Pragmatic clinical trials to advance research in children and adolescents with eating disorders.

OBJECTIVE: To discuss the utility of pragmatic clinical trials (PCTs) to help advance research in eating disorders (EDs). METHODS: We describe challenges associated with traditional explanatory research trials and examine PCTs as an alternative, including a review of the PRECIS-2 tool. RESULTS: There are many challenges associated with the design and completion of traditional RCTs within the field of EDs. Pragmatic clinical trials are studies that closely align with conditions available in everyday practice and focus on outcomes that are relevant to patients and clinicians. Results of PCTS maximize applicability and generalizability to clinical settings. DISCUSSION: Available therapies established for the treatment of EDs provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In addition to a general overview of PCTs, we draw upon published literature and our own experiences involving adjunctive olanzapine for the treatment of children and youth with anorexia nervosa to help highlight challenges associated with randomized controlled trial (RCT) design and implementation, and offer pragmatic suggestions that would allow patients greater choice in treatment trials, while at the same time capturing outcomes that are most likely to advance treatment efforts. CONCLUSIONS: Pragmatic clinical trials provide alternatives to RCT design that can help bolster research in EDs that aims to explore real-world effects of interventions. PUBLIC SIGNIFICANCE: Available therapies established for the treatment of eating disorders (EDs) in children and adolescents provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In this article, we discuss the utility of pragmatic trials to help promote research that can help advance knowledge that is relevant to clinical care settings.

Examining the role of artificial intelligence to advance knowledge and address barriers to research in eating disorders.

OBJECTIVE: To provide a brief overview of artificial intelligence (AI) application within the field of eating disorders (EDs) and propose focused solutions for research. METHOD: An overview and summary of AI application pertinent to EDs with focus on AI's ability to address issues relating to data sharing and pooling (and associated privacy concerns), data augmentation, as well as bias within datasets is provided. RESULTS: In addition to clinical applications, AI can utilize useful tools to help combat commonly encountered challenges in ED research, including issues relating to low prevalence of specific subpopulations of patients, small overall sample sizes, and bias within datasets. DISCUSSION: There is tremendous potential to embed and utilize various facets of artificial intelligence (AI) to help improve our understanding of EDs and further evaluate and investigate questions that ultimately seek to improve outcomes. Beyond the technology, issues relating to regulation of AI, establishing ethical guidelines for its application, and the trust of providers and patients are all needed for ultimate adoption and acceptance into ED practice. PUBLIC SIGNIFICANCE: Artificial intelligence (AI) offers a promise of significant potential within the realm of eating disorders (EDs) and encompasses a broad set of techniques that offer utility in various facets of ED research and by extension delivery of clinical care. Beyond the technology, issues relating to regulation, establishing ethical guidelines for application, and the trust of providers and patients are needed for the ultimate adoption and acceptance of AI into ED practice.

Exploring biologically oriented precision mental health initiatives for the care of patients with eating disorders: A narrative review.

OBJECTIVE: Eating disorders (EDs) represent a major public health burden. Increasingly, studies suggest mental health (MH) fields are failing to improve the effectiveness of treatments and that alternative models of care must be considered. Precision mental health (PMH) seeks to tailor treatment to individual needs and relies on a comprehensive understanding of the neurobiological and physiological underpinnings of mental illness. METHODS: In this narrative review, published literature with focus on biological application of PMH strategies for EDs is reviewed and summarised. RESULTS: A total of 39 articles were retained for the review covering a variety of themes with relevance to PMH. Many studies of biological markers with PMH applicability focused on anorexia nervosa. Although a variety of potential PMH research applications were identified, the review failed to identify any evidence of implementation into routine ED practice. CONCLUSIONS: Despite the theoretical merit of biological application of PMH in ED treatment, clinical applications for standard practice are lacking. There is a need to invest further in studies that seek to identify biological markers and investigate neurobiological underpinnings of disease in hopes of targeting and developing treatments that can be better tailored to the individualised needs of patients.

Approach to anorexia nervosa and atypical anorexia nervosa in adolescents.

OBJECTIVE: To address screening, diagnosis, and treatment of adolescents with anorexia nervosa and atypical anorexia nervosa in primary care. SOURCES OF INFORMATION: A literature search was conducted in PubMed using the subject headings anorexia nervosa, adolescents, COVID-19, review, guidelines, and primary care. Applicable articles were reviewed, with key recommendations summarized. Most evidence is level I. MAIN MESSAGE: Recent studies suggest that the global COVID-19 pandemic contributed to an increase in the incidence of eating disorders, particularly among teenagers. This has resulted in increasing responsibility for primary care providers regarding the assessment, diagnosis, and management of these disorders. Moreover, primary care providers are in ideal positions to identify adolescents at risk of eating disorders. Early intervention is of utmost importance for avoiding long-term health consequences. High rates of atypical anorexia nervosa indicate a need for providers to have awareness of weight biases and stigmas. Treatment primarily involves a combination of renourishment and psychotherapy, generally through family-based therapy, with pharmacotherapy playing a lesser role. CONCLUSION: Anorexia nervosa and atypical anorexia nervosa are serious, potentially life-threatening illnesses that are best addressed through early detection and treatment. Family physicians are in an optimal position to screen for, diagnose, and treat these illnesses.

Health professionals' familiarity and experience with providing clinical care for pediatric avoidant/restrictive food intake disorder.

OBJECTIVE: The current study explored the experience and familiarity of pediatric health professionals with avoidant/restrictive food intake disorder (ARFID), and assessed the application of diagnostic criteria in a series of clinical vignettes. METHOD: Pediatric health professionals were invited to complete an online survey. Data from 93 health professionals from medical and allied health roles who completed the survey were analyzed. RESULTS: Respondents providing care for pediatric feeding/eating disorders were more likely to report familiarity with ARFID than those not typically providing care for feeding/eating disorders. Clinicians who had provided care for pediatric ARFID reported more confidence in clinical management of ARFID than did those who had not yet provided care for ARFID, though there were overall relatively low levels of confidence in providing care for ARFID. Respondents to the clinical vignettes were more likely to confer a diagnosis of ARFID when there were symptoms of both psychosocial impairment and weight loss than when there was psychosocial impairment alone. DISCUSSION: The results suggest variability in current application of diagnostic criteria for ARFID, low confidence in clinical management of ARFID, and ambiguity in clinicians' judgments regarding whether psychosocial impairment is sufficient to meet a diagnosis of ARFID.

Attitudes toward physical activity as a treatment component for adolescents with anorexia nervosa: An exploratory qualitative study of patient perceptions.

OBJECTIVE: Anorexia nervosa (AN) with compulsive exercise is associated with poor treatment outcomes. This study sought to understand the attitudes of adolescents with AN from various stages of treatment, toward physical activity research practices and physical activity as a component of treatment. METHOD: Seventeen adolescents 12-18 years old (15 female) with AN (10 with acknowledged history of compulsive exercise) were recruited from a Canadian Tertiary Care Hospital's Eating Disorder Program. Six inpatients, 5-day program patients, and six outpatients treated by either the inpatient and/or day treatment program in the past 2 years completed individual, semi-structured interviews that were audio-recorded and transcribed. Results were analyzed deductively using qualitative techniques. RESULTS: Participants recognized both benefits (psychological, sociological, and physiological) and risks (trigger negative thoughts, increase competitive behavior) of implementing physical activity into acute AN treatment. Patient characteristics, such as stage of treatment and exercise history, had an impact on participants' perceptions toward physical activity in AN. Participants suggested that the ideal physical activity program would be focused on fun, individualized and progressively integrated, group-based, and directly supported by staff. Although the majority of participants stated that they would wear an activity monitor for research purposes, concerns were voiced regarding compliance and the potential impact on eating disorder symptomatology. DISCUSSION: Participants overwhelmingly supported the careful implementation of structured physical activity and physical activity psychoeducation into the acute treatment of adolescents with AN. This study allows for the inclusion of patient voices in the conversation surrounding the role of physical activity in AN treatment.

Asceticism, perfectionism and overcontrol in youth with eating disorders.

PURPOSE: Personality traits such as perfectionism and asceticism, and combinations of these traits (i.e., overcontrol) have been related to eating disorder (ED) diagnosis, symptoms, and chronicity in adult patients with EDs. However, as limited evidence exists in adolescents, the aim of the present study was to examine these links in a clinical sample of adolescents with EDs. METHOD: A retrospective chart review was conducted on 178 adolescents (91% females; Mage = 15.73 years, SD = 1.31) receiving services at a tertiary care pediatric ED program. An examination of variability in mean levels of perfectionism, asceticism, and overcontrol across ED symptom groups (restrictive and binge/purge ED subtypes) was conducted to learn of diagnostic differences, while correlations were used to explore the association of these personality traits with comorbid anxiety and depressive symptoms. Hierarchical linear regression was used to assess whether overcontrol was related to length of stay (LOS) in an inpatient program. RESULTS: Results indicated that adolescents with binge-purge symptoms had higher levels of perfectionism, asceticism and overcontrol compared to those with restrictive symptoms, and that greater levels of perfectionism, asceticism and overcontrol were associated with elevated depression and anxiety symptoms. Additionally, overcontrol predicted greater LOS in the inpatient ED program. CONCLUSION: Results suggest the importance of assessing, monitoring and targeting overcontrol in treatment for adolescents with EDs given its impact on comorbid symptoms and LOS. LEVEL OF EVIDENCE: Level III, evidence obtained from case-control analytic studies.

Severe alcohol intoxication among Canadian Youth: A 2-year surveillance study.

PURPOSE: To obtain data on Canadian youth, aged 11 to 15 years, presenting to paediatric emergency departments, with severe alcohol intoxication and to describe demographics, presentations to hospital, concurrent substance use, comorbidities, and short-term outcomes of admission to emergency departments. METHODS: Between March 2013 and February 2015, through the established methodology of the Canadian Paediatric Surveillance Program, Canadian paediatricians and paediatric subspecialists were surveyed monthly to identify cases of young adolescents presenting to paediatric emergency departments across Canada with severe alcohol intoxication. Those that identified cases were subsequently sent a detailed questionnaire. The detailed questionnaires were then screened to ensure the reported cases met the study's inclusion criteria. RESULTS: A total of 39 cases (18 females and 21 males) were included in the final analysis. Overall, results indicate over 90% of presenting youth had consumed spirits, 39% had concurrent substance use and 46% experienced serious medical morbidity. Almost two-thirds of youth were admitted to hospital for a period ranging from 10 hours to 5 days; 12 youth required intubation. Follow-up referrals were provided to two-thirds of youth, with variable supports given. No statistically significant differences between sexes were noted for blood alcohol level or concurrent substance use. CONCLUSION: Although rates of alcohol use in adolescents have been steadily decreasing, results from this surveillance study suggest that severe intoxication arising from the use of alcohol alone, and with concurrent substance use, results in significant immediate health consequences in young adolescents. Results from this study also highlight characteristics of patients, initial treatments and initial referrals across Canadian paediatric healthcare facilities, the results of which highlight variability and may aid in the guidance of a future longitudinal study, prevention strategies, and public health messaging.

Cocreating research priorities for anorexia nervosa: The Canadian Eating Disorder Priority Setting Partnership.

OBJECTIVE: The Canadian Eating Disorder Priority Setting Partnership was established to identify and prioritize the top 10 research priorities for females, 15 years or older, with anorexia nervosa, by incorporating equal input from those with lived experience, families, and healthcare professionals. METHOD: This project, which closely followed the James Lind Alliance guidelines, solicited research priorities from the Canadian eating disorder community by means of a five-step process including use of a survey, response collation, literature checking, interim ranking survey, and in-person prioritization workshop. RESULTS: The initial survey elicited 897 priorities from 147 individuals, with almost equal representation from all three stakeholder groups. From this, 603 responses aligned with the project objectives and were collapsed into 71 broader indicative questions. Based on available systematic reviews, 18 indicative questions were removed as they were considered answered by existing literature while 8 indicative questions were added from the recommendations of the reviews. In total, 61 indicative questions were ranked in an interim ranking survey, where 21 questions were prioritized as important by at least 20% of respondents. As a final step, 28 individuals from across Canada attended the prioritization workshop to coestablish the top 10 research priorities. DISCUSSION: Top priorities were related to treatment gaps and the need for more surveillance data. This systematic methodology allowed for a transparent and collaborative approach to identifying current priorities from both the service user and provider perspective. Wide dissemination is anticipated to promote work that is of high relevance to patients, families, and clinicians.

Characteristics and clinical trajectories of patients meeting criteria for avoidant/restrictive food intake disorder that are subsequently reclassified as anorexia nervosa.

OBJECTIVE: To examine the initial assessment profiles and early treatment trajectories of youth meeting the criteria for avoidant/restrictive food intake disorder (ARFID) that were subsequently reclassified as anorexia nervosa (AN). METHOD: A retrospective cohort study of patients assessed and treated in a tertiary care eating disorders (ED) program was completed. RESULTS: Of the 77 included patients initially meeting criteria for ARFID, six were reclassified as having AN (7.8%) at a median rate of 71 days after the first assessment. Patients in this cohort presented at very low % treatment goal weight (median 71.6%), self-reported abbreviated length of illness (median 6 months), and exhibited low resting heart rates (median 46 beats per minute). Nutrition and feeding focused worries related more to general health as opposed to specific weight and shape concerns or fears at assessment in half of those reclassified with AN. Treatment at the 6-month mark varied among patients, but comprised family and individual therapy, as well as prescription of psychotropic medication. CONCLUSION: Prospective longitudinal research that utilizes ARFID-specific as well as traditional eating disorder diagnostic measures is required to better understand how patients with restrictive eating disorders that deny fear of weight gain can be differentiated and best treated.

Bingeing, Purging, and Suicidal Ideation in Clinical and Non-Clinical Samples of Youth.

Suicidal ideation is a serious mental health concern reported by adolescents. Despite understanding of increased suicidal ideation in patients with eating disorders (EDs) and obesity, few studies have compared how disordered eating (bingeing, vomiting and over exercising) is associated with suicidal ideation in clinical and non-clinical samples of youth across the ED and weight spectrum. The present study aimed to 1) comparatively examine rates of suicidal ideation and disordered eating behaviors in clinical samples of youth with EDs, complex obesity, or from the community, and 2) examine whether disordered eating was associated with suicidal ideation above and beyond age, body mass index, diagnosis, treatment-seeking status, and depressive symptoms in large samples of males vs. females in an attempt to understand whether these behaviors should lead to concern regarding suicidal ideation. Data from charts on treatment-seeking adolescents diagnosed with either an ED (N = 315), severe complex obesity (N = 212), and from the community (N = 3036) were pooled together for comparative purposes. Results showed that suicidal ideation was higher in youth seeking treatment for an ED (50.2%) and obesity (23.7%) as compared to youth from the community (13%). Binary logistic regression analyses revealed that vomiting (OR = 1.73 for females, 8.17 for males) and over-exercising (OR = 1.47 for females, 1.68 for males) was significantly associated with suicidal ideation in both males and females. Findings underscore the importance of screening for suicidal ideation in youth who report vomiting or over-exercising despite diagnostic presentation, age, weight, or treatment setting.

Development of the Ottawa Disordered Eating Screen for Youth: The ODES-Y.

OBJECTIVE: To develop a concise screening tool that allows for early identification of disordered eating in youth. STUDY DESIGN: In this 2-step classification accuracy study, questions for the Ottawa Disordered Eating Screen-Youth, a 2-question screening tool (index test), were conceptualized by clinician-scientists from tertiary care pediatric eating disorder and weight-related clinics, and was validated using retrospective data (2004-2010) from a community-based study, the Research on Eating and Adolescent Lifestyles (REAL) study. RESULTS: Analyses of contrast between the index test and the reference standard using data from 2892 (1714 females) students between grade 7 and grade 12 revealed classification statistics of 67.1% for sensitivity, 85.9% for specificity, 4.7 for positive likelihood ratio, 0.38 for negative likelihood ratio, 50.6% for positive predictive value, and 92.4% for negative predictive value for females and 61.1% for sensitivity, 93.9% for specificity, and 9.9 for positive likelihood ratio, 0.41 for negative likelihood ratio, 32.3% for positive predictive value, and 98.0% for negative predictive value for males. CONCLUSIONS: Our findings suggest that the index test has utility as a short and accurate screening tool for earlier detection of disordered eating thoughts and behaviors in youth. Additional research is needed to best determine how the index test can be administered to youth across various health care, school, public health, and surveillance settings in clinically sensitive pragmatic ways.

Avoidant restrictive food intake disorder: First do no harm.

OBJECTIVE: This opinion piece offers some considerations, both medical and psychological, for the use of nasogastric tube (NGT) feedings in the treatment of avoidant restrictive food intake disorder (ARFID) in children and adolescents. METHOD: Although there is empirical support for the use of NGT feedings in the treatment of anorexia nervosa, this evidence base does not exist for the treatment of ARFID. As such, there is need to delineate pragmatic considerations in the use of this procedure. RESULTS: Issues of medical necessity notwithstanding, we advise that the use of this procedure be considered more cautiously due to the oral sensitivities inherent in many individuals with ARFID and the potential psychological consequences. These sensitivities may make the experience of NGT feedings particularly aversive, with the potential of creating iatrogenic conditioned food aversions. DISCUSSION: This article encourages clinicians to give careful thought and attention when considering NGT feedings in children and adolescents with ARFID.

Use of cyproheptadine to stimulate appetite and body weight gain: A systematic review.

OBJECTIVE: A systematic review identifying the use of cyproheptadine (CY) as an appetite stimulant was completed. METHOD: Studies of any design exploring the efficacy of CY as an appetite stimulant in all age groups and populations were included. Primary outcomes of studies included were weight gain, appetite stimulation, and/or caloric/nutritional intake increase. The review was completed in accordance with PRISMA standards. RESULTS: A total of 46 articles across 21 different treatment populations met criteria for the review, including 32 randomized controlled trials, 4 prospective cohort studies, 4 retrospective cohort studies, 4 case reports and 2 case series. Of these, 39 demonstrated that CY resulted in significant weight gain in the sample under study. Studies exploring the use of CY in those with malignant/progressive disease states, such as HIV and cancer, showed minimal to no benefit of the medication. Transient mild to moderate sedation was the most commonly reported side effect. Studies included were heterogeneous in terms of methods as well as study patient demographics, characteristics and concurrent medical conditions. Few studies provided objective measures of appetite change. DISCUSSION: CY appears to be a safe, generally well-tolerated medication that has utility in helping facilitate weight gain in patients drawn from a variety of underweight populations. Future prospective randomized controlled studies in low weight patients that include objective measures of appetite and intake are needed to better understand the mechanism by which CY augments weight gain.

Building evidence for the use of descriptive subtypes in youth with avoidant restrictive food intake disorder.

OBJECTIVE: To examine characteristics of patients with Avoidant/Restrictive Food Intake Disorder (ARFID) in an effort to identify and describe subtypes of the disorder. METHOD: A retrospective chart review was completed for patients aged 8-17 years assessed over a 17-year period. RESULTS: Seventy-seven patients were included in the study, the majority of whom were female (n = 56, 73%). The average age of patients was 13.7 years (SD = 2.4 years). Three specific subtypes of ARFID (aligning with example presentations outlined in the DSM-5) were identified: (a) those with weight loss and/or medical compromise as a consequence of apparent lack of interest in eating (n = 30, 39%); (b) restriction arising as a result of sensory sensitivity (n = 14, 18%); and (c) restriction based upon food avoidance and/or fear of aversive consequences of eating (n = 33, 43%). Clinical characteristics of patients varied depending on the assigned subtype. DISCUSSION: Our findings highlight the need for further research into the relative merit of subtype-assignment in patients with ARFID and whether such practice would aid in the recommended treatment. Further research is required to understand whether these categories are generalizable and applicable to other samples such as young children or adults with ARFID, and how treatment options might differ according to subtype.

Approche de l'anorexie mentale et de l'anorexie mentale atypique chez l'adolescent.

OBJECTIF: Aborder le dépistage, le diagnostic et le traitement de l'anorexie mentale et de l'anorexie mentale atypique chez les adolescents en soins primaires. SOURCES DE L'INFORMATION: Une recherche documentaire a été effectuée dans PubMed à l'aide des rubriques thématiques en anglais anorexia nervosa, adolescents, COVID-19, review, guidelines et primary care. Les articles pertinents ont été passés en revue et les principales recommandations ont été résumées. La plupart des données probantes sont de niveau I. MESSAGE PRINCIPAL: De récentes études font valoir que la pandémie mondiale de la COVID-19 a contribué à une augmentation de l'incidence des troubles du comportement alimentaire, en particulier chez les adolescents. Il s'ensuit de plus grandes responsabilités pour les professionnels des soins primaires concernant l'évaluation, le diagnostic et la prise en charge de ces troubles. En outre, les professionnels des soins primaires sont bien placés pour identifier les adolescents à risque de troubles du comportement alimentaire. Une intervention précoce revêt une importance capitale pour éviter les conséquences à long terme pour la santé. Des taux élevés d'anorexie mentale atypique indiquent la nécessité que les professionnels soient sensibilisés aux préjudices et à la stigmatisation entourant le poids. Le traitement comporte principalement une combinaison de renutrition et de psychothérapie, généralement au moyen d'une thérapie familiale, et la pharmacothérapie joue un rôle secondaire. CONCLUSION: L'anorexie mentale et l'anorexie mentale atypique sont des maladies graves et potentiellement mortelles, et leur prise en charge optimale comprend la détection et le traitement précoces. Les médecins de famille sont très bien placés pour dépister, diagnostiquer et traiter ces maladies.

Adolescent pregnancy and eating disorders: a minireview and case report.

BACKGROUND: Despite the fact that eating disorders (EDs) during pregnancy and early child bearing can both individually increase risk to mother and child, there is a paucity of research exploring pregnancy in adolescence and concomitant EDs. CASE: We report the case of a 16-year-old female with atypical anorexia nervosa, who experiences a remission of her ED behavior during pregnancy, followed by a severe relapse in the post-partum period. CONCLUSION: In this case, pregnancy functioned as a motivator for remission in our patient with concomitant ED. Further research is needed to identify risks of EDs in adolescent pregnancy, to explore the trajectory of pre-existing EDs during pregnancy and to identify effective interventions for prolonging remission into the post-partum period.

Determining treatment goal weights for children and adolescents with anorexia nervosa.

One of the challenges faced by paediatric health professionals treating children and adolescents with anorexia nervosa (AN) is determining the specific weight needed to achieve physical, emotional and cognitive recovery. Clinicians and researchers have struggled to standardize process, methods and terminology around what is now referred to as the 'treatment goal weight' (TGW). This practice point summarizes recommendations drawn from common methods used to determine TGWs in children and adolescents with AN, which are based on both the evidence-based literature and expert consensus. An individualized approach to the determination of the TGW is offered, with some specifics for special clinical situations. Multiple factors inform the process of establishing a TGW for a child or adolescent with AN but individualized attention, especially to premorbid weights, heights, body mass index percentiles, and paediatric growth charts, is essential. The need for ongoing follow-up and regular reassessment in this population is also highlighted.

From questions to answers: Examining the role of pediatric surveillance units in eating disorder research.

Pediatric Surveillance Units (PSUs) provide a unique model for the study of pediatric eating disorders (EDs). Australia, Britain, and Canada have surveillance programs that have generated valuable epidemiological and clinical data on early-onset eating disorders (EOED). The PSUs represent an important collaborative tool that has helped shape our understanding of EOEDs and offers potential to contribute to decisions regarding health resource allocation and public health policy. This paper reviews the role of PSUs as a unique model to study pediatric EDs and its success in translating the knowledge generated by these programs into improving the health of children and adolescents with EDs worldwide.

Exploring the association between eating disorders and gender dysphoria in youth.

This study reviews the overlap between eating disorders (EDs) and gender dysphoria (GD) in an adolescent population. A retrospective chart review was conducted on a clinical population presenting for concerns of GD. It was noted that five of the 97 patients had been found to be suffering from an ED at presentation. An additional 10 patients were noted to have ED-related symptoms. Although ED risk was elevated in trans males and females, absolute risk was higher in trans males when compared to population based prevalence rates. Our results suggest that rates of EDs and ED-related symptoms are high in patients presenting with GD, and that standard screening for these symptoms should be considered in both populations at assessment and over the course of treatment.