Pediatric acute hospitalization for anorexia nervosa: an economic evaluation.

BACKGROUND: Anorexia nervosa (AN) is a psychiatric disorders which may potentially led to a high risk of health medical complications, suicide and self-harming behaviour. Since Covid-19 pandemic onset in March 2020, evidence suggested an increase occurrence of AN. The main aim of the retrospective analysis is to define the cost of hospitalization in the acute phase (HAP) at IRCCS Bambino Gesù Children Hospital, Rome, Italy, over 2 years study. Secondary purposes are defining the main risk factors for a prolonged hospitalization (including age, sex and comorbidities) and the possible influence of Covid-19 pandemic on AN admission and hospital stay. METHODS: for the purpose of the study, we included children and adolescents aged less than 18 years, admitted to IRCCS Bambino Gesù Children Hospital, Rome, Italy, with a diagnosis of AN. Medical costs were calculated consulting the Lazio Regional Health Service Tariffs. Basing on the date of hospital admission, patients were later divided into two subgroups: subgroup A included patients hospitalized prior than Covid-19 onset (from March 2019 to February 2020) and subgroup B those admitted after (from March 2020 to October 2022). RESULTS: a total of 260 patients has been included in the study with a median age of 15 years (range 6-18 years). The total health care cost of AN hospitalized patients was of EUR 3,352,333 with a median cost of EUR 11,124 for each admission (range EUR 930 - 45,739) and a median daily cost of EUR 593 (range EUR 557-930). Median cost was higher in case of comorbidities, guarded patients, enteral feeding. A prolonged hospitalization has been documented in subgroup A with a higher economic burden. CONCLUSIONS: the economic burden of eating disorders is of note. Adequate sanitary policies as well as health economic analyses are required to gain insight into the cost-effectiveness of AN management. TRIAL REGISTRATION: 2526-OPBG-2021.

The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study.

OBJECTIVE: Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED. METHOD: This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change. RESULTS: Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21-30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1-17.3) kg/m2 . The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930-1500) kcal/day. Seventy-three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93-1.00], p = .035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission. DISCUSSION: The incidence of severe RFS was low in this cohort and was associated with lower admission weight. PUBLIC SIGNIFICANCE: This study is one of the largest studies to utilize consensus-defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced.

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.

Economic evidence for prevention and treatment of eating disorders: An updated systematic review.

OBJECTIVE: This systematic review updates an existing review examining the cost-effectiveness of interventions to prevent and treat eating disorders (EDs). METHOD: Literature search was conducted in Academic Search Complete, MEDLINE, CINAHL, PsycINFO, EconLit, Global Health, ERIC, Health Business Elite, and Health Policy Reference Center electronic databases, capturing studies published between March 2017 to April 2023. Hand-searching was conducted as supplementary including gray literature search. Included articles were (1) full economic evaluations or return-on-investment studies, (2) in English and (3) aimed at prevention and treatment of any ED. Included studies were added and synthesized with previously reviewed studies. Screening and extraction followed PRISMA guidelines. Quality assessment was conducted using the Drummond checklist. PROSPERO registration CRD42021287464. RESULTS: A total of 28 studies were identified, including 15 published after the previous review. There were nine prevention, seven anorexia nervosa (AN) treatment, five bulimia nervosa (BN) treatment, four binge-eating disorder (BED), and three non-specific ED treatment studies. Findings indicate value-for-money evidence supporting all interventions. Quality assessment showed studies were fair-to-good quality. DISCUSSION: There has been significant growth in cost-effectiveness studies over the last 5 years. Findings suggest that interventions to prevent and treat ED offer value for money. Interventions such as Featback (ED prevention and non-specific ED treatment); focal psychodynamic therapy, enhanced cognitive behavioral therapy, and high-calorie refeeding (AN treatment); stepped-care with assisted self-help and internet-based cognitive behavioral therapy (BN treatment); and cognitive behavioral therapy guided self-help intervention (BED treatment) have good quality economic evidence. Further research in implementation of interventions is required. PUBLIC SIGNIFICANCE STATEMENT: The increasing prevalence of ED globally has significant impact on healthcare systems, families, and society. This review is showcasing the value for money of interventions of eating disorders prevention and treatment. This review found that existing interventions offers positive economic benefit for the healthcare system.

OBJETIVO: Esta revisión sistemática actualiza una revisión existente que examina la rentabilidad de las intervenciones para prevenir y tratar los trastornos de la conducta alimentaria (TCA). MÉTODO: Se realizó una búsqueda bibliográfica en las bases de datos electrónicas Academic Search Complete, MEDLINE, CINAHL, PsycINFO, EconLit, Global Health, ERIC, Health Business Elite y Health Policy Reference Center, abarcando estudios publicados entre marzo de 2017 y abril de 2023. Se realizó una búsqueda manual como complemento, incluyendo la búsqueda de literatura gris. Los artículos incluidos eran (1) evaluaciones económicas completas o estudios de retorno de inversión, (2) en inglés y (3) dirigidos a la prevención y tratamiento de cualquier TCA. Los estudios incluidos se añadieron y sintetizaron con estudios previamente revisados. El cribado y la extracción siguieron las pautas PRISMA. La evaluación de la calidad se realizó utilizando la lista de verificación de Drummond. Registro en PROSPERO CRD42021287464. RESULTADOS: Se identificaron 28 estudios, incluyendo 15 publicados después de la revisión anterior. Hubo nueve estudios de prevención, siete de tratamiento de anorexia nerviosa (AN), cinco de tratamiento de bulimia nerviosa (BN), cuatro de trastorno por atracón (TpA) y tres de tratamiento de TCA no especificados. Los hallazgos indican evidencia de valor por dinero que respalda todas las intervenciones. La evaluación de la calidad mostró que los estudios eran de calidad aceptable a buena. DISCUSIÓN: Ha habido un crecimiento significativo en los estudios de rentabilidad en los últimos cinco años. Los hallazgos sugieren que las intervenciones para prevenir y tratar los TCA ofrecen valor por dinero. Intervenciones como Featback (prevención de TCA y tratamiento de TCA no específicos); terapia psicodinámica focal, terapia cognitivo-conductual mejorada y rehabilitación nutricional con alto contenido calórico (tratamiento de AN); atención escalonada con autoayuda asistida y terapia cognitivo-conductual en línea (tratamiento de BN); y terapia cognitivo-conductual guiada de autoayuda (tratamiento de TpA) tienen una buena evidencia económica de calidad. Se requiere más investigación en la implementación de intervenciones.

[Anorexia nervosa: demographic, socio-economic and cultural data still too limited]. / Anorexie mentale, des données démographiques, socio-économiques et culturelles encore trop limitées.

Although eating disorders are a public health issue, treating anorexia nervosa from a demographic and socio-economic perspective remains a challenge. Data are scarce, patchy and often of questionable quality. Such a lack of data on a somatopsychic illness with serious repercussions is a real problem, since reliable, longitudinal and detailed information could provide additional answers in understanding the illness, both in terms of age, sex and gender structure, and in terms of family, social and environmental factors.

Adherence to a Mediterranean Diet, Body Composition and Energy Expenditure in Outpatients Adolescents Diagnosed with Anorexia Nervosa: A Pilot Study.

Weight restoration is the primary goal of treatment for patients with Anorexia Nervosa (AN). This observational pilot study aims to describe adherence to the Mediterranean Diet (MD) and the consequent process of weight and functional recovery in outpatient adolescents diagnosed with AN. Eight patients with a median age of 15.1 (14.0-17.1) years were seen at baseline and after six months. Anthropometrics, body composition, and resting energy expenditure (REE) were assessed. The KIDMED questionnaire, the 24 h recall, and a quantitative food frequency questionnaire were used to evaluate adherence to the MD. The median KIDMED score increased from 5.5 (T0) to 10 (T1), which was not significant. Intakes of grams of carbohydrates, lipids, mono-unsaturated fatty acids, and fiber increased (p = 0.012, p = 0.036, p = 0.036, p = 0.025). Weight significantly increased (p = 0.012) as well as lean body mass (p = 0.036), with a resulting improvement of the REE (p = 0.012). No association between anthropometrics and body composition and the KIDMED score was found. The MD could represent an optimal dietary pattern for weight gain and nutritional restoration in patients with AN, and it could lead to an improvement in body composition and resting energy expenditure.

Narrative review of inpatient nutritional management of anorexia nervosa with management recommendations for Australian tertiary health services.

BACKGROUND: Patients with anorexia nervosa (AN) may experience life-threatening malnutrition-related complications requiring inpatient medical stabilisation. Several management guidelines have been developed but discrepancies exist because of limited high-level evidence. AIMS: To review the evidence base for recommendations contained in Victorian health services guidelines for the nutritional management of inpatients with AN. METHODS: MEDLINE and Embase databases were searched for published studies on the nutritional management of inpatients with AN, combined with a manual search through citations. Studies including patients with AN aged 16 years and older were included. Case reports, small case series of <10 patients, studies of nonmedical management and studies with an exclusive paediatric population were excluded. The search results were compared with AN inpatient medical management guidelines sourced from large tertiary health services across Victoria, Australia. RESULTS: The search yielded 584 studies, subsequently reduced to nine studies using the inclusion and exclusion criteria. The results suggest that commencing refeeding at a higher caloric value allows faster weight gain and shorter hospitalisation. Enteral tube feeding is preferential to parenteral nutrition because of infrequent and milder complications. Zinc supplementation showed a doubled rate of body mass index increase compared with placebo. Comparison with Victorian health services guidelines revealed inconsistent recommendations for high-calorie refeeding and micronutrient supplementation. CONCLUSION: The evidence supports high-calorie refeeding of 2000 kcal/day in AN inpatient medical management and zinc supplementation in improving the rate of weight restoration. This is inconsistently reflected in different Victorian health services guidelines. Updated national consensus guidelines could assist in improving consistency of evidence-based health care.

Day hospital program for anorexia nervosa in children and adolescents: Assessment, management and specific focus on early onset anorexia nervosa.

INTRODUCTION: The French day hospital program specialized in eating disorders (ED) opened in January 2018. Our study presents preliminary data on clinical profiles of patients with anorexia nervosa (AN). We describe more specifically clinical characteristics of patients with early onset AN and according to their therapeutics orientations. Then, we compare the weight gain of patients managed only in day-patient (DP) treatment with those managed initially inpatient (IP) treatment and relays in DP. METHODS: Ninety-two patients with AN, aged between 8 and 18 years, were evaluated with several questionnaires (EDI-2, EDE-Q, BSQ, EDS-R, CDI, STAI-Y, VSP-A, EPN-13). RESULTS: Patients with early onset AN, n = 23 (25.3%), presented more restrictive behaviors, less marked dietary symptomatology, a lower degree of clinical perfectionism and a less marked feeling of ineffectiveness than adolescent patients with AN. Regarding the choice of hospitalization modality (DP alone or IP-DP), the only difference highlighted was the severity of patient undernutrition. Among the patients who were treated (IP-DP n = 27 vs DP alone n = 25), the weight evolution after one month and at discharge was favorable for both groups. CONCLUSION: These preliminary data suggest the effectiveness of DP in the care of AN in children and adolescents.

Integrating clinician and patient case conceptualization with momentary assessment data to construct idiographic networks: Moving toward personalized treatment for eating disorders.

Eating disorders are serious psychiatric illnesses with treatments ineffective for about 50% of individuals due to high heterogeneity of symptom presentation even within the same diagnoses, a lack of personalized treatments to address this heterogeneity, and the fact that clinicians are left to rely upon their own judgment to decide how to personalize treatment. Idiographic (personalized) networks can be estimated from ecological momentary assessment data, and have been used to investigate central symptoms, which are theorized to be fruitful treatment targets. However, both efficacy of treatment target selection and implementation with 'real world' clinicians could be maximized if clinician input is integrated into such networks. An emerging line of research is therefore proposing to integrate case conceptualizations and statistical routines, tying together the benefits from clinical expertise as well as patient experience and idiographic networks. The current pilot compares personalized treatment implications from different approaches to constructing idiographic networks. For two patients with a diagnosis of anorexia nervosa, we compared idiographic networks 1) based on the case conceptualization from clinician and patient, 2) estimated from patient EMA data (the current default in the literature), and 3) based on a combination of case conceptualization and patient EMA data networks, drawing on informative priors in Bayesian inference. Centrality-based treatment recommendations differed to varying extent between these approaches for patients. We discuss implications from these findings, as well as how these models may inform clinical practice by pairing evidence-based treatments with identified treatment targets.

Design and testing of a health economic Markov model for treatment of anorexia nervosa.

OBJECTIVES: Anorexia Nervosa (AN) is a severe psychiatric disorder and knowledge about the cost-effectiveness of potential interventions is limited. The aim of this paper is to introduce the Trimbos Institute health economic cost-effectiveness model for Anorexia Nervosa (AnoMod-TI), a flexible modeling tool for assessing the long-term cost-effectiveness of interventions for AN in late adolescent and adult patients, which could support clinical decision making. METHODS: AnoMod-TI is a state-transition cohort simulation (Markov) model developed from a Dutch societal perspective, which consists of four health states - namely full remission (FR), partial remission (PR), AN and death. Results are expressed as total healthcare costs, QALYs and incremental cost-effectiveness ratio. RESULTS: For the purpose of demonstrating AnoMod-TI and how it could be used to estimate cost-effectiveness over a 20-year time horizon, it was applied to a hypothetical treatment scenario. Results illustrate how a relatively costly intervention with only modest effects can still be cost-effective in the long term. CONCLUSIONS: AnoMod-TI can be used to examine long-term cost-effectiveness of various interventions aimed at either treating AN or preventing relapse from a state of partial or full remission. AnoMod-TI is freely available upon request to the authors.

Real-life self-control conflicts in anorexia nervosa: An ecological momentary assessment investigation.

BACKGROUND: Individuals with anorexia nervosa (AN) are often thought to show heightened self-control and increased ability to inhibit desires. In addition to inhibitory self-control, antecedent-focused strategies (e.g., cognitive reconstrual-the re-evaluation of tempting situations) might contribute to disorder maintenance and enable disorder-typical, maladaptive behaviors. METHODS: Over a period of 14 days, 40 acutely underweight young female patients with anorexia nervosa (AN) and 40 healthy control (HC) participants reported their affect and behavior in self-control situations via ecological momentary assessment during inpatient treatment (AN) and everyday life (HC). Data were analyzed via hierarchical analyses (linear and logistic modeling). RESULTS: Conflict strength had a significantly lower impact on self-control success in AN compared to HC. While AN and HC did not generally differ in the number or strength of self-control conflicts or in the percentage of self-control success, AN reported self-controlled behavior to be less dependent on conflict strength. CONCLUSIONS: While patients with AN were not generally more successful at self-control, they appeared to resolve self-control conflicts more effectively. These findings suggest that the magnitude of self-control conflicts has comparatively little impact on individuals with AN, possibly due to the use of antecedent-focused strategies. If confirmed, cognitive-behavioral therapy might focus on and help patients to exploit these alternative self-control strategies in the battle against their illness.

The clinical effectiveness and cost-effectiveness of a 'stepping into day treatment' approach versus inpatient treatment as usual for anorexia nervosa in adult specialist eating disorder services (DAISIES trial): a study protocol of a randomised controlled multi-centre open-label parallel group non-inferiority trial.

BACKGROUND: Anorexia nervosa (AN) is a serious and disabling mental disorder with a high disease burden. In a proportion of cases, intensive hospital-based treatments, i.e. inpatient or day patient treatment, are required, with day patient treatment often being used as a 'step-down' treatment after a period of inpatient treatment. Demand for such treatment approaches has seen a sharp rise. Despite this, the relative merits of these approaches for patients, their families, and the NHS and wider society are relatively unknown. This paper describes the rationale for, and protocol of, a two-arm multi-centre open-label parallel group non-inferiority randomised controlled trial, evaluating the effectiveness and cost-effectiveness of these two intensive treatments for adults with severe AN: inpatient treatment as usual and a stepped care day patient approach (the combination of day patient treatment with the option of initial inpatient treatment for medical stabilisation). The main aim of this trial is to establish whether, in adults with severe AN, a stepped care day patient approach is non-inferior to inpatient treatment as usual in relation to improving body mass index (BMI) at 12 months post-randomisation. METHODS: 386 patients with a Diagnostic and Statistical Manual 5th edition diagnosis of severe AN or related disorder, with a BMI of ≤16 kg/m2 and in need of intensive treatment will be randomly allocated to either inpatient treatment as usual or a stepped care day patient approach. Patients in both groups will receive treatment until they reach a healthy weight or get as close to this point as possible. Assessments will be conducted at baseline (prior to randomisation), and at 6 and 12 months post-randomisation, with additional monthly symptom monitoring. The primary outcome will be BMI at the 12-month post-randomisation assessment. Other outcomes will include psychosocial adjustment; treatment motivation, expectations and experiences; cost-effectiveness; and carer burden. DISCUSSION: The results of this study will provide a rigorous evaluation of two intensive treatment approaches which will inform future national and international treatment guidelines and service provision. TRIAL REGISTRATION: ISRCTN ISRCTN10166784 . Registered 28 February 2020. ISRCTN is a primary registry of the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) network and includes all items from the WHO Trial Registration Data Set.

First onset of treatment of patients with eating disorders and treatment course: Results of data from a German health insurance company.

OBJECTIVE: This study examines, inpatient treatment costs, and typical treatment courses of patients with an eating disorder using secondary data. METHOD: The data were provided by a German health insurance company (data from 4.2 million members from 2004 to 2010; corresponds to a market share of 6% of all statutorily insured persons in Germany). An age and gender matched control group without an eating disorder diagnosis was assessed for comparisons from the same dataset. RESULTS: Two thousand seven hundred and thirty four cases with an eating disorder diagnosis (anorexia nervosa [AN], bulimia nervosa [BN] or combination [ANBN]) were identified. The inpatient costs of treatment were €5471.15 for BN, €9080.26 for AN, €10,809.16 for ANBN and €339.37 for the control group. Interestingly, there are numerous mild episodes of eating disorders that could be successfully treated solely on an outpatient basis with a short treatment duration. CONCLUSION: Our findings suggest that course and severity of eating disorders can vary from mild to very severe. Data from health insurance companies depict rather different disease and treatment courses than studies on primary data derived from treatment institutions.

Assessment of Long-Term Treatment Results in Women Suffering from Anorexia Nervosa in Adolescence.

INTRODUCTION: Reports assessing long-term treatment outcomes for anorexia nervosa (AN) are divergent and refer to different populations. They lack long-term observations in AN patients in Poland. AIM OF THE STUDY: Analysis of the recovery, relapse rate, and predictive factors in patients treated due to AN in adolescence. MATERIAL AND METHODS: A total of 201 subjects were given a survey. Ninety-seven women were recruited: 56 reported to the clinic and 41 filled in the survey. RESULTS: The average period from hospitalization to the survey was 7.76 ±4.39 years. Remission was found in 78.4%, 21.6% still pre-sented AN, and 84.2% required a one-off hospitalisation, 10.5% twice. The average BMI was: 20.08 ±3.24 kg/m 2 . The rate of attempted suicides was 6.2%. Predictive factors for poor outcome were as follows: older age of the patient when falling ill, lower SDS-BMI score at the onset of AN, transition from the restrictive type of AN into a binge-eating/purging type, and fail-ure to maintain contact with the mother. CONCLUSIONS: 1. Most girls suffering from the restricting type of AN in adolescence are cured permanently. 2. The severity of symptoms in these girls does not eliminate the chance of recovery and achieving important life goals, com-pleting education, finding a life partner, and having children. 3. Girls with a smaller degree of cachexia at onset of AN, with no binge-eating/purging symptoms, maintaining regular con-tact with their mothers, have a better prognosis for recovery. 4. Six per cent of women treated in their youth for AN face the risk of attempted suicide, which points to the need to monitor their mental state for many years.

Phase 2 of family-based treatment: an exploratory assessment of clinician practices.

PURPOSE: In manualized family-based treatment (FBT) for eating disorders, phase 1 of the 3-phase treatment-during which parents are put in control of eating-related issues-is perhaps the most critical phase, and is comprehensively addressed in the manual. Phase 2, during which control over eating is gradually returned to the patient, is more variable and the manual dedicates less space to this phase. The purpose of the current exploratory study was to assess Phase 2 practices of clinicians providing FBT and to compare these practices to the guidance offered in the manual. METHODS: In the current study, a survey assessing Phase 2 practices was sent to clinicians. Twenty-seven providers responded. Two providers reported that they did not provide FBT in an outpatient setting. One reported not currently providing outpatient FBT but had in the past. The remaining providers were currently providing FBT in an outpatient setting. RESULTS: No items addressing the core interventions of Phase 2, including encouraging age-appropriate independent eating, were endorsed by 100% of respondents as being addressed 100% of the time in Phase 2. CONCLUSION: Responses reflected some adherence to the manual, along with examples of therapist drift and incorporation of therapeutic interventions that are not described in the FBT manual. Adherence to manualized treatments may improve outcome for some patients, while allowing for flexibility to address clinical situations that are not addressed in the manual. LEVEL OF EVIDENCE: V. Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Insufficient Assessment and Treatment of Vitamin D in the Medical Management of Adolescents with Anorexia Nervosa.

PURPOSE: Suboptimal vitamin D levels are implicated in low bone mineral density, a common medical complication of anorexia nervosa. This study aimed to examine the frequency of vitamin D assessment and treatment for adolescents with anorexia nervosa in outpatient medical management. DESIGN AND METHODS: Retrospective chart review was used to examine 179 adolescents (M age = 15.5 years, SD = 2.2), newly diagnosed with anorexia nervosa at a tertiary care medical center in the United States between January 2000 and July 2016. RESULTS: Only 16% of patients (n = 29) received serum vitamin D assessments following diagnosis, of whom 52% had suboptimal vitamin D levels (n = 15). Only three patients with suboptimal vitamin D were advised to begin supplementation. No patients in our sample were encouraged to begin prophylactic vitamin D supplementation. CONCLUSIONS/PRACTICE IMPLICATIONS: Findings from this study highlight the critical need for widespread care team education about vitamin D assessment and treatment in the medical management of adolescents with anorexia nervosa, particularly in light of the potentially serious consequences of bone mineral density.

Optimising care pathways for adult anorexia nervosa. What is the evidence to guide the provision of high-quality, cost-effective services?

The aim of this paper is to consider how changes in service planning and delivery might improve the care pathways for adult anorexia nervosa. Although anorexia nervosa has a long history in Europe, its framing as a mental disorder is quite recent. The changing forms and increasing epidemiology of eating disorders has led to the expansion of specialised services. Although some services provide care over the entire clinical course, more often services are divided into those that care for children and adolescents or adults. The transition needs to be carefully managed as currently these services may have a different ethos and expectations. Services for adults have a broad range of diversity (diagnostic subtype, medical severity, comorbidity, stage of illness and psychosocial functioning) all of which impacts on prognosis. A tailored, approach to treatment planning could optimise the pathway. Facilitating early help seeking and rapid diagnosis in primary care and reducing specialised services waiting lists for assessment and treatment could be a form of secondary prevention. The use of precision models and /or continuous outcome monitoring might reduce the third of patients who require more intensive care by applying augmentation strategies. Finally, gains from intensive care might be sustained by relapse prevention interventions and community support to bridge the transition home. Together these measures might reduce the proportion of patients (currently a third) with ill health for over 20 years. For this group rehabilitation strategies may improve functioning until new treatment emerge.

Healthcare use and costs of adults with anorexia nervosa and bulimia nervosa in Taiwan.

OBJECTIVE: This study aimed to examine the health service use and healthcare costs of adults with anorexia nervosa (AN) and bulimia nervosa (BN) in Taiwan. METHOD: AN and BN cases between 2002-2013 were extracted from a national health insurance database. For each AN and BN case, we randomly selected 10 controls with no eating disorder, matched for sex, age, urbanization of residence, and year of medical visit. The percentage and frequency of health services use and costs in the year preceding and after the diagnosis of AN/BN were compared between groups. We used generalized linear models with gamma distribution and log link function to determine the effects of age, sex, and psychiatric comorbidities on the total cost adjusting for physical comorbidities and to calculate the mean cost difference between groups by using marginal and incremental effects. RESULTS: Both individuals with AN and BN had significantly elevated healthcare utilization and costs compared to controls during the baseline and one-year period after diagnosis. Patients with AN had more than three times higher total costs (US $792) and patients with BN had two times higher total costs (US $320) than individuals without eating disorders. Comorbidity of depressive disorder and older age significantly increased healthcare costs among both individuals with AN and BN. DISCUSSION: There are high medical and economic burdens of care for individuals with AN and BN. Early diagnosis and integrated care for eating disorders are important tasks to reduce disease burden in Taiwan.