Disordered eating in transgender and gender non-conforming youth: A comparison to community-based and clinical samples.

OBJECTIVE: This study investigates eating pathology in transgender and gender non-conforming (TGNC) youth compared to a community-based sample and individuals with eating disorders (EDs). METHOD: Participants (ages 13-21 years) included TGNC youth from a paediatric gender clinic (N = 97), a demographically matched community-based sample of cisgender males (N = 97) and cisgender females (N = 97), and treatment-seeking patients with EDs (N = 112). The Eating Disorder Examination Questionnaire (EDE-Q) was used to assess ED cognitions and behaviours. RESULTS: Transgender and gender non-conforming participants reported significantly higher EDE-Q global scores compared to the cisgender samples, but significantly lower than the ED sample. Transgender and gender non-conforming individuals reported a higher likelihood of objective binge episodes (OBEs) than the cisgender groups, albeit lower than youth with EDs. A substantial proportion of TGNC participants scored in elevated ranges on the EDE-Q global score (35% ≥ score of 3, 17% ≥ score of 4), significantly higher than cisgender males (0% ≥ score of 3, 0% ≥ score of 4) and females (9% ≥ score of 3, 3% ≥ score of 4). CONCLUSIONS: Findings indicate that TGNC youth exhibit increased ED cognitions and OBEs compared to cisgender samples, highlighting the need for screening and addressing ED symptoms in this population.

Early weight gain predicts treatment response in adolescents with anorexia nervosa enrolled in a family-based partial hospitalization program.

OBJECTIVE: Improved treatment outcome in family-based treatment (FBT) for anorexia nervosa (AN) is predicted by weight gain occurring early in the course of treatment (i.e., about 4 lbs by week 4). Although prior work suggests that early weight gain in higher levels of care (e.g., partial hospitalization programs [PHP]) predicts weight restoration at discharge, no study has examined the specific rate of gain within FBT-informed PHP programs that best predicts treatment response. METHOD: This study examined rate of weight gain in pounds and percent expected body weight (EBW) that predicts positive outcome in 70 patients (M age = 15.49 years, SD = 2.56) with AN who were enrolled in a family-based PHP. RESULTS: Receiver operator characteristic analyses demonstrated that changes in %EBW during weeks 2-5 were more useful than changes in weight in predicting positive outcome. Gaining at least 8.9 pounds or over 8% of EBW in the first 4 weeks of treatment significantly predicted positive outcome. DISCUSSION: Findings suggest that positive outcome in an FBT-informed PHP is predicted by rapid weight gain in the initial weeks of treatment. Research is needed to identify specific family and patient characteristics that facilitate weight gain and to develop corresponding interventions to improve outcome.

Adapting treatment in an eating disorder program to meet the needs of patients with ARFID: Three case reports.

Avoidant/restrictive food intake disorder (ARFID) was introduced in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. Three different subtypes of ARFID are described: individuals who seem disinterested in eating, those who avoid certain foods because of a sensitivity to specific characteristics of the food, and those who are concerned about an aversive experience associated with eating. There is currently no first-line treatment for ARFID. Three case studies are presented of patients with ARFID who participated in a family-based partial hospitalization program/intensive outpatient program for eating disorders. A description of the course of treatment is included, as well as ways in which the eating disorder program adapted treatment to more closely meet the unique needs of these patients. An approach with emphasis on parental involvement seems promising, although research is needed to investigate this more fully.

Effect of Hospitalization on Percent Median Body Mass Index at One Year, in Underweight Youth With Restrictive Eating Disorders.

PURPOSE: Data from low-weight patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED treatment programs were analyzed to determine whether there was an association between hospitalization and gain to at least 90% median body mass index (mBMI) at 1-year follow-up. METHODS: Data were retrospectively collected for 322 low-weight (<85% mBMI at intake) patients aged 9-21 years, who presented with restrictive EDs to 14 adolescent medicine-based ED programs in 2010. Positive outcome was defined as being at least 90% mBMI (%mBMI = patient's body mass index/mBMI for age × 100) at 1-year follow-up. Association between treatment at a higher level of care and gain to at least 90% mBMI was analyzed for 140 patients who were <85% mBMI at the time of presentation, had not been previously hospitalized, and had 1-year follow-up data available. RESULTS: For patients presenting at <85% mBMI, those who were hospitalized in the year following intake had 4.0 (95% confidence interval: 1.6-10.1) times the odds of gain to at least 90% mBMI, compared with patients who were not hospitalized, when controlling for baseline %mBMI. CONCLUSION: In this national cohort of patients with restrictive EDs presenting to adolescent medicine-based ED programs at <85% mBMI, those who were hospitalized had greater odds of being at least 90% mBMI at 1-year follow-up.

Avoidant/restrictive food intake disorder: a new eating disorder diagnosis in the diagnostic and statistical manual 5.

PURPOSE OF REVIEW: Avoidant/restrictive food intake disorder (ARFID) is a new eating disorder diagnosis in the 5th edition of the diagnostic and statistical manual (DSM-5), published in 2013. The purpose of this review is to describe the creation of ARFID as a diagnostic category, and to explain the DSM-5 diagnostic criteria; to demonstrate what is known thus far about the prevalence of ARFID and characteristics of patients with this disorder; to provide guidance to the pediatrician and other providers on making a diagnosis of ARFID; and to discuss evolving treatment approaches. RECENT FINDINGS: Several studies have been published recently on the prevalence and characteristics of patients with ARFID. Research has just begun to focus on new assessment measures, approaches to treatment based on established therapies for other eating/psychiatric disorders, and short-term outcomes. Robust treatment studies are in development. SUMMARY: The addition of ARFID to the DSM-5 has captured a category of patients with clinically significant restrictive eating, but without weight and shape concerns, who were poorly classified in the past. Future research is needed to further elucidate the presentation, characteristics, diagnostic instruments, and effective management.

History of Overweight/Obesity as Predictor of Care Received at 1-year Follow-Up in Adolescents With Anorexia Nervosa or Atypical Anorexia Nervosa.

PURPOSE: Previous research has indicated that patients with anorexia nervosa (AN) or atypical AN with premorbid history of overweight/obesity have greater weight loss and longer illness duration than patients with no such history. However, little is known about the association of premorbid overweight/obesity and receiving inpatient medical care during treatment for an eating disorder. METHODS: Using logistic regression, we sought to determine if history of overweight/obesity was associated with receiving inpatient medical care in a sample of 522 patients (mean age 15.5 years, 88% female) with AN/atypical AN. RESULTS: Binary results demonstrated greater percent weight loss (27.4% vs. 16.2%) and higher percent median body mass index (%mBMI, 99.8% vs. 85.2%) at presentation in those with a history of overweight/obesity (p < .001) but no difference in duration of illness (p = .09). In models adjusted for demographics and percent weight loss, history of overweight/obesity was associated with lower odds of receiving inpatient medical care (odds ratio .60 [95% confidence interval: .45-.80]) at 1-year follow-up. However, these associations were no longer significant after adjusting for %mBMI. Mediation results suggest that %mBMI fully mediates the relationship between history of overweight/obesity and inpatient medical care, in that those with a history of overweight/obesity are less likely to receive care due to presenting at a higher weight. CONCLUSIONS: Our findings suggest that, despite greater degree of weight loss and no difference in duration of illness, participants with a history of overweight/obesity are less likely to receive inpatient medical care.

Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative.

PURPOSE: Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities. METHODS: Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2). RESULTS: Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0). CONCLUSIONS: Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.

Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative.

PURPOSE: The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year. METHODS: Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed. RESULTS: At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration. CONCLUSIONS: The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a "new disorder" in DSM-5.

PURPOSE: To evaluate the DSM-5 diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) in children and adolescents with poor eating not associated with body image concerns. METHODS: A retrospective case-control study of 8-18-year-olds, using a diagnostic algorithm, compared all cases with ARFID presenting to seven adolescent-medicine eating disorder programs in 2010 to a randomly selected sample with anorexia nervosa (AN) and bulimia nervosa (BN). Demographic and clinical information were recorded. RESULTS: Of 712 individuals studied, 98 (13.8%) met ARFID criteria. Patients with ARFID were younger than those with AN (n = 98) or BN (n = 66), (12.9 vs. 15.6 vs. 16.5 years), had longer durations of illness (33.3 vs. 14.5 vs. 23.5 months), were more likely to be male (29% vs. 15% vs. 6%), and had a percent median body weight intermediate between those with AN or BN (86.5 vs. 81.0 and 107.5). Patients with ARFID included those with selective (picky) eating since early childhood (28.7%); generalized anxiety (21.4%); gastrointestinal symptoms (19.4%); a history of vomiting/choking (13.2%); and food allergies (4.1%). Patients with ARFID were more likely to have a comorbid medical condition (55% vs. 10% vs. 11%) or anxiety disorder (58% vs. 35% vs. 33%) and were less likely to have a mood disorder (19% vs. 31% vs. 58%). CONCLUSIONS: Patients with ARFID were demographically and clinically distinct from those with AN or BN. They were significantly underweight with a longer duration of illness and had a greater likelihood of comorbid medical and/or psychiatric symptoms.

Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders.

PURPOSE: To determine the distribution of eating disorders (ED) in children and adolescents comparing the fourth edition of the Diagnostic and Statistical Manual (DSM) to the proposed fifth edition DSM criteria. METHODS: A total of 215 consecutive patients (15.4 ± 3.3 years) presenting for initial ED evaluation to adolescent medicine physicians from six institutions were assigned ED diagnoses using current DSM-IV criteria as well as proposed DSM-5 criteria. RESULTS: Diagnoses of anorexia nervosa and bulimia nervosa increased using the proposed DSM-5 criteria (from 30.0% to 40.0% and from 7.3% to 11.8%, p < .001). Approximately 14% of patients received the presumptive DSM-5 diagnosis of avoidant/restrictive food intake disorder. Cases of ED not otherwise specified decreased from 62.3% to 32.6% (p < .001). CONCLUSIONS: Proposed DSM-5 criteria substantially decreased the frequency of ED not otherwise specified diagnoses and increased the number of cases of anorexia nervosa and bulimia nervosa in a population of young patients presenting for ED treatment. Avoidant/restrictive food intake disorder appears to be a significant diagnosis.

An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses.

PURPOSE: This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally. METHODS: Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses. RESULTS: The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites. CONCLUSION: A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.

Children and adolescents with eating disorders: the state of the art.

BACKGROUND: Eating disorders in children and adolescents remain a serious cause of morbidity and mortality in children, adolescents, and young adults. The working knowledge of pathophysiology, recognition, and management of eating disorders continues to evolve as research in this field continues. OBJECTIVES: This article builds on previous background and position papers outlining issues relevant to the care of the adolescent patient with an eating disorder. METHODS: The eating disorder special interest group from the Society for Adolescent Medicine recognized the need to update the state of the art published guidelines for the care of the adolescent patient with an eating disorder. This article was a multidisciplinary, group effort to summarize the current knowledge of best practice in the field. RESULTS: This article summarizes newer findings on pathogenesis and etiology, prevention and screening, risk factors, nutritional issues, care from the primary care clinician's perspective, appropriate use of a multidisciplinary team, and issues of managed care and reimbursement. CONCLUSIONS: Primary prevention combined with early recognition and treatment helps decrease morbidity and mortality in adolescents with eating disorders.