Who gets treated for an eating disorder? Implications for inference based on clinical populations.

BACKGROUND: The minority of people with an eating disorder receive treatment. Little is known about predictors of receiving treatment. METHODS: Using data from the Growing Up Today Study we identified correlates of receiving treatment for an eating disorder among the 1237 U.S. women who answered questions on treatment history in 2013 and reported meeting criteria for subthreshold eating disorder in ≥ 1 year between 1996 and 2013. Logistic regression models using generalized estimating equations were used to estimate the relative odds of receiving treatment. RESULTS: Approximately 11% of the women reported receiving treatment for an eating disorder. Independent of type of eating disorder, those who had received a diagnosis of depression or anxiety were more likely (odds ratio (OR) = 3.05 95% confidence interval (CI) 1.87-4.97) to receive treatment for an eating disorder. Women with obesity were approximately 85% less likely to receive treatment (OR = 0.13, 95% CI 0.04-0.46) regardless of their type of eating disorder or history of depression of anxiety diagnosis. CONCLUSIONS: Most women meeting criteria for an eating disorder do not receive treatment. Women with BED or obesity are the least likely to receive treatment.

Associations between presenting weight and premorbid weight and the medical sequelae in hospitalized youth with anorexia nervosa or atypical anorexia nervosa.

PURPOSE: To identify unique treatment considerations for youth with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) and premorbid overweight or obesity, we examined unique relationships between premorbid and presenting weight status and medical sequelae in youth with AN/AAN requiring medical hospitalization. DESIGN AND METHODS: We performed a retrospective study of 150 youth aged mean [SD] of 14.1[2.3] years, hospitalized for AN/AAN. Independent t-tests and Fischer's exact tests assessed differences in demographic and clinical characteristics by premorbid weight status. Logistic regressions assessed associations between premorbid and presenting weight status and vital sign or laboratory abnormalities. RESULTS: Compared to youth with premorbid 'normal' weights, youth with premorbid overweight/obesity demonstrated greater percent (p = .042) and faster rate (p < .001) of weight loss and had 10.9 times the odds of having anemia (p = .025). Youth with AN (<5th percentile for body mass index [BMI]) were more likely to experience hypoglycemia (p < .018) than youth with AAN (≥5th percentile BMI). Greater percent of weight loss significantly predicted bradycardia (p < .001) and hypoglycemia (p = .002), independent of premorbid or presenting weight status. CONCLUSION: Acute medical management of AN/AAN should be commensurate for hospitalized patients, regardless of premorbid weight status. However, those with more significant weight loss and those presenting as underweight may warrant particular monitoring for complications such as bradycardia and hypoglycemia. PRACTICE IMPLICATIONS: In youth with AN/AAN, high percent of weight loss warrants closer monitoring for medical complications during hospitalization. Those with premorbid overweight/obesity may need additional monitoring for anemia, as there may be additional contributors to anemia aside from malnutrition.

Eating disorders occur at high rates in adolescents with epilepsy and are associated with psychiatric comorbidities and suicidality.

OBJECTIVES: To assess the occurrence rate, characteristics, and impact of eating disorders (EDs) in adolescents with epilepsy. METHODS: In this observational study, adolescents with epilepsy seen in a single center between 2013 and 2022 who had comorbid EDs were compared to two control groups of adolescents with only epilepsy and only EDs. Patients with intellectual disability or autism spectrum disorder were excluded. Data retrieved included demographic and anthropometric details and clinical variables relating to seizure types, EDs, and psychiatric disorders and behaviors. RESULTS: A total of 376 subjects were included in the study: 84 adolescents with both epilepsy and eating disorders, 135 with only epilepsy, and 157 with only EDs. The rate of EDs in adolescents with epilepsy was 7.0% (95% confidence interval [CI] 5.6%-8.5%) overall, 11.3% (95% CI 8.8%-14.3%) in females, and 3.1% (95% CI 1.9%-4.8%) in males. The median (interquartile range [IQR]) time difference between the onset of epilepsy to an ED was 1.6 (.5-3.6) years. Among adolescents with epilepsy, those with an ED were more likely to be female (p = .001) and have a lower body mass index z-score (zBMI) percentile (p < .001). Epilepsy type, seizure frequency, or seizure duration were not specific for having or not having EDs. Among adolescents with EDs, those with epilepsy had a younger onset of their EDs (p < .001), included relatively more males (p = .007), and consisted of more cases of anorexia-nervosa-restrictive type (p < .001), and fewer cases of bulimia nervosa (p = .04) and binge eating disorder (p = .003). Adolescents with epilepsy and a comorbid ED were more likely to have psychiatric comorbidities such as depression, anxiety, and suicidality than adolescents with only epilepsy or EDs. SIGNIFICANCE: EDs should be suspected and screened for in intellectually intact female and male adolescents with epilepsy, irrespective of their epilepsy type. If disturbed eating behaviors or EDs are identified, further evaluation should be directed at detecting other psychopathologies, including suicidality.

Assessment of Patients With ARFID Presenting to Multi-Disciplinary Tertiary Care Program.

There are no standard assessment approaches for Avoidant Restrictive Food Intake Disorder (ARFID). We describe our approach to multidisciplinary assessment after assessing more than 550 patients with ARFID. We collected online survey (ARFID-specific instruments, measures of anxiety, depression) measures. Electronic medical record data (mental health and gastrointestinal diagnoses, micronutrient and bone density assessments, and growth parameters) were extracted for the 239 patients with ARFID seen between 2018 and 2021 with both parent and patient responses to online surveys. We identified 5 subtypes/combinations of subtypes: low appetite; sensory sensitivity; fear + sensory sensitivity; fear + low appetite; fear + sensory sensitivity + low appetite. Those with appetite-only subtype had higher mean age (14.0 years, P < 0.01) and the lowest average body mass index z score (-1.74, P < 0.01) compared to other subtypes. Our experience adds to understanding of clinical presentations in patients with ARFID and may aid in assessment formulation.

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.

The scale matters: assessing body size with figure rating scales in a diverse sample of young adults.

PURPOSE: To explore intersectional differences in weight perception accuracy in a diverse sample of young adults using CDC-defined weight status labels and four separate figure rating scales (FRS). METHODS: This cross-sectional study of 322 18-25-year-olds with body mass index (BMI) ranging from 18.5 to 57.2 (MBMI = 26.01, SD = 6.46) enrolled participants as part of a larger university subject pool cohort in the U.S. MidSouth. Height and weight measurements were obtained. Participants (55% Black, 45% white; 74% female) selected images that best represented their current body size using four FRS and described their weight perception using five labels from "very underweight" to "very overweight/obese". Receiver operating characteristic (ROC) curve analyses were used to compare variability in classification of weight status by FRS and weight perception category across gender and race. RESULTS: Area under the curve (AUC) statistics indicated all scales were significantly better at classifying weight status than chance. Among Black females and Black males, the culturally adapted scale had the strongest discriminatory ability [(AUC = 0.93, SE = 0.02, p < 0.001, 95% CI = 0.89-0.97) and (AUC = 0.93, SE = 0.04, p < 0.001, 95% CI = 0.86-1.00), respectively]. Among white females, the silhouette scale had the strongest discriminatory ability (AUC = 0.93, SE = .03, p < 0.001, 95% CI = 0.88-0.99). Among white males, the photo-based scale had the strongest discriminatory ability (AUC = 0.84, SE = 0.06, p = 0.001, 95% CI = 0.71-0.96). Across all groups, weight perception labels were the weakest classifier of weight status. CONCLUSION: Weight perception labels are an ineffective method of assessing weight status and FRS accuracy varies by race and gender, suggesting the value of gender- and culturally tailored scales. LEVEL OF EVIDENCE: Level III. Evidence obtained from well-designed cohort or case-control analytic studies.

Social and economic cost of eating disorders in the United States: Evidence to inform policy action.

OBJECTIVE: To estimate one-year costs of eating disorders in the United States (U.S.) from a societal perspective, including the costs to the U.S. health system, individual and family productivity costs, lost wellbeing, and other societal economic costs, by setting and payer. Findings will inform needed policy action to mitigate the impact of eating disorders in the U.S. METHOD: Costs of eating disorders were estimated using a bottom-up cost-of-illness methodology, based on the estimated one-year prevalence of eating disorders. Intangible costs of reduced wellbeing were also estimated using disability-adjusted life years. RESULTS: Total economic costs associated with eating disorders were estimated to be $64.7 billion (95% CI: $63.5-$66.0 billion) in fiscal year 2018-2019, equivalent to $11,808 per affected person (95% CI: $11,754-$11,863 per affected person). Otherwise Specified Feeding or Eating Disorder accounted for 35% of total economic costs, followed by Binge Eating Disorder (30%), Bulimia Nervosa (18%) and Anorexia Nervosa (17%). The substantial reduction in wellbeing associated with eating disorders was further valued at $326.5 billion (95% CI: $316.8-$336.2 billion). DISCUSSION: The impact of eating disorders in the U.S. is substantial when considering both economic costs and reduced wellbeing (nearly $400 billion in fiscal year 2018-2019). Study findings underscore the urgency of identifying effective policy actions to reduce the impact of eating disorders, such as through primary prevention and screening to identify people with emerging or early eating disorders in primary care, schools, and workplaces and ensuring access to early evidence-based treatment.

How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians.

OBJECTIVE: Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians. METHOD: We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston Children's Hospital, University of Michigan C. S. Mott Children's Hospital, and Penn State Hershey Children's Hospital. In-depth, semi-structured, qualitative interviews explored participants' definitions of recovery. Interviews were analyzed using inductive data-driven thematic analysis. Statistical analyses followed to examine the distribution within each theme by respondent type. RESULTS: Qualitative analysis resulted in the emergence of four overarching themes of ED recovery: (a) psychological well-being, (b) eating-related behaviors/attitudes, (c) physical markers, and (d) self-acceptance of body image. Endorsement of themes two and four did not significantly differ between patients, parents, and clinicians. Clinicians were significantly more likely to endorse theme one (χ2 = 9.90, df = 2, p = .007, φc = 0.356) and theme three (χ2 = 6.42, df = 2, p = .04, φc = 0.287) than patients and parents. DISCUSSION: Our study demonstrates overwhelming support for psychological markers as indicators of ED recovery by all three groups. Clinicians should remain open to additional markers of recovery such as body acceptance and eating-related behaviors/emotions that may be of critical importance to patients and their caregivers.

Psychosocial, behavioral and clinical correlates of children with overweight and obesity.

BACKGROUND: Psychological and behavioral correlates are considered important in the development and persistence of obesity in both adults and youth. This study aimed to identify such features in youth with severe obesity (BMI ≥ 120% of 95thpercentile of sex-specific BMI-for-age) compared to those with overweight or non-severe obesity. METHODS: Youth with BMI ≥ 85th percentile were invited to participate in a prospective research registry where data was collected on attributes such as family characteristics, eating behaviors, dietary intake, physical activity, perception of health and mental well-being, and cardiometabolic parameters. RESULTS: In a racially/ethnically diverse cohort of 105 youth (65% female, median age 16.1 years, range 4.62-25.5), 51% had severe obesity. The body fat percent increased with the higher levels of obesity. There were no differences in the self-reported frequency of intake of sugar sweetened beverages or fresh produce across the weight categories. However, the participants with severe obesity reported higher levels of emotional eating and eating when bored (p = 0.022), levels of stress (p = 0.013), engaged in fewer sports or organized activities (p = 0.044), and had suboptimal perception of health (p = 0.053). Asthma, depression and obstructive sleep apnea were more frequently reported in youth with severe obesity. The presence of abnormal HDL-C, HOMA-IR, hs-CRP and multiple cardiometabolic risk factors were more common among youth with severe obesity. CONCLUSIONS: Youth with severe obesity have identifiable differences in psychosocial and behavioral attributes that can be used to develop targeted intervention strategies to improve their health.

Cross-sectional and Prospective Examination of Weight Misperception and Depressive Symptoms Among Youth with Overweight and Obesity.

This study aims to determine the association between weight misperception (considering oneself average or underweight) and depressive symptoms among youth with overweight/obesity. Linear regression models (adjusted for age, BMI, parental education, percent poverty) were used to examine cross-sectional (wave II, 1996, n = 3898, M age = 15.9, SD = 0.13) and longitudinal (from wave II to IV, 1996-2008/2009, n = 2738, M age = 28.5, SD = 0.06) associations between weight misperception and depressive symptoms (Center for Epidemiologic Studies-Depression Scale) in a subsample of White, Black, Asian, Hispanic, and Multi-racial male and female youth with overweight/obesity participating in the National Longitudinal Study of Adolescent Health. Average BMI was 29.0 (0.16) at wave II and 35.7 (0.23) at wave IV. Thirty-two percent misperceived their weight status as average weight (n = 1151, 30 %) or underweight (n = 99, 3 %). In fully adjusted cross-sectional models, White (ß = -1.92, 95 % CI = -2.79, -1.06) and Multi-racial (ß = -4.43, 95 % CI = -6.90, -1.95) youth who perceived themselves as average weight had significantly lower depressive symptoms compared to accurate weight-perceivers. In fully adjusted longitudinal models, White youth (ß = -0.41, 95 % CI = -0.81, -0.004) who perceived themselves as average weight had significantly lower depressive symptoms 12 years later. Findings suggest that weight misperception may be protective against depression among White adolescents and young adults with overweight/obesity. Clinical and population interventions should consider potential harmful effects of correcting weight misperceptions on the mental health of youth with overweight/obesity.

Weight misperception among young adults with overweight/obesity associated with disordered eating behaviors.

OBJECTIVE: The purpose of this study was to examine the cross-sectional association between weight misperception among young adults with overweight/obesity and disordered eating behaviors. METHOD: In a subsample of young adults with overweight or obesity participating in Wave III (2001-2002) of The National Longitudinal Study of Adolescent to Adult Health (n = 5,184), we examined the cross-sectional association between weight under-perception (i.e., perceiving oneself to be at a healthy body weight or underweight) and disordered eating (fasting/meal skipping for weight control, purging/pills for weight control, overeating/loss of control eating, and use of performance-enhancing products/substances). RESULTS: About 20% of young adult females under-perceived their weight compared to 48% of males. Individuals who misperceived their weight as healthy were significantly less likely to report fasting/meal skipping (Females: OR: 0.25, 95% CI: 0.14-0.43; Males: OR: 0.31, 95% CI: 0.20-0.48) and vomiting or taking diet pills/laxatives/diuretics (Females: OR: 0.10, 95% CI: 0.04-0.25; Males: OR: 0.10, 95% CI: 0.04-0.25) for weight control. Among females, those who misperceived their weight status as healthy were also less likely to report overeating or loss of control eating (OR: 0.41, 95% CI: 0.24-0.71). Greater use of performance-enhancing products/substances was seen among males who under-perceived their weight as healthy (OR: 2.06, 95% CI: 1.57-2.72) and among both females (OR: 2.29, 95% CI: 1.40-20.0) and males (OR: 2.27, 95% CI: 1.13-4.55) who perceived themselves to be underweight. DISCUSSION: Weight under-perception among young adults with overweight/obesity may convey some benefit related to disordered eating behaviors, but could be a risk factor for the use of performance-enhancing products/substances. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord ; 49:937-946).

Disentangling the relative influence of schools and neighborhoods on adolescents' risk for depressive symptoms.

OBJECTIVES: Although schools and neighborhoods influence health, little is known about their relative importance, or the influence of one context after the influence of the other has been taken into account. We simultaneously examined the influence of each setting on depression among adolescents. METHODS: Analyzing data from wave 1 (1994-1995) of the National Longitudinal Study of Adolescent Health, we used cross-classified multilevel modeling to examine between-level variation and individual-, school-, and neighborhood-level predictors of adolescent depressive symptoms. Also, we compared the results of our cross-classified multilevel models (CCMMs) with those of a multilevel model wherein either school or neighborhood was excluded. RESULTS: In CCMMs, the school-level random effect was significant and more than 3 times the neighborhood-level random effect, even after individual-level characteristics had been taken into account. Individual-level indicators (e.g., race/ethnicity, socioeconomic status) were associated with depressive symptoms, but there was no association with either school- or neighborhood-level fixed effects. The between-level variance in depressive symptoms was driven largely by schools as opposed to neighborhoods. CONCLUSIONS: Schools appear to be more salient than neighborhoods in explaining variation in depressive symptoms. Future work incorporating cross-classified multilevel modeling is needed to understand the relative effects of schools and neighborhoods.

Managing adolescent obesity and the role of bariatric surgery.

PURPOSE OF REVIEW: This update explores the current management options for adolescent obesity with a specific focus on bariatric surgery. RECENT FINDINGS: Research has highlighted the serious health complications associated with adolescent obesity and thus emphasized the need for effective interventions. With the increasing severity of obesity seen in younger populations, coupled with the modest effects of most behavioral and even pharmacologic interventions, there has been increased interest in, and attention on, bariatric surgery in younger populations. Recent adult-focused guidelines regarding the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient outline the importance of careful patient selection, in addition to close monitoring, with a particular focus on preventing nutritional deficiencies. Several recent publications have focused on issues specific to bariatric surgery in the adolescent patient including the relationship between a patient's physical and emotional maturity and timing of surgery. SUMMARY: Adolescent obesity is prevalent with increasing severity and long-term health implications. To date nonsurgical interventions have had modest effects. Bariatric surgery is becoming more common and has been shown to be well tolerated and effective in adolescents, but requires careful preoperative screening and postoperative monitoring.

Hypertension awareness and control among young adults in the national longitudinal study of adolescent health.

BACKGROUND: Young adults are less likely than older adults to be aware they have hypertension or to be treated for hypertension. OBJECTIVE: To describe rates of hypertension awareness and control in a cohort of young adults and understand the impact of health insurance, utilization of preventive care, and self-perception of health on rates of hypertension awareness and control in this age group. DESIGN AND PARTICIPANTS: Cross-sectional study of 13,512 young adults participating in Wave IV of the National Longitudinal Study of Adolescent Health in 2007-2008. MAIN MEASURES: We defined hypertension as an average of two measured systolic blood pressures (SBP) ≥ 140 mmHg, diastolic blood pressures (DBP) ≥ 90 mmHg, or self-report of hypertension. We defined hypertension awareness as reporting having been told by a health care provider that one had high blood pressure, and assessed awareness among those with uncontrolled hypertension. We considered those aware of having hypertension controlled if their average measured SBP was < 140 mmHg and DBP was < 90 mmHg. KEY RESULTS: Of the 3,303 young adults with hypertension, 2,531 (76%) were uncontrolled, and 1,893 (75%) of those with uncontrolled hypertension were unaware they had hypertension. After adjustment for age, sex, race/ethnicity, weight status, income, education, alcohol and tobacco use, young adults with uncontrolled hypertension who had (vs. didn't have) routine preventive care in the past 2 years were 2.4 times more likely (95% confidence interval [CI] 1.68-3.55) to be aware, but young adults who believed they were in excellent (vs. less than excellent) health were 64% less likely to be aware they had hypertension (OR 0.36, 95% CI 0.23-0.57). Neither preventive care utilization nor self-rated health was associated with blood pressure control. CONCLUSIONS: In this nationally representative group of young adults, rates of hypertension awareness and control were low. Efforts to increase detection of hypertension must address young adults' access to preventive care and perception of their need for care.

Assessing growth in children and adolescents with Avoidant/Restrictive Food Intake Disorder.

BACKGROUND: Although growth delays and disruption are a well described medical complication of restrictive eating disorders in children and young adolescents, this complication has received less attention in patients with Avoidant/Restrictive Food Intake Disorder (ARFID). Patients with ARFID have challenges with adequacy of food volume and variety that are not related to body image but are instead related to lack of interest in eating, sensory concerns, and/or fears of aversive consequences. Because onset of ARFID is commonly before puberty, concerns regarding growth adequacy may present an additional treatment challenge and a unique opportunity for support. REVIEW: Child and adolescent patients with other restrictive eating disorders are at risk of irreversible deleterious impact on growth and development, particularly when onset is before or around puberty. Although faltering growth is a defining feature of ARFID, less attention has been paid to methods for examining growth concerns in young patients with ARFID and training providers to assess growth adequacy when prepubertal and peripubertal patients present with this diagnosis. Providers working with patients under 18 years of age with eating disorders will benefit from the tools discussed in this narrative review to adequately assess growth and development against genetic potential, recognize alterations in growth that are a result of nutritional deficiencies, and support and maximize catch-up growth and development when it has been impaired. CONCLUSION: Established pediatric growth monitoring tools and techniques to assess adequacy of growth can be applied to child and adolescent patients presenting with ARFID. These tools can improve long term outcomes in linear height for these patients and allow for monitoring during and after treatment until growth and development is complete. Medical providers caring for patients presenting with ARFID will need to establish best practices for assessing and monitoring growth.

Pediatric hospital utilization for patients with avoidant restrictive food intake disorder.

BACKGROUND: Avoidant restrictive food intake disorder (ARFID) is a relatively new feeding and eating disorder added to the DSM-5 in 2013 and ICD-10 in 2018. Few studies have examined hospital utilization for patients with ARFID specifically, and none to date have used large administrative cohorts. We examined inpatient admission volume over time and hospital utilization and 30-day readmissions for patients with ARFID at pediatric hospitals in the United States. METHODS: Using data from the Pediatric Health Information System (PHIS), we identified inpatient admissions for patients with ARFID (by principal International Classification of Diseases, 10th Revision, ICD-10 diagnosis code) discharged October 2017-June 2022. We examined the change over time in ARFID volume and associations between patient-level factors (e.g., sociodemographic characteristics, co-morbid conditions including anxiety and depressive disorders and malnutrition), hospital ARFID volume, and hospital utilization including length of stay (LOS), costs, use of enteral tube feeding or GI imaging during admission, and 30-day readmissions. Adjusted regression models were used to examine associations between sociodemographic and clinical factors on LOS, costs, and 30-day readmissions. RESULTS: Inpatient ARFID volume across n = 44 pediatric hospitals has increased over time (ß = 0.36 per month; 95% CI 0.26-0.46; p < 0.001). Among N = 1288 inpatient admissions for patients with ARFID, median LOS was 7 days (IQR = 8) with median costs of $16,583 (IQR = $18,115). LOS and costs were highest in hospitals with higher volumes of ARFID patients. Younger age, co-morbid conditions, enteral feeding, and GI imaging were also associated with LOS. 8.5% of patients were readmitted within 30 days. In adjusted models, there were differences in the likelihood of readmission by age, insurance, malnutrition diagnosis at index visit, and GI imaging procedures during index visit. CONCLUSIONS: Our results indicate that the volume of inpatient admissions for patients with ARFID has increased at pediatric hospitals in the U.S. since ARFID was added to ICD-10. Inpatient stays for ARFID are long and costly and associated with readmissions. It is important to identify effective and efficient treatment strategies for ARFID in the future.

Recent studies indicate that Avoidant Restrictive Food Intake Disorder (ARFID) is a complex feeding and eating disorder often diagnosed in younger children. To date, there are no large studies using administrative data to examine hospital utilization or costs among patients with ARFID. In a geographically diverse cohort of pediatric hospitals in the United States, we found inpatient admissions for ARFID have increased over time and that ARFID is associated with long, costly stays and readmissions which has important implications for identifying efficient treatment strategies. Future studies are needed to explore effective and efficient treatment strategies and prevent readmissions in this patient population.

Weight Stigma Associated With Mental Health Concerns Among College Students.

INTRODUCTION: Weight stigma is widespread and exists across numerous domains including health care, educational institutions, workplaces, mass media, and interpersonal relationships. Weight stigma experienced during the college years may be particularly consequential because the college years are a period of increased vulnerability for the development of mental health concerns. The purpose of the present study was to examine how experiences of weight stigma relate to mental health concerns, including symptoms of eating disorders, anxiety, and depression, among college students. METHODS: Prevalence of interpersonal and anticipated weight stigma was examined among 2,707 students participating in the 2018-2019 and 2019-2020 Healthy Minds Study and tested for differences in prevalence across student characteristics. Logistic regression was used to explore relationships between measures of weight stigma and student mental health. Analyses were conducted in 2021-2023. RESULTS: Interpersonal and anticipated weight stigma were reported by 12.3% and 15.3% of students, respectively. Experiences of interpersonal and anticipated weight stigma were generally lowest among cisgender male students, heterosexual students, those with the fewest financial concerns, and those who did not perceive themselves to be "overweight." Both interpersonal and anticipated weight stigma were associated with elevated odds of high weight concerns, past-month binge eating, past-month purging, high eating disorder risk, moderate/severe anxiety symptoms, and moderate/severe depressive symptoms. CONCLUSIONS: Findings implicate interpersonal and anticipated weight stigma as potential risk factors for a range of mental health concerns. Weight stigma is an under-recognized and under-funded public health problem.

Variation in care for inpatients with avoidant restrictive food intake disorder leads to development of a novel inpatient clinical pathway to standardize care.

INTRODUCTION: There is limited evidence to guide management of patients with avoidant restrictive food intake disorder (ARFID) admitted for medical stabilization. We describe variations in inpatient care which led to the development of a multidisciplinary inpatient clinical pathway (ICP) to provide standardized management and examine differences after the ICP was implemented. METHODS: A retrospective review of patients with ARFID admitted to Adolescent Medicine, Gastroenterology, and General Pediatrics at a single academic center was conducted. We compare hospital utilization and use of consulting services during the pre-ICP (2015-2017) and post-ICP (2018-2020) periods. RESULTS: 110 patients were admitted with ARFID (n = 57 pre- vs. n = 53 post-ICP). Most presented with moderate/severe malnutrition (63% pre vs. 81% post; p = 0.11) and co-morbid anxiety and/or depression (74% pre vs. 92% post; p = 0.01). There was some variation in use of enteral tube feeding by service in both periods (p = 0.76 and p = 0.38, respectively), although overall use was consistent between periods (46% pre vs. 58% post; p = 0.18). Pre-ICP, use of the restrictive eating disorder protocol differed across services (p < 0.001), with only AM using it. Overall, utilization of the restrictive eating disorder protocol decreased from 16% pre-ICP to 2% post-ICP (p = 0.02). There was variation by service in psychiatry/psychology (range 82-100% by service; p = 0.09) and social work consultations (range 17-71% by service; p = 0.001) during the pre-ICP period, though variation was reduced in the post-ICP period (p = 0.99 and p = 0.05, respectively). Implementation of the ICP led to improvements in these consultative services, with all patients in the post-ICP period receiving psychiatry/psychology consultation (p = 0.05) and an increase in social work consults from 44 to 64% (p = 0.03). Nutrition consults were consistently utilized in both periods (98% pre vs. 100% post; p = 0.33). CONCLUSION: The ICP was developed to standardize inpatient medical stabilization for patients with ARFID. In this single center study, implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: there were improvements in the use of consulting services and a reduction in the use of the restrictive eating disorder protocol. The ICP demonstrates the potential to further standardize and improve care over time.

There is limited evidence to guide management of children and adolescents with Avoidant Restrictive Food Intake Disorder (ARFID) admitted for medical stabilization. The study describes the variation in inpatient care for ARFID, which led to the development of a multidisciplinary standardized inpatient clinical pathway (ICP). The ICP centers the experience of the patient and family with an emphasis on biopsychosocial support. Implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: There were improvements in the use of psychiatry/psychology and social work consulting services and a reduction in the use of the restrictive eating disorder protocol. Future research is needed to better understand the impact of the inpatient clinical pathway to improve care over time.

Middle school food environments and racial/ethnic differences in sugar-sweetened beverage consumption: findings from the Healthy Choices study.

BACKGROUND: Prior studies have demonstrated disproportionate clustering of fast food outlets around schools. PURPOSE: The purpose of this study is to determine if racial/ethnic differences in middle school student self-reported sugar-sweetened beverage (SSB) consumption is explained by differential distributions of food outlets surrounding their schools. METHODS: Baseline (2005) data were analyzed from 18,281 middle school students in 47 Massachusetts schools participating in Healthy Choices, an obesity prevention program. Linear mixed effects models were used to examine the association of individual race/ethnicity and daily SSB consumption and the potential mediating effect of the density of food outlets (the number of fast food outlets and convenience stores in a 1500 m buffer area surrounding the school) on this association adjusting for individual and school demographics. RESULTS: More SSB consumption was reported by students of all racial/ethnic minority groups compared to their White peers except Asians. The density of fast food restaurants and convenience stores was not associated with individual SSB consumption (ß=0.001, p=0.875) nor did it mediate the association of race/ethnicity and SSB consumption. CONCLUSIONS: Racial and ethnic differences in SSB consumption among MA middle school students cannot be fully explained by the location of fast food restaurants and convenience stores.

The contribution of school environmental factors to individual and school variation in disordered weight control behaviors in a statewide sample of middle schools.

We investigated the contribution of school environmental factors to individual and school variation in disordered weight control behaviors (DWCB). Analyses were based on self-report data gathered from 18,567 middle-school students in 2005 and publicly available data on school characteristics. We observed large differences across schools in percent of students engaging in DWCB in the past month, ranging from less than 1% of the student body to 12%. School-neighborhood poverty was associated with higher odds of DWCB in boys. Preventive strategies need to account for wide variability across schools and environmental factors that may contribute to DWCB in early adolescence.