Different Approaches to Weighing Patients

Vol. 30 / No. 4 — Eating Disorders Review

Patient wishes overruled established treatment guidelines.

A recent study sought to uncover reasons that clinicians regularly fail to weigh patients appropriately during cognitive-behavioral therapy (CBT) for eating disorders. Drs. A. Daglish and G. Waller of Sheffield University, Sheffield, UK [see also article on abbreviated CBT elsewhere in this issue] evaluated patient- and clinician-based reasons this occurs (Int J Eat Disord.2019. June 7. doi:101002/eat.23096 [epub ahead of print]).

After surveying 74 clinicians who practice CBT, using case vignettes that varied in patient diagnosis and distress levels, the two researchers found that clinicians were more likely to weigh patients with anorexia nervosa than to weigh patients with bulimia nervosa, but less likely to weigh those who were distressed at the idea of being weighed.

Clinicians who thought weighing was helpful were more likely to do so. The authors note that their recruitment strategy may have tended to attract participants already predisposed to weighing.  Moreover, it seems possible that such a survey might bias reporting toward what is perceived to be best (rather than actual) practice. In each case, actual rates of weighing could be lower than described. The authors suggest these findings call for enhanced training and supervision around the benefits of open weighing of people in eating disorders treatment.

Peer Mentoring Program Yields Positive Results

Vol. 30 / No. 4 — Eating Disorders Review

A pilot program in Australia helped both mentors and mentees.

A “mentor” is someone who teaches or gives help and advice to a less experienced and often younger person. This very modern word goes back to the ancient Greeks and to a character, Mentor, a trusted friend and advisor to Odysseus in Homer’sOdyssey. This concept has reached across the ages and now is found in most specialties, particularly education and social work. A pilot study in Australia recently evaluated a peer mentor program for “mentors,” persons recovered from an eating disorder, and “mentees,” individuals who currently had an eating disorder (J Eat Disord. 2019. doi: org/10.1186/s40337-019-0245-3).

In this pilot study, Dr. Jennifer Beveridge and co-workers at Swinburne University of Technology, Hawthorne, Australia, and St. Vincent’s Hospital, Melbourne, Australia, recruited 30 mentees and 17 mentors for a peer mentoring program. The mentors were all recovered from an eating disorder for at least a year, and for study purposes were staff members at St. Vincent’s Hospital, employed specifically for the program.  Mentees had current eating disorders, and had actively transitioned out of an inpatient treatment program but remained in outpatient treatment for their eating disorder.

The program consisted of 13 sessions given over 6 months. The participants completed the EDE-Q and measures of quality of life, mood, and perceived levels of disability. Semi-structured interviews were conducted for qualitative evaluation of the overall program. An individualized Wellness Plan was designed for each participant.  The mentors all attended separate bimonthly group supervision sessions, where the participants received further education, including training, and peer support.

Thirty participants (28 females and 2 males) agreed to participate in the study. The mentees ranged in age from 18 to 50 years (median age: 28 years). Most mentees (28)  had diagnoses of anorexia nervosa, 1 was diagnosed with bulimia nervosa, and 1 had other specific feeding or eating disorder (OSFED).Eight withdrew during the study, due to need for overseas travel, moving, returning home to a regional area after treatment, and lack of motivation to continue with the program.

Improvements noted at the end of the study

Over the time of the study, the mentees increased their body mass index (BMI, mg/kg2), in contrast to the typical weight loss reported after discharge from treatment. They also had improvements in eating disorders symptoms over the course of the study, including improved mood, less disability, and improved quality of life.

Overall, the mentoring relationship was a positive experience for both mentees and mentors. The mentees reported feeling inspired by their mentors, and that the sessions were much more relaxed and nonjudgmental than treatment sessions. However, the mentors themselves had increases in the EDE-Q Global Eating Concern and Shape Concern scores, though none reached the pathologic range.  Dr. Beveridge reported, “Qualitative results highlighted that the mentoring relationship was a positive experience for both mentees and mentors, instilling an increased hope for recovery in mentees and an opportunity for mentors to reflect on their own recovery with increased confidence.”

This strategy has been shown to be helpful in mood disorders and although results were mixed, deserves further attention for EDs as well.

Eating Disorders Treatment and Concomitant Substance Use among Teens

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The combination can affect completion of outpatient treatment.

Chemical dependency and eating disorders commonly co-occur. This produces many challenges; for example, ED programs tend to be uncomfortable with clients with addiction, and addiction programs are often uncomfortable dealing with clients with eating disorders. It appears that treating one problem at a time does not work optimally.

A 2015 study published in the journal Psychiatry Researchfound that more than 13% of female patients with bulimia also had a substance use disorder. About one-third of men and 7% of women diagnosed with the binge-eating/purging type of anorexia met the criteria for alcohol dependence.

Adolescent patients with substance abuse and eating disorders have different characteristics and are more likely to drop out early from eating disorder treatment, according to a team of researchers from Montreal. Dr. Ryan Kirkpatrick and psychologist Linda Booij, associate professor of psychology at Concordia University, Montreal, and their colleagues investigated whether teens with eating disorders who used substances responded better to outpatient treatment compared to teens with eating disorders who did not use substances (Int J Eat Disord. 2019. Doi:10.1002/eat.23017 [E-pub before print].

Dr. Kirkpatrick and colleagues specifically wanted to study teens who used drugs, tobacco, or alcohol socially (off and on), without developing addictions or showing problematic behavior. One goal was identifying teens at greater risk of dropping out of treatment or those who might need a more specific form of treatment. The study group included about 200 teens who received outpatient treatment at Hotel Dieu Hospital at the Kingston Health Sciences Center, Montreal.

Heeding warning signs that can improve outcome

As previously described in the literature, teens who used substances were more likely to have bulimia nervosa or binge/purge type anorexia nervosa. They also reported that teenagers who used substances before entering treatment regularly used more self-harming behaviors, like cutting, and displayed more impulsivity.  However, the two groups showed similar severity of eating disorders. As noted earlier, dropout was higher in the substance use group.

These findings might help clinicians be more alert to the possibility that a teen with substance use is more likely to drop out of treatment early. More broadly, the results raise the issue of refining eating disorders treatment to improve their fit for people with co-occurring EDs and substance disorders.

Ten-Session CBT Proposed

Vol. 30 / No. 4 — Eating Disorders Review

A shorter period of CBT might reduce costs and make treatment available to more patients.

During a plenary session at the 2019 ICED meeting in New York in March, Glenn Waller, DPhil, of the Department of Psychology at the University of Sheffield, Sheffield, UK, described a 10-session cognitive behavioral therapy (CBT-T) program that he and his  colleagues have recently developed.

Dr. Waller pointed to the ICED conference theme, “Start Spreading the News,” and asked where the news is coming from and where is it going. “We should be listening,” he said.  “We have effective but not perfect therapies; these could be better,” he added. Dr. Waller and colleagues have developed a shortened form of CBT that is showing early promise. He added some key (and perhaps provocative) points contrasting traditional psychotherapy and CBT-T:

1. More therapy does not make for a better outcome, according to Dr. Waller. He said, “Typically, if we do wait for patients to spring into action in bulimia nervosa, the number of sessions is usually a mean of 45. This is twice the recommended number of sessions.”
2. Manuals improve outcomes but many clinicians don’t even pick them up; “we still rely on osmosis,” he said.
3. Therapists don’t need specific training for a specific disorder.
4. Most therapists are over-trained for what they do.
5. If he had his choice, Dr. Waller said, he would develop treatment models that don’t rely on over-trained, overly expensive therapists. More therapy doesn’t make for better outcomes, he added.

Dr. Waller said that CBT-T began as a result of many frustrations, especially from poor attention to patient outcomes.  One of the questions his group and others have had to face was how to get patients into therapy quickly and effectively. A faster turnover was needed to deal with resource limitations, where lengthy waiting lists keep people from receiving needed treatment.

To test the efficacy of CBT-T, Dr. Waller and colleagues recently treated 93 non-underweight adult eating disorder patients. These patients received a protocolized 10-session program of CBT, which was delivered by clinical assistants, under supervision (Int J Eat Disord. 2018; 51:262).  By the end of their therapy 31% of the patients had dropped out. Statistically significant changes in EDE-Q Global and subscale scores as well as ED behaviors were seen at the end of treatment and at a three-month follow-up.  The authors note the magnitude of change was in the range seen in studies of more traditional CBT approaches. (More recently, Pellizer, Waller, and Wade [Eur ED Rev,2019, epub ahead of publication] reported a second trial of 52 individuals treated by 6 different trainees, with similarly encouraging results.)

Dr. Waller and his colleagues were pleased to find that the shorter-term CBT showed similar efficacy as that reported in larger, separate studies of longer-term therapy, and it could mean reduced patient costs and improved access to care. He added, “We initially thought that shorter treatment would not be as effective, but patient experiences were generally very good. Briefer therapy can work just as well as longer therapy. Now we have to transmit the news: we as clinicians can be more treatment-resistant than patients are, and we need to spread the news to patients and others that briefer treatment is better.”

These results should prompt discussion and perhaps reconsideration of treatment models for eating disorders. Can some therapies be shorter? Which individuals might benefit, and which need longer treatment?  And, finally, while short-term outcomes are encouraging, is long-term outcome similarly positive?

Early Results of an Online Screening for Eating Disorders

Vol. 30 / No. 4 — Eating Disorders Review

The National Eating Disorders Association online program reveals a treatment gap.

Two years ago, a group of clinicians working with the National Eating Disorders Association (NEDA), headquartered in New York City, developed an online screener to examine the possibility of eating disorder diagnosis and risk among adult respondents. Such an online screener might raise awareness about EDs, and more people might seek treatment as a result. The clinicians recently reported their preliminary results (Int J Eat Disord. 2019. 52:721).

Dr. E.E. Fitzsimmons-Craft at the Washington University School of Medicine, St. Louis, MO, and colleagues at numerous institutions, analyzed the results from 71,362 adults who completed the Stanford-Washington University Screen on the NEDA website over 6 months in 2017. The profile of the respondents was: 91% female; 7.7% between the ages of 18 to 24 years; 89.6% non-Hispanic; and 84.7% White.  Remarkably, 86% screened positive for an ED. Additionally, 10.2% were screened as being at high risk for developing an eating disorder and 85.9% had never received treatment. Only 3% were currently in treatment, and another 11% had been treated in the past.

The authors believe that the NEDA screening tool may be an important and helpful way to detect eating disorders in the general community, citing the fact that more than 71,000 adults responded over only 6 months.  The screen readily identifies large numbers of people who appear to have eating disorders. Most striking is the finding that most were not receiving (or never had received) treatment.  This underscores the importance of past work emphasizing that improving treatment utilization will have a more positive impact than increasing treatment effectiveness (Moessner and Bauer, 2017; 50:1378). [The results may also indicate that the screening may confirm the visitor’s suspicions that they have an eating disorder and thus help move them one step closer to treatment.]

Anorexia Nervosa 30 Years after the Diagnosis

Vol. 30 / No. 4 — Eating Disorders Review

Some unexpected results occurred.

In 1985, a long-term study of Swedish adolescents was begun in Gothenburg, Sweden. First, every eighth grader (4291 students born in 1970) was screened for anorexia nervosa (AN). This uncovered 254 teens with the disease, to be included in a long-term study.  An additional 27 adolescents with anorexia who were born in the early 1970s were added to the study. The final study group included 51 patients with AN and 51 healthy gender-matched controls, bringing the total number of participants to 102.

Follow-up has been done every 10 years (the last at the 30-year mark), and the researchers were able to include all but 4 of the original group in the follow-up, for a 96% rate.  Sandra Rydberg Dubros and colleagues noted that the outcome might be more favorable due to the fact that teens only were included and half the sample came from the general community (Br J Psychiatry.doi.org/10.1192/bpj.2019.11).

Results: Age and perfectionism played a role

There were no deaths, but as for full recovery, the outcome was the same as that reported in earlier long-term studies.  Seventy-six of the original 102 patients had fully recovered. During the elapsed 30 years, participants had an eating disorder for 10 years, on average, and 23% did not receive psychiatric treatment. Good outcome was predicted by later age at onset among individuals with adolescent-onset eating disorders and premorbid perfectionism.

At an earlier follow-up point 18 years after the study was begun, 6 of the 51 participants with AN still had their eating disorder.   Twelve years later, the researchers were very surprised to learn that the percentage of those with eating disorders had modestly risen, not fallen, as expected.  The outcome was more favorable than most clinicians would expect, perhaps due to the non-clinical portion of the sample.

Managing Low Bone Mineral Density in Adolescents with Eating Disorders: A Review of Pathophysiology, Diagnostic Modalities, and Treatment

Vol. 30 / No. 4 — Eating Disorders Review

Erin Knopf, MD and Philip S. Mehler, MDEating Recovery Center, Denver, Colorado

Medical complications are frequently seen in patients with anorexia nervosa (AN) and bulimia nervosa (BN).1 Loss of bone mineral density (BMD), though not often the initial focus of eating disorder treatment, can persist long after apparent recovery from AN. It is a well-established consequence of poor nutritional intake, and is particularly concerning for the developing bodies of adolescent patients. Adolescence is a critical time for bone development, because 40% to 60% of peak bone mass accrues during these years.2 Unfortunately, the peak age of onset for AN also occurs during adolescence. The time of onset, type and duration of the eating disorder, as well as the degree of nutritional deficit, will determine whether peak adult bone mass can be achieved.

Since low bone density is most often associated with AN, BN is not considered a risk factor.1 If bone accrual is interrupted by the malnutrition associated with AN, life-long adverse sequelae to bone health can occur. These include long-term increased risk of fractures, osteoporosis, and limited longitudinal growth, impairing eventual height. Although osteoporosis is considered an adult disease, there is increasing evidence that factors in childhood contribute to its development and morbidity in adulthood.3

Osteoporosis is defined as a “reduction in bone mass and disruption of bone architecture, resulting in reduced bone strength and increase of bone fractures.”4 Osteopenia is also defined as reduced bone mass, but this is less severe than in osteoporosis.  Among adults, the type of bone density is determined by bone densitometry, defined by a T-score of -1 to -2.5 for osteopenia, and -2.5 or lower for osteoporosis.5 However, these definitions are not applicable to adolescent and pediatric populations. According to a systematic review of bone health in AN, there is a paucity of available data regarding bone health and prevalence of poor bone health in adolescents.2

Pathophysiology of Low Bone Marrow Density

Bone is dynamic, with ongoing formation of new bone as well as continuing resorption of existing bone. In AN, malnutrition leads to an uncoupling of bone formation and bone resorption. Thus, high rates of bone resorption with decreased bone formation lead to rapid bone loss, potentially resulting in osteopenia and osteoporosis.1 This is secondary to disruption of hormonal levels and regulatory processes of the hypothalamic-pituitary-adrenal (HPA) axis and hypothalamic-pituitary-gonadal (HPG) axis. Severe malnutrition causes an adaptive state of hypercortisolemia. High cortisol levels directly inhibit the HPG axis, impair calcium absorption and renal processing of calcium, inhibit osteoprotegerin (OPG) secretion, which normally inhibits bone reabsorbing osteoclasts, and increases the receptor activator of nuclear factor kappa B ligand  (RANKL), which also increases osteoclast activity.2 Furthermore, the states of low energy and hypercortisolemia both have an inhibitory effect on the HPG axis, leading to a hypogonadal state, which is characterized by low estrogen levels and amenorrhea.

Estrogen normally inhibits bone resorption by blocking secretion of inflammatory cytokines and RANKL. In males, low testosterone levels similarly have an adverse effect on bone density.2  Pubertal changes and growth during adolescence are directly dependent on rising levels of sex hormones, which in turn stimulate increased secretion of growth hormone (GH) and insulin-like growth factor (IGF-1). GH and IGF-1 are essential for bone accrual. In patients with AN, studies show a state of GH resistance.2 This in turn leads to further decreased bone formation. IGF-1 levels are thus reduced in AN, which inhibits osteoblast bone-forming activity.1 

Diagnostic Imaging in Adolescents

The preferred method for assessing the state of bone health in AN is with dual-energy x-ray absorptiometry (DXA) scans. This provides an image of two-dimensional areal bone mineral density (aBMD) and bone mineral content (BMC). Any individual with a 9- to 12-month history of AN should have a DXA scan, with follow-up every 2 years while their eating disorder is active.1 Appropriate interpretation of these values in adolescents relies on the use of Z-scores, as opposed to T-scores, which represent standard adult reference points for older patients.  DXA scans are seen as the preferred screening method because of their relatively low cost, low degree of radiation exposure, and widespread availability.

Adolescent Data Review

Several studies have demonstrated increased fracture risk in adults with AN, but few have focused on fracture risk in adolescents. Faje et.al (2014) were the first to examine the risk of childhood and adolescent fractures. The authors compared the risk among 310 patients with AN compared to normal-weight controls. The average age of the subjects was 16 years, with a mean duration of AN of almost 2 years.  Faje et al. found increased fracture prevalence and lower aBMD in those with AN compared to controls.6 Though a single aBMD may not be enough to extrapolate the fracture risk for a patient with AN, the overall increased fracture risk in patients with AN seems to be related to bone strength and accrual disruptions in adolescents.  Shepherd et al. (2018) found that bones are 10% smaller in adolescents with AN compared to healthy children. Their retrospective study of 111 patients under the age of 20 was the first to examine bone accrual in relation to linear growth.7

One study analyzed limitations of aBMD as a focal measurement of bone health. Singhal et al. (2018) conducted the first study to evaluate both bone microarchitecture and strength with high-resolution peripheral quantitative computed tomography (pQCT). The authors found that microarchitectural changes in the bone may precede measurable deficits in aBMD in females with AN.8 Their results further illustrate that aBMD does not fully capture all the detrimental effects of malnutrition affecting the bone, especially in younger patients. They also found  that adolescents and young adults with AN had thinner and more porous cortices, lower trabecular bone volume fraction with lower trabecular number and spacing, and higher levels of marrow adipose tissue. Higher levels of marrow adipose tissue have previously been associated with greater fracture risks.8 

Treatment Recommendations

Weight restoration remains the primary goal of treatment for AN.2 Present data supports that negative energy states increase bone resorption independent of other hormonal influences.9 Therefore, normalization of nutritional intake and weight gain are the upmost priorities for treatment of an adolescent with AN, and are necessary to stave off further bone mineral loss. Beyond weight restoration, other treatments to improve BMD in adolescents are somewhat controversial.

There are some other potential treatments that may be considered. Physical activity is generally viewed as being protective of bone health in older, normal-weight individuals. Current evidence, however, has not been able to substantiate such a protective effect in the context of the low-energy state and amenorrhea that characterize AN.2  Caution is often recommended,  with risk/benefit consideration, before allowing aerobic physical activity in patients with AN. Exercise can interfere with the primary goal of weight restoration, and may be deleterious to bone microarchitecture at low body weights.10  DiVasta et al. (2016) examined whether low-magnitude mechanical stimulation (LMMS) contributes to normalization of bone turnover. Noting that bed rest is often required for critically ill patients with AN, the authors wondered if the suppression of bone turnover associated with bed rest could be attenuated by LMMS. In their randomized, double-blind, placebo-controlled trial, 100 females aged 13-21, admitted to the hospital with medical complications of AN, were assigned to one of two groups: (1) an LMMS platform or (2) a placebo platform. The LMMS platform delivered small vibrations, and the placebo platform made an identical noise but did not vibrate.

DiVasta and colleagues found that participants assigned to the LMMS platform had stabilization in markers of bone formation without adverse effects on weight restoration. In contrast, those who used the placebo platform exhibited significant decreases in bone formation markers.10 These findings indicate that LMMS may be a safe, noninvasive, non-pharmacologic method to maintain bone health.

Pharmacologic treatment is often used in adult populations for low BMD, but limited data exist for adolescent patients with eating disorders. Hormonal replacement is incorrectly recommended as a means of preventing bone resorption associated with the hypogonadal condition seen in eating disorders. Often, bone loss in AN is inaccurately compared to the osteoporosis of postmenopausal women. A recent study found that the bone loss in AN evolves as a result of different pathophysiological mechanisms. In this study, a comparison of bone microarchitectures using high-resolution pQCT of young AN patients, postmenopausal subjects, and controls found that the reduction of trabeculae is rapid in AN and comparable to that in postmenopausal women, but the cortical and subcortical  bones were less compromised in AN.11 Additionally, great caution is imperative when discussing hormonal replacement in adolescents since increased hormone levels (estrogen and testosterone) can lead to premature closure of growth plates. Overall, a systematic review by Robinson et al. (2017) found discrepancies in outcomes when exogenous hormone replacement was used. The review noted one study that found physiologic replacement doses of transdermal 17-bestradiol increased spinal and hip BMD in adolescent women with AN, although “complete ‘catch-up’ to a comparable BMD in health controls did not occur.12 Physiologic estrogen replacement achieved by transdermal administration does improve BMD in adolescents with AN, though weight gain appears to improve BMD more.9 A number of studies have suggested that the use of estrogen/progesterone combination oral contraceptives has been ineffective and could also be detrimental to bone health, due to suppression of endogenous gonadal secretions as well as suppression of systemic IGF-1 secretion.9 In contrast, the “physiologic” doses achieved through transdermal application may be effective because this does not suppress IGF-1 and it avoids hepatic first-pass metabolism. According to the American College of Obstetricians and Gynecologists, the combination of transdermal estradiol and cyclic oral progesterone for sexually active adolescents, to treat loss of BMD, is not effective for preventing pregnancy. 13

Bisphosphonates are also used in adult women with AN  to treat their osteoporosis but there are few studies of bisphosphonate use in adolescents with AN. Golden et al. (2005) conducted a double-blind, randomized trial comparing alendronate with placebo in 32 adolescent females. They found that in the treatment group, there was a positive independent effect on BMD, increasing it at the femoral neck and lumbar spine. However, the authors concluded that weight restoration remained the most important determinant of BMD and recommended that until additional studies could demonstrate efficacy, the use of bisphosphonates should be limited to controlled trials.14 The adverse side effects associated with bisphosphonates limit their use in adolescent females.12Bisphosphonates have a long half-life and can be released slowly from bone over a period of years.2 There is also a teratogenic risk, which is important to consider. 12 Yet, it is interesting to note that bisphosphonates have been used for years in adolescent patients with osteogenesis imperfecta without reports of significant adverse effects.1  There are, as yet, no studies of teriparatide or denosumab in adolescent patients with AN.

Conclusion

There are some notable limitations in reviewing currently available data for adolescents. First, there are more available data regarding medical complications in adults than in adolescents. Of the studies that did focus on adolescent populations, most were retrospective in nature and only evaluated female patients with AN. There are very little data on adolescent males with AN. Additionally, there are other limitations when conceptualizing and defining BMD abnormalities in children and adolescents. One interesting point is that the International Society of Clinical Densitometry (ISCD) recommends that the term “osteopenia” be limited to adult patients with mild deficits in bone mass. In fact, a DEXA Z-score of £-2 is labeled as “below the expected range for age” for adolescents (Misra et al., 2015, p. 3).  The Pediatric Position Development Conference (PDC), a subgroup of the ISCD, limits diagnoses of osteoporosis in children and adolescents by requiring a BMD Z-score of £-2 and at least one vertebral compression fracture or the presence of a significant fracture history (fractures of two or more long bones by the age of 10 years or three or more long bone fractures at any age up to 19 years). The DXA scan itself may not be as useful in adolescents and, as studies mentioned earlier have indicated, it will be important to consider microarchitecture in future studies that evaluate bone outcomes in AN.

Use of HR-pQCT may provide more accurate assessment of bone health, and may be more accurate in predicting prognosis as well as for reliably tracking outcomes throughout treatment. 8, 15All studies have commented on the need for more longitudinal data and for judicious deliberation before initiating medicinal treatments.  But, in the meantime, some assessment of the state of bone health in patients with a history of AN is a prudent practice and is the first step to initiate further treatment considerations, given the high prevalence of low BMD in adolescents with AN.

References

1. Mehler PS, Andersen AE. Eating Disorders: A Guide to Medical Care and Complications(3rd ed.). Baltimore, USA: Johns Hopkins University Press, 2017.
2. Misra M, Golden N H, Katzman DK. State of the art systematic review of bone disease in anorexia nervosa. International Journal of Eating Disorders.2015; 49(3), 276–292.
3. Steelman J, Zeitler P. Osteoporosis in pediatrics. Pediatrics in Review.2001;22(2), 56-65. doi:10.1542/pir.22-2-56
4. Masi L. Epidemiology of osteoporosis. Clinical Cases in Mineral and Bone Metabolism.2008; 5(1): 11-13
5. Karaguzel, G, Holick, M. (2010). Diagnosis and treatment of osteopenia. Reviews in Endocrine and Metabolic Disorder. 2010;11(4), 237-251.
6. Faje AT, Fazeli P K, Miller KK, et al. (2014). Fracture risk and areal bone mineral density in adolescent females with anorexia nervosa. International Journal of Eating Disorders.2014; 47(5), 458–466.
7. Shepherd S, Kyriakou A, Shaikh MG, et al. Longitudinal changes in bone parameters in young girls with anorexia nervosa. 2018; 116, 22–27.
8. Singhal V, Tulsiani S, Campoverde K J, et al. Impaired bone strength estimates at the distal tibia and its determinants in adolescents with anorexia nervosa. 2018;106, 61–68.
9. Swenne I, Stridsberg M. Bone metabolism in adolescent girls with eating disorders and weight loss: independent effects of weight change, insulin-like growth factor-1 and oestradiol. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity.2014; 20(1), 33–41.
10. DiVasta AD, Feldman HA, Rubin CT, et al. The ability of low-magnitude mechanical signals to normalize bone turnover in adolescents hospitalized for anorexia nervosa. Osteoporosis International.2016; 28(4), 1255–1263.
11. Milos G, Häuselmann H, Krieg M, et al. Are patterns of bone loss in anorexic and postmenopausal women similar? Preliminary results using high resolution peripheral computed tomography. 2014; 58, 146–150.
12. Robinson L, Aldridg, V, Clark E M, et al. (2017). Pharmacological treatment options for low bone mineral density and secondary osteoporosis in anorexia nervosa: a systematic review of the literature. Journal of Psychosomatic Research.2017; 98, 87–97.
13. ACOG Committee Opinion No. 702: Female Athlete Triad. (2017). Obstetrics & Gynecology.2017; 109 (6), 511-1516.
14. Golden NH, Iglesias EA, Jacobson MS. Alendronate for the treatment of osteopenia in anorexia nervosa: a randomized, double-blind, placebo-controlled trial. Journal of Clinical and Endocrinologic Metabolism.2005; 90(6):3179–3185.
15. Roggen I, Vanbesien J, Gies I, et al. Forearm bone mineralization in recently diagnosed female adolescents with a premenarchal onset of anorexia nervosa. International Journal of Eating Disorders, 2016; 49(8), 809–812.

3 Socio-cultural Factors to Consider When Working with Chinese-American Clients

3 Socio-cultural Factors to Consider When Working with Chinese-American Clients

By Stephanie Ng

While previous research on eating disorders and body image has mostly focused on the experiences of white women (Bordo, 2009), more and more studies have found that these issues are becoming increasingly common in Asian contexts (Pike & Dunne, 2015), as well as amongst Chinese individuals more specifically (Mak & Lai, 2011; Tam, Ng, Yu, & Young, 2007). However, despite the clear evidence that eating disorders and body image concerns have significant negative consequences, research on these issues in Asian individuals has been sparse or inconclusive. Furthermore, cultural stigma towards mental illness in Asian contexts may result in the underreporting of struggles, contributing to the illusion that these issues are not nearly as prevalent as they actually are, and thus resulting in a lack of research attention paid to individuals in Asian contexts, and a lack of understanding on cross-cultural differences in the expression of food and eating-related distress. As such, it is crucial for research to be conducted on the culturally specific risk factors and symptoms that may arise in this population, so that mental health practitioners can provide better care for these individuals. 

Having grown up in Hong Kong and having experienced an eating disorder in this cultural context, these issues are near and dear to my heart. From personal experience and from speaking to friends of mine who have also grown up in Chinese contexts, I have seen that many of us struggled with body image concerns that went untreated, or in some cases, completely undetected. With my personal and academic interest in this research area, I decided to explore how conflicting expectations regarding cultural eating norms and body image standards in Chinese cultural contexts affect emotional and behavioral outcomes of Chinese adolescent women as the topic of my senior honors thesis. 

Based on my findings and my personal experiences, I would like to bring attention to three key factors that practitioners should keep in mind when treating clients from Chinese contexts.  

1. Body dissatisfaction is not necessarily linked to a fear of weight gain

While body dissatisfaction in western samples have largely found it to be linked to a fear of weight gain, studies in Asian populations suggest that specific features and proportions of body parts may play a larger role in contributing to body dissatisfaction in these individuals (Brady et al., 2017). Cultural emphases on features and proportions in Chinese culture are evident in idioms that link morality with appearance (e.g., “a white complexion is powerful enough to hide seven faults”) and expressions that posit the possession of proportionate physical features as the most desirable, or even just what is considered ‘normal’ (e.g., the expression that describes a person with ‘correct’ or ‘regular’ features literally translates to “having all five senses in proportion”). Importantly, although this sense of dissatisfaction is not necessarily related to body weight, it was still found to contribute to disordered behaviors and attitudes in my thesis sample, including engagement in compulsive exercise, restrictive eating and plastic surgery, as well as feeling shame and guilt towards one’s body.

Moreover, due to the normativity of smaller bodies in Chinese contexts, as a result of factors such as genetic predisposition and traditional dietary habits, individuals in Chinese contexts may be subjected to even more stringent weight standards than women from other ethnic backgrounds. For instance, a number of women in my thesis sample noted that they were aware that they were by no means overweight, but that they were heavier than their friends or their past selves, and thus felt the need to lose weight to fit back into that normative range. Other studies have also found that stereotypes of thinness as the “norm” in Asian contexts exacerbate existing media pressures to be thin, as individuals in these contexts may feel that being thin is a necessary prerequisite to fit into their social groups (Liou & Bauer, 2010).

2. Accountability towards family members’ expectations may serve as an unhealthy source of pressure in Chinese clients. 

Filial piety, or respect towards elder members of the family, is of great importance in Chinese contexts. Even when the women in my sample reported being offended or hurt by the comments of their family members, they expressed that they ultimately still felt accountable to their expectations. In multiple instances, women were able to establish a sense of confidence in the short term, or when they were not with their family members (e.g., when they were studying abroad), but would be easily triggered by comments from family members when they came into contact with them again. As such, it appears to be particularly important for practitioners to help Chinese clients establish coping mechanisms for approaching family-related social gatherings, which may have strong implications for their continued progress in recovery.

Another important point to note is that inter-generational differences in perceptions of weight can be a significant source of stress in the lives of these clients. In past generations, the Chinese experienced numerous periods of poverty, famine and food shortages, resulting in the perception of larger and plumper body shapes as representative of health and wealth, and smaller body shapes as the
norm. Ironically, now that the present generation actuallyhas access to an abundance of food and more comfortable lifestyles, it is the thin body shape that is sought after as the representation of success and wellbeing. Older family members may struggle to understand and empathize with the difficulties of the current generation – specifically, that of dealing with actual physical changes in tandem with shifts in cultural connotations of weight gain – which may lead to them to make unintentionally hurtful comments.

As such, it is especially important for practitioners working with Chinese clients to examine emotions surrounding familial relationships and help these clients establish healthy boundaries with family members and/or include family members in therapy sessions so as to collaboratively work towards establishing healthier familial relationships.

3. Conditional acceptance of body weight/shape may be of particular concern in this population. 

As noted above, a number of women in my sample expressed that they were not currently dissatisfied with their weight, but were easily triggered by external factors, such as undergoing life events that prevented them from exercising strict control over their diet or physical activity (e.g., busy exam or work periods), or receiving body-related comments from family members. Although most of these women knew they were objectively not overweight by any means, or even acknowledged they were thin, they were frequently plagued by worries of gaining weight in the future.

Some might argue this conditional acceptance of body weight/shape is not a concern, as long as these women are satisfied with their bodies in the present. I argue, however, that this phenomenon is particularly concerning. First, it means that these women are ill-equipped to deal with the inevitable fluctuations in weight that they will face in life, whether these are due to life circumstances (e.g., school or work-related stress), natural ageing processes or major life events (e.g., pregnancy). Second, given the collectivistic nature of Chinese culture, and the fact that familial relationships constitute an important part of the identity and wellbeing of individuals from these contexts, a continued sense of distress surrounding familial gatherings due to body or weight-related triggers can be a significant stressor in the lives of these individuals.

A mental health practitioner’s job is not just limited to helping alleviate the impact of current stressors, but also supporting the client in learning to buffer and to be resilient towards future stressors that may arise. As such, it is important for practitioners to be particularly vigilant towards red flags for problematic behaviors and attitudes, and to equip clients with a skill set to combat their onset. 

The existing research on western populations is undoubtedly valuable, shedding light on the ways in which disordered eating attitudes and behaviors can represent remarkably similar underlying insecurities and fears, as well as providing a general structure from which to measure and diagnose symptoms. However, a patient-practitioner relationship is arguably the most therapeutic when a deep level of understanding and compassion is established, and when the practitioner is able to provide recovery prompts that the patient perceives as relevant and realistic. Given that one’s cultural background is such a significant part of one’s identity, a better understanding of cultural nuances on the part of the practitioner is crucial to providing more sensitive and comprehensive care for these clients.

3 Ways to Support Parents Who Are Supporting their Child Through an Eating Disorder

3 Ways to Support Parents Who Are Supporting their Child Through an Eating Disorder

by JD Ouellette, Expert by Experience/Family Peer Support ProviderI am no stranger to the reality of doing hard adulting, having provided end of life care to my mother and sister, who died at 61 and 41 of lung cancer. These experiences didn’t approach the torment that was having a daughter with anorexia. There’s something so elemental about both feeding one’s child and such a strong connection with one’s identity as a parent, that having a loved one of any age be unable to eat is painful and terrifying in specific ways. The heartbreaking statistics that show us eating disorders are the deadliest of all mental illnesses, and that recovery is neither quick nor guaranteed adds to the terror. 

Often, and just when we are at our most depleted, we have to deal with the rest of society – frequently including as part of medical care – not trusting what we are telling them. “It’s a genetic, neurobiological disorder with a psychosocial component and affects people with specific temperamental profiles” is my go-to sentence when discussing anorexia.

“Ohhhhh, you don’t have to tell me! I watch lots of Lifetime TV Movies/had a friend in college who had anorexia/took an abnormal psych class in 1984/went to medical school/etcetera and I know it’s all about control – they can’t control their lives, so they control their food. Have you tried not being the food police? Also, why are you a bad parent?” Lest you think the last is hyperbole, I was actually asked by someone why I was confessing to being a terrible mother when I was discussing my daughter’s eating disorder.

The #1 way you can support parents is with EMPATHY. Put yourself in our shoes and think about what you would need if you were walking in them. You would need people – from partners to coworkers to friends and neighbors and doctors and other clinicians – to understand that while they may have some passing experience with eating disorders, they have likely not read 7 books, 34 articles, listened to 5 podcasts, watched a couple of hours of TED Talks and videos to ascertain the state of research and treatment in the month since their child was diagnosed with a life-threatening eating disorder.

You would think it reasonable they used Internet magic to connect with other parents in similar situations, wouldn’t caution them against listening to Experts by Experience from groups available via FEAST and other organizations, and would not suggest they step back from talking to “those people” and leave things to the “real” experts.  You also would not want anyone to blithely suggest you are enmeshed or codependent for trying to save the life of your loved one of any age; a common clinical and societal diagnosis if your child is older, as mine was, when ill.

The #2 way you can support parents who are fighting this battle is LOGISTICAL SUPPORT if appropriate to a family’s circumstances. There needs to be a name for carpooling that is actually you-just-drive-the-other-kids-everywhere-and-feed-them-while-you-have-them. I’ve been both on the initiating and receiving ends of meal trains when someone receives a cancer diagnosis and it’s the best part of humanity we see and feel at those times. Full nutritional normalization for child with an eating disorder is often a traumatizing process, so if you can host siblings for dinner, that’s a huge help. And if you are the very best kind of friend or family member, you can express willingness to be trained in refeeding skills to give us a break. Oh, and grocery shopping help would not be amiss – there’s a point where we hate the very sight of food (okay, many points).

There’s a corollary to this as well and it’s for the parents of a child with an eating disorder: ask for and accept help. Seriously, you have likely never needed it more. I am, by temperament and socialization, a person who prefers to be the helper versus the helpee. I learned a lot about myself in helping my daughter fight anorexia and beat it into submission and one thing was that it was actually selfish of me to resist asking for the help I readily gave others. Asking for what you need is a surprisingly efficient way of getting it and yet one many of us don’t do often enough.

EDUCATION is the 3rd way and I mean both receiving and giving. Click on the links we post, read the articles we recommend, and learn enough to both be able to support us well in ways such as understanding the treatment model we are using, or the long journey this will be, or the ways you can make it easier for our loved ones to socialize, or the ways in which prevailing culture can be a toxic influence. One casualty of having a child with a serious illness is it can be isolating and many people fall out of touch with longtime friends because the diet/exercise/clean eating talk is too painful, common concerns can seem trivial, we’ve just lost our fun spark, etcetera. Friends that “get it” are precious.

We are seven years out from diagnosis and all is well – all is amazing actually – and my time is spent very differently now. My presence in online and on-ground peer support communities is a large part of my free time and I have friends as close as siblings I’ve only met in person a time or two. Luckily, I still have the group of friends who were with us before this happened and who supported me as I have outlined here. They trusted me to have done my research. They understood when I disappeared. They respected me when I began socializing again and said, “I am now a no-body shame/diet talk zone” and they opened their eyes to toxic cultural norms, as well. And if you want someone to deliver a concise and thorough primer on eating disorders in 2019 and gently and firmly connect misconceptions, my friend Kelly is just the one to do it and I cannot adequately explain how supported that makes me feel.

Parents of a child diagnosed with an eating disorder need the same support as if a child was diagnosed with cancer and that doesn’t happen for most families. Eating disorders and the common co-morbids that accompany them are not seen as “casserole illnesses”, but that can change! You can be part of changing it and it’s both as easy and hard as having empathy, providing logistical support, and educating yourself so that you can educate others – powerful ways to support a parent whose child has been diagnosed with an eating disorder and ones that will earn you a special spot in the heart of an exhausted, committed Warrior Parent.

Eating disorders are still a part of our life – but in the best way possible; helping other families get to this place of ease and joy in recovery.

Food Refusal and Avoidant Eating in Children, including those with Autism Spectrum Conditions: A Practical Guide for Parents and Professionals Interview

Dr. Gillian Harris and Dr. Elizabeth Shea joined us for an interview on their book, Food Refusal and Avoidant Eating in Children, including those with Autism Spectrum Conditions: A Practical Guide for Parents and Professionals. What follows are our questions in italics, and their thoughtful responses.

You divided your book, Food Refusal and Avoidant Eating in Children, including those with Autism Spectrum Conditions: A Practical Guide for Parents and Professionals, into 2 Parts. In Part 1, you provide information on the development stages of acceptance and rejection of new foods in infants and children. What can you tell us about neophobic factors that may impact a child’s eating behavior?

The neophobic response (fear of new foods) can be seen in all children from the age of around 2 years. At this stage, toddlers have learned what the foods they have been eating from infancy look like and which packets they come from. As they move on to the stage of language development they begin to sort things in their mind according to categories. They have a visual image of the foods they eat and exactly what they look like. If a food doesn’t look like a food they recognize they will refuse it. It can also be that they will refuse a food they have eaten before but which doesn’t quite look the same as usual. So, parents might add some cheese to some pasta and that will be refused; it doesn’t look the same. They will also refuse foods if the packet they come in changes! In the neophobic stages most parents will have a child who becomes rather fussy, and might insist on their bread being toasted to an exact shade of brown, and their yoghurt only being strawberry flavored! Any mixed textured foods are more likely to be refused too, quite often, because the child can’t see what exactly it is they are eating.

The neophobic response is more extreme in those children who are sensory sensitive; they respond more to taste, to touch, to smell, and the way things look. So, very food avoidant children are more likely to be more neophobic. Whereas other children will move out of this neophobic response over the next few years, (they learn that foods are more or less the same even if they look a little different), very avoidant children don’t move on. They restrict the number of foods they will accept, until they eat only a very narrow range, sometimes as few as 5 foods.

Please tell us about “disgust responses”.

Infants learn which foods are safe to eat, but that means they also learn some foods are not safe to eat. In the early years, the disgust response can be triggered by a taste, a texture, or just the sight of a food. There are big differences in just how children and adults react to tastes and textures. Some are very sensitive to the taste of bitter, so green vegetables will taste disgusting to one child but not to another. Some are more sensitive to texture; ‘slimy’ textured foods are difficult for many children and adults to accept. Many dislike ripe bananas, or certain types of jellied fish. ‘Slimy’ textures are more likely to be seen in foods that are starting to rot, and bitter tasting foods are more likely to be poisonous; so these disgust responses are quite sensible.

The disgust response can also be triggered by a combination of foods, so one food a child might like can’t touch another liked food; the beans mustn’t touch the potato. But then most adults wouldn’t mix their ice-cream with their bolognaise sauce!

As children get a little older, other types of disgust come into play. There will be foods that are not eaten at all in their house, perhaps because their family is vegetarian. Foods that haven’t ever been eaten can quite often trigger a learned disgust response. Children who are very avoidant eaters and who have kept to a limited range of foods in early childhood, very often feel disgusted by foods they don’t and can’t eat. This might mean they can’t sit at the dining table when the rest of the family is eating different foods. They might gag and vomit when they see foods they don’t like; their reaction is one of extreme disgust and very uncomfortable for the child.

Should parents worry if their child is eating less than children of the same age?

Children’s appetites are driven by their energy needs and their rate of growth. A shorter child will need less food than a taller child; a very active child will need more food than a more placid child. So, ‘no’, parents shouldn’t worry if their child is eating less than another child of the same age. The important thing to check is that your child is following along their expected height line on the centile charts. A child who started off on the 2ndcentile at a few months old can still be expected to be on the 2ndcentile at 5 years old; and a child who started off on the 50thcentile should stay on that line. The smaller child will have a smaller appetite. If your child is active and growing as expected then no need to worry.

There is a difference of course between eating less food than another child, and eating fewer foods than another child. Some children will also eat fewer foods than other children. This is because some children are very responsive to food cues and will eat anything that is presented, other children can be a little more wary.  If you add up all the food your child eats and you have around 30 different foods (including all those biscuits and candy) then you usually don’t have to worry.

What are symptoms that suggest ARFID is present?

I would expect a parent to tell me their child has usually been quite difficult to feed right from infancy; disliking the feel of ‘lumpy’ solids in their mouth, and quite often being reluctant to pick up finger foods. They quite often continue to prefer milk feeds to solid food. As the child goes into the neophobic stage, then parents report the foods their child did eat gradually get rejected, until they are only accepting 10 or so foods. The foods they usually accept are more likely to be brown/ beige carbohydrates (potato chips, bread, cookies) with smooth yogurts or custards. These children are often ‘brand loyal’, as well. They will only eat one make of potato crisps or one flavor pudding. Anything with a difficult texture (chewy, stringy, slimy) will be refused. This means avoidant children are very unlikely to accept fruit, vegetables, meat, and fish. Avoidant children would rather go without any foods than eat foods they dislike.

Most young children will imitate others, especially other children, and want to eat what they eat. Avoidant children don’t imitate others’ eating behaviors because they are so fearful of foods, so they don’t move out of the neophobic stage.

Please share some markers that indicate a child is ready to move forward with new foods.

This is one of the most common questions asked by parents when they come to clinic and forms part of any assessment of avoidant eating. Whether a child or young person is ready to move on is usually very individual to that child and depends on a number of factors which include their age, whether they have additional issues such as autism and how motivated they are to try something new. Having said that, there are general markers to watch out for; any of the following may indicate the child is ready:

• Showing an interest in what others are eating, particularly friends.
• Accepting a different flavour or brand of a preferred food when offered.
• Asking for a new food.
• Eating something new spontaneously, perhaps in a restaurant or on holiday.

Over the years we have found that across the board, the age of the child is a significant factor in readiness, quite simply – the older the child, the more willing they usually are to trying something new. This is because as children get older they have more capacity to cope with fears and worries and can also be taught strategies for dealing with these. Age also brings a desire to be more like their peer group. We have met many an avoidant eater who is keen to eat the same foods as their friends or cope with a school trip, for example, without being seen as ‘different’ from the crowd. This is where motivation is key, the more motivated the child or young person is the more likely it is they will be able to choose a food to try, expose themselves to that food, for example, by watching others eat it, and finally put it in their own mouth! For children with relatively typical development this stage of readiness often begins around the Junior school age (eight and above) and runs into adolescence. For young people with additional autism, this stage is typically 3-4 years later, so perhaps not until later adolescence.

One strategy you encourage for children with ARFID is to set a daily schedule. Please explain.

Scheduling is a key strategy for children and young people with ARFID and leads to a number of benefits which include:

• Increasing the number of ‘eating opportunities’ a child has in a typical day.
• Allowing calorie intake to be stable and regular and avoiding ‘compensatory’ eating.
• Involving school or college in an overall eating plan for that young person.
• ‘Training’ the child to recognize and respond to appetite ‘cues’.
• Helping the family as a whole to manage the stress of mealtimes.

Let’s deal with each of these in turn. Many reluctant children eat small amounts at mealtimes and may also be very slow. This causes parents a lot of stress about whether the child is having ‘enough’ to eat. By scheduling regular ‘eating opportunities’ (we would recommend 6 of these in a typical day) the reluctant eater is getting multiple chances to take in the right amount of calories they need for growth. In addition, because these calories are going in at regular times (again we recommend these are ‘timetabled’ to fit the child’s daily activities) the child is better able to concentrate in school and have the energy needed for their day. For this to work it is crucial that school or college are on board and allow the child’s preferred foods to be eaten there. Without such involvement, we often find the child ‘compensates’ for lost calories during the day (perhaps because they were not allowed crisps or cookies in school) and eats a large amount of these at home.

Scheduling in this way also teaches the child to start to recognize appetite ‘cues’, such as when they are starting to feel hungry. This is particularly useful for children with autism who lack ‘interoceptive’ awareness, or an understanding of what is going on inside their body. It is also useful when introducing a new food, as this is more likely to be eaten if the child is feeling hungry. Lastly, scheduling means the ARFID child can often be included in family mealtimes without the pressure of this being the only time the parent can get those precious calories in.  [NB: I stopped using the words ‘meal’ or ‘snack’ some years ago as I found this can put extra pressure onto families where the child does not eat typical meals or snacks].

What are some skills you recommend when anxiety is active for those with ARFID and autism regarding food?

Anxiety is a major factor in both autism and ARFID so for those with both it is really difficult to manage. The first thing to say is that if there is any extra anxiety happening outside of food, such as transition to high school or college or changes such as moving house do not make any alterations to the child’s eating pattern. This is very important as any increase in anxiety leads to an associated increase in sensory issues which leads to more food rejection. At such times (which also include pleasurable events like seasonal holidays), keep all routines around foods and mealtimes the same, now is not the time for adding something new! If the young person’s anxiety has become more worrying and they are at risk of harming themselves, or are displaying significant behavior changes, or are more withdrawn, then seek immediate professional help.

For those young people who show some signs of readiness (see above) then they may be ready themselves to try and deal with the anxiety associated with eating, in particular, in trying something new. One of the main problems with anxiety in relation to foods is that the physical symptoms of anxiety such as fast heart rate, theneed to go to the toilet, or lack of appetite all prevent us from being able to eat! For this we recommend learning some basic relaxation techniques such as:

• Learning to breathe slowly and from the diaphragm.
• Learning to relax muscles in the body known as ‘Progressive Muscle Relaxation’ or using a practice such as yoga or Tai Chi.
• Imagining or visualizing being in a calm and safe space or using ‘mindfulness’ techniques.

Using a relaxation technique regularly lowers general anxiety and when used just before trying a new food for the first time it also lowers the chance of sensory rejection and increases the possibility of the child being able to go through with putting the food in their mouth. In addition, for the most able young people talking about their fears and worries around food can also help them achieve the goal of adding a new food to their diet.