Thursday, April 11, 2019

Current Research and News 2/2019


Eating Recovery Center’s Binge Eating Treatment and Recovery Program launches study to examine successful treatment elements. Eating Recovery Center (ERC), announces the launch of a new study that will examine elements of treatment that are necessary for successful reduction of and/or abstinence from binge eating and other eating disordered behaviors in a sample of patients with binge eating disorder (BED) and Bulimia Nervosa (BN). Conducted through ERC’s Binge Eating Treatment and Recovery (BETR) Program, this groundbreaking study will examine predictors of successful treatment in 100 consecutive patients admitted to ERC’s Residential and Partial Hospitalization program. The study will also look at how treatment impacts psychosocial variables, behavioral indices – such as binge eating intensity, frequency, and duration – and medical and health related outcomes. To learn more, click here.

An experimental investigation into the use of eye-contact in social interactions in women in the acute and recovered stages of anorexia nervosa. People with anorexia nervosa (AN) report significant difficulties in social functioning and a growing literature is beginning to explain some of the differences in social skills that might underlie the social challenges experienced by patients. One vital area of social functioning that has been largely neglected to date is how eye-contact is used in the context of social stimuli and in social situations. METHODS: This cross-sectional, experimental study used eye-tracking to measure the frequency and duration of eye-contact made with the eye region of interest (ROI) of (1) static social stimuli (man and woman Ekman faces displaying basic emotions); (2) moving social stimuli (a video of two actors conversing); and (3) during a real-life social interaction in 75 women (25 with AN, 25 recovered from AN, and 25 non-AN controls; mean age = 27.18, SD = 6.19). RESULTS: Participants showed greater eye-contact during a real-life social interaction than when viewing static social stimuli. Those with AN made contact with the eye ROI of the static and moving social stimuli and during a real-life social interaction significantly less often and for significantly less time than non-AN controls. Those recovered from AN showed greater eye-contact than the acute group but significantly less eye-contact with the eye ROI across the static and moving social stimuli and during the real-life social interaction than non-AN controls. DISCUSSION: These findings contribute new knowledge regarding the types of social skills that people with AN may need additional support with to allow them to make greater use of social support in their recovery. Int J Eat Disord. 2018 Dec 22. doi: 10.1002/eat.22993. [Epub ahead of print]

Large-scale genomic studies of anorexia and bulimia are turning up clues about the conditions’ development and persistence. Find the links here:

The University of Chicago's Eating Disorders Program (PI: Dr. Jennifer Wildes) is looking for adolescent girls aged 12-19 for a research study being conducted to better understand relations between biological measures, cognitive function, and eating problems in adolescent girls. The study includes interviews, questionnaires, behavioral tasks, an MRI brain scan, and a blood draw. Individuals may be eligible to participate if… They are female. They are between the ages of 12 and 19 years old. They are currently restricting the amount of food they eat. The study will occur across at least 2 study visits at the University of Chicago in Hyde Park. Participants can receive $150 for taking part in study activities. For more information, please call (773) 834-0362 or email

Differential diagnosis of eating disorders. The clinical symptoms of eating disorders can mimic those of other chronic diseases including gastrointestinal and endocrine disorders making the diagnosis and management of both conditions challenging. The review listed below describes what is known about eating disorders in adolescents with chronic gastrointestinal and endocrine diseases, focusing on celiac disease, inflammatory bowel disease, diabetes, and thyroid disorders. Click on the link for more:  (purchase required for the full article)

Current Research and News 3/2019

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Changes in eating disorder characteristics over the years. Since 1980, the diagnostic criteria of patients with eating disorders (ED) have changed over the years. Are these changes also expressed in the clinical features of the ED patients? A cross-sectional sample was drawn consisting of 100 consecutive female patients' files diagnosed with anorexia nervosa (AN) and bulimia nervosa (BN) and bulimia nervosa and admitted at an inpatient unit from the first of January 1990, 2000, and 2010, respectively. Several reliable and well-validated questionnaires (Eating Disorder Inventory, Body Attitude Test, Symptom Checklist, and the Beck Depression Inventory) were administered and scores were compared. The ratio AN/BN remained the same (65/35). No differences were found between the three cohorts except for depression, which increased over the years. This pattern is the same for the subsamples of anorexia nervosa and bulimia nervosa. Specific characteristics of eating disorder pathology did not change across time. Eur Eat Disord Rev. 2018 Sep;26(5):417-421. doi: 10.1002/erv.2603. Epub 2018 May 17.

Treatment of Anorexia Nervosa-New Evidence-Based Guidelines. Evidence-based practice guidelines aim to support all groups involved in the care of patients with anorexia nervosa by providing them with scientifically sound recommendations regarding diagnosis and treatment. The German S3-guideline for eating disorders has been recently revised. In this paper, the new guideline is presented and changes, in comparison with the original guideline published in 2011, are discussed. Further, the German guideline is compared to current international evidence-based guidelines for eating disorders. Many of the treatment recommendations made in the revised German guideline are consistent with existing international treatment guidelines. Although the available evidence has significantly improved in quality and amount since the original German guideline publication in 2011, further research investigating eating disorders in general, and specifically anorexia nervosa, is still needed. J Clin Med. 2019 Jan 29;8(2). pii: E153. doi: 10.3390/jcm8020153. Read the full article here:

A new study has found that a persistent low body mass index (BMI) in children, starting as young as age 2 for boys and 4 for girls, may be a risk factor for the development of anorexia nervosa in adolescence…see below.

Developmental Premorbid Body Mass Index Trajectories of Adolescents With Eating Disorders in a Longitudinal Population Cohort. Objective: To examine whether childhood body mass index (BMI) trajectories are prospectively associated with later eating disorder (ED) diagnoses. Method: Using a subsample from the Avon Longitudinal Study of Parents and Children (N = 1,502), random-coefficient growth models were used to compare premorbid BMI trajectories of individuals who later developed anorexia nervosa (n = 243), bulimia nervosa (n = 69), binge-eating disorder (n = 114), and purging disorder (n = 133) and a control group without EDs or ED symptoms (n = 966). BMI was tracked longitudinally from birth to 12.5 years of age and EDs were assessed at 14, 16, and 18 years of age. Results: Distinct developmental trajectories emerged for EDs at a young age. The average growth trajectory for individuals with later anorexia nervosa veered significantly below that of the control group before 4 years of age for girls and 2 years for boys. BMI trajectories were higher than the control trajectory for all other ED groups. Specifically, the mean bulimia nervosa trajectory veered significantly above that of controls at 2 years for girls, but boys with later bulimia nervosa did not exhibit higher BMIs. The mean binge-eating disorder and purging disorder trajectories significantly diverged from the control trajectory at no older than 6 years for girls and boys. Conclusion: Premorbid metabolic factors and weight could be relevant to the etiology of ED. In anorexia nervosa, premorbid low weight could represent a key biological risk factor or early manifestation of an emerging disease process. Observing children whose BMI trajectories persistently and significantly deviate from age norms for signs and symptoms of ED could assist the identification of high-risk individuals. Journal of the American Academy of Child and Adolescent Psychiatry, February 2019 Volume 58, Issue 2, Pages 191–199 Read the full text here:

Children with avoidant/restrictive food intake disorder and anorexia nervosa in a tertiary care pediatric eating disorder program: A comparative study. The purpose of this study was to examine the medical and psychological characteristics of children under the age of 13 years with avoidant restrictive food intake disorder (ARFID) and anorexia nervosa (AN) from a Canadian tertiary care pediatric eating disorders program. Method: Participants included 106 children assessed between 2013 and 2017 using the Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM-5). Data were collected through clinical interviews, psychometric questionnaires, and chart review. Information collected included medical variables (e.g., weight, heart rate, need for inpatient admission, and duration of illness from symptom onset); medical comorbidities (e.g., history of food allergies, infection, and abdominal pain preceding the eating disorder); and psychological variables (e.g., psychiatric comorbidity, self-reported depression and anxiety, and eating disorder related behaviors and cognitions). Results: Children with ARFID had a longer length of illness, while those with AN had lower heart rates and were more likely to be admitted as inpatients. Children with ARFID had a history of abdominal pain and infections preceding their diagnoses and were more likely to be diagnosed with a comorbid anxiety disorder. Children with AN had a higher drive for thinness, lower self-esteem, and scored higher on depression. Discussion: This is the first study to look at DSM-5 diagnosis at assessment and include psychometric and interview data with younger children with AN and ARFID. Understanding the medical and psychological profiles of children with AN and ARFID can result in a more timely and accurate diagnosis of eating disorders in younger children. Int J Eat Disord. 2019 Feb 1. doi: 10.1002/eat.23027. [Epub ahead of print]

Long-term outcome and psychiatric comorbidity of adolescent-onset anorexia nervosa. To assess the outcome of adolescents with anorexia nervosa (AN) about 20 years after first treatment. Methods: Sixty-two women diagnosed with AN during adolescence were invited to participate. Of these 62 patients, 38 agreed to participate and were assessed with a battery of questionnaires and interviews. A control group of 30 women of similar age was also assessed. Results: Of the patients who completed the full assessment, 13 (34%) presented some degree of eating disorder (ED) at follow-up (10 (26%) met full Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for an ED and 3 (8%) showed partial remission of an ED). The remaining 25 (66%) patients had fully recovered from AN. The duration of untreated illness before admission was significantly associated with an increased risk of a current ED (odds ratio (OR) = 3.334 (1.3-8.7); p = .014). Of the patients who had recovered totally from their ED, 24% showed another psychiatric disorder. This percentage rose to 70% in patients with a current ED. Conclusion: Sixty-six percent of adolescents who completed the assessment achieved remission of their AN. Comorbidity was more common in the current ED group. The variable that best predicted complete remission was the number of years without treatment, showing the importance of detection and early intervention. Clin Child Psychol Psychiatry. 2019 Feb 15:1359104519827629. doi: 10.1177/1359104519827629.

How Genetic Variation May Impact Antidepressant Efficacy in Eating Disorder Treatment

Understanding the role of dietary deficiencies and genetic factors on the efficacy of medication can be an effective tool when treatment planning with patients and families.
Incorporating information about individualized genetics as part of a larger conversation about medication trials or compliance may be useful for some patients and their treatment allies, including in confronting treatment resistance and limiting time spent pursuing treatment strategies with poor or limited evidence for success.
Also, patients’ belief of themselves as having “treatment-resistant depression” or being “non-responders” to medications may be compassionately challenged if they understand, biologically, why previous trials were not expected to be successful, and that future trials could be.
In concert with nutritional and psychotherapies, many eating disorders patients referred to an inpatient level of care utilize antidepressant medications in an effort to alleviate symptoms. The majority of antidepressant medications rely on monoamine presence in the brain, either serotonin, as in “selective serotonin reuptake inhibitors” (SSRIs), or serotonin and norepinephrine, as in “serotonin-norepinephrine reuptake inhibitors” (SNRIs), or similar mechanisms.
Norepinephrine action also indicates dopamine reuptake in the prefrontal cortex of the brain, which is the third monoamine action, though not often mentioned in the medication titles. With the best intentions, families and sufferers may seek relief of depression, anxiety and OCD symptoms with these otherwise recommended and effective medications. Without exception, however, every antidepressant medication trial in malnourished eating disorder patient populations shows these medications are no more effective than placebo. Below are factors that contribute to this phenomenon.
From here forward, monoamines will refer to serotonin, norepinephrine, and dopamine unless stated individually. Proteins from nutritional intake are processed in the human body through a series of mechanisms that lead to the production of monoamines. This is a complex process, with many contributing factors, such as folic acid, tryptophan or tyrosine, gonadal steroid levels, and individualized genetic considerations.
It is well established that common eating disorder behaviors, including food restriction, purging, and excessive exercise, impact nutrient availability in the body. Sustained starvation or significant purging would limit both proteins and vitamins, and excessive exercise would drive the body to use those resources for other purposes.
These nutritional deficits lead to a diminished capacity to produce monoamines. For example, excluding proteins rich in tyrosine and tryptophan would limit the basic building blocks for monoamine production.
Folate, which is the naturally occurring form of folic acid found in leafy vegetables, legumes, and fruits, is also an integral part of monoamine synthesis. Cereals and breads are often fortified with synthetic folate (folic acid). Folate is metabolized by the body into L-methylfolate, which is one of several critical components of neurotransmitter production. If L-methylfolate is deficient, monoamine synthesis is reduced.

Folic Acid & Genetics

Being human involves myriad and mysterious quirks, among them, the occurrences of genetic variations, termed polymorphisms, in the general population. There are several widespread polymorphisms which can impact an individual’s ability to metabolize folate or folic acid into L-methylfolate naturally. One particular polymorphism, at MTHFR (methylenetetrahydrofolate reductase), is becoming increasingly well known, accessible for testing and extremely relevant to this discussion.
Approximately sixty percent of the general population has at least one polymorphism at this site reducing the synthesis of L-methylfolate, and thirty percent has both polymorphisms at the foci, significantly impacting L-methylfolate synthesis.
Therefore, eating disorders suffers from the MTHFR gene polymorphism can compound their genetic L-methylfolate deficit (and therefore their monoamine deficit) significantly through nutritional restriction.


Clinicians, sufferers and treatment allies may consider whether testing for the common polymorphism is worthwhile and worth the potential expense. L-methylfolate augmentation in sufferers with known MTHFR polymorphyisms may significantly improve medication efficacy in those with a history of “failed” medication trials or family history of poor response to medications if genetic factors limited response. However, in eating disorder patients, even with recognition and appropriate treatment of the genetic considerations, it remains clear that nutritional restoration remains the gold standard for optimal response to medications to be possible.

1. Corrina P. Ferguson, et al; Are Serotonin Selective Reuptake Inhibitors Effective in Underweight Anorexia Nervosa; Int J Eat Disord 25: 11-17, 1999.
2. Tanaka, T et al; Genome-wide Association Study of Vitamin B6, Vitamin B12, Folate and Homocysteine Blood Concentrations; The American Journal of Human Genetics 84, 477-482, April 10, 2009; Fava M, et al Folate in Depression: Efficacy, Safety and Differences in Formulations, and Clinical Issues, Journal of Clinical Psychiatry 2009; 70 (suppl 5):12-17; Stahl, S.M., Stahl’s Essential Psychopharmacology; neuroscientific basis and practical application, 4th edition; 2013, p. 347 – 348
3. Stahl, S.M., Stahl’s Essential Psychopharmacology; neuroscientific basis and practical application, 4th edition; 2013, p. 347 – 349

About the Author:
Katherine Godwin, M.D., has served as medical director and attending physician of the Laureate adult eating disorders program since 2010. She joined the program as medical director of outpatient services in 2008 and was the medical director of Laureate’s independent living program for outpatient eating disorder care, Magnolia House, from 2007-2010. She has practiced at Laureate since 2005.
Dr. Godwin is board certified by the American Board of Psychiatry and Neurology She received her medical degree from Creighton University in Omaha, Nebraska, and completed her residency in psychiatry at the University of California, San Diego where she served as chief resident.
Katherine Godwin, M.D., shares her expertise locally and nationally about psychopharmacologic considerations with eating disorders. Dr. Godwin is an advocate for patients and their families. She encourages her patients to participate actively in treatment and to work together with their care team for optimal symptom management.