Psilocybin therapy and anorexia nervosa: a narrative review of safety considerations for researchers and clinicians.

BACKGROUND: Clinical trials using psilocybin therapy to treat anorexia nervosa (AN) are currently underway. The safety and tolerability of psilocybin is of utmost importance in individuals with AN who may present unique medical vulnerabilities. The purpose of this review is to describe how the common physiologic adverse effects of psilocybin may impact medical complications experienced by individuals with AN in clinical trials of psilocybin therapy. MAIN BODY: The physiologic underpinnings of common adverse effects following psilocybin administration are described, including tachycardia, hypertension, electrocardiogram changes, nausea, headache, and lightheadedness. These anticipated physiologic changes are described in relation to the common medical correlates seen in individuals with AN. Risk mitigation strategies for each adverse effect are proposed. CONCLUSION: Early evidence suggests that psilocybin therapy is well-tolerated in individuals with AN. Understanding the unique medical complications of AN, and how they may be impacted by common physiologic adverse effects of psilocybin administration, leads to tailored risk mitigation strategies to enhance safety and tolerability of this novel intervention.

Characterizing Medical Complications in Publicly Insured Youth With Eating Disorders.

PURPOSE: The present study describes the occurrence of eating disorder (ED)-related medical diagnoses in a publicly insured sample of youth with EDs. The study also compares ED medical diagnoses with other psychiatric disorders and identifies high-risk demographic groups. Improved screening practices are needed in public mental health systems where treatment is critical for youth with EDs. METHODS: Medicaid claims data were obtained from the state of California, including beneficiaries ages 7-18 who had at least one service episode between January 1, 2014, and December 31, 2016. From this population we extracted demographic and claims data for those youth who received an ED diagnosis during the 3-year period as a primary or secondary diagnosis (n = 8,075). Random subsamples of youth with moderate/severe mental illness were drawn for comparison: primary or secondary diagnosis of mood/anxiety disorder (N = 8,000) or psychotic disorder (n = 8,000) were also extracted. Medical diagnoses were compared within youth with EDs (across diagnostic categories) and across psychiatric diagnoses (EDs, mood/anxiety disorders, psychotic disorders). Logistic regression analyses were used to adjust for demographic characteristics. RESULTS: Three-quarters of youth with EDs received no diagnosis of an ED-related medical complication. Bradycardia was the most prevalent diagnosis suggestive of medical instability. Odds of medical diagnosis were greater for ED than other psychiatric disorders but varied with age and gender. Across all diagnoses, Latinx youth were less likely to receive ED-related diagnoses suggesting medical instability. DISCUSSION: Most publicly insured youth with EDs received no ED-related medical diagnosis, underscoring the structural barriers to receiving expert medical care.

Clinical characteristics of hospitalized male adolescents and young adults with atypical anorexia nervosa.

OBJECTIVE: To describe the clinical characteristics of male adolescents and young adults hospitalized for medical complications of atypical anorexia nervosa (atypical AN) and to compare their clinical characteristics with females with atypical AN and males with anorexia nervosa (AN). METHOD: A retrospective review of electronic medical records for patients with atypical AN and AN aged 9-25 admitted to the UCSF Eating Disorders Program from May 2012 to August 2020 was conducted. RESULTS: Among 21 males with atypical AN (mean age 15.1 ± 2.7, mean %mBMI 102.0 ± 11.8), medical complications evidenced by admission laboratory values included anemia (52.9%), vitamin D insufficiency/deficiency (52.6%), and zinc deficiency (31.6%). Compared with females with atypical AN (n = 69), males with atypical AN had longer length of stay (11.4 vs 8.4 days, p = .004), higher prescribed kcal at discharge (4114 vs 3045 kcal, p < .001), lower heart rate nadir (40.0 vs 45.8, p = .038), higher aspartate transaminase (AST, 37.9 vs 26.2 U/L, p = .032), higher alanine transaminase (ALT, 30.6 vs 18.3 U/L, p = .005), and higher rates of anemia (52.9% vs 19.4%, p = .005), with no differences in vitamin D, zinc, and vital signs. Compared with males with AN (n = 40), males with atypical AN had no significant differences in vital signs or laboratory assessments during the hospitalization. DISCUSSION: Atypical AN in males leads to significant medical comorbidity, and males with atypical AN require longer hospital stays compared to females with atypical AN. Rates of abnormal vital signs and abnormal serum laboratory values during hospital admissions do not differ in males with atypical AN compared to AN. PUBLIC SIGNIFICANCE: Adolescent and young adult males with atypical anorexia nervosa experience significant medical complications. Males with atypical anorexia nervosa had longer hospitalizations and higher prescribed nutrition at discharge than females. Medical complications of atypical anorexia nervosa in male adolescents and young adults were generally equal to those of male adolescents and young adults with anorexia nervosa. Clinicians should be aware of unique medical complications of males with atypical anorexia nervosa.

Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with atypical anorexia nervosa.

OBJECTIVE: The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose. METHOD: Patients were enrolled upon admission and randomized to meal-based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t-tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight). RESULTS: Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p = .008, Cohen's d = -.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p < .001, Cohen's d = .51) and greater hypomagnesemia (29% vs. 11%, p = .03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p < .001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p < .001), weight gain was 1.6%mBMI (.8, 2.4) greater (p < .001), and hypomagnesemia odds were 70% (12, 128) lower (p = .02). DISCUSSION: Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group. PUBLIC SIGNIFICANCE: The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital.

Course and outcome in individuals with atypical anorexia nervosa: Findings from the Study of Refeeding to Optimize iNpatient Gains (StRONG).

OBJECTIVE: We previously reported that participants with atypical anorexia nervosa (atypical AN) had higher historical and admission weights, greater eating disorder psychopathology, but similar rates of amenorrhea and weight suppression at baseline as compared to anorexia nervosa (AN); here, we compare 1-year outcomes. METHOD: Weight, % median body mass index (%mBMI), Eating Disorder Examination Questionnaire (EDE-Q) scores, resumption of menses, and rehospitalizations were examined at 3, 6, and 12 months post-discharge. Analyses (N = 111) compared changes in %mBMI, weight suppression, and EDE-Q scores over time between atypical AN and AN. RESULTS: Among the participants (48 atypical AN, 63 AN), both groups gained weight but those with atypical AN had lower gains than those with AN in %mBMI (p = .02) and greater weight suppression (p = .002) over time. EDE-Q scores improved over time, independent of weight suppression, with no significant difference between atypical AN and AN. Groups did not differ by rates of resumption of menses (80% atypical AN, 76.9% AN) or rehospitalization (29.2% atypical AN, 37.9% AN). Greater weight suppression predicted longer time to restore menses and more days of rehospitalization. DISCUSSION: Individuals with atypical AN regained a smaller proportion of body mass and were more weight suppressed over time. Change in eating disorder cognitions, resumption of menses, and rehospitalization rates at 1-year follow-up did not differ between groups. There was no significant difference in weight suppression between groups for those who were psychologically improved at 12 months. Findings highlight limitations in our understanding of weight recovery in atypical AN. New metrics for recovery are urgently needed. PUBLIC SIGNIFICANCE: Little is known about outcome in atypical anorexia nervosa (atypical AN). We examined recovery metrics in young people with atypical AN and anorexia nervosa (AN) 1 year after medical hospitalization. Individuals with atypical AN showed slower weight gain and remained further from their pre-illness weight. There were no differences in the rates of psychological recovery, resumption of menses, or rehospitalization. New metrics are needed to assess recovery in atypical AN.

Sex differences in cholesterol and triglyceride levels among hospitalized adolescents and young adults with eating disorders.

OBJECTIVE: To determine sex differences in cholesterol and triglyceride levels among adolescents and young adults hospitalized for medical complications of eating disorders. METHODS: A retrospective electronic medical record review of patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical stabilization, between 2012 and 2020, was conducted. Non-fasting total cholesterol and triglycerides were collected; however, LDL and HDL levels were not available. RESULTS: Among 83 males and 441 females, mean ± SD age was 15.5 ± 2.8 years, 64.1% had anorexia nervosa, and admission percent median body mass index was 87.3 ± 13.9. The proportion of males and females with high total cholesterol (13.3% vs. 18.1%, Cramer's V = 0.05, p = .28) and high triglyceride levels (9.6% vs. 8.1%, Cramer's V = 0.02, p = .63) did not differ. Mean total cholesterol levels were higher in females compared to males (F 169.6 ± 41.1 mg/dL vs. M 154.5 ± 45.1 mg/dL, Cohen's d = 0.36, p = .003), although a majority were within the normal range. In adjusted linear regression models, male (compared to female) sex (B = -14.40, 95% CI -24.54, -4.27) and higher percent median body mass index (B = -0.33, 95% CI -0.60, -0.06) were associated with lower total cholesterol levels in adjusted models (R2 = 0.04). DISCUSSION: Building on prior work showing equally severe complications of eating disorders in males compared to females, we did not find sex differences in those presenting with high total cholesterol or triglycerides. Future research is needed to understand the pathophysiology and role of dyslipidemia in acute malnutrition, and the impact of nutritional rehabilitation and weight restoration. PUBLIC SIGNIFICANCE: We found that the proportion of male and female adolescents and young adults hospitalized for medical complications of an eating disorder with high total cholesterol did not significantly differ. Although average total cholesterol levels were higher in female compared to male patients with eating disorders, a majority of these levels remained within the normal range. Patients with more severe malnutrition had a higher risk of elevated total cholesterol levels. Clinicians should consider monitoring cholesterol levels in young people hospitalized for restrictive eating disorders.

What medical providers need to elevate outpatient care for adolescents and young adults with binge-eating disorder: A novel protocol.

PURPOSE: Binge-eating disorder (BED) in adolescents and young adults is underrecognized and understudied and no standardized guidelines exist for medical providers caring for this population. To highlight the lack of extant evidence, we examine the demographic characteristics of youth with BED in an academic eating disorders (EDs) program and primary care clinic and describe the needs of their medical care providers. METHOD: A retrospective chart review was conducted for patients who met criteria for BED from July 2021 to June 2022. We surveyed their medical providers to understand their needs in caring for this population. A multidisciplinary team with expertise in the care of youth with EDs amalgamated current evidence in caring for youth with BED into a protocolized care schema designed for implementation in the outpatient medical setting. RESULTS: Eighteen youth with BED were reviewed, 14 identified as female, 3 as male, and 1 as "Other." Average age was 15.4 (2.7) years old, and mean body mass index was 35.90 (8.25). 33.3% (6) patients identified as White/Caucasian, followed by 22.2% (4) Hispanic/Latinx. Eleven of 18 were privately insured. The most common medical recommendations were for regular meals and snacks and for individual psychotherapy. Medical providers desired more education about identification and management of youth with BED. CONCLUSIONS: To address the lack of medical care guidelines for youth with BED, recommendations in this Forum include: increased education for medical providers, standardized medical monitoring, an emphasis on psychotherapy, and a weight-inclusive orientation. PUBLIC SIGNIFICANCE: Adolescents and young adults with BED are underrecognized and undertreated. Little is known about the characteristics of these patients and the medical care these patients receive within academic EDs program. For the first time, preliminary recommendations for medical care are provided.

The social epidemiology of binge-eating disorder and behaviors in early adolescents.

BACKGROUND: Binge-eating disorder (BED) is the most common eating disorder phenotype and is linked to several negative health outcomes. Yet, little is known about the social epidemiology of BED, particularly in early adolescence. The objective of this study was to examine the associations between sociodemographic characteristics and BED and binge-eating behaviors in a large, national cohort of 10-14-year-old adolescents in the United States (U.S.) METHODS: We conducted a cross-sectional analysis of two-year follow-up data from the Adolescent Brain Cognitive Development (ABCD) Study (2018 - 2020) that included 10,197 early adolescents (10 - 14 years, mean 12 years) in the U.S. Multivariable logistic regression models were used to assess the associations between sociodemographic characteristics and BED and binge-eating behaviors, defined based on the Kiddie Schedule for Affective Disorders and Schizophrenia. RESULTS: In this early adolescent sample (48.8% female, 54.0% White, 19.8% Latino/Hispanic, 16.1% Black, 5.4% Asian, 3.2% Native American, 1.5% Other), the prevalence of BED and binge-eating behaviors were 1.0% and 6.3%, respectively. Identifying as gay or bisexual (compared to heterosexual; adjusted odds ratio [AOR]: 2.25, 95% CI 1.01-5.01) and having a household income of less than $75,000 (AOR: 2.05, 95% CI: 1.21-3.46) were associated with greater odds of BED. Being male (AOR: 1.28, 95% CI: 1.06-1.55), of Native American (AOR: 1.60, 95% CI: 1.01-2.55) descent, having a household income less than $75,000 (AOR: 1.34, 95% CI: 1.08-1.65), or identifying as gay or bisexual (AOR for 'Yes' Response: 1.95, 95% CI: 1.31-2.91 and AOR for 'Maybe' Response: 1.81, 95% CI: 1.19-2.76) were all associated with higher odds of binge-eating behaviors. CONCLUSION: Several sociodemographic variables showed significant associations with binge-eating behaviors, which can inform targeted screening, prevention, and education campaigns for BED among early adolescents.

Binge-eating disorder is the most common eating disorder, yet little research has characterized the social and demographic factors that contribute to it, especially in adolescents. We studied the social and demographic risk factors for binge-eating disorder and binge-eating behaviors for U.S. children aged 10­14. Low household income, identifying as gay or bisexual, and being of Native American descent were associated with engagement in binge-eating behaviors. Low household income and identifying as gay or bisexual were associated with binge-eating disorder. These results can help better identify, prevent, and spread awareness of binge-eating disorder.

Modification of an inpatient medical management protocol for pediatric Avoidant/Restrictive Food Intake Disorder: improving the standard of care.

BACKGROUND: No guidelines currently exist that represent a standardization of care for Avoidant/Restrictive Food Intake Disorder (ARFID) on an inpatient service. Unique features of this diagnosis (e.g., sensory sensitivity contributing to involuntary emesis) suggest that established protocols that were developed for anorexia nervosa might be less effective for adolescents with ARFID. To inform improved inpatient medical stabilization and care for these patients, we first provide an overview of clinical characteristics for patients with ARFID who presented to a pediatric hospital for inpatient eating disorder care. We use these descriptives to outline the rationale for, and executions of, modifications to an inpatient protocol designed to flexibly meet the needs of this clinical population. METHODS: Chart review with descriptive statistics were conducted for patients who had received an ARFID diagnosis from March 2019 to March 2023 (N = 32, aged 9-23). We then present a case series (n = 3) of adolescents who either transitioned to a novel adjusted protocol from an original standard of care on the inpatient service, or who received only the standard protocol. RESULTS: The sample was aged M(SD) = 15.6 (3.3) years, 53% male, and a majority (69%) presented with the ARFID presentation specific to fear of negative consequences. On average, patients had deviated from their growth curve for just over two years and presented with mean 76% of their estimated body weight. Of those requiring nasogastric tube insertion during admission (n = 8, 25%), average duration of tube placement was 15 days. From within this sample, case series data suggest that the adjusted protocol will continue to have a positive impact on care trajectory among adolescents admitted for ARFID including improved weight gain, reduction of emesis, and improved food intake. CONCLUSIONS: Findings demonstrate the likely need to tailor established medical inpatient protocols for those with ARFID given different symptom presentation and maintenance factors compared to patients with anorexia nervosa. Further research is warranted to explore the longer-term impact of protocol changes and to inform standardization of care for this high priority clinical population across care sites.

No current standard of care exists for pediatric patients with Avoidant/Restrictive Food Intake Disorder (ARFID) who are hospitalized for medical stabilization related to complications secondary to malnutrition. Clinical features of this diagnosis (e.g., sensory sensitivity) suggest that existing treatment protocols developed for patients with other restrictive eating disorders, like anorexia nervosa, may be less effective for patients with ARFID. This study first describes a pediatric sample of patients with ARFID upon admission to an inpatient service. Then, a case series is used to illustrate the potential benefits of using an adjusted protocol that was modified to better suit the needs of children and adolescents with ARFID. Findings support future study of the proposed adjusted protocol and may inform future standardization of improved care for this high priority clinical population.

"But the reality is it's happening": A qualitative study of eating disorder providers about psilocybin-assisted psychotherapy.

OBJECTIVE: This study invited providers who care for patients with eating disorders to inform engagement, communication, and collaboration with psilocybin-assisted psychotherapy interventions. METHOD: Medical and mental health providers who treat patients with eating disorders were recruited via professional referral networks and participant driven sampling from across California to participate in one of five focus groups. Discussion topics included prior knowledge of psychedelic therapy, interest/concerns related to psilocybin therapy, and opportunities for collaboration. Study team members completed iterative rounds of coding with a grounded theory approach. RESULTS: A total of 32 participants reported a range of familiarity with psychedelics. Some raised concerns about the risks of administering psilocybin to malnourished patients and to those with psychological comorbidities. Despite these concerns, participants were hopeful to see psilocybin therapy as a treatment for patients with eating disorders. In anticipating challenges, providers had concerns about equity in access to care among publicly insured and non-English speaking patients. They requested opportunities for continuing education about psilocybin therapy. DISCUSSION: Our findings demonstrate provider interest in psilocybin therapy for the treatment of patients with eating disorders. As psilocybin therapy interventions are developed, providers caring for patients with eating disorders value collaboration to improve longitudinal patient outcomes. PUBLIC SIGNIFICANCE: This study invited healthcare providers of patients with eating disorders to discuss their thoughts around the use of psilocybin-assisted psychotherapy in this population. Findings will help inform emerging psilocybin therapy clinical trials with the goal of successful translation and adoption in real world clinical settings.

Parental self-efficacy: Longitudinal impact on clinical outcomes across levels of care in adolescent anorexia nervosa.

OBJECTIVE: Parental self-efficacy in the domain of weight restoration for adolescents with restrictive eating disorders is central to success in family-based interventions. We sought to characterize this parental self-efficacy during a brief hospitalization for medical stabilization and follow-up among patients with anorexia nervosa (AN) or atypical AN (AAN) enrolled in the StRONG clinical trial to understand the potential impact of inpatient treatment on caregiver empowerment. METHODS: Patients were enrolled upon hospital admission and refed per protocol. We examined correlates of the Parents Versus Anorexia (PVA) scale, a measure of parental self-efficacy in the domain of weight restoration, at admission, discharge, 10-days, 1-month, and 3-months post-discharge. Multi-level models evaluated associations among PVA scores and change in %median BMI and Eating Disorder Examination-Questionnaire (EDE-Q) global scores over 3-months post-discharge. RESULTS: Parents of N = 67 adolescents and young adults M(SD) age 15.79 (2.20) years and 85.00 (11.86) %median BMI participated. PVA scores did not change significantly during hospitalization (p = .053), which lasted on average 10.7 ± 4.5 days. PVA scores increased post-discharge (p = .009), with significant increase between discharge and 1-month post-discharge (p = .045). PVA scores were not associated with subsequent clinical outcomes. Rather, a main effect of time significantly predicted higher %median BMI and improved EDE-Q scores (p < .001). DISCUSSION: The finding that parental self-efficacy did not deteriorate during the inpatient stay is promising given the medical necessity of hospitalization to ensure short-term safety in some cases and the importance of parental self-efficacy to support long-term recovery. PUBLIC SIGNIFICANCE: Family-based treatment is the recommended treatment for young people with AN and AAN, serious psychiatric illnesses that may require inpatient medical stabilization. Prior evidence suggests that parental self-efficacy in the outpatient setting is a key component of treatment success. The current study suggests that parental self-efficacy and longer-term treatment outcomes are not undermined by a brief inpatient hospitalization.

Eating disorders in sexual minority adolescents and young adults: examining clinical characteristics and psychiatric co-morbidities in an inpatient medical setting.

BACKGROUND: Sexual minority adolescents and young adults are at higher risk of eating disorders compared to heterosexual peers. However, little is known about the clinical and psychiatric presentation of this population requiring inpatient medical stabilization. Given the increased risk for eating disorder behaviors in sexual minority individuals amidst increased rates of medical hospitalizations secondary to eating disorders, it is important to understand presenting characteristics of this population. The objectives of this study were to (1) describe the clinical characteristics of sexual minority adolescents and young adults with eating disorders admitted for medical instability and (2) compare psychiatric co-morbidities and suicidality of sexual minority adolescents and young adults to heterosexual peers. METHODS: A retrospective chart review was conducted of 601 patients admitted to a large inpatient eating disorders medical stabilization unit between 2012 and 2020. Data collected included demographics, medical data including vital signs, and psychiatric characteristics. Chi square or t-tests were used to examine potential differences in clinical characteristics and psychiatric co-morbidities between groups. Modified Poisson regression was used to assess associations between sexual orientation and psychiatric co-morbidities. RESULTS: Over one fifth (21.1%, n = 103) of our inpatient sample identified as a sexual minority individual. The average age of participants was 15.6 years (2.7). Sexual minority adolescents and young adults had higher percent median body mass index compared to heterosexual peers and yet equally severe vital sign instability on admission. Sexual minority adolescents and young adults were almost 1.5 times more likely to have a psychiatric comorbidity with higher rates of depression, anxiety, and post-traumatic stress disorder. Sexual minority adolescents and young adults were approximately two times more likely to have a history of self-injurious behaviors and/or suicidality. CONCLUSIONS: Sexual minority adolescents and young adults with eating disorders have equally severe vital sign instability despite higher percent median body mass index on admission for medical stabilization. Sexual minority adolescents and young adults hospitalized for medical complications of eating disorders are far more likely to have an additional mental health disorder and a history of self-harm and/or suicidality, which may portend a less favorable long-term prognosis.

Linear growth in young people with restrictive eating disorders: "Inching" toward consensus.

Background: While the assessment of acute medical stability in patients with eating disorders should never be minimized, careful attention toward other specific age-related consequences of malnutrition can improve psychological outcomes and reduce long-term, potentially irreversible medical complications, like linear growth impairment. Review: While the impact of malnutrition on linear growth is widely recognized, emerging data highlight consensus in several key areas: the time from onset to time of diagnosis, age at illness onset, pubertal stage at illness onset, and adequacy of weight restoration to achieve catch-up growth. This review provides concrete and actionable steps to help providers identify and explore deviations in expected growth and development while prioritizing early and aggressive weight restoration to provide the best opportunity for catch-up linear growth in patients with eating disorders. Conclusion: The impact of restrictive eating disorders on growth and development cannot be overstated, particularly in pre- and peripubertal patients. While many consequences of malnutrition are reversible, the loss of genetic height potential may prove irreversible without early and aggressive weight restoration.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization.

BACKGROUND: Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts. METHODS: A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index. RESULTS: Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037). CONCLUSIONS: Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

Gender diverse is a term that includes gender identities such as (but not limited to) transgender, non-binary, and gender fluid. Eating disorders are becoming increasingly recognized among this population. In recent years there has been a better understanding of the risk factors and screening for eating disorders in the outpatient setting for gender diverse adolescents. However, the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents with eating disorders requiring inpatient medical stabilization are poorly understood. This study examines these characteristics in gender diverse adolescents hospitalized for eating disorder-related medical complications from 2012 to 2020. Gender diverse adolescents presented for medical hospitalization with signs of malnutrition, including vital sign instability and laboratory abnormalities, as well as additional psychiatric diagnoses such as depression and anxiety. Understanding the medical, anthropometric, and psychiatric presentation of this population can lead to more tailored and comprehensive care with the potential to reduce the risks of adverse health outcomes.

Assessment of vitamin D among male adolescents and young adults hospitalized with eating disorders.

PURPOSE: Medical complications of eating disorders in males are understudied compared to females, as is the case of vitamin D deficiency. The aim of this study was to assess vitamin D levels among male and female adolescents and young adults hospitalized for medical complications of eating disorders. METHODS: We retrospectively reviewed electronic medical records of patients aged 9-25 years (N = 565) admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Serum vitamin D (25-hydroxy) level was assessed at admission as was history of prior calcium, vitamin D, or multivitamin supplementation. Linear regression was used to assess factors associated with vitamin D levels. RESULTS: A total of 93 males and 472 females met eligibility criteria (age 15.5 ± 2.8, 58.8% anorexia nervosa; admission body mass index 17.6 ± 2.91). Among male participants, 44.1% had 25-hydroxyvitamin D levels < 30 ng/mL, 18.3% had 25-hydroxyvitamin D levels < 20 ng/mL, and 8.6% had 25-hydroxyvitamin D levels < 12 ng/mL. There were no significant differences in 25-hydroxyvitamin D levels in males compared to females, except that a lower proportion (1.9%) of female participants had 25-hydroxyvitamin D levels < 12 ng/mL (p = 0.001). Only 3.2% of males reported calcium or vitamin D-specific supplementation prior to hospital admission, while 8.6% reported taking multivitamins. White race, prior calcium/vitamin D supplementation, and higher calcium levels were associated with higher vitamin D levels on admission. CONCLUSIONS: Nearly half of patients admitted to the hospital for malnutrition secondary to eating disorders presented with low 25-hydroxyvitamin D levels; males were more likely than females to have severe vitamin D deficiency. These findings support vitamin D assessment as part of the routine medical/nutritional evaluation for hospitalized eating disorder patients, with particular attention on male populations.

Medical complications of eating disorders in males are understudied compared to females. Little is known about vitamin D levels in male adolescents and young adults with eating disorders. We studied vitamin D levels in male and female adolescents and young adults hospitalized at the University of California, San Francisco between 2012 and 2020. We found that 44% of males had low vitamin D levels. Despite nearly half of males having low vitamin D, few were receiving calcium, vitamin D, or multivitamin supplementation prior to the hospitalization. White race, prior calcium or vitamin D supplementation, and higher calcium levels were associated with higher vitamin D levels. Medical providers should consider assessing for low vitamin D levels among males and females with eating disorders.

Renal Function in Patients Hospitalized With Anorexia Nervosa Undergoing Refeeding: Findings From the Study of Refeeding to Optimize Inpatient Gains.

PURPOSE: Among complications of malnutrition secondary to anorexia nervosa (AN) or atypical anorexia nervosa (AAN), renal impairment remains poorly elucidated. Evaluating renal function in hospitalized pediatric patients with AN and AAN undergoing refeeding will yield important information to guide clinicians in screening and managing renal dysfunction in this population. METHODS: This is a secondary analysis of data from the Study of Refeeding to Optimize Inpatient Gains trial, a multicenter randomized clinical trial comparing higher calorie refeeding versus lower calorie refeeding in 120 adolescents and young adults hospitalized with medical instability secondary to AN or AAN. Baseline disease characteristics were obtained. Vital sign measurements, weight, electrolytes, and fluid status were evaluated daily to ascertain medical stability. Renal function on admission and throughout hospitalization was quantified using daily creatinine measurement and calculation of the estimated glomerular filtration rate (eGFR) using the modified Schwartz equation. Regression analysis and mixed linear models were utilized to evaluate factors associated with eGFR. RESULTS: Of the 111 participants who completed treatment protocol, 33% had a baseline eGFR less than 90, suggesting renal impairment. Patients who experienced more rapid weight loss and more severe bradycardia were more likely to have low admission eGFR. While eGFR improved during refeeding, eGFR change by day based on refeeding treatment assignment did not reach statistical significance (95% confidence interval, -1.61, 0.15]; p = .095). DISCUSSION: Renal impairment is evident on admission in a significant number of adolescents and young adults hospitalized with AN and AAN. We demonstrate that short-term medical refeeding yields improvement in renal function.

Sex differences and associations between zinc deficiency and anemia among hospitalized adolescents and young adults with eating disorders.

PURPOSE: To determine sex differences in and associations between zinc deficiency and anemia among adolescents and young adults hospitalized for medical complications of eating disorders. METHODS: We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability, between May 2012 and August 2020. Descriptive statistics, crude, and adjusted logistic regression models were used to assess the association between zinc deficiency (< 55 mcg/dL) and anemia (< 13.6 g/dL in males [M] and < 11.8 g/dL in females [F]). RESULTS: A total of 87 males and 450 females met eligibility criteria (age 15.98 ± 2.81, 59.4% anorexia nervosa; admission body mass index 17.49 ± 2.82). In unadjusted comparisons, plasma zinc in males and females were not statistically different (M 64.88 ± 14.89 mcg/dL vs F 63.81 ± 13.96 mcg/dL, p = 0.517); moreover, there were no differences in the percentage of males and females with zinc deficiency (M 24.14% vs F 24.89%). However, a greater percentage of males than females were anemic (M 50.00% vs F 17.61%, p < 0.001), with similar findings in the subgroup with anorexia nervosa. In logistic regression models stratified by sex and eating disorder diagnosis, zinc deficiency was significantly associated with anemia in males (AOR 3.43, 95% CI 1.16, 10.13), but not females (AOR 1.47, 95% CI 0.86, 2.54). CONCLUSIONS: For the first time, we demonstrate that zinc deficiency is equally severe in males compared to females hospitalized with medical complications from eating disorders, with nearly a quarter of inpatients experiencing zinc deficiency. Anemia is more common in males than females hospitalized with eating disorders. LEVEL OF EVIDENCE: Level V: descriptive cross-sectional study.

Mental Health Care of Detained Youth Within Juvenile Detention Facilities.

Mental health treatment of juvenile offenders and undocumented immigrant youth in detention provides a unique opportunity for treatment providers. Although the work may be challenging, the clinical needs and opportunities for early and meaningful interventions are significant. One of the best clinical experiences a psychiatrist can have is working with extremely high-risk youth to help them find safer and better developmental pathways. Few settings can offer such an opportunity to leverage clinical skills to improve the lives and futures of children and adolescents as are afforded to those professionals lucky enough to work in juvenile justice settings.

Restrictive Eating Disorders: Accelerating Treatment Outcomes in the Medical Hospital.

Pediatric patients with anorexia nervosa and atypical anorexia nervosa may present to hospitals with significant vital sign instability or serum laboratory abnormalities necessitating inpatient medical hospitalization. These patients require specialized care, numerous resources, and interdisciplinary collaboration during what can be a protracted admission. Recent evidence informs areas in which care can be accelerated, and published protocols from major children's hospitals are helpful roadmaps to creating a streamlined hospitalization. In our narrative review, we focused on 3 key areas: (1) implementation of a rapid nutritional rehabilitation program; (2) assessment and management of the refeeding syndrome; and (3) early integration of psychoeducation and therapeutic interventions during inpatient hospitalization. A practical review of the literature in these 3 areas will give concrete, actionable information to pediatric hospitalists as they care for young people with restrictive eating disorders.