Momentary skills use predicts decreased binge eating and purging early in day treatment: An ecological momentary assessment study.

OBJECTIVE: Emerging research indicates that skills acquisition may be important to behavior change in cognitive behavior therapy (CBT) for eating disorders. This study investigated whether skills use assessed in real time during the initial 4 weeks of CBT-based day treatment was associated with momentary eating disorder behavior change and rapid response to treatment. METHODS: Participants with DSM-5 bulimia nervosa or purging disorder (N = 58) completed ecological momentary assessments (EMA) several times daily for the first 28 days of treatment. EMA assessed skills use, the occurrence of binge eating and/or purging, and state negative affect. Rapid response was defined as abstinence from binge eating and/or purging in the first 4 weeks of treatment. RESULTS: Greater real-time skills use overall, and use of "planning ahead," "distraction," "social support," and "mechanical eating" skills in particular, were associated with a lower likelihood of engaging in binge eating or purging during the same period. After controlling for baseline group differences in overall difficulties with emotion regulation, rapid and non-rapid responders did not differ in overall skills use, or skills use at times of higher negative affect, during the EMA period. DISCUSSION: Momentary use of skills appears to play an important role in preventing binge eating and purging, and certain skills appear to be particularly helpful. These findings contribute to the literature elucidating the processes by which CBT treatments for eating disorders work by providing empirical evidence that skills use helps to prevent binge eating and purging behaviors. PUBLIC SIGNIFICANCE: Individuals with eating disorders learn new skills during treatment to help them improve their symptoms. This study shows that for people with eating disorders, using skills helps prevent eating disorder behaviors in the moment. Certain skills may be particularly helpful, including planning ahead, distracting activities, support from others, and focusing on eating meals and snacks regardless of how one is feeling. These findings help us better understand how treatments work.

A pilot study of a virtually delivered dissonance-based eating disorder prevention program for young women with type 1 diabetes: within-subject changes over 6-month follow-up.

INTRODUCTION: In an uncontrolled study, we previously demonstrated the feasibility and preliminary efficacy of our virtual diabetes-specific version (Diabetes Body Project) of the eating disorder (ED) prevention program the Body Project. The aim of the current study was to evaluate further this program for women with type 1 diabetes (T1D) by assessing within-subject changes in outcomes from pretest over 6-month follow-up. METHODS: Young women with T1D aged 16-35 years were invited to participate in Diabetes Body Project groups. A total of 35 participants were allocated to five Diabetes Body Project groups (six meetings over 6 weeks). Primary outcome measures included ED risk factors and symptoms, and secondary outcomes included three T1D-specific constructs previously found to be associated with ED pathology: glycemic control as measured by HbA1c level, diabetes distress, and illness perceptions. RESULTS: Within-subject reductions, with medium-to-large effect sizes, were observed for the primary (ED pathology, body dissatisfaction, thin-ideal internalization, and appearance ideals and pressures) and secondary outcomes (within-condition Cohen's ds ranged from .34 to 1.70). CONCLUSION: The virtual Diabetes Body Project appears to be a promising intervention worthy of more rigorous evaluation. A randomized controlled trial with at least a 1-year follow-up is warranted to determine its efficacy compared to a control condition.

Maintenance treatment for eating disorders following inpatient or day treatment: outcomes of intensive outpatient group and individual CBT treatments.

Relapse is a substantial problem in eating disorders. Until recently, there have been few investigations into maintenance treatments aimed at helping patients maintain improvements made in treatment. This study compared the outcomes of group-based intensive outpatient versus individual cognitive behavioural therapy (CBT)-based maintenance treatments for eating disorders, following inpatient or day treatment. In this sequential cohort study, patients received the type of maintenance treatment (intensive outpatient group or individual CBT) available at the time. A total of 221 patients with eating disorders were included, and data were examined retrospectively. Cox regression was used to determine whether treatment type predicted rate of return to clinically significant symptoms over the 12 months following inpatient or day treatment. Intensive outpatient group versus individual CBT maintenance treatment did not predict differential rate or trajectory of return to clinically significant symptoms in diagnostic subgroups and the overall sample. Maintenance treatment type did not predict changes in weight/shape concerns between end-of-inpatient or day treatment) and 6- or 12-month follow-up (after controlling for diagnosis). Although the treatments appeared similarly effective in helping patients maintain gains made in intensive treatment, individual CBT may be a more time- and cost-efficient approach to delivering maintenance treatment.

Randomised controlled trial of the effects of increased energy intake on menstrual recovery in exercising women with menstrual disturbances: the 'REFUEL' study.

STUDY QUESTION: Does increased daily energy intake lead to menstrual recovery in exercising women with oligomenorrhoea (Oligo) or amenorrhoea (Amen)? SUMMARY ANSWER: A modest increase in daily energy intake (330 ± 65 kcal/day; 18 ± 4%) is sufficient to induce menstrual recovery in exercising women with Oligo/Amen. WHAT IS KNOWN ALREADY: Optimal energy availability is critical for normal reproductive function, but the magnitude of increased energy intake necessary for menstrual recovery in exercising women, along with the associated metabolic changes, is not known. STUDY DESIGN, SIZE, DURATION: The REFUEL study (trial # NCT00392873) is the first randomised controlled trial to assess the effectiveness of 12 months of increased energy intake on menstrual function in 76 exercising women with menstrual disturbances. Participants were randomised (block method) to increase energy intake 20-40% above baseline energy needs (Oligo/Amen + Cal, n = 40) or maintain energy intake (Oligo/Amen Control, n = 36). The study was performed from 2006 to 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were Amen and Oligo exercising women (age = 21.0 ± 0.3 years, BMI = 20.8 ± 0.2 kg/m2, body fat = 24.7 ± 0.6%) recruited from two universities. Detailed assessment of menstrual function was performed using logs and measures of daily urinary ovarian steroids. Body composition and metabolic outcomes were assessed every 3 months. MAIN RESULTS AND THE ROLE OF CHANCE: Using an intent-to-treat analysis, the Oligo/Amen + Cal group was more likely to experience menses during the intervention than the Oligo/Amen Control group (P = 0.002; hazard ratio [CI] = 1.91 [1.27, 2.89]). In the intent-to-treat analysis, the Oligo/Amen + Cal group demonstrated a greater increase in energy intake, body weight, percent body fat and total triiodothyronine (TT3) compared to the Oligo/Amen Control group (P < 0.05). In a subgroup analysis where n = 22 participants were excluded (ambiguous baseline menstrual cycle, insufficient time in intervention for menstrual recovery classification), 64% of the Oligo/Amen + Cal group exhibited improved menstrual function compared with 19% in the Oligo/Amen Control group (χ2, P = 0.001). LIMITATIONS, REASONS FOR CAUTION: While we had a greater than expected dropout rate for the 12-month intervention, it was comparable to other shorter interventions of 3-6 months in duration. Menstrual recovery defined herein does not account for quality of recovery. WIDER IMPLICATIONS OF THE FINDINGS: Expanding upon findings in shorter, non-randomised studies, a modest increase in daily energy intake (330 ± 65 kcal/day; 18 ± 4%) is sufficient to induce menstrual recovery in exercising women with Oligo/Amen. Improved metabolism, as demonstrated by a modest increase in body weight (4.9%), percent body fat (13%) and TT3 (16%), was associated with menstrual recovery. STUDY FUNDING/COMPETING INTEREST(S): This research was supported by the U.S. Department of Defense: U.S. Army Medical Research and Material Command (Grant PR054531). Additional research assistance provided by the Penn State Clinical Research Center was supported by the National Center for Advancing Translation Sciences, National Institutes of Health, through Grant UL1 TR002014. M.P.O. was supported in part by the Loretta Anne Rogers Chair in Eating Disorders at University of Toronto and University Health Network. All authors report no conflict of interest. TRIAL REGISTRATION NUMBER: NCT00392873. TRIAL REGISTRATION DATE: October 2006. DATE OF FIRST PATIENT'S ENROLMENT: September 2006.

Feasibility of a virtually delivered eating disorder prevention program for young females with type 1 diabetes.

OBJECTIVE: This study aimed to develop a virtual diabetes-specific version of the eating disorder (ED) prevention program the Body Project, and to assess feasibility and preliminary efficacy of this program for young females with type 1 diabetes. METHOD: Young females with type 1 diabetes aged 16-35 years were invited to participate in the study. A total of 35 participants were allocated to five Diabetes Body Project groups (six meetings over 6 weeks) and completed pretest assessments; 26 participants completed all sessions and posttest assessments (<7 days after last meeting). Primary measures included ED risk factors and symptoms, and secondary outcomes included diabetes-specific constructs previously found to be associated with ED psychopathology (e.g., diabetes distress and illness perceptions). RESULTS: The ease of recruitment, timely conduct of five groups, moderate drop-out rate and appreciation of the intervention by participants indicated that the Diabetes Body Project is feasible. Meaningful reductions occurred on the primary outcomes (i.e., ED psychopathology, body dissatisfaction, and thin ideal internalization) and on internalization of appearance ideals and appearance pressures at posttest (Cohen's d ranging from .63 to .83, which are medium to large effects). Small to medium effect sizes were found for diabetes illness perceptions and distress (.41 and .48, respectively). DISCUSSION: The virtual Diabetes Body Project is a promising and much-needed intervention, worthy of more rigorous evaluation. A randomized controlled trial is warranted to determine its effectiveness compared with a control condition.

Severe and enduring anorexia nervosa: Fertile ground for iatrogenic development.

Care providers and individuals with severe and enduring anorexia nervosa (SE-AN) are weathering a perfect storm in which the sickest patients receive the least evidence-based treatment and iatrogenic factors play a significant role. Examining access to treatment from an ethical perspective is one strategy for developing more objective protocols related to the care of individuals with SE-AN.

A feasibility study comparing a web-based intervention to a workshop intervention for caregivers of adults with eating disorders.

OBJECTIVE: To assess for the validity of a future trial, the current feasibility study aimed to compare the feasibility and efficacy of a web- and workshop-based education intervention for caregivers of adults with eating disorders. METHODS: Psychoeducation was provided to caregivers, who were randomly assigned to a web or workshop condition. Independent samples t tests were conducted to analyse the between-group effect sizes for intervention condition with regard to change over time. A random selection of participants from each intervention provided qualitative feedback about their experiences. RESULTS: Overall, participants reported positive experiences in both education interventions. From baseline to the end of intervention, small between-group effect sizes were observed for changes in caregiver accommodation, problem-solving abilities, the quality of psychological health, and the quality of social relationships, favouring the web-based intervention, and changes in expressed emotion in the family context, caregiver burden, perceived stress, and the quality of the environment, supporting the workshop intervention. CONCLUSIONS: There was a difference in initial feasibility of the web intervention. A future large-scale trial of these interventions is supported by the results of this feasibility study.

Rapid improvements in emotion regulation predict intensive treatment outcome for patients with bulimia nervosa and purging disorder.

OBJECTIVE: Rapid and substantial behavior change (RSBC) early in cognitive behavior therapy (CBT) for eating disorders is the strongest known predictor of treatment outcome. Rapid change in other clinically relevant variables may also be important. This study examined whether rapid change in emotion regulation predicted treatment outcomes, beyond the effects of RSBC. METHOD: Participants were diagnosed with bulimia nervosa or purging disorder (N = 104) and completed ≥6 weeks of CBT-based intensive treatment. Hierarchical regression models were used to test whether rapid change in emotion regulation variables predicted posttreatment outcomes, defined in three ways: (a) binge/purge abstinence; (b) cognitive eating disorder psychopathology; and (c) depression symptoms. Baseline psychopathology and emotion regulation difficulties and RSBC were controlled for. RESULTS: After controlling for baseline variables and RSBC, rapid improvement in access to emotion regulation strategies made significant unique contributions to the prediction of posttreatment binge/purge abstinence, cognitive psychopathology of eating disorders, and depression symptoms. DISCUSSION: Individuals with eating disorders who rapidly improve their belief that they can effectively modulate negative emotions are more likely to achieve a variety of good treatment outcomes. This supports the formal inclusion of emotion regulation skills early in CBT, and encouraging patient beliefs that these strategies are helpful.

The direct health care costs of eating disorders among hospitalized patients: A population-based study.

OBJECTIVE: To estimate the direct health care costs of eating disorders in Ontario, Canada, in 2012, using a prevalence-based cost-of-illness approach. METHOD: We selected a population-based sample of all patients eligible for public health care insurance over the age of 4 with a hospitalization for an eating disorder at any point since 1988. We estimated total and mean direct net costs per patient in 2012, from the third public payer perspective, by sex, age group, and health service type. RESULTS: In 2012, there were 6,326 patients ever hospitalized for an eating disorder. They had a mean age of 31 at hospitalization, were mostly female (93%), and generally from high-income, urban neighborhoods. Direct total costs were just under $63 million CAD; direct net costs were roughly $48 million CAD. Mean net costs per patient were higher for females than males ($7,743.40 and $6,340.50, respectively), and higher for patients under 20 and patients 65+ ($17,961.50 and $14,953.90, respectively). The main cost drivers were psychiatric hospitalizations and physician visits, although this varied by age group. For younger patients, net costs were mainly because of psychiatric hospitalizations, while for older patients net costs were mainly because of psychiatric and nonpsychiatric hospitalizations, and other care. DISCUSSION: The cost of eating disorders is substantial and varies by sex and age group. Our findings suggest that, from a health care utilization/cost perspective, the effect of eating disorders is likely to persist over the lifespan.

Initial Findings From Project Recover: Overcoming Co-Occurring Eating Disorders and Posttraumatic Stress Disorder Through Integrated Treatment.

This pilot study is the initial investigation of an integrated cognitive behavioral therapy (CBT) for co-occurring eating disorders (ED) and posttraumatic stress disorder (PTSD). Following a course of intensive hospital-based ED treatment focused on ED behavioral symptom interruption, 10 individuals with ED-PTSD received 16 sessions of CBT that focused on maintaining improvements in ED symptoms outside of the hospital environment and integrated cognitive processing therapy for PTSD. We hypothesized that the treatment would be associated with significant improvements in PTSD symptoms, depression, and anxiety, as well as sustained improvements in ED symptomatology. There were statistically significant improvements in clinician-rated PTSD symptoms (gav = 4.58), depression (gav = 1.37), and anxiety (gav = 1.00). As expected, there was no statistically significant change in ED cognitions (gav = .28). Reliable change analyses revealed that only 1 participant experienced deterioration in ED cognitions over the course of the integrated treatment. Of the 9 participants who were remitted from behavioral ED symptoms at the end of intensive treatment/beginning of the integrated treatment, 8 remained behaviorally remitted at poststudy treatment, which is encouraging given the high rate of rapid relapse following intensive ED treatment. Findings from this study provide preliminary support for the efficacy of an integrated CBT for ED-PTSD.

Frontline clinicians' perspectives on and utilization of trauma-focused therapy with individuals with eating disorders.

With this study, we sought to survey clinicians regarding their perspectives and use of concurrent or integrated psychotherapy for co-occurring eating disorders (EDs) and posttraumatic stress disorder. We conducted a quantitative survey of 184 frontline ED clinicians to investigate whether, and to what extent, they view concurrent EDs and trauma-focused therapy as clinically important. We also assessed clinicians' specific concerns regarding concurrent EDs and trauma-focused treatment, as well as barriers to implementation of an evidence-based concurrent treatment. On the whole, clinicians reported that addressing trauma-related symptoms in individuals with EDs is highly important and should be administered concurrently. Although clinicians reported anticipating many important benefits of concurrent treatment, they also reported anticipating several potential negative side effects, and they reported a number of perceived barriers to implementation. Clinicians working in hospital settings anticipated more complications, expected fewer benefits, and perceived more barriers to the administration of concurrent treatment.

Adjunctive graded body image exposure for eating disorders: A randomized controlled initial trial in clinical practice.

OBJECTIVE: Graded body image exposure is a key component of CBT for eating disorders (EDs). However, despite being a highly anxiety-provoking intervention, its specific effectiveness is unknown. The aims of this initial study were to investigate the feasibility and preliminary effectiveness of individualized graded body image exposure to a range of feared/avoided body image-related situations in a sample of partially remitted ED patients. METHOD: Forty-five female adult participants were randomly assigned to maintenance treatment as usual (MTAU) only or MTAU plus five sessions of graded body image exposure. RESULTS: The graded body image exposure intervention led to large improvements in body avoidance as measured by two different methods. In addition, there was evidence of a significant impact of body image exposure on the overvaluation of shape, but not weight, 5 months after treatment. DISCUSSION: Taken together, the current results provide evidence of the feasibility of adjunctive individualized graded body image exposure within a clinical treatment program and suggest that graded body image exposure reduces body avoidance behaviors in partially remitted ED patients. Our findings suggest that individualized graded body image exposure shows promise as an intervention targeting the overvaluation of shape in EDs.

Predictors of rapid relapse in bulimia nervosa.

OBJECTIVE: Relapse remains a significant concern in bulimia nervosa, with some patients relapsing within months of treatment completion. The purpose of the study was to identify predictors of relapse within the first 6 months following treatment. METHOD: The 116 participants were bingeing and/or vomiting ≥ 8 times per month before day hospital (DH), and had ≤ 2 episodes per month in the last month of DH and the first month after DH. Rapid relapse was defined as ≥ 8 episodes per month for 3 months starting within 6 months. RESULTS: The rate of rapid relapse was 27.6%. Patients who relapsed soon after DH had higher frequencies of bingeing and vomiting before treatment, engaged in less body avoidance before treatment and were more likely to be slow responders to treatment. Weight and shape concerns and body checking were not significant predictors. DISCUSSION: More frequent bulimic symptoms accompanied by less body avoidance may indicate an entrenchment in the illness which in turn augurs a labored and transient response to DH treatment that is difficult to sustain after intensive treatment ends.

Eating disorders in individuals with type 1 diabetes: case series and day hospital treatment outcome.

Women with type 1 diabetes are at high risk for eating disorders (ED), a combination that can increase medical complications and mortality. As little is known about treatment response in this population, clinical presentation and treatment outcome in an extended case series were assessed. A chart review at the Eating Disorders Day Hospital Program at Toronto General Hospital identified a total of 100 individuals with type 1 diabetes assessed 1990-2012. Of 37 who attended day hospital, most experienced improvement in ED symptoms, but only 18.8% had a good immediate treatment outcome, while 43.8% had an intermediate outcome and 37.5% had a poor outcome (meeting diagnostic criteria at discharge). This is poorer than program outcomes in individuals without diabetes (χ(2) = 12.2, df = 2; p = 0.002). Factors influencing treatment engagement and outcome must be further studied and used to improve treatment results in this high-risk group.

Pilot study comparing multi-family therapy to single family therapy for adults with anorexia nervosa in an intensive eating disorder program.

Multi-family therapy (MFT) has yet to be evaluated in families of adults with anorexia nervosa (AN). The study aims were: (i) assess the feasibility of MFT for AN; and, (ii) assess whether MFT is associated with improved outcomes for families compared with single-family therapy (SFT). Adult patients with AN consecutively referred to an eating disorder treatment program were assigned (non-randomly) to receive eight sessions of SFT or MFT. Assessment occurred pre-therapy, immediately post-therapy, and at 3-month follow-up. A total of 37 female patients (13 SFT, 24 MFT) and 45 family members (16 SFT, 29 MFT) completed treatment. There were significant time effects for patients' BMI, eating disorder-related psychopathology and multiple family outcome measures. There were no differences between MFT and SFT on family outcome measures at end of treatment and 3 months post treatment. MFT is a feasible intervention that can be used in adult intensive treatment for those with AN.

The effectiveness of an individualized form of day hospital treatment.

The traditional group format of day hospital treatment for eating disorders restricts individual tailoring of treatment, which is challenging when complex cases are referred. In 2007 we introduced a new program that included individual sessions. Patients referred to this program were older, had longer illness duration, and more pre-treatment symptoms than the original group program. These clients also had more psychopathology, and were more likely to have a diagnosis of anorexia nervosa binge/purge subtype. Weight gain and abstinence from symptoms were less likely for patients in this new program. However, premature discharge, rapid response, symptom frequencies, and relapse rates did not differ.

2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013.

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhoea and osteoporosis. This consensus statement represents a set of recommendations developed following the 1st (San Francisco, California, USA) and 2nd (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team and implementation of treatment contracts. This consensus paper has been endorsed by the Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians and other healthcare professionals, the American College of Sports Medicine and the American Medical Society for Sports Medicine.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013.

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad.

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.

Depression, disturbed eating behavior, and metabolic control in teenage girls with type 1 diabetes.

BACKGROUND: Depression and disturbed eating behavior (DEB) are more common in girls with type 1 diabetes (T1D) than in the general population, and may negatively affect metabolic control. OBJECTIVE: To examine the relationship among depression, DEB, and metabolic control in teenage girls with T1D. METHODS: Metabolic control, body mass index and interview-ascertained symptoms of depression, and DEB were assessed twice in 98 girls with T1D, 9-14 y at baseline and 5 yr later at 14-18 yr. RESULTS: At year 5, 12.2% of girls reported current depressive symptoms, 49.0% reported current DEB, and 13.3% had a full or subthreshold eating disorder (ED). Eating Disorder Examination score was higher in girls with depression (1.4 ± 1.3 vs. 0.5 ± 0.7; p = 0.03), and 75.0% of girls with depression also endorsed DEB vs. 45.3% of girls without depression (p = 0.05). Girls with an ED were at high risk for depressive symptoms; 69.2% reported depressive symptoms vs. 22.0% of girls with no DEB (p = 0.004). Metabolic control was not significantly associated with either depression or DEB in this cohort. A regression model using baseline and year 5 depression and DEB to predict year 5 hemoglobin A1c was not significant overall. CONCLUSIONS: Depression and DEB were common and frequently concurrent in this cohort. It was encouraging that poor metabolic control was not yet strongly associated with either depression or DEB. Early detection and treatment may help to prevent the development of entrenched difficulties in this triad of mood, eating behavior, and metabolic control in a vulnerable population.