One Negative Effect of Weight Restoration among Men

Vol. 28 / No. 4 — Eating Disorders Review

In one study, short-term weight gains led to abnormal adipose tissue deposits in the abdomen.

Men recovering from anorexia nervosa (AN) may regain weight in an unhealthy way, according to a team of Italian researchers. In the first study to assess body composition in men with AN and how this changes with final weight restoration, Marwan El Ghoch, MD, and colleagues at Villa Garda Hospital, Verona, Italy, found that short-term weight restoration resulted in a pattern of abnormal central adiposity (Int J Eat Disord. 2017; doi:10.1022/eat.22721).

The researchers used dual-energy x-ray absorptiometry (DXA) to measure body composition in 10 men before and after complete weight restoration and in a control group of 10 healthy men matched by age and the AN patients’ post-treatment body mass index (BMI, kg/m2).

Treatment involved an adapted intensive form of enhanced cognitive behavioral therapy (CBT-E) for 13 weeks, followed by 7 weeks of CBT-E treatment given in a day hospital. During the early weeks of the program, patients work with a dietician until their BMI reaches 18.5. The program incrementally increases daily energy intake from 1500 to 3000 kcal. Once the patient’s BMI reaches 19.0, dietary intake is adjusted so hus body weight remains stable within a 2-kg window. Men whose medical conditions remained stable also had twice-weekly physical exercise sessions led by a physiotherapist. During these sessions, patients performed calisthenics to restore muscle strength and flexibility and to improve posture; aerobic exercises were used to help improve cardiovascular health.

Three patterns emerged with weight gain

The researchers reported three notable changes as the patients regained their body weight. First, the men appeared to have lost proportionately larger amounts of adipose tissue in their arms and legs than in their trunks. Second, as expected, the men with AN had lower BMIs, total lean mass scores, and fat mass scores before treatment than did their healthy peers (not surprisingly).

Finally, after short-term weight restoration, the men with AN had gained more body fat in their midsection in contrast to the healthy age-matched men. Dr. El Ghoch noted that his group had reported the same pattern of change in body composition with weight restoration in an earlier study of women with AN.

Examining Patients’ Capacity to Consent to Treatment

Vol. 28 / No. 4 — Eating Disorders Review

Patients with diminished mental ability respond more poorly in treatment.

Many genetic, psychosocial, and interpersonal factors work against treatment success in patients with anorexia nervosa (AN). These patients are often very reluctant to enter treatment, and impaired decision-making could further complicate this situation. According to a group in the Netherlands, people with AN with diminished mental capacity appear to do even less well in treatment and have poorer ability to make decisions than do patients without mental health problems. This does not improve with weight restoration (B J Psych Open. 2017; 3: 147. doi:10.1192/bjpo.bp.116.003905).

Isis F.M. Elzakkers, MD, and colleagues at the Eating Disorders Unit, Altrecht Mental Institute, Zeist, The Netherlands, examined decisional capacity at baseline and 1 and 2 years later. The Dutch group designed a longitudinal study of 70 adult female patients with severe AN. At baseline, psychiatrists established mental capacity, and clinical and neuropsychological data (especially regarding decision-making capacity) were collected. Then, after one and two years, clinical and neuropsychological tests were repeated, and admission and remission rates recalculated.

Participants completed the Eating Disorder Examination Questionnaire (EDEQ) and their body mass index (BMI, kg/m2) was established. The participant’s’ medical record provided information about admissions, treatments, and social functioning. Full remission was defined as weight in the normal range (BMI: 18.5 to 25.0), resumption of menses, and having no disabling anorectic cognitions. Clinicians with ED treatment experience used the MacArthur Competence Assessment Tool-Treatment (MacCAT-T), a semi-structured interview, to determine the level of mental capacity to consent to treatment. The Iowa Gambling Task (IGT) was also used to further assess each individual’s decision-making capacity.

One year later

After a year, 56 of the original group of 70 women (80%) agreed to continue on in the study, and at 2 years, 50 (71%) took part. At 1 year, 82% of the original group was still in treatment. After 2 years, 48 women, or 69%, were still receiving regular care. Only one participant in this study was held under the Mental Health Act at baseline, not due to his eating disorder but to comorbid alcohol dependence. One patient died of AN-related complications; a second patient died after the second follow-up. Both patients had been judged to have diminished mental capacity to consent to treatment at baseline, and both had BMIs below 15 kg/m2.

Mobile Apps Show Promise for Treatment among Young Patients

Vol. 28 / No. 4 — Eating Disorders Review

Little evidence yet, but benefits stem from easier access to care.

It seems like a natural step—using mobile phone software applications (“apps”) designed for children and adolescents with mental health problems. Certainly, the technology is widely available, since in 2017 most children and teens have access to mobile phones. In one study, the authors reported that 72% of children aged 0 to 11, and 96% of those 12 to 17 years of age had their own cell phones (J Med Internet Res. 2013; 15: e: 120; doi:10.2196/jmir.2600).

When a team of researchers from the University of Bath and Oxford Health National Health Service Foundation Trust, Keynsham, UK, did an extensive literature review of mobile phone studies, only 24 publications qualified to be included in their final review (J Med Internet Res. 2017; 19:e176). The authors also found a nearly nonexistent evidence base for the use of such apps, especially among adolescents.

Rebecca Grist, PhD, and her colleagues reported that the 24 publications they examined in the final phase of their study utilized a total of 15 apps, 2 of which could be downloaded. For the rest, 2 small randomized trials and one case study did not demonstrate any significant effect on intended health outcomes. None of 6 articles reviewing the content of 6 apps for children and adolescents, including those with eating or body image disorders, had been evaluated in a research context. The authors found that the majority of the health-oriented apps cited lacked adequate source information, and many also lacked privacy policies.

A promising approach despite few evidence-based studies

The advantages of mobile devices include their constant availability, anonymity for the user, low cost, and the ability for information to reach across most geographical barriers. Limited evidence exists to support apps for depression (Mobiletype) and OCD (Mayo Clinic Anxiety Coach). One app designed to improve body image and self-esteem (Pretty), was tested in a community sample of 206 girls 12 to 18 years of age (Veldhuis, doctoral dissertation; http://research.vu.nl/ws/portafiles/portal/1125682). The study involved use of Pretty and a similar app in a comparison group. Pretty asked users to rate the weight status of pictured models, whereas the comparison mobile app asked neutral questions about a famous singing duo. No significant differences were seen between the very different apps on measures of self-esteem or body satisfaction. Neither app improved body satisfaction levels, although significant improvements in self-esteem appeared after using either mobile app.

Despite the current lack of evidence for apps being helpful for users with mental health issues, the authors believe apps have a bright future and are particularly well suited for adolescents, most of whom are familiar with and regularly use the technology. Clearly, the mental health field will track broader society in a continued rapid evolution toward all sorts of technology-assisted treatments

A Screening Tool for Binge Eating Disorder

Vol. 28 / No. 4 — Eating Disorders Review

 7-point screening tool helps raise awareness of BED among clinicians.

Although it’s now the most common eating disorder, BED wasn’t formally recognized until the DSM-5 was published in 2013. Under-diagnosis of BED is believed to be relatively common. In an earlier survey testing physicians’ knowledge about binge eating and treatment recommendations for obesity treatment, more than 40% of physicians responded that they never screened or assessed patients for possible underlying binge-eating (Int J Eat Disord. 2004; 35:348).

One answer, according to the results of a recent study, may be use of the 7–point Binge Eating Disorder Screener (BEDS-7) in clinical practice (Prim Care Companion CNS Disord. 2017; Jun 29; 19(3). doi: 10.4088/PCC.16m02075). The BEDS-7 questionnaire contains items to examine eating a patient’s eating patterns and behaviors during the past 3 months. In contrast to screening tools such as the Eating Disorder Assessment for DSM-5 and the Eating Disorder Screen for Primary Care, the BEDS-7 only assesses BED. (For a sample of the BEDS-7, see: www.bingeeatingdisorder.com/hcp/media/BingeEatingDisorder_Screener_Apr16.pdf)

A test in 2 waves

Barry K. Hermann, MD, and colleagues tested the BEDS-7 in two study waves. Web-based surveys were administered at two time points to randomly selected primary care physicians serving adults and psychiatrists. In the first wave, an introduction to a downloadable version of the BEDS-7 and an invitation to use it in clinical practice was sent to 550 primary care physicians and psychiatrists. Of this group, 517 physicians consented to be re-contacted.

The authors found that most physician used the BEDS-7 for 1 to 4 patients (primary care physicians, 39.5%; psychiatrists, 56.3%), or in 5 to 9 patients (26.3% of primary care physicians and 21.9% of psychiatrists, respectively). The screening tool encouraged clinicians to do further tests for BED. Clinicians reported that the most important use of the BEDS-7 was for identifying patients with BED and encouraging or initiating discussions about binge eating. The most common reason primary care physicians and psychiatrists gave for not using the BED-7 was “forgetting that it was available.”

An easy-to- use tool that stimulates discussion

Most of the physicians, primary care physicians, and psychiatrists acknowledged the importance of being up-to- date on BED, and they noted that the screening test was valuable and easy to use. From wave 1 to wave 2, clinicians reported gaining significantly increased knowledge about BED. Perhaps not surprisingly, confidence in diagnosing and in treating patients with BED was significantly higher among psychiatrists than among the primary care physicians. Most respondents rated the BEDS-7 as very or somewhat valuable and easy to use.

One limitation to this tool is that it only assesses BED. Nonetheless, it could be useful for identifying patients with undiagnosed binge eating and for stimulating discussions with patients about the disorder and its symptoms.

Highlighting the Stress on Parents Caring for AN Patients

Vol. 28 / No. 4 — Eating Disorders Review

Needed changes in parenting style during FBT-based treatment can create marital stress.

In family-based treatment (FBT) for teens with anorexia nervosa (AN), parents are assigned the task of managing their son or daughter’s eating to help produce rapid weight restoration. In addition, parents are urged to work as a team united against the eating disorder.

Dr. Renee Rienecke, a psychologist at the University of South Carolina, Charleston, investigated the effects this intense treatment effort have upon marital satisfaction by evaluating parents of 53 adolescents with EDs enrolled in a partial hospitalization program (Eat Disord. 2017; doi.org/10.1080/10640266.2017.1330320). Dr. Rienecke reports that nearly half of the mothers and a third of the fathers indicated decreased satisfaction with their marriage over the course of their child’s treatment. Children whose parents reported a decrease in marital satisfaction then scored worse on measures of eating disorder psychopathology.

Just like caregivers for persons with other life-threatening illnesses, caregivers of children and teens with eating disorders experience high levels of distress, and can benefit from support. Thus, far few studies have examined how FBT can help. In FBT, most parents have to modify their usual parenting style. One example is that instead of the normal pattern of giving their teens more autonomy and independence, the parents now have to make food choices for the child and monitor him or her closely and to a degree that doesn’t correspond to the youth’s age. Working together so closely in such stressful situations can either bring families together or have the opposite effect of driving them apart.

In this study, marital discord was measured with two main questionnaires, the ENRICH Marital Satisfaction (EMS) Scale and DE symptoms with the Eating Disorder Examination. The EMS Scale is a 15-item self-report questionnaire with two subscales, the Idealistic Distortion Subscale, which includes questions such as ‘I am very happy with how we handle role responsibilities in our marriage,’ rated on a 5-point Likert scale (strongly disagree to strongly agree), and a 10-item Marital Satisfaction Subscale (J Family Psychol. 1993; 7:176). Patients’ weights and heights were also recorded. The majority of patients (67.9%) had diagnoses of AN; 18.9% were diagnosed with other specified feeding or eating disorder, and 13.2% had avoidant/restrictive food intake disorder. Nearly 90% of the families were intact.

A trend to decreased satisfaction emerged.

Although mean marital satisfaction did not change from before to after treatment, closer inspection showed that 46% of mothers and 35% of fathers had experienced decreased satisfaction with their marriages while their child was being treated for an ED. Though it was a small study, parents who had a decrease in marital satisfaction during treatment had worse scores on the EDE at the end of treatment. This suggests marital satisfaction among patients undertaking FBT is worthy of further attention.

BED and Body Image

Vol. 28 / No. 4 — Eating Disorders Review

Patients may benefit from treatment specially directed at overvaluation of weight and shape.

Concerns about body image in BED have been well studied among overweight individuals, but much less is known about people with BED who are of normal weight. A group at Temple University’s Eating Disorders Program compared body image concerns among 189 Philadelphia women with and without BED and 19 normal-weight women without BED (Body Image. 2017; 22: 6).

Overvaluation of shape and weight and body dissatisfaction differ in that “overvaluation of shape and weight refers to a stable influence of shape and weight on one’s self-concept,” according to authors Dr. Angelina Yiu and her colleagues. In contrast, body dissatisfaction is attached to negative attitudes, judgments, and evaluations of one’s body that tend to change based on mood or shape or weight gain or loss.

Dr. Yiu et al. hypothesized that the group with BED would have significantly greater over-evaluation of shape and weight compared to women in the non-BED groups, and that overweight women with BED would report the greatest weight and shape concerns. In order, this concern would be less in the normal-weight women, then the overweight women with BED, and finally normal-weight women without BED. (See also the lead article, “Looking and Lamenting May be Fatal,” elsewhere in this issue.)

The research team used several screening questionnaires, including the Eating Disorder Examination -16.0, the Structured Clinical Interview for the DSM IV-Test Revision (DSM-IV-TR), and the Body Comparison Task. The Body Comparison Task, completed on a laptop computer, asks a series of questions including a pre-test question, ‘How satisfied do you feel about your weight right now?” Participants then view 20 images of slim females dressed in shape-revealing clothing. As the women viewed each image they listened to a recording that instructed them to compare their bodies to the model, and then rated weight satisfaction with the same scale used at baseline.

A role for BED, but not for excess weight

Just as the authors had hypothesized, overvaluation of shape and weight was significantly greater among the women with BED compared to those without it. Regardless of actual weight, decreases in weight satisfaction in response to the body comparison task and overvaluation of shape and weight were highest among the women with BED.

Greater evaluation of shape and weight and decreased weight satisfaction among women with BED highlights a distinction between BED and obesity/overweight. And, the findings underscore that women with BED may benefit from treatment that specifically targets overvaluation of shape and weight.

EDs as an Aftermath of Military Sexual Trauma

Vol. 28 / No. 4 — Eating Disorders Review

Victims who report abuse face widespread social and professional retaliation.

Military sexual trauma (MST) has been defined as psychological trauma resulting from a physical sexual assault occurring while the victim is serving on active duty or in active military training (Veterans Benefits, 2011). The Department of Veterans Affairs suggests that 25% of women and 1% of men serving in the military have experienced MST at some time during their service (Veterans Administration, 2016).

In their recent study, Rebecca K. Blais, PhD, and colleagues at VA centers in Salt Lake City and Logan, UT, San Francisco, and Philadelphia, reported that a group of veterans with positive screenings for MST had nearly twice the likelihood of other veterans of developing an eating disorder. One year after the initial screening, the researchers also found that at one-year follow-up, the increased likelihood of an eating disorder connected to a diagnosis of MST was stronger among male veterans than among female veterans (Int J Eat Disord. 2017; doi:10.1002/eat.2270).

Still largely unexplored territory

Limited work has examined the link between MST and ED risk, and whether this risk varies by gender. Previous reports have linked MST, female gender, and EDs, but in some instances this association was limited to female veterans with comorbid posttraumatic stress disorder (PTSD).

On the other hand, the authors note that male veterans with a history of MST may be at increased risk for eating disorders due to stressors secondary to masculinity and rape myth stereotypes (Int J Adolesc Med & Health. 2013; 25:269). In addition, male veterans may be less likely to seek or to receive mental health treatment (Women’s’ Health Issues. 2012; 22:e61). Many veterans, male and female alike, are extremely reticent to report such assaults, and often with good reason. As the Rand Corporation reported in a study commissioned by the Department of Defense, 62% of veterans who had complained of MST experienced either social or professional retaliation, including loss of promotions and harassment, along with physical attacks from their peers.

In their recent study, Dr. Blais and colleagues studied a large representative cohort of male and female veterans who had served in operations Enduring Freedom and Iraqi Freedom. Two cohorts were used, one that involved a 1-year follow-up and one using a 5-year follow-up. Military sexual trauma was screened with the VHA MST screener, which uses two questions to determine if sexual trauma has occurred. All mental health disorders were identified with ICD-9 codes retrieved from clinical data.

A snapshot of veterans affected by MST and EDs

Three percent of the 18,488 veterans screened reported experiencing MST. Female veterans, veterans who had never married, younger non-Black veterans, veterans on active duty in the Navy/Coast Guard and the Air Force who had positive screenings for MST were more likely to be diagnosed with an ED. Other risk factors included higher rates of comorbid PTSD, depressive disorders, alcohol-related disorders, and substance-related disorders.

The authors noted that the incidence of MST and eating disorders among veterans are an understudied public health concern and share many of the same psychiatric distress patterns with PTSD, depression, substance misuse, and homelessness. The researchers also reported that male veterans are more vulnerable to psychiatric distress and dysfunction than previously thought. These findings echo an earlier study that showed that males with a history of MST had higher levels of suicidal ideation and planning, PTSD, and poorer perceived health than did female veterans (Psychiatry Res. 2015; 227:246).

Gaining a better understanding of the relationship between MST and the development of an eating disorder may help researchers and clinicians improve awareness of the problem. Increased awareness may then lead to improved screening. Better screening strategies and earlier intervention can be powerful nonmilitary weapons to bring this often-hidden problem into the light.