disorders. This growing body of literature suggests that while exercise has received relatively little attention, it deserves greater focus, both in research and in clinical practice.

Collegiate Female Athletes’ Knowledge About Eating Disorders

Vol. 29 / No. 6 — Eating Disorders Review

Knowing the signs and symptoms of an eating disorder brought the lowest scores.

Athletes are a group at high risk for disordered eating, and one would hope they would be knowledgeable about eating disorders. In fact, athletic organizations such as the National Association of Intercollegiate Athletics (NCAA) have engaged in raising awareness about eating disorders (these efforts may focus on larger athletic programs). When a team of American and Swedish researchers compared general knowledge about eating disorders and confidence in that knowledge among a group of female athletes, they were surprised to learn that despite the women’s confidence in their knowledge of eating disorders, their actual understanding fell far short.

Dr. Megan E. Rosa-Caldwell and colleagues recruited 51 women from an NCAA Intercollegiate Athletics university and asked them to complete a 30-question exam assessing 5 different categories related to eating disorders (Peer J. 2018; doi 10.7717/peer). 5868).

Most scores were unsatisfactory

Fifty-one female college athletes (mean age: 19.7 years) completed the study. The average score was 69.1%. Only 23% achieved an adequate score of >80% correct, despite the fact that most thought their level of knowledge was good. Most could identify risk factors but scored the worst on identifying signs and symptoms. As the authors noted, most of the athletes lacked knowledge about eating disorders.

Some possible explanations

While there is a substantial amount of research on eating disorders risk and prevalence of this among athletes at large universities, little research has been done at smaller athletic programs, which often lack the resources that are present at the larger universities, such as access to team physicians, team-specific athletic trainers, or dietitians.

The authors note that overconfidence may also play a role, citing the Dunning Kruger effect, first outlined in the 1990s (J Personality Soc Psychol. 1999; 77:1121). An individual may have high confidence in his or her knowledge of a subject but in fact does not have the ability to see the limitations of their knowledge. Coaches or teammates who cannot recognize problematic eating behavior but who are also confident in their ability to do so can have serious ramifications.

This study points to potential challenges in small collegiate athletic programs and may also identify an overlooked need for increased efforts to improve awareness efforts. An individual may lack the knowledge to identify signs and symptoms of disordered eating among his or her peers, yet have high confidence in the ability to do so. Improving knowledge about eating disorders in these athletes could thus have a large impact.

Update: Cyberbullying Increases Eating Disorder Risk

Vol. 29 / No. 6 — Eating Disorders Review

Studies of nonclinical samples have shown an association between cyberbullying and negative emotions, low self-esteem, unhealthy eating behaviors, and body dissatisfaction.  Psychologist J.H. Marco and a team of researchers from the University of Valencia, Spain, took this a step further, to test the association among a sample of patients with diagnoses of eating disorders, and a second group at high risk of developing an eating disorder (Cyberpsychol Behav Soc Netw.2018; 21:611).  In the first study, 80 participants with eating disorders (41.2% with bulimia nervosa criteria; 33.8% with anorexia nervosa-restrictive type criteria, and 25% with eating disorders not otherwise specified criteria). In the second study, the sample included 156 male and female elite athletes.  In both studies, cyberbullying correlated with depression and eating disorder psychopathology. These findings underscore the impact of cyberbullying and possible links to development of disordered eating.

Mortality in Bulimia Nervosa

Vol. 30 / No. 6 — Eating Disorders Review

A study highlights risks of heart disease and death with BN.

Mortality risk is known to be elevated in people with anorexia nervosa.   Whether this is also true for those with BN is less clear; some studies have shown increased risks, but other have not, and overall there is less research on mortality in BN.  Moreover, if there is increased risk, it is unclear if it represents medical risk or risk of suicide (or both).  A recent study from Quebec shows that risk of heart disease and of death is elevated in those with BN.

In this study, Tith et al. (JAMA Psychiatry, published online, October 16, 2019) examined 818 women hospitalized for BN.  About 415,000 women hospitalized for pregnancy-related reasons were used as the comparison group.  All participants were followed for 12 years.

Increased risks identified

The results showed that there was a 4.25-fold increase in risk for heart disease, and a 4.7-fold increase in risk of dying overall.  The authors note one caveat:  participants were in the hospital for treatment of BN. Hospitalization for treatment of BN is not common, suggesting that these patients were severely ill.

These are important results that emphasize the magnitude of the risks related to BN. They also tend to question prevailing ideas about the lower severity of BN as opposed to AN.  Finally, they seem to pose a strong argument for pushing to identify the presence of BN as early as possible.  We know from experience that people with BN often first present in treatment 3 to5 years after the onset of symptoms, but it seems very unlikely that medical risks are similarly delayed.

Can Fracture Risk in AN Be Reduced with Adrenal Hormones?

Vol. 30 / No. 6 — Eating Disorders Review

Patient age plays an important role.

Establishing and maintaining healthy bones is an important topic for everyone, and particularly for teenage girls with anorexia nervosa, where the disorder reduces bone mineral density (BMD) and skeletal strength,  and thus drastically increases the risk of future fractures. This risk is striking: a patient with AN has a 7-fold greater incidence of fractures at various sites than does the average healthy teenager. Some of this has to do with delayed closure of the physes (also known as closure of the epiphyses).  The growth plate, or physis, is the translucent, cartilaginous disc separating the epiphysis from the metaphysis and diaphysis (bone shaft) and is where longitudinal growth of long bones takes place. The loss of BMD and skeletal strength in these young patients is believed to be irreversible, and no effective therapies have yet been discovered.

Dr. Amy D. DiVasta and colleagues recently tried counteracting loss of BMD in teen patients with AN by using adrenal hormone supplementation. The authors designed a 12-month, randomized, placebo-controlled study of 70 girls 11 to 18 years of age (J Adolesc Health. October 2019. 65:462). The authors hypothesized that prescribing two adrenal hormones, dehydroeopiandrosterone (DHEA) and estrogen replacement therapy (ERT)  might slow or at least interfere with BMD loss among these young patients. The authors followed changes with serial measurements of BMD with dual-energy x-ray absorptiometry (DEXA) scans and peripheral quantitative computed tomography (pQCT).

Seventy female adolescents were enrolled in the study and randomized to hormone therapy or placebo. Those in the treatment arm (n=35) were given  oral micronized DHEA (50 mg daily) for the first 3 months, to minimize side effects related to estrogen. Then they received 9 months of DHEA and ERT (20 ug ethinyl estradiol/0.1 mg levonorgestrel). The other group (also n=35) were given a placebo for the 12 months of the study. All participants were assessed at 3, 6, 9, and 12 months, and all were advised to take a daily dose of calcium (1300 mg) and vitamin D (400 IU). If participants were vitamin D deficient at baseline, they received a treatment dose of 2000 IU of vitamin D3 daily for 3 months. All participants also had additional measurements of height weight, and BMI-Z scores were established for each girl.

BMD did not improve in younger patients

For the teens with AN and open physes, the combination of DHEA and ERT supplementation did not improve bone density, geometry, or strength compared with teens in the control group. Attenuation of bone loss and enhancement of bone strength was limited to older teens and young adults.

In this study, the authors recruited only girls who were postmenarcheal or who had a bone age of at least 13 years. Based on their earlier studies, they expected that these girls would have already gone through their growth spurt, would now be in the growth deceleration phase, and would have attained 96% of their final height. Older adolescents and young women in the authors’ previous studies had arrested bone loss determined by DEXA scans, and had improved after 18 months of the same ERT regimen.

Nearly half of the participants in this study had at least one open physis shown on magnetic resonance imaging, and, in these girls, the adrenal supplementation regimen was not beneficial.  The authors added that if AN occurs before puberty, more profound skeletal effects occur, especially compromised osteoblast activity with lower BMD measurements in both the axial and appendicular skeleton. In contrast, patients with onset of AN during adulthood are more likely to have bone deficits only in the axial skeleton.

The authors concluded that the DHEA and ERT supplements were ineffective for young women with AN and open physes, and that other strategies, such as using transdermal estrogen, should be considered for these generally younger patients, in addition to standard care, including medical, nutritional, and psychological support.

Involuntary Hospitalization for Anorexia Nervosa

Vol. 30 / No. 6 — Eating Disorders Review

By Mary K. Stein, Managing Editor

One of the most daunting aspects of anorexia nervosa arises when a patient refuses treatment despite being seriously ill. Due to the egosyntonic nature of AN, a patient may feel the “disorder” is a part of her, and doesn’t want it to go away.

Involuntary admission and treatment are particularly controversial for eating disorder patients, particularly for those with AN, the deadliest eating disorder. Even if the disorder is life-threatening, patients often refuse to be hospitalized, and are only admitted for treatment after pressure from clinicians, friends, teachers, or employers (Am J Psychiatry, 2007; 164:108). As Schreyer and colleagues note, ethical guidelines require clinicians to provide care that benefits patients, avoids harm, and enhances self-determination, but treatment rejection by patients seriously ill with AN presents an ethical dilemma because simultaneously upholding these core principles is not possible (Int J Eat Disord. 2016; 49:407).

Vigorous debate continues over compulsory treatment of severely ill patients with AN.   Numerous studies have sought to clarify or to offer guidelines for admitting such patients or for finding alternative care.

Clinical, Medicolegal, and Ethical Challenges

Admission for treatment poses clinical, medicolegal, and ethical challenges, according to Dr. Terry Carney and colleagues (Psych Clin N Am. 2019; 42:299). The authors note that there are few studies involving relatively small numbers of patients, and these studies show that short-term weight restoration does save patients and ‘turn them around.’ However, the outcome shows that long-term follow-up shows that their outcomes are considerably worse than for patients who voluntarily seek treatment. Patients who are involuntarily admitted for treatment are also much less likely to seek care after being discharged. Thus, involuntary admission may be futile or contraindicated for some persons with severe and enduring AN; these patients have impairments in quality of life that can equal those seen in patients with depression or schizophrenia. The experience of Guardia and colleagues with voluntary admission of 139 patients with eating disorders to Johns Hopkins University’s eating disorders program provides interesting information (Am J Psychiatry. 2007; 164:106). Many of these patients felt that they had been coerced into treatment.  The patients’ average age was 25 years, 55% had AN, and a perception of coercion was strongest among the 35 patients under 18 years of age than among the other 104 adult patients.

A Medicolegal and Human Rights Challenge

Age is an important consideration for medicolegal considerations, according to Dr. Carney and his co-workers. Involuntary treatment of an adolescent with AN is governed by the same laws that apply to other important decisions; parental consent is required as defined in common law. The laws also differ by location and by definition—for example, in Israel and some parts of Australia, AN does not qualify as a mental illness warranting involuntary mental health admission and treatment. Three forms of involuntary treatment are authorized by civil commitment laws in 46 states and the District of Columbia. Two forms of involuntary commitment are available in Connecticut, Maryland, Massachusetts and Tennessee, where court-ordered outpatient treatment has not yet been adopted.

One study of 75 admissions to a specialist Australian anorexia program over nearly 5 years, provided some helpful information (Int J Psychiatry Relat Sci. 2006; 43:159). Twenty-seven admissions were made under mental health committal by adult guardianship orders; 7 admissions considered for coercion resulted in patients agreeing to informal admissions, following a “strategic” initiation and abandonment of resorting to law.  Slightly more than a third (36%) of admissions were for patients younger than 20, and just one-third of admissions occurred as sole events; one-fourth had four or more admissions for treatment. Three-fourths of the patients had comorbidities, and one-third had 2 or more comorbid conditions. About 40% of admissions were for less than 3 weeks (mean: 49 days).

Some patient characteristics suggested that coercion was necessary, such as young age at admission, critically low body mass index (BMI, kg/m2), multiple prior admissions, and comorbid conditions. Neither gender nor the type of AN was significant in this study; statistically significant associations were found between use of coercion and the refeeding syndrome, the use of tube feeding and locked wards. Coerced admission was also tied to critically low BMIs. Nearly 28% of patients had a BMI lower than 12 when they were admitted; nearly two-thirds of that sample had a BMI less than 14.

Multiple prior admissions also were a predictor of coercion. According to the authors, coerced patients (80%) are more likely than voluntary patients (57%) to have been admitted before for treatment of AN or related conditions. More than a third of the coerced patients had been admitted 6 or more times previously, compared to 1 in 10 of the voluntarily admitted patients.

The often dire medical status of (BMIs usually 10-12) and the presence of the refeeding syndrome places clinicians under pressure to take action to keep the patient from becoming critically ill and even facing death. Persuading patients that they are gravely ill and medically compromised is one more challenge because while they may not wish to die, many of these patients don’t have the “insight” to understand the very serious threat to their survival. Because of the nature of AN, and due to the possibility of brain atrophy, most patients will resist any attempts at refeeding. Then, clinicians are faced with minimizing feelings of anger or breach of the therapeutic relationship.

So many questions remain and need to be addressed, such as how mental health committal can be made more productive and more acceptable to patients. Other questions include: how long should a patient be committed, and how can treatment be monitored through advocacy protections? Psychiatrists  Drs. Athanasios Douzenis and Ioannis Michopoulos, of the University of Athens, Greece, conclude that in some cases, involuntary treatment can save the lives of young patients with AN but in other cases it can break the therapeutic relationship and lead patients to abandon treatment altogether (Int J Law and Psychiatry. 2015;39:31). There is no scientific consensus on the correct course of action.  Ultimately, the authors note, “It is the clinician who has to decide for whom and when to approve involuntary treatment or not.”

(See also an excellent article, “Involuntary Treatment of Patients with Eating Disorders,” by Watson, Bowers, and Andersen in the March/April 2019 issue of EDR.)

Eating Disorders and College Students

Eating Disorders and College Students

By Sydney Brodeur McDonald, Ph.D., LCP

Kayla* was a 19-year-old sophomore art student who garnered the attention of her professors and was thought of as a protégé in the expression of abstract images. She was quiet with pink streaks in her hair, she wore layers of clothes and sometimes seemed to disappear into her own internal world. Mentors at times wondered if she was too thin, but her work was impeccable and they had no idea how to express their concern. She suffered a cardiac arrest in her studio at the art school on a Tuesday night and with her, her art died.

Kayla had struggled with anorexia in high school and never fully recovered, and her relapse went unaddressed in a college environment because her eating disorder bloomed and gained strength in her isolation.

Eating disorders have a very high mortality rate relative to other mental health disorders, and they thrive on secrecy. Contrary to popular belief, eating disorders are not a choice and the illness is often accompanied by distorted beliefs about food and body shape and size. Eating disorders are cunning, manipulative and self-protective making it all the more difficult for the person suffering to independently reach out for help.

According to the National Center for Education Statistics, in 2016 41% of all US adolescents aged 18 – 24 were enrolled in a college or university. This number has increased by 16% since 1970, and this shift has changed the experience of university life, including the extent and availability of student support services such as counseling centers and student health. College can be an exciting time marked by exponential personal growth, social and education knowledge acquisition, and entry into adulthood. However, it is also a vulnerable stage of life, and a time when young people are at risk for an eating disorder developing or worsening. While approximately 6% of women on college campuses meet criteria for anorexia or bulimia, as many as 40% report body image concerns, weight management behaviors and out of control eating (Schwitzer & Choate, 2015). In other words, social pressures, burgeoning identity, and first tastes of independence combine to create the perfect conditions for disordered eating.

Further, western cultural idealization of a thin frame is an added complication for college students today, and while faced with these often unattainable ideals, college students are also in an environment where regular well-balanced meals are rare, binge-eating and drinking is normalized, and diet mentality is rampant. This creates a risky environment for a cycle of binge eating, weight gain, dieting, body image disturbance, and disordered eating cycles. As many as 36 – 50% of adolescent girls diet and, of these, NEDA reports that 35% of “normal” dieters progress to unhealthy dieting, and of those, 20-25% develop partial or full syndrome eating disorders.

Meanwhile, the landscape of college mental health has shifted considerably in the past two decades. While enrollment has exponentially increased, so has the demand for support services such as counseling, but for most universities, the demand far exceeds the available resources. For example, between 2011 and 2015, Virginia Commonwealth University’s counseling center experienced a 45% increase in the number of students seeking counseling services. The impact of this increase is significant, and while accessing college mental health is a priority, it also means that the availability of ongoing services for students is scarce. According to the Center for Collegite Mental Health (CCMH), most college counseling centers are beginning to move to a triage model of mental health and focusing their efforts on crisis intervention, brief counseling, and referral to community providers. Also according to CCMH, the average number of appointments attended by students in a college counseling center is 4.55.

Contrast this with the typical length of outpatient treatment for patients with eating disorders, for which estimates range from 30 sessions to seven years. This essentially means that college students with eating concerns are unlikely to receive adequate treatment at their college counseling centers. However counseling centers can assist with early identification and be an entry point into appropriate outpatient services or higher levels of care.

Early identification of eating disorders is critical in order to effectively prevent the potentially life-long impact of the disease on the body and brain. Malnutrition can lead to bone density loss, suspend brain development, interrupt reproductive processes, and more. Without prompt and sufficient treatment physical consequences can be irreversible. Furthermore, eating disorders can negatively impact social, psychological, and academic functioning. Treating people who are struggling with the onset of symptoms of an eating disorder as quickly as possible and at the highest level of care needed likely leads to the best possible outcome for those students. Early identification through student health, residence halls as well as university counseling services are likely the best way to ensure that young people do not struggle unnecessarily.

Strategies to Support Students with Eating Disorders or in Recovery: 

1. Educate students with a history of disordered eating/eating disorders, along with their parents and treatment teams about the risk of relapse that entering college presents.
2. Ensure that students with a history or current struggle with disordered eating are equipped with a treatment team (RD, MD, psych provider, and therapist) with scheduled appointments before beginning college.
3. Parents and college students should not expect that the university resources will be sufficient if someone has an active eating disorder or an eating disorder in remission.
4. Provide resources for understanding warning signs and strategies for early identification and intervention to professors, residence life personnel, and other university support providers.
5. Align universities with ED support networks and provide them with resources for understanding the first signs and efforts of early identification.
6. Assist university counseling center staff with developing a network of external providers experienced in treating eating disorders so that the referral process is as seamless as possible.
7. Train residence hall personnel and other front line staff to know how to intervene with students who are struggling with eating concerns or body image issues.

*Name changed for privacy

Veritas Collaborative can partner with your university counseling center, providing assistance in efforts around early identification and the referral process. For more information, please contact admissions@veritascollaborative.com or (855) 875-5812.