Triggers for eating disorder onset in youth with anorexia nervosa across the weight spectrum.

To aid in more targeted eating disorder (ED) prevention efforts, we sought to identify sociodemographic and weight-related risk factors for identified triggers for the onset of anorexia nervosa (AN) in youth. We conducted a retrospective chart review of youth admitted for medical treatment of AN between January 2015 and February 2020. From multidisciplinary admission notes, we extracted patient-reported reasons for diet/exercise changes. We used qualitative thematic analysis to identify ED triggers, then categorized each trigger as binary variables (presence/absence) for logistic regression analysis of risks associated with each trigger. Of 150 patients, mean (SD) age was 14.1(2.3) years. A total of 129 (86%) were female and 120 (80%) were Non-Hispanic White. Triggers included environmental stressors (reported by 30%), external pressures of the thin/fit ideal (29%), internalized thin/fit ideal (29%), weight-related teasing (19%), and receiving health education (14%). Younger age was associated with higher odds of weight-related teasing (p = .04) and health education (p = .03). Males had greater odds of internalized thin/fit ideal than females (p = .04). Those with premorbid body mass indices ≥85th percentile for age and sex had greater odds of reporting positive reinforcement (p = .03) and weight-related teasing (p = .04) than those with weights <85th percentile. We use these findings to detail potential targets for advancing ED prevention efforts.

Evaluation of a one-hour asynchronous video training for eating disorder screening and referral in U.S. Pediatric Primary Care: A pilot study.

OBJECTIVE: Develop and pilot-test the efficacy of an online training in improving comfort, knowledge, and behaviors related to eating disorders (EDs) screening among U.S.-based pediatric primary care providers (PCPs). METHODS: PCPs (N = 84) completed a baseline survey assessing comfort, knowledge, and behaviors regarding ED screening and referral, then watched a 1-h training video followed by a post-video survey. Half of the participants were randomly assigned to complete spaced-education questions in the following 2 months. All participants completed a 2-month follow-up survey. We used McNemar's and McNemar-Bowker tests to assess differences from baseline to post-video and post-video to follow-up, and logistic models to assess differences by spaced-education condition. RESULTS: From baseline to post-video, there were significant improvements in PCPs' knowledge about and comfort in screening and making referrals for EDs (p < .05). There were no differences between spaced-education conditions in knowledge and behaviors from baseline or post-video to follow-up, but spaced-education participants reported significantly greater comfort in screening for BN (p < .01) and BED (p < .01) compared to non-spaced-education participants. DISCUSSION: Findings suggest that a 1-h asynchronous training can improve PCP comfort, knowledge, and behavior in screening for EDs; spaced-education may provide slight additional benefits in PCP comfort. PUBLIC SIGNIFICANCE: The delivery of an 1-h asynchronous online video training helped to improve PCPs' comfort, knowledge, and behavior in screening and referral for EDs among pediatric populations. This has implications for future evaluations of brief trainings among this provider population, which could ultimately help to improve early identification of EDs and referrals to appropriate treatment.

Dietary Supplements for Weight Loss: Legal Basis for Excise Tax and Other Government Action to Protect Consumers from a Public Health Menace.

PURPOSE: Dietary supplements sold for weight loss pose a risk to public health due to deceptive claims and unscrupulous manufacturing practices in the context of weak federal regulation. Efforts to strengthen U.S. federal oversight have not been successful, thus action at the state and local levels should be explored. This study investigates proposed action to impose excise taxes on weight-loss supplements. METHODS: We reviewed U.S. federal law on taxation at federal, state, and local levels and precedent for taxation of harmful consumer products to promote public health. We assessed the rationale, legal viability, and potential effectiveness of proposed excise taxes on weight loss supplements. RESULTS: Taxation of tobacco and sweetened beverages is effective in reducing consumer use. Imposition of excise taxes on weight-loss supplements is within the authority of federal, state, and local governments, though is least politically feasible at the federal level. State or local taxation of these products has clear rationale, legal viability, and likelihood of effectiveness in reducing the public health burden posed by these products. CONCLUSIONS: Excise taxation is an effective policy intervention to reduce consumer use, particularly among youth, and is a promising public health strategy to decrease consumer exposure to noxious weight-loss supplements.

Disproportionate Use of Over-the-counter Diet Pills Among Latinx Youth and Increased Use Over Time Among Latinx Females: Results of US National Study.

PURPOSE: Over-the-counter diet pills are target-marketed to Latinx communities, raising concerns about youth use of these harmful products. METHODS: Multivariable logistic models estimated odds ratios (ORs) of diet-pill use in a representative sample of US Latinx and White students (2009-2013; N = 33,824). RESULTS: Latinx students had 30%-40% higher odds of past-30-day diet-pill use than White peers (males: OR = 1.39; 95% confidence interval = 1.10, 1.76, females: OR = 1.34; 95% confidence interval = 1.12, 1.61), and inequities among females widened, with one in 10 Latinx females reporting past-30-day use by 2013 (10.0% Latinx females vs. 6.2% White non-Latinx females). DISCUSSION: Higher prevalence of over-the-counter diet-pill use in Latinx relative to white youth-and increasing use over time for Latinx females-underscores the need for stronger restrictions on marketing and sale to youth.

Peer-to-Peer Social Media Communication About Dietary Supplements Used for Weight Loss and Sports Performance Among Military Personnel: Pilot Content Analysis of 11 Years of Posts on Reddit.

BACKGROUND: Over 60% of military personnel in the United States currently use dietary supplements. Two types of dietary supplements, weight loss and sports performance (WLSP) supplements, are commonly used by military personnel despite the associated serious adverse effects such as dehydration and stroke. OBJECTIVE: To understand peer-to-peer communication about WLSP supplements among military personnel, we conducted a pilot study using the social media website, Reddit. METHODS: A total of 64 relevant posts and 243 comments from 2009 to 2019 were collected from 6 military subreddits. The posts were coded for year of posting, subreddit, and content consistent with the following themes: resources about supplement safety and regulation, discernability of supplement use through drug testing, serious adverse effects, brand names or identifiers, and reasons for supplement use. RESULTS: A primary concern posted by personnel who used supplements was uncertainty about the supplements that were not detectable on a drug test. Supplements to improve workout performance were the most frequently used. CONCLUSIONS: Our pilot study suggests that military personnel may seek out peer advice about WLSP supplements on Reddit and spread misinformation about the safety and effectiveness of these products through this platform. Future directions for the monitoring of WLSP supplement use in military personnel are discussed.

COVID-19 and eating disorder and mental health concerns in patients with eating disorders.

BACKGROUND: The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines how young people with EDs feel the COVID-19 pandemic has affected their living environments as well as their ED and MH symptoms and motivation for ED recovery. METHODS: Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess their perceptions of the impact of the COVID-19 pandemic. Participants reported on concerns of their ED worsening due to increased time living in a "triggering environment" due to the pandemic as well as perceived COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with ED and MH symptoms. RESULTS: The majority of respondents reported concern for worsening of their ED due to a "triggering environment" (63%). Most reported an increase in ED thoughts (74%), feelings of anxiety (77%), depression (73%), and isolation (80%) they perceived to be related to the pandemic. Nearly one-third reported decrease in motivation to recover (29%) they perceived to be related to the pandemic. After adjusting for age and ED diagnosis, participants who reported concern for worsening of their ED due to a triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report concern for worsening of their ED due to a triggering environment. CONCLUSIONS: Our findings demonstrate the perceived negative impact the COVID-19 pandemic has had on the self-reported ED and MH symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

The COVID-19 pandemic and subsequent stay-at-home orders implemented across the world dramatically altered daily life for people of all ages. Previous research has detailed the profound impact the pandemic has had on mental health (MH), particularly among individuals with eating disorders (ED) [22]. This study explored how individuals with eating disorders perceive the COVID-19 pandemic to have impacted their ED symptoms and overall MH. Participants included adolescent/young adults (AYAs) with a diagnosed ED who were given a four-part survey on how they perceive the COVID-19 pandemic to have affected their ED symptoms and treatment and MH (89 participants). AYAs in the study reported feeling that their ED symptoms and MH concerns worsened due to the pandemic. Those who reported concern that their ED would worsen due to a "triggering" living environment were even more likely to report feeling that their ED and MH worsened due to the pandemic. A large percentage of participants also reported a decreased motivation to recover from their ED that they attributed to the pandemic. Overall, individuals with EDs may be at risk for worsening symptoms during the COVID-19 pandemic. Our results underscore the need for increased monitoring of patients with EDs during the pandemic.

Access to care and worsening eating disorder symptomatology in youth during the COVID-19 pandemic.

BACKGROUND: Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors. METHODS: AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, and completed a COVID-19-specific survey (n = 89). We examined bivariate associations of four markers of care: i) access to care, ii) changes in care, iii) perceived disruption to care, and iv) quality of care. Using multiple logistic regression, we examined the associations of pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n = 16). RESULTS: In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing care with at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly one-third (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were significantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching significance (p = 0.07). CONCLUSIONS: Our findings show the majority of AYA who had care prior to the pandemic continued receiving some element of their multi-disciplinary ED treatment and perceived their care as high quality. None of the markers of care described were statistically associated with increased ED thoughts and behaviors.

The COVID-19 pandemic has had a negative impact on our global community's mental health, in particular those struggling with psychiatric illnesses, such as eating disorders (ED). Stay-at-home orders and social distancing have limited in-person access to ED treatment and as a result, many care providers have transitioned to using videoconferencing platforms. Clinicians who care for patients with EDs worry that these sudden changes in accessing treatment, on top of mental health challenges associated with the pandemic, may contribute to worsening ED symptoms. In this study, we asked adolescent and young adult patients with EDs about their symptoms, access to treatment, changes in care, disruptions in treatment and quality of care since the pandemic started. Our results demonstrate that patients with established care teams have maintained treatment and perceive their care as high quality, though the majority are experiencing worsening ED thoughts and behaviors. Patients who perceive their quality of care as worse than usual might be more likely to have intrusive ED thoughts. Continued access to care could also be protective against increased ED behaviors. Ultimately, our study highlights the need for continued support of patients during this challenging time.

The Association of Malnutrition, illness duration, and pre-morbid weight status with anxiety and depression symptoms in adolescents and young adults with restrictive eating disorders: a cross-sectional study.

BACKGROUND: Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symptoms, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and pre-morbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs. METHODS: 145 participants with restrictive EDs (anorexia nervosa [AN], other specified feeding and eating disorders [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants' pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. We used multiple linear regression to examine the association of malnutrition, ED duration, and pre-morbid weight status with symptoms of anxiety and depression. RESULTS: Mean (SD) age was 16.4(3.0) years; 87% were female; 89% white; 85% had AN, 6% OSFED, 10% ARFID. Of these, 2/3 had ED symptoms ≥1 year, 1/3 had previous higher level of ED care (HLOC), and half were taking psychiatric medications. Mean %eBMI was 90% (range 57-112%). Mean GAD-7 was 9.4(5.9) and CES-D was 24(13.8), indicating most participants had clinically significant anxiety and/or depression. Degree of malnutrition was not significantly associated with anxiety or depression adjusting for age, sex, sexual orientation, ED diagnosis, and use of psychiatric medication. Those with longer duration of ED symptoms had higher depression scores after adjusting for malnutrition, HLOC, length of ED symptoms, and time in our care (p = 0.038). Patients with pre-morbid BMIs ≥75th percentile had lower depression scores than those with pre-morbid BMIs <75th percentile (p = 0.014). CONCLUSIONS: We find high degree of clinically relevant anxiety and depression symptoms in a population of AYAs with EDs. Our findings suggest that factors beyond malnutrition play a role in the co-morbid mood and anxiety disorders in this population. Overall, rapid ED diagnosis and comprehensive treatment for patients with EDs across the weight spectrum-and especially those with psychiatric co-morbidities-will likely aid in recovery.

People with eating disorders (EDs) often also struggle with anxiety and depression. Unfortunately, this can mean their disease is more severe, harder to treat, and more dangerous and potentially fatal. ED treatment often primarily focuses on nutrition and weight gain, and sometimes loses focus on the person's mood and anxiety. Additionally, patients can present at any weight, but not enough is known about how baseline weight before weight loss might affect mood. In this study, we focus on adolescents/young adults with restrictive EDs to understand what places them at risk for depression and anxiety. We find that the majority of our participants have clinically significant anxiety and depression. However, degree of malnutrition was not related to level of anxiety and depression. Struggling with an ED for longer time was associated with increased depression and possibly anxiety as well. We also find that those who had relatively high baseline weights prior to weight loss had lower depression and anxiety scores than those who had lower baseline weights. Early identification and treatment of individuals with EDs is important, and there are likely other factors beyond malnutrition that we need to understand in order to identify those at risk for depression and anxiety.