Improving programme‐led and focused interventions for eating disorders: An experts' consensus statement—A UK perspective

Avoidant Restrictive Food Intake Disorder (ARFID) was first included as a diagnostic category in 2013, and over the past 10years has been adopted by the international eating disorder community. While greater awareness of these difficulties has increased identification, demand and enabled advocacy for clinical services, the heterogeneous nature of ARFID poses unique challenges for eating disorder clinicians and researchers. This commentary aims to reflect on some of these challenges, focussing specifically on the risk of viewing ARFID through an eating disorder lens. This includes potential biases in the literature as most recent research has been conducted in specialist child and adolescent eating disorder clinic settings, bringing in to question the generalisability of findings to the broad spectrum of individuals affected by ARFID. We also consider whether viewing ARFID predominantly through an eating disorder lens risks us as a field being blinkered to the range of effective skills our multi-disciplinary feeding colleagues may bring. There are opportunities that may come with the eating disorder field navigating treatment pathways for ARFID, including more joined up working with multi-disciplinary colleagues, the ability to transfer skills used in ARFID treatment to individuals with eating disorder presentations, and most notably an opportunity to provide more effective treatment and service pathways for individuals with ARFID and their families. However, these opportunities will only be realised if eating disorder clinicians and researchers step out of their current silos.

To examine suicide risk by eating disorder severity and symptom presentation in a nationwide sample of college students. The Healthy Minds Study is the largest mental health survey of college populations in the United States. We analyzed the most recent available data (2015-2017) with 71,712 randomly selected students from 77 campuses. We estimated associations between two measures of suicidality (ideation and attempts) and three validated measures of eating disorder symptoms (the SCOFF, weight concerns scale, and the eating disorder examination questionnaire binge and purge items). Importantly, we also controlled for co-occurring symptoms of depression and anxiety, based on validated screening tools. The large, diverse sample provided a unique opportunity to assess whether certain individual characteristics were associated with increased risk. Eating disorder symptoms, even at subthreshold levels, were highly predictive of suicidality. Relative to students with no apparent eating disorder symptoms, students with the highest symptom levels (a SCOFF score of 5) had 11 times higher odds of attempting suicide, while those with subthreshold symptoms had two times higher odds. We also observed a strong association between suicide attempts and eating disorder presentations that included purging. Students from marginalized backgrounds, particularly gender and sexual minorities, were at increased risk for suicide and eating disorders. In the largest known study to date, findings suggest that eating disorders should be a priority within broader campus suicide prevention efforts, should be assessed along a continuum of severity and symptom presentation, and should focus on reaching vulnerable students.

In a series of four studies, the aim of the current research project was to evaluate the cognitive-behavioral theory and treatment (CBT) of eating disorders. The first study (Chapter 5) was a meta-analysis (Linardon, Wade, De la Piedad Garcia, & Brennan, in press) of randomized controlled trials (RCT) testing the efficacy of CBT for eating disorders. Pooling data from 79 RCTs, results showed that therapist-led and guided self-help CBT were efficacious for individuals with bulimia nervosa (BN) and binge eating disorder (BED). There was no evidence to suggest that CBT was more efficacious than other psychological interventions in anorexia nervosa (AN). Having found evidence supporting the efficacy of CBT for certain eating disorder presentations, the second study (Chapter 6), which was a systematic review, focused on identifying the reliable factors that mediate, moderate, or predict outcome during CBT (Linardon, de la Piedad Garcia, & Brennan, 2016b). This review found that mediators and moderators of change have been largely unexplored, and that no reliable predictors of outcome emerged. Therefore, based on existing evidence, it was concluded that it remains unclear how, for whom, and under what conditions, CBT for eating disorders works. To understand the mechanisms through which CBT for eating disorders may work, a cross-sectional evaluation of the cognitive-behavioral model in a large non-clinical sample was employed for the third study (Chapter 8; under review). This study validated the conceptual pathways hypothesized by the cognitive model; it also identified two additional variables that might be important mechanisms of change during CBT, body checking and dichotomous thinking. The inclusion of body checking and dichotomous thinking within the cognitive-behavioral model explained nearly three times the amount of variance in disordered eating symptoms than the model without these variables. The third study offered the necessary statistical support for the cognitive-behavioral model and its hypotheses. The final study (Chapter 10) utilized a single case experimental design (n=8) to test the hypothesized cognitive-behavioral mechanisms of change during a CBT guided self-help program. The potential mechanisms of change examined were shape and weight concerns, dietary restraint, and adherence to regular eating strategies. Preliminary evidence showed that an adherence to regular eating in the second week of CBT was associated with a concurrent decrease in dietary restraint and binge eating. From this study, there was no evidence that other potential mechanisms were operating to reduce binge eating behavior. Based on these four independent research studies, this thesis gathered converging evidence in support for the underling cognitive-behavioral model of eating disorders. Further, these findings suggest that CBT for eating disorders is likely to contain several theory-specific mechanisms that are responsible for this treatments effectiveness. More broadly, the current thesis offers support for the contention that CBT for eating disorders “works” because of the reason outlined by its underlying model and because of its specific therapeutic mechanisms.

There are growing calls for a comprehensive, evidence-based national eating disorder (ED) strategy for England. This is due to the rising prevalence of EDs, the lack of national guidance around different ED presentations (and potentially varying treatment needs), ad hoc data collection, and inconsistencies in both care and evaluation of service provision quality. Furthermore, the shift towards remote delivery of care during the COVID-19 pandemic underscores the need for government strategy to include specific guidance on remote delivery of ED services. The increased use of remote healthcare presents an opportunity to mitigate regional disparities in the provision of care. However, there are distinct challenges when delivering ED services remotely. In this position paper, we firstly highlight the growing need for a comprehensive national ED strategy to combat the rising prevalence and harm of EDs. Secondly, we specify the importance of ensuring that future governmental strategy incorporates evidence-based guidelines specific to remote delivery of ED services. This is crucial for promoting consistent provision of ED care. We set out the lack of comprehensive national data, and the need for further research into remote service delivery.

A Survey of NAPNAP Members’ Clinical and Professional Research Priorities

Eating Disorders: What Are the Risks?

: This presentation seeks to explore the interplay between various types of psychological traumas and their potential correlation with the development of distinct types and severities of eating disorders. Emphasis will be placed on elucidating the underlying biological underpinnings and psychological and developmental factors that contribute to the manifestation of diverse eating disorder phenotypes in individuals who have experienced childhood maltreatment.Drawing upon existing research and novel insights, I will present some data from studies investigating the notion that the observed variations in eating disorder presentations may be linked especially to environmental influences. Contrary to the conventional focus on genetic determinants, our findings suggest that the differential ecophenotypic expression of eating disorders may not solely be attributed to DNA variants but rather to the complex interplay between genetic predispositions and environmental contexts.In particular, I will expose the concept of an ecophenotype characteristic of eating disorders associated with childhood maltreatment, positing that the unique ecological context in which an individual is raised significantly influences the trajectory and severity of their eating disorder. This exploration extends beyond a mere examination of genetic markers, shedding light on the environmental and ecosystemic factors that shape the development of an individual’s relationship with food and body image.Disclosure of InterestNone Declared

This study aims to describe the spectrum of children with restrictive early onset eating disorders (EOEDs), defined as below 13 years of age, presenting to a tertiary institution in Asia and comparing them with older adolescents with eating disorders. This is a retrospective case review of Asian children who were treated in an eating disorder center. Baseline characteristics and inpatient management at first presentation of children younger than 13 years of age (EOED) were compared to those in older adolescents. A total of 288 patients with restrictive eating disorders were analyzed with 53 (18%) patients having onset younger than age 13 at initial presentation. There were no significant differences in percentage weight loss and hospitalization rates between the two age groups. Patients with EOED presented with significantly shorter duration of symptoms, and lower rates of secondary amenorrhea. More patients with EOED required phosphate supplementation compared to those in older age group. Despite having a shorter duration of illness, Asian children with EOED had similar percentage weight loss and rates of admission due to malnutrition as those in older Asian adolescent patients. This study underlined the severity of EOEDs and the need for early recognition and medical assessment.

It has been suggested that childhood obsessive-compulsive disorder (OCD) may be a risk factor for the development of an eating disorder (ED) later in life, but prospective studies are lacking. We aimed to determine the prevalence of ED at follow-up and clinical predictors in a longitudinal clinical sample of adolescents/young adults diagnosed with OCD in childhood. All contactable (n=231) young people with OCD assessed over 9 years at a national and specialist paediatric OCD clinic were included in this study. At follow-up, 126 (57%) young people and parents completed the ED section of the Developmental and Well-being Assessment. Predictors for ED were investigated using logistic regression. In total, 16 participants (12.7%) had a diagnosis of ED at follow-up. Having an ED was associated with female gender and persistent OCD at follow-up. There was a trend for family history of ED being predictive of ED diagnosis. Five (30%) of those who developed an ED at follow-up had ED symptoms or food-related obsessions/compulsions at baseline. A difference in predictors for an ED versus other anxiety disorders at follow-up was identified. This study provides initial evidence that baseline clinical predictors such as female gender and family history of ED might be specific to the later development of ED in the context of childhood OCD. Clinicians should be alert to ED subthreshold symptoms in young girls presenting with OCD. Future longitudinal studies are needed to clarify the relationship between childhood OCD and later ED.

Background Eating Disorders (EDs) comprise a significant portion of the mental health morbidity of young people, yet underdetection is a major problem. To identify and tackle the barriers to service engagement, health promotion initiatives require concrete information about how EDs are viewed by adolescents. This study sought to explore young people’s ED literacy and their attitudes towards people with EDs. Methods Ethical approval was granted by St John of God Research Ethics Committee. 260 schools from across Ireland were invited to participate. 63 schools agreed to recruit students to the survey, which could be completed either online or on paper. Participants were randomly allocated to view one of five vignettes depicting a young person with symptoms consistent with Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Depression or Type 1 Diabetes. Participants were asked to identify the illness described. They also indicated their beliefs regarding illness duration, level of personal control over the illness, likely causes of the illness, and the target’s personal characteristics. Differences between the vignette conditions were explored in SPSS via chi-square tests (for categorical variables) and analyses of variance with post hoc Bonferroni-corrected comparisons (for continuous variables that met the necessary statistical conditions). Results 290 students completed the survey. Participants were aged between 15–19 ( M = 16.76, SD = 0.89), attended a range of school types (single-sex/mixed-sex, public/private), and 51% were female. Six participants had been affected by an ED themselves, and 62.4% knew someone with an ED. However, responses to the vignettes showed poor recognition of the symptoms of EDs in comparison with Depression ( χ² [4, n = 2 83] = 36.125, p .001). Only small minorities of those who encountered the AN (20.4%), BN (12.5%) and BED (0%) vignettes correctly named the illness described. Analysis of the attitude variables showed that all three EDs were seen as significantly longer in duration than Depression ( F [4,267] = 6.208, p .001). All three EDs were rated more individually-caused than either Depression or T1 Diabetes ( F [4,269] = 18.53, p .001), and participants believed that the BED target had significantly more personal control over their disorder than the Depression or T1 Diabetes targets ( F [4,264] = 3.56, p = 0 .008). All three ED targets were ascribed significantly less positive personality traits than the T1 Diabetes target ( F [4,255] = 12.91, p .001). Conclusion The results indicate the need for greater public education regarding the symptoms of EDs, so that young people can identify and seek help for problematic eating in themselves and their peers. Health promotion initiatives should also address the stigmatising or blaming attitudes to EDs that can inhibit detection and treatment, particularly the perception that EDs are self-inflicted.

Eating disorders among middle school students in a Chinese population: Prevalence and associated clinical correlates

An examination of direct, indirect and reciprocal relationships between perfectionism, eating disorder symptoms, anxiety, and depression in children and adolescents with eating disorders

Perspectives of young people with eating disorders and their parents on helpful aspects of care should be incorporated into evidence-based practice and service design, but data are limited.AimsTo explore patient and parent perspectives on positive and negative aspects of care for young people with eating disorders. Six online focus groups with 19 young people aged 16-25 years with existing or past eating disorders and 11 parents. Thematic analysis identified three key themes: the need to (a) shift from a weight-focused to a more holistic, individualised and consistent care approach, with a better balance in targeting psychological and physical problems from an early stage; (b) improve professionals' knowledge and attitude towards patients and their families at all levels of care from primary to 'truly specialist'; (c) enhance peer and family support. Young people and parents identified an array of limitations in approaches to care for young people with eating disorders and raised the need for change, particularly a move away from a primarily weight-focused treatment and a stronger emphasis on psychological needs and individualised care.Declaration of interestNone.

Eating disorders in young people with type 1 diabetes mellitus confer additional health risks beyond those conferred by the disease itself. Risk factors for developing eating disorders are poorly understood. The current study aimed to examine risk factors for eating disturbance in young people with type 1 diabetes mellitus. Both diabetes specific risk factors, such as body mass index (BMI), glycaemic control and diabetes-related conflict, and also more general risk factors such as dysfunctional perfectionism and low self-esteem were assessed. Fifty young people aged 14-16 and their primary caregiver were asked to complete interviews and questionnaires about their eating attitudes and behaviours, dysfunctional perfectionism, self-esteem, family conflict, and general mental health symptoms. Recent weight and height and glycaemic control were extracted from the medical file. Different factors distinguished those young people who displayed eating disorder attitudes from those who did not (higher BMI-z, poorer glycaemic control, and lower self-esteem) and those young people who displayed eating disorder behaviour from those who did not (lower self-esteem and higher diabetes-related family conflict). The results of the current study suggest that there might be different factors associated with eating disorders (ED) attitudes and ED behaviours, but that food/eating-related factors, family factors, and intra-personal factors are all important. Furthermore there are some gender differences in the presence of ED attitudes and behaviours and preliminary evidence that higher body mass indexes (BMIs) impact on girls more than they do on boys.

Weighty perspectives: contemporary challenges in obesity and eating disorders.