Paternal age at childbirth and eating disorders in offspring.

BACKGROUND: Advanced paternal age at childbirth is associated with psychiatric disorders in offspring, including schizophrenia, bipolar disorder and autism. However, few studies have investigated paternal age's relationship with eating disorders in offspring. In a large, population-based cohort, we examined the association between paternal age and offspring eating disorders, and whether that association remains after adjustment for potential confounders (e.g. parental education level) that may be related to late/early selection into fatherhood and to eating disorder incidence. METHOD: Data for 2 276 809 individuals born in Sweden 1979-2001 were extracted from Swedish population and healthcare registers. The authors used Cox proportional hazards models to examine the effect of paternal age on the first incidence of healthcare-recorded anorexia nervosa (AN) and all eating disorders (AED) occurring 1987-2009. Models were adjusted for sex, birth order, maternal age at childbirth, and maternal and paternal covariates including country of birth, highest education level, and lifetime psychiatric and criminal history. RESULTS: Even after adjustment for covariates including maternal age, advanced paternal age was associated with increased risk, and younger paternal age with decreased risk, of AN and AED. For example, the fully adjusted hazard ratio for the 45+ years (v. the 25-29 years) paternal age category was 1.32 [95% confidence interval (CI) 1.14-1.53] for AN and 1.26 (95% CI 1.13-1.40) for AED. CONCLUSIONS: In this large, population-based cohort, paternal age at childbirth was positively associated with eating disorders in offspring, even after adjustment for potential confounders. Future research should further explore potential explanations for the association, including de novo mutations in the paternal germline.

Case management at an outpatient unit for severe and enduring eating disorder patients at Stockholm Centre for Eating Disorders- a study protocol.

BACKGROUND: Patients with severe and enduring eating disorders (SEED) are seriously ill and have a low quality of life. Case management (CM), originally developed for adult patients with severe mental disabilities, has been shown to enhance social functioning and improve quality of life, while reducing the number and length of hospitalizations. In 2014, a special unit based on CM, for patients with SEED (the Eira unit) was started at Stockholm Centre for Eating Disorders, Sweden. METHOD/DESIGN: This study aims to investigate if CM can improve SEED patients' quality of life, and reduce their eating disorder symptoms as well as their health care consumption. Methods for data collection are a semi-structured diagnostic interview, self-report questionnaires, and a qualitative interview. The diagnostic interview and the self-report assessments will be done at start of treatment and at follow-ups after 1, 2, and 3years. The qualitative interview will be conducted 1 year after start of treatment. The study is approved by the ethical review board in Stockholm in compliance with the Helsinki Declaration. DISCUSSION: CM is a possible new contribution to the treatment methods for SEED. It does not aim at remission, but rather to accept life as it is, and to enhance quality of life in the presence of the ED. This study will investigate the potential benefits of this novel intervention in a special unit for SEED patients. TRIAL REGISTRATION: Clinicaltrials.gov Id: NCT02897622.

Evaluation of a guided internet self-treatment programme for bulimia nervosa in several European countries.

OBJECTIVE: The purposes of this study were to evaluate the use of an online guided self-treatment programme for bulimia nervosa (BN) and to determine predictors of outcome. Data were collected in four European countries where the programme was simultaneously used. METHOD: One hundred and twenty-seven BN or subthreshold BN female patients (mean age of 24.7 years) participated in a 4-month intervention using a CBT based online-guided self-help programme. Contact during the treatment period included weekly e-mails with a coach. ASSESSMENT: Measures included the Eating Disorders Inventory-2 (EDI-2) and the Symptom Check List-Revised (SCL-90R). RESULTS: Severity of eating disorders symptoms and general psychopathology improved significantly. Twenty-three per cent of patients were symptom free at the end of treatment. The dropout rate was 25.2%. A better score of general psychological health was a predictor of a better outcome. CONCLUSIONS: This study encourages further developments and research on innovative therapy approaches, particularly for those disorders such as BN, with difficult therapy and unclear prognosis.

Binge eating in surgical weight-loss treatments. Long-term associations with weight loss, health related quality of life (HRQL), and psychopathology.

BACKGROUND: Studies that have investigated the relationship between binge eating and the long-term outcome of bariatric surgery have shown mixed results. Does binge eating affect long-term BMI, health-related quality of life (HRQL), or psychopathology after surgery? METHODS: We assessed 173 bariatric patients before and three years after weight loss surgery with regard to weight, binge eating, HRQL, and psychopathology. RESULTS: Binge eating before and after weight loss surgery was unrelated to long-term BMI outcome. Binge eating after weight loss surgery was associated with more psychopathology and lower HRQL. CONCLUSIONS: Binge eating before or after weight loss surgery does not predict long-term BMI outcome. Therefore, exclusions from surgery for this reason alone are difficult to motivate. However, results show that binge eating after weight loss surgery is common and is associated with more psychopathology and lower HRQL, which might increase the vulnerability for future weight regain and complications beyond the follow-up period of the present study. The high rate of binge eating after surgery and its negative association with HRQL and psychopathology suggest that we need to be observant of the occurrence and potential effects of binge eating in the context of bariatric surgery.

Physical activity in treatment units for eating disorders: clinical practice and attitudes.

OBJECTIVE: Physical activity (PA) in eating disorders (ED) may be harmful, but in a therapeutic setting also beneficial. The purpose of this survey was to examine these contradictory aspects of PA in ED specialist treatment settings. We examined whether 1) PA is assessed by the unit, 2) the units have guidelines for managing excessive PA, 3) the units have staff with higher education and special competence in PA and exercise science, 4) how units regard PA in ED, 5) whether regular PA is integrated in the treatment programs, and 6) how the units rate the role of PA in the treatment of ED compared with other mental disorders. METHODS: Of the 49 units located in Scandinavia and the United Kingdom, 41 (84%) responded to a questionnaire. RESULTS: In 28 units (68%) PA was assessed regularly. Excessive PA was considered a harmful symptom in ED, and most units reported guidelines to manage excessive PA. Thirty-two units included PA in their treatment programmes. Clinicians found PA most relevant in the treatment of obesity and, except for binge eating, less for ED. CONCLUSION: PA was more commonly integrated in treatment compared to previous studies. Future research should address how to manage excessive PA, and the potential beneficial role of PA in the treatment of ED.

Psychometric properties of the Eating Disorders in Obesity questionnaire: validating against the Eating Disorder Examination interview.

Inconclusive results of how weight-loss treatment (WLT) results are affected by participants' eating disorders and/or binge eating are partly due to the variation caused by the multitude of assessment instruments used. The objective of the present study was to evaluate the psychometric properties of a short DSM-IV-based assessment instrument designed to be used specifically in WLT settings, the Eating Disorders in Obesity (EDO) questionnaire. Participants were 97 patients seeking WLT at four surgical and one non-surgical clinics. Participants were assessed by the EDO and the Eating Disorder Examination (EDE) interview . The validity and reliability of the EDO was measured as concordance with the EDE, and test-retest agreement of the EDO, respectively. Validity as well as reliability was found to be good for both eating disorders diagnoses and binge eating as a distinct symptom. Results suggest that the EDO is a short, easily administered instrument with good psychometric properties which makes it a suitable, economical method of assessing eating disorders and binge eating in clinical WLT settings.

Reasons for non-participation in follow-up research on eating disorders.

OBJECTIVE: Lack of participation in follow-ups is thought to be a serious bias in outcome research on eating disorders; however, little systematic knowledge exists about the problem. The present study aimed to delineate non-participation in long-term follow-up research, and explore the reasons for non-participation. METHOD: Eating disorder patients (N=840) entering a naturalistic, longitudinal multi-centre study were divided into participators (N=508) and non-participators (N=332) in 36-month follow-ups. Non-participators were further classified as either active (i.e. refused participation or failed to attend scheduled appointments) or passive non-participators (i.e. could not be traced). RESULTS: Active non-participators exhibited significantly lower levels of general and eating disorder psychopathology at intake compared to participators, while passive non-participators reported higher levels of hostility. DISCUSSION: Systematic exploration of non-participation in longitudinal research can help to mitigate the problem of indistinct results due to missing data. Barriers to successful longitudinal research and how to overcome non-participation at endpoint are discussed.

Gender comparisons in psychological characteristics of obese, binge eaters.

OBJECTIVE: To investigate differences between male and female, obese binge eaters in levels of depression, anxiety and self-esteem. In addition, to make comparisons in these psychological characteristics, for both genders, between obese, binge eaters and obese nonbingers. METHOD: Participants consisted of 48 female (26 binge eaters and 22 nonbingers) and 13 male (4 binge eaters and 9 nonbingers) outpatients in a hospital weight-loss program. Participants completed the following: Questionnaire on Eating and Weight Patterns--Revised, Beck Depression Inventory, Beck Anxiety Inventory and the Coopersmith Self-Esteem Inventory. RESULTS: Females had a significantly higher level of depression (p<0.003) than males. No other significant gender differences were found. However significant differences between binge eaters and nonbingers were found, for both genders, in depression (p<0.0001) and anxiety (p<0.008) with the binge eaters having higher scores than the nonbingers, and in self-esteem (p<0.0001) with the binge eaters having lower scores than the nonbingers. CONCLUSION: Females have higher levels of depression compared to males, but no gender differences were found in anxiety or self-esteem. In both genders, binge eaters have higher levels of depression and anxiety and lower levels of self-esteem compared to nonbingers.

Socio-economic variables and eating disorders: a comparison between patients and normal controls.

OBJECTIVE: Previous research demonstrates that the relationship between socio-economic status (SES) and eating disorders is not consistent. The present study compares SES and demographic factors among Swedish women, randomly drawn from the population register and female patients seen for treatment. METHOD: 223 consecutive eating disorder patients (ED) between 18 and 24 years of age (anorexia, n=26, bulimia, n=127, Eating disorder not otherwise specified, n=70) were compared with 750 normal controls (CONT) between 18 and 24 years of age. Both groups were assessed using the same questionnaire regarding SES and demographic factors. RESULTS: ED's have a higher SES background and live in more privileged socio-demographic areas than CONT. ED's have lower social status, have more separations, and are more often single than CONT. CONCLUSION: These data demonstrate a connection between high socio-economic and demographic data, low social status and eating disorder patients compared to normal controls.

Estimation of the population "at risk" for eating disorders in a non-clinical Swedish sample: a repeated measure study.

OBJECTIVE: To estimate the late-adolescent population "at risk" for eating disorders (EDs), establish its stability over time using repeated measures, and analyse its social and demographic background factors. METHOD: The Eating Disorder Inventory (EDI) and a number of related questions were administered to students in their last year of high school in five Swedish towns in 1993 (n=3855) and 1998 (n=2925). RESULTS: It was found that 6% of girls were "at risk" for eating disorders with no increase over time. There was an association between this risk and certain socio-demographic factors (living alone, moving away from home early, excessive physical training and experiences of bullying). No differences were found between cities of different size. CONCLUSION: A considerable proportion of girls in late adolescence are preoccupied with weight and dieting, and may be considered "at risk" for developing a clinical eating disorder. This proportion seems to be fairly stable over time.

Co-occurrence of ego function change and symptomatic change in bulimia nervosa: a six-year interview-based study.

Low ego strength is theoretically thought of as causing difficulties in interpersonal relations and leading to the development of psychiatric symptomatology. Patients with bulimia nervosa were previously shown to have low ego strength and were studied to investigate whether gains in ego strength occur over time and are associated with improvement in symptoms. The average patient had an ego strength at a borderline level at index and at a neurotic level 6 years later. Less positive change in ego strength was associated with a low initial Eating Disorder Inventory (EDI) Symptom score a long Time in Treatment, and having been referred for specialist care. Positive changers significantly more often stopped vomiting/abusing laxatives and showed several non-significant tendencies to improve in other symptomatic aspects as well. Several methodological caveats are discussed, but these findings may contribute to the identification of mechanisms whereby long-term improvement occurs in bulimia nervosa.

Food selection in anorectics and bulimics: food items, nutrient content and nutrient density.

OBJECTIVE: The food selection and nutrient intake were investigated in women with anorexia nervosa, bulimia nervosa and controls. METHODS: Dietary data was obtained by 24-hour recall, and 7-day recording among eating disordered patients, and by 3-day registration among controls. RESULTS: The intake of energy and nutrients differed from controls, as expected, while there were no differences between anorectics and bulimics in this respect, except for iron. There were only minor differences among the three groups studied with respect to nutrient density. Energy percentages of protein, fat, and carbohydrates, were similar in all groups, but a subdivision of the macronutrients into respective sources showed that bulimics had a lower relative and absolute intake of carbohydrates from bread and cereals than anorectics and controls. CONCLUSION: Eating disorder patients, despite their marginal food intake, still met the minimum requirement for most nutrients according to the Nordic Nutrient recommendations.

Binge eating versus nonpurged eating in bulimics: is there a carbohydrate craving after all?

Food selection and macro nutrient content were evaluated in a group of bulimic subjects, both during the nonpurged intake and the bingeing. Dietary data was assessed by single 24-hour recall. As expected, energy distribution and food selection differed markedly between the nonpurged diet and the binges. The main differences were related to an inverse relationship in the order of macro nutrients, fat being the dominant and protein the least important source of macro nutrients during binge eating. The nutrient content during binges admittedly had a preponderance for fat. Nevertheless, the primary choice of food items during binges was carbohydrates, which was shown both by a greater quantity and by the subjects' own desires.

Outcome, recovery, relapse and mortality across six years in patients with clinical eating disorders.

The study describes course and outcome over 6 years for adults with eating disorders. Special interest is paid to clinically critical events such as relapse and premature death. Seventy-seven per cent of the 30 prospectively studied patients had no eating disorder diagnosis after 6 years. Among the recovered patients, the total risk of relapse was 48%. The mortality was 17.8 times higher than expected. The overall pattern of results confirm earlier ones for anorexia nervosa and extend the limited database for bulimia nervosa. Of particular importance may be 1) that no patient in this sample suffered more than one major relapse and 2) that the risk for premature death may be twice as high among bulimic as among restricting patients.

A three-year prospective study of life events and course for adults with anorexia nervosa/bulimia nervosa.

Attempts to understand the pathogenesis and course of eating disorders have increasingly included investigation of stressful life events. We report a prospective study in which major life events were assessed 1, 2, and 3 years after the patient's initial presentation to a university hospital psychiatric department. Using a combined questionnaire and interview procedure based on items from the Psychiatric Epidemiologic Research Interview, we studied 25 adults with DSM-III-R anorexia nervosa or bulimia nervosa. Evidence for an influence of life events on improvement was obtained the 1st year. Events explained a substantial 30% of the variability in follow-up status, with analyses taking potential confounds into consideration unable to explain the finding. Also, significant correlations between events and self-rated variables (Eating Disorder Inventory and Beck Depression Inventory) were obtained at one of the follow-ups, but in all, the data did not consistently imply that life events affect the patients' course.

Ego functioning predicts first-year status in adults with anorexia nervosa and bulimia nervosa.

Severe personality disturbance is a feature that possibly explains chronicity in eating disorders, a largely inexplicable development in terms of previously investigated factors. We tested this hypothesis in a group of 41 anorectics and bulimics with ratings of 13 ego functions and of status at 1-year follow-up. Patients who still were preoccupied with weight or shape and had a DSM-III-R eating disorder at follow-up had more severe ego disturbance at initial presentation than those who were free from symptoms. The relevance of demographics, syndromal diagnosis and clinical factors other than ego functioning was limited. The importance of ego functioning for prognosis in eating disorders thus appears to overshadow that of several factors that have been extensively cited in the literature.

Impulsivity and long-term prognosis of psychiatric patients with anorexia nervosa/bulimia nervosa.

Few if any reliable indicators of long-term outcome have been found in eating disorders. Impulsivity was the strongest predictor in the present study of 35 adults with anorexia nervosa or bulimia nervosa. This variable accounted for 25% of anorectic symptoms at 2 to 3 years follow-up and 14% at 4 to 6 years (Eating Attitudes Test). The relationship was specific insofar as impulsivity predicted neither depression nor overall mental health. Cognitive impairment may be one reason for the poor prognosis of impulsive patients.

Eating Disorder Inventory in Sweden: description, cross-cultural comparison, and clinical utility.

The Eating Disorder Inventory is one of very few tests for anorexia nervosa and bulimia nervosa that measures not only symptoms but also psychological characteristics believed to be central in these disorders. This study of 425 patients and control subjects showed that patients had markedly higher scores than controls and recovered patients on all eight scales. Individuals with bulimia nervosa scored higher on a few of the scales than those with anorexia nervosa, as did binge eaters at all weights compared with those who only restricted eating. Comparison with Canadian subjects showed several differences in normal controls. Since the technical properties of our Swedish version of the EDI were excellent, these differences may be meaningful rather than artifacts of the translation. Finally, the analyses indicated that the EDI may be useful for purposes of screening for eating disorders, and possibly for differential diagnosis.