Assessment and treatment of compulsive exercise in anorexia nervosa - A combined investigation of Compulsive Exercise Activity Therapy (LEAP) and Compulsive Exercise Test subscales.

INTRODUCTION: Compulsive exercise is a transdiagnostic feature of eating disorders which adversely affects aspects of recovery, such as length of hospitalisation, risk of a chronic outcome, and risk of relapse. CompuLsive Exercise Activity TheraPy (LEAP) aims to reduce compulsive exercise through a cognitive behavioural approach. This study aims to investigate the effect of LEAP on compulsive exercise behaviour using subscales of the Compulsive Exercise Test (CET), a measure of exercise in individuals with eating disorders. Predictive validity of the CET's subscales and its ability to predict eating psychopathology are investigated. METHOD: This study used data from a randomized controlled trial of LEAP (1). Linear mixed modelling was used to investigate the effect of LEAP on compulsive exercise behaviour, and the predictive ability of CET subscales on various outcomes. The CET was compared to other exercise measures to assess its superiority in predicting eating psychopathology. RESULTS: LEAP was superior in reducing the scores of the CET's Avoidance and Rule Driven Behaviour and Exercise Rigidity subscales. All subscales made a contribution to the respective models. The CET was superior to other measures in predicting eating pathology. CONCLUSION: The results lend credibility to LEAP's ability to reduce core parts of compulsive exercise. The CET has been found to target important aspects of compulsive exercise behaviour, and has was superior to other exercise measures in predicting eating psychopathology.

The economic cost of bulimia nervosa and binge eating disorder: a population-based study.

BACKGROUND: The most common eating disorders (EDs) are bulimia nervosa (BN) and binge eating disorder (BED), serious psychiatric illnesses that have devastating effects on the physical and psychological wellbeing of sufferers. EDs range in complexity and severity but can be life-threatening without appropriate treatment. Although it is well-known that quality of life impacts is high for ED sufferers, research regarding fiscal and related costs is severely limited. The aim of this study was to understand economic and other costs of EDs at the community level. METHOD: Data were derived from 2017 household community representative structured interview of 2977 people aged ⩾ 15 years in South Australia. ED diagnoses, health systems, productivity, transaction, out-of-pocket expenses and other related costs of BN and BED were used to estimate the economic burden of EDs in South Australia. RESULTS: The annual total economic cost of EDs in 2018 was estimated at $84 billion for South Australia. This included $81 billion from the burden of disease as the result of years lived with disability (YLD) ($62 billion) and years of life lost ($19 billion). The health system costs, productivity and tax revenue loss to the Australian economy were estimated at $1 billion, $1.6 billion and $0.6 billion, respectively. CONCLUSIONS: The YLD average cost in 2018 in South Australia was $296 649 per person. This is two-thirds of the costs borne by individuals and the wider economy. Prevention and management initiatives for EDs need to take into account these costs when assessing their potential benefits.

Burden and health state utility values of eating disorders: results from a population-based survey.

BACKGROUND: There are no published estimates of the health state utility values (HSUVs) for a broad range of eating disorders (EDs). HSUVs are used in economic evaluations to determine quality-adjusted life years or as a measure of disorder burden. The main objective of the current study is to present HSUVs for a broad range of EDs based on DSM-5 diagnoses. METHODS: We used pooled data of two Health Omnibus Surveys (2015 and 2016) including representative samples of individuals aged 15 + years living in South Australia. HSUVs were derived from the SF-6D (based on the SF-12 health-related quality of life questionnaire) and analysed by ED classification, ED symptoms (frequency of binge-eating or distress associated to binge eating) and weight status. Multiple linear regression models, adjusted for socio-demographics, were used to test the differences of HSUVs across ED groups. RESULTS: Overall, 18% of the 5609 individuals met criteria for ED threshold and subthreshold. EDs were associated with HSUV decrements, especially if they were severe disorders (compared to non-ED), binge ED: -0.16 (95% CI -0.19 to -0.13), bulimia nervosa: -0.12, (95% CI -0.16 to -0.08). There was an inverse relationship between distress related binge eating and HSUVs. HSUVs were lower among people with overweight/obese compared to those with healthy weight regardless of ED diagnosis. CONCLUSIONS: EDs were significantly associated with lower HSUVs compared to people without such disorders. This study, therefore, provides new insights into the burden of EDs. The derived HSUVs can also be used to populate future economic models.

Prevalence of DSM-5 diagnostic threshold eating disorders and features amongst Aboriginal and Torres Strait islander peoples (First Australians).

BACKGROUND: There is a dearth of research into mental disorders amongst Aboriginal and Torres Strait Islander peoples (herein First Australians) and especially into eating disorders. In order to understand the healthcare needs of this population, accurate prevalence data is needed. This study aimed to estimate the prevalence of eating disorders amongst First Australians at the diagnostic threshold level and to compare clinical features and health related quality of life (HRQoL) in First and other Australians with and without an eating disorder. METHODS: Data were sourced from the general population 2015 and 2016 Health Omnibus Surveys in South Australia. Trained interviewers conducted via face to face interviews with 6052 people over 15 years old. Eating disorder questions were based on the Eating Disorder Examination and Health Related Quality of Life (HRQoL) measured with the Short-Form 12 v1. The response and participation rates were over 50% and 68% respectively in both surveys. Body Mass Index (BMI) and First Australian status were derived from interview questions. Data were weighted to population norms and analysed using statistical methods for complex surveys. RESULTS: Twenty-five of 92 (27%) First Australian survey respondents had an eating disorder (majority Other or Unspecified Feeding or Eating Disorder characterised by recurrent binge eating). This was significantly more than the prevalence of other Australians with an eating disorder group (p = .04). First Australians with an eating disorder had higher levels of weight/shape overvaluation than all other groups. They were also younger and had poorer Mental HRQoL (MHRQoL) than other Australians without an eating disorder. On logistic regression, First Australian status was not independently associated with having an eating disorder, however, age, Body Mass Index (BMI) and MHRQoL emerged as significant independent variables for the increased rate of eating disorders in First Australians. CONCLUSIONS: Eating disorders were very common in First Australians and were associated with high levels of overvaluation, binge eating frequency and poor MHRQoL. High levels of overvaluation were unexpected. The implications of these findings include an urgent need for further research, and the development of culturally appropriate assessment instruments and treatments for First Australians with eating disorders.

Assessing the Cost-Effectiveness of Interventions That Simultaneously Prevent High Body Mass Index and Eating Disorders.

Eating disorders (ED) are among the top three most common debilitating illnesses in adolescent females, while high Body Mass Index (BMI) is one of the five leading modifiable risk factors for preventable disease burden. The high prevalence of eating and weight-related problems in adolescence is of great concern, particularly since this is a period of rapid growth and development. Here, we comment on the current evidence for the prevention of EDs and high BMI and the importance of assessing the cost-effectiveness of interventions that integrate the prevention of EDs and high BMI in this population. There is evidence that there are effective interventions targeted at children, adolescents and young adults that can reduce the prevalence of risk factors associated with the development of EDs and high BMI concurrently. However, optimal decision-making for the health of younger generations involves considering the value for money of these effective interventions. Further research investigating the cost-effectiveness of potent and sustainable integrated preventive interventions for EDs and high BMI will provide decision makers with the necessary information to inform investment choices.

The Real Happy Study: Protocol for a Prospective Assessment of the Real-World Effectiveness of the HAPIFED Program-a Healthy APproach to weIght management and Food in Eating Disorders.

The prevalence of obesity with comorbid binge eating behaviour is growing at a faster rate than that seen for either obesity or eating disorders as separate conditions. Approximately 6% of the population are affected and they potentially face a lifetime of poor physical and mental health outcomes and an inability to sustain long-term weight loss. Current treatment options are inadequate in that they typically address either obesity or eating disorders exclusively, not the combination of both conditions. By treating one condition without treating the other, relapse is common, and patients are often left disappointed with their lack of weight loss. An integrated approach to treating these individuals is needed to prevent a worsening of the comorbidities associated with excess body weight and eating disorders. A new therapy has recently been developed, named HAPIFED, which addresses both overweight/obesity and comorbid binge eating behaviour with the combination of behavioural weight loss therapy and cognitive behaviour therapy-enhanced (CBT-E). The aim of this paper is to document the protocol for the Real Happy Study, which will evaluate the effectiveness of the HAPIFED program in treating overweight or obesity with comorbid binge-eating behaviour in a real-world setting.

Estimation of a Relative Risk Effect Size when Using Continuous Outcomes Data: An Application of Methods in the Prevention of Major Depression and Eating Disorders.

INTRODUCTION: The raw mean difference (RMD) and standardized mean difference (SMD) are continuous effect size measures that are not readily usable in decision-analytic models of health care interventions. This study compared the predictive performance of 3 methods by which continuous outcomes data collected using psychiatric rating scales can be used to calculate a relative risk (RR) effect size. METHODS: Three methods to calculate RR effect sizes from continuous outcomes data are described: the RMD, SMD, and Cochrane conversion methods. Each conversion method was validated using data from randomized controlled trials (RCTs) examining the efficacy of interventions for the prevention of depression in youth (aged ≤17 years) and adults (aged ≥18 years) and the prevention of eating disorders in young women (aged ≤21 years). Validation analyses compared predicted RR effect sizes to actual RR effect sizes using scatterplots, correlation coefficients ( r), and simple linear regression. An applied analysis was also conducted to examine the impact of using each conversion method in a cost-effectiveness model. RESULTS: The predictive performances of the RMD and Cochrane conversion methods were strong relative to the SMD conversion method when analyzing RCTs involving depression in adults (RMD: r = 0.89-0.90; Cochrane: r = 0.73; SMD: r = 0.41-0.67) and eating disorders in young women (RMD: r = 0.89; Cochrane: r = 0.96). Moderate predictive performances were observed across the 3 methods when analyzing RCTs involving depression in youth (RMD: r = 0.50; Cochrane: r = 0.47; SMD: r = 0.46-0.46). Negligible differences were observed between the 3 methods when applied to a cost-effectiveness model. CONCLUSION: The RMD and Cochrane conversion methods are both valid methods for predicting RR effect sizes from continuous outcomes data. However, further validation and refinement are required before being applied more broadly.

A systematic review of cost-effectiveness studies of prevention and treatment for eating disorders.

BACKGROUND: Eating disorders are serious mental disorders and are associated with substantial economic and social burden. The aim of this study is to undertake a systematic review of the cost-effectiveness studies of both preventive and treatment interventions for eating disorder. METHOD: Electronic databases (including the Cochrane Controlled Trial Register, MEDLINE, PsycINFO, Academic Search Complete, Global Health, CINAHL complete, Health Business Elite, Econlit, Health Policy Reference Center and ERIC) were searched for published cost-effectiveness studies of eating disorder prevention and treatment including papers published up to January 2017. The quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS: In all, 13 studies met the review inclusion criteria as full cost-effectiveness studies and 8 were published since 2011. The studies included three modelled and one trial-based study focused on prevention, two trial-based and one modelled study for anorexia nervosa treatment and three trial-based studies for bulimia nervosa treatment. The remaining studies targeted binge-eating disorder or non-specific eating disorder treatment. The average percent of CHEERS checklist items reported was 71% (standard deviation 21%). Eating disorder interventions were mainly cost-saving or more effective and more costly compared to comparators; however, some results did not reach statistical significance. In the two studies that achieved 100% CHEERS checklist, one study reported that a cognitive dissonance intervention might be cost-effective for prevention of anorexia nervosa and bulimia nervosa with a 90% participation rate and the second study supported lisdexamfetamine to be cost-effective in the treatment of binge-eating disorder. Insufficient evidence for long-term cost-effectiveness (e.g. over 2 years) was found. CONCLUSION: Cost-effectiveness studies in eating disorder appear to be increasing in number over the last 6 years. Findings were inconsistent and no firm conclusion can be drawn with regard to comparative value-for-money conclusions. However, some promising interventions were identified. Further research with improved methodology is required.

The cost-effectiveness of cognitive behavioral therapy for bulimia nervosa in the Australian context.

OBJECTIVE: This study was to model the cost-effectiveness of specialist-delivered cognitive behavioral therapy for bulimia nervosa (CBT-BN) compared to no intervention within the Australian context. METHOD: An illness-death model was developed to estimate the cost per disability-adjusted life-year (DALY) averted of CBT-BN over 2 years from the healthcare perspective. Target population was adults aged 18-65 years with BN. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted. Uncertainty and sensitivity analyses were conducted to test the robustness of results. RESULTS: Primary analysis indicated that CBT-BN was associated with greater DALY averted (0.10 DALY per person) and higher costs ($1,435 per person) than no intervention, resulting the mean ICER of $14,451 per DALY averted (95% uncertainty interval [UI]: $8,762 to $35,650). Uncertainty analysis indicated CBT-BN is 99% likely to be cost-effective at a threshold of $50,000 per DALY averted. Including the patients' time and travel costs resulted in the mean ICER of $18,858 per DALY averted (95% UI: $11,235 to $46,026). Sensitivity analysis indicated the intervention was not cost-effective if over 80% people discontinued treatment. Other analyses including a reduced time horizon, increased remission rates, and 4-month effect size of CBT-BN increases the ICERs but these ICERs remained well below under a threshold of $50,000 per DALY averted. CONCLUSION: This study has demonstrated that CBT-BN for adults with BN is a cost-effective treatment intervention. Further research is required to investigate the practicability of CBT-ED and the cost-effectiveness of other formats of CBT-BN delivery.

The modeled cost-effectiveness of family-based and adolescent-focused treatment for anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a prevalent, serious mental disorder. We aimed to evaluate the cost-effectiveness of family-based treatment (FBT) compared to adolescent-focused individual therapy (AFT) or no intervention within the Australian healthcare system. METHOD: A Markov model was developed to estimate the cost and disability-adjusted life-year (DALY) averted of FBT relative to comparators over 6 years from the health system perspective. The target population was 11-18 year olds with AN of relatively short duration. Uncertainty and sensitivity analyses were conducted to test model assumptions. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted. RESULTS: FBT was less costly than AFT. Relative to no intervention, the mean ICER of FBT and AFT was $5,089 (95% uncertainty interval (UI): dominant to $16,659) and $51,897 ($21,591 to $1,712,491) per DALY averted. FBT and AFT are 100% and 45% likely to be cost-effective, respectively, at a threshold of AUD$50,000 per DALY averted. Sensitivity analyses indicated that excluding hospital costs led to increases in the ICERs but the conclusion of the study did not change. CONCLUSION: FBT is the most cost-effective among treatment arms, whereas AFT was not cost-effective compared to no intervention. Further research is required to verify this result.

The modelled cost-effectiveness of cognitive dissonance for the prevention of anorexia nervosa and bulimia nervosa in adolescent girls in Australia.

BACKGROUND: Eating disorders (EDs), including anorexia nervosa (AN) and bulimia nervosa (BN), are prevalent disorders that carry substantial economic and social burden. The aim of the current study was to evaluate the modelled population cost-effectiveness of cognitive dissonance (CD), a school-based preventive intervention for EDs, in the Australian health care context. METHOD: A population-based Markov model was developed to estimate the cost per disability adjusted life-year (DALY) averted by CD relative to no intervention. We modelled the cases of AN and BN that could be prevented over a 10-year time horizon in each study arm and the subsequent reduction in DALYs associated with this. The target population was 15-18 year old secondary school girls with high body-image concerns. This study only considered costs of the health sector providing services and not costs to individuals. Multivariate probabilistic and one-way sensitivity analyses were conducted to test model assumptions. RESULTS: Findings showed that the mean incremental cost-effectiveness ratio at base-case for the intervention was $103,980 per DALY averted with none of the uncertainty iterations falling below the threshold of AUD$50,000 per DALY averted. The evaluation was most sensitive to estimates of participant rates with higher rates associated with more favourable results. The intervention would become cost-effective (84% chance) if the effect of the intervention lasted up to 5 years. CONCLUSION: As modelled, school-based CD intervention is not a cost-effective preventive intervention for AN and BN. Given the burden of EDs, understanding how to improve participation rates is an important opportunity for future research.

Lower educational level and unemployment increase the impact of cardiometabolic conditions on the quality of life: results of a population-based study in South Australia.

PURPOSE: To investigate if sociodemographic characteristics increase the adverse effects of cardiovascular diseases (CVD) and cardiometabolic risk factors (CMRF) on health-related quality of life (HRQoL). METHODS: Cross-sectional, face-to-face survey investigating 2379 adults living in South Australia in 2015 (57.1 ± 14 years; 51.7% females). Questions included diagnosis of CMRF (obesity, diabetes, hypertension, dyslipidaemia) and CVD. Physical and mental HRQoL were assessed using the SF-12v1 questionnaire. Multiple linear regression models including confounders (sociodemographic, lifestyle, use of preventive medication) and interaction terms between sociodemographic variables and cardiometabolic conditions were used in adjusted analysis. RESULTS: The prevalence of CMRF (one or more) was 54.6% and CVD was 13.0%. The physical HRQoL reduced from 50.8 (95%CI 50.2-51.4) in healthy individuals to 45.1 (95%CI 44.4-45.9) and 39.1 (95%CI 37.7-40.5) among those with CMRF and CVD, respectively. Adjustment for sociodemographic variables reduced these differences in 33%, remaining stable after controlling for lifestyle and use of preventive medications (p < 0.001). Differences in physical HRQoL according to cardiometabolic conditions were twice as high among those with lower educational level, or if they were not working. Among unemployed, having a CMRF or a CVD had the same impact on the physical HRQoL (9.7 lower score than healthy individuals). The inverse association between cardiometabolic conditions and mental HRQoL was subtle (p = 0.030), with no evidence of disparities due to sociodemographic variables. CONCLUSIONS: A lower educational level and unemployment increase the adverse effects of cardiometabolic conditions on the physical HRQoL. Targeted interventions for reducing CMRF and/or CVD in these groups are necessary to improve HRQoL.

Socioeconomic Correlates of Eating Disorder Symptoms in an Australian Population-Based Sample.

BACKGROUND: Recent research has challenged the stereotype that eating disorders are largely limited to young, White, upper-class females. This study investigated the association between indicators of socioeconomic status and eating disorder features. METHODS AND FINDINGS: Data were merged from cross-sectional general population surveys of adults in South Australia in 2008 (n = 3034) and 2009 (n = 3007) to give a total sample of 6041 participants. Multivariate logistic regressions were employed to test associations between indicators of socioeconomic status (household income, educational level, employment status, indigenous status and urbanicity) and current eating disorder features (objective binge eating, subjective binge eating, purging, strict dieting and overvaluation of weight/shape). Eating disorder features occurred at similar rates across all levels of income, education, indigenous status, and urbanicity (p > 0.05). However, compared to working full-time, not working due to disability was associated with an increased risk of objective binge eating (odds ratio (OR) = 2.30, p < 0.01) and purging (OR = 4.13, p < 0.05), engagement in home-duties with an increased risk of overvaluation of weight/shape (OR = 1.39, p < 0.05), and unemployment with an increased risk of objective binge eating (OR = 2.02, p < 0.05) and subjective binge eating (OR = 2.80, p < 0.05). Furthermore, participants with a trade or certificate qualification were at a significantly increased risk of reporting strict dieting compared to participants without a tertiary qualification (OR = 1.58, p <0.01). Limitations included the small numbers of indigenous participants (n = 115) and participants who reported purging (n = 54), exclusion of excessive exercise (which is associated with eating disorders, particularly in males), and the conduct of interviews by laypersons. CONCLUSIONS: Overall, symptoms of eating disorders are distributed equally across levels of socioeconomic status. This study highlights the need for universal access to specialised services, to train healthcare workers in the detection and diagnosis of eating disorders in diverse subgroups, and to combat barriers to help-seeking experienced by people who do not conform to the demographic stereotype of an eating disorder. The increased prevalence of various eating disorder features in those who are not working could be addressed by providing support to help sufferers join the workforce, or engage in meaningful social or community activities to improve resilience against the development of eating disorders.

The assessment and treatment of unhealthy exercise in adolescents with anorexia nervosa: A Delphi study to synthesize clinical knowledge.

This study aimed to explore and synthesize expert clinical knowledge on defining and managing unhealthy exercise in adolescents with AN. The Delphi methodology was used. Clinicians (n = 25) considered experts in the treatment of AN in adolescents were recruited internationally to form the panel. The first round of the questionnaires was comprised of five open-ended questions regarding defining, assessing, and treating unhealthy exercise in adolescents with AN. Statements were derived from this data using content analysis, and included as Likert-based items in two subsequent rounds, in which panellists were required to rate their level of agreement for each item. All 25 respondents completed the three rounds of questionnaires. Consensus was achieved for 59.0% of the items included in the second and third round of questionnaires. Although consensus was not achieved, compulsive exercise was the preferred term for the panel when referring to unhealthy exercise in adolescents with AN. The panel clearly delineated features of unhealthy and healthy exercise, and endorsed a number of items considered important to assess for when evaluating exercise in this clinical population. A variety of treatment approaches and strategies reached consensus. Notably, for those who are medically stable and progressing toward recovery, the panel recommended initial exercise restriction practices and reintroducing healthy exercise behaviors, rather than exercise cessation practices. The current findings can serve as preliminary treatment guidelines. A unified approach to labeling and defining unhealthy exercise in the eating disorder literature and clinical settings is required to achieve further progress.

Anorexia nervosa: aetiology, assessment, and treatment.

Anorexia nervosa is an important cause of physical and psychosocial morbidity. Recent years have brought advances in understanding of the underlying psychobiology that contributes to illness onset and maintenance. Genetic factors influence risk, psychosocial and interpersonal factors can trigger onset, and changes in neural networks can sustain the illness. Substantial advances in treatment, particularly for adolescent patients with anorexia nervosa, point to the benefits of specialised family-based interventions. Adults with anorexia nervosa too have a realistic chance of achieving recovery or at least substantial improvement, but no specific approach has shown clear superiority, suggesting a combination of re-nourishment and anorexia nervosa-specific psychotherapy is most effective. To successfully fight this enigmatic illness, we have to enhance understanding of the underlying biological and psychosocial mechanisms, improve strategies for prevention and early intervention, and better target our treatments through improved understanding of specific disease mechanisms.

Assessment of quality of life in people with severe and enduring anorexia nervosa: a comparison of generic and specific instruments.

BACKGROUND: Criticisms that generic measures of health-related quality of life (HRQoL) are not sensitive to impairment in anorexia nervosa (AN) has spurred the development of disease-specific measures. This study aimed to compare the psychometric properties of a generic to a disease-specific measure of HRQoL. METHODS: 63 participants with AN completed measures of a generic HRQoL (SF-12), disease-specific HRQoL (Eating Disorders Quality of Life Questionnaire; EDQOL), functional impairment (days out of role; DOR; Work and Social Adjustment Scale; WSAS), and eating disorder severity (Eating Disorder Examination; EDE) at baseline, post-treatment, and 6- and 12-months follow-up. Cronbach's α was computed for the SF-12 and EDQOL (internal consistency). Correlations were assessed between SF-12/EDQOL scores and DOR, WSAS, and EDE scores (convergence validity). Three sets of three multiple linear regressions were performed using SF-12 and EDQOL scores as predictors and change in DOR, WSAS, and EDE global scores from baseline to (i) post-treatment, (ii) 6-month follow-up, (iii) and 12-month follow-up as dependent variables (predictive validity and sensitivity). RESULTS: The EDQOL displayed stronger internal consistency (α = 0.92) than the SF-12 (α = 0.80). The SF-12 converged more strongly with DOR and the WSAS (r(p) = -0.31 to -0.63 vs. 0.06 to 0.70), while the EDQOL converged more strongly with the EDE (r(p) = -0.01 to 0.48 vs. -0.01 to -0.37). The SF-12 demonstrated stronger predictive validity (ß = -0.55 to 0.29) and sensitivity to changes in ED severity (ß = -0.47 to 0.32). CONCLUSIONS: The SF-12 is a valid and sensitive measure of HRQoL impairment in patients with AN. While the SF-12 may be preferred in research comparing EDs to other populations, and in research and practice as an indicator of functional impairment; the EDQOL may be preferred by clinicians and researchers interested in HRQoL impairment specifically associated with an ED and as an additional indicator of ED severity.

Self-recognition of eating-disordered behavior in college women: further evidence of poor eating disorders "mental health literacy"?

Self-recognition of eating-disordered behavior was examined among female college students (n = 94) with a high level of bulimic-type eating disorder symptoms. A vignette was presented describing a fictional young woman with bulimia nervosa. Participants were asked whether they might currently have a problem such as the one described, while also completing self-report measures of eating disorder symptoms, general psychological distress, and functional impairment. Less than half (47.9%) of participants believed that they currently had a problem with their eating. In both bivariate and multivariable analysis, the variables most strongly associated with self-recognition were overall levels of eating disorder psychopathology, prior treatment for an eating problem, and the use of self-induced vomiting as a means of controlling weight or shape. No other eating disorder behaviors were independently associated with self-recognition. The findings support the hypothesis that young women with eating disorder symptoms may be unlikely, or at least less likely, to recognize a problem with their eating behavior when that behavior does not entail self-induced vomiting. Health promotion and early intervention programs for eating disorders may need to address the perception that, among young women of normal or above-average body weight, only problems with eating that involve self-induced vomiting are pathological.

Treatment for severe and enduring anorexia nervosa: a review.

OBJECTIVE: Many patients with anorexia nervosa develop an intractable and debilitating illness course. Our aims were to (i) conduct a systematic review of randomised controlled trials (RCTs) of treatment for chronic anorexia nervosa participants, and (ii) identify research informing novel therapeutic approaches for this group. METHODS: Systematic search (SCOPUS plus previous reviews date 2011) of literature for (i) RCTs of treatment that included anorexia nervosa participants with a mean duration of illness of at least 3 years, (ii) studies reporting new treatments addressing factors associated with chronicity. RESULTS: Evidence of efficacy for treatment approaches in severe and enduring anorexia nervosa is limited. Only one unpublished RCT designed to test a specific psychological approach for these patients was identified. There is a probable advantage for specialist psychotherapy over treatment as usual, and a promising study of relapse prevention with cognitive behaviour therapy (CBT) for anorexia nervosa (CBT-AN). Open trials have, however, reported developments in psychological therapies that warrant further specific evaluation. These include forms of CBT modified for anorexia nervosa, cognitive remediation therapy with emotion skills training, the Maudsley Model for Treatment of Adults with Anorexia Nervosa, the Community Outreach Partnership Program, Specialist Supportive Clinical Management and the approach of Strober with its emphasis on therapeutic alliance and flexible goals. CONCLUSIONS: Treatment trials need to move beyond targeting core eating disorder pathology (primarily weight restoration) and examine efficacy and effectiveness in minimising harm and reducing personal and social costs of chronic illness. There is also a need to develop better definitions of chronicity, with or without treatment 'resistance' specifiers.

Eating disorder features in indigenous Aboriginal and Torres Strait Islander Australian peoples.

BACKGROUND: Obesity and related cardiovascular and metabolic conditions are well recognized problems for Australian Aboriginal and Torres Strait Islander peoples. However, there is a dearth of research on relevant eating disorders (EDs) such as binge eating disorder in these groups. METHODS: Data were obtained from interviews of 3047 (in 2005) and 3034 (in 2008) adults who were participants in a randomly selected South Australian household survey of individuals' age > 15 years. The interviewed comprised a general health survey in which ED questions were embedded. Data were weighted according to national census results and comprised key features of ED symptoms. RESULTS: In 2005 there were 94 (85 weighted) First Australian respondents, and in 2008 65 (70 weighted). Controlling for secular differences, in 2005 rates of objective binge eating and levels of weight and shape influence on self-evaluation were significantly higher in indigenous compared to non-indigenous participants, but no significant differences were found in ED features in 2008. CONCLUSIONS: Whilst results on small numbers must be interpreted with caution, the main finding was consistent over the two samples. For First Australians ED symptoms are at least as frequent as for non-indigenous Australians.