The association between leptin and weight maintenance outcome in anorexia nervosa.

OBJECTIVE: Relapse after weight restoration in anorexia nervosa (AN) is a critical problem. Higher body fat percentage after weight gain has been shown to predict better weight maintenance outcome. Leptin, a fat-derived hormone, has been associated with progress during weight gain, but its association with weight maintenance is unknown. This study aims to determine whether leptin levels after weight restoration in AN are associated with weight maintenance. METHOD: Participants were 41 women with AN hospitalized for inpatient treatment. Participants were evaluated 2-4 weeks after weight restoration to body mass index (BMI) ≥ 19.5 kg/m2 for plasma leptin and body composition. Weight maintenance outcome was defined by whether a participant maintained a BMI of at least 18.5 kg/m2 at the end of 1 year following hospital discharge. RESULTS: Twenty (48.8%) out of 41 patients maintained their weight at 1 year. Percent body fat and leptin were significantly higher in the group who maintained weight (body fat, p = .004, Hedges' g = 0.944; log-leptin, p = .010, Hedges' g = 0.821), but there were no differences in predischarge BMI, duration of illness, and duration of amenorrhea. Using regression modeling, only higher log-leptin (pWald = .021) and percent body fat (pWald = .010), as well as fat-adjusted leptin (pWald = .029), independently predicted weight maintenance at 1 year. DISCUSSIONS: Our findings suggest that for acutely-weight restored women with AN, higher predischarge leptin measurements are associated with better outcome in the year following treatment. Prospective studies examining leptin as well as other parameters of metabolic health could offer insights into biomarkers that may improve clinical outcomes.

Relationship between three factor eating questionnaire-restraint subscale and food intake.

OBJECTIVE: Dietary restraint refers to an individual's intention to restrict food intake, measured via self-report questionnaires, whereas dietary restriction refers to actual reduction in caloric intake. The aim of this research was to investigate the association between dietary restraint scales and actual caloric restriction. METHOD: Data were collected from six previously published or two ongoing eating behavior studies in which participants (n = 183) completed the Three Factor Eating Questionnaire (TFEQ) and Eating Disorders Examination Questionnaire (EDE-Q) and participated in a laboratory-based research lunch meal. Participants were individuals with anorexia nervosa (AN), bulimia nervosa (BN), and healthy controls (HC). The primary analysis was the association between TFEQ Restraint subscale and caloric intake in the meal. RESULTS: There was a significant negative correlation between total caloric intake and TFEQ Restraint scores (r = -.60, p < .001) and EDE-Q Restraint scores (r = -.54, p < .001). For TFEQ Restraint score, this relationship was significant within each diagnostic group (HC: r = -.32, p = .007; AN: r = -.38, p < .001; BN: r = -.43, p = .02). DISCUSSION: These results suggest that the TFEQ Restraint scale is a useful measure of dietary restriction, especially among individuals with eating disorders.

Fat preference and fat intake in individuals with and without anorexia nervosa.

Fat restriction is a characteristic eating behavior among individuals with anorexia nervosa (AN), and laboratory meal studies demonstrate restricted fat intake among low-weight patients. The Geiselman Food Preference Questionnaire-I© (FPQ) is a validated self-report measure that yields a fat preference score (FPS). Prior research reported that patients with AN had a significantly lower FPS than did healthy control (HC) participants. The goal of the current study was to compare self-reported fat preference (FPS) to fat intake (multi-item meal (MIM) study) in low-weight ANs and HCs. Specific aims were 1) to determine if the FPS differed between ANs and HCs; 2) to determine if fat and energy intakes differed between ANs and HCs; and 3) to determine if the FPS was associated with fat and energy intakes in ANs and HCs. Forty-four female AN inpatients and 48 female HCs completed the FPQ and participated in a MIM study. Compared to HCs, ANs consumed less energy (469.1 ±â€¯397.7 vs. 856.4 ±â€¯346.8 kcal, p < 0.001), less fat (16.4 ±â€¯20.4 vs. 36.7 ±â€¯18.9 g, p < 0.001), and a smaller percentage of calories from fat (22.9 ±â€¯13.8 vs. 36.6 ±â€¯8.0%, p < 0.001) at the MIM. Compared to HCs, ANs also had a lower FPS (79.7 ±â€¯27.4 vs. 102.3 ±â€¯18.9, p < 0.001). The FPS was significantly and positively correlated with caloric intake (r = 0.481, p < 0.01), total fat (r = 0.453, p < 0.01), and the percentage of calories from fat (r = 0.37, p < 0.05) in ANs as well as in HCs (kcal: r = 0.583, p < 0.001; fat: r = 0.621, p < 0.001; % fat kcal: r = 0.601, p < 0.001). The FPS is related to objective measures of energy and fat intake in patients with AN as well as in healthy individuals.

Rigor and reproducibility via laboratory studies of eating behavior: A focused update and conceptual review.

OBJECTIVE: The eating behavior of individuals with eating disorders has been examined in laboratory settings over the last 30 years. In this focused review, we build on prior research and highlight several feeding laboratory paradigms that have successfully demonstrated quantifiable and observable behavioral disturbances, and thereby add rigor and reproducibility to the examination of disturbances of eating behavior. This review describes the measures commonly obtained via these laboratory techniques. Supporting Information Appendices with detailed information about implementation are provided to allow for the reproducible execution of these techniques across labs. METHODS/RESULTS: Literature documenting the existence of objective abnormalities in eating behavior among individuals with eating disorders or in comparison to healthy controls (n > 40) is briefly summarized. These protocols, conducted across at least 17 independent labs, are sensitive and reproducible, can be used to assess subjective and physiological parameters associated with eating, and elucidate the impact of treatment. Laboratory studies from patients with eating disorders compared with healthy controls reproducibly demonstrate both that patients with Anorexia Nervosa ingest fewer calories and that individuals with Bulimia Nervosa and Binge-Eating Disorder ingest more calories when asked to binge-eat. DISCUSSION: Feeding laboratory studies have the potential for quantifying the characteristic behavioral psychopathology of patients with eating disorders, and may provide a useful tool to explore the potential utility of new treatments for individuals with Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder.

The effect of acute weight restoration on dietary fat preference in hospitalized patients with anorexia nervosa.

OBJECTIVE: Individuals with anorexia nervosa (AN) restrict fat intake. The Geiselman Food Preference Questionnaire-I© (FPQ) is a validated self-report instrument that yields a fat preference score (>100 = high fat preference, <100 = low fat preference). The goal of the study was to assess the utility of the FPQ in patients with AN. SPECIFIC AIMS: (1) to examine change in fat preference scores before and after weight restoration in hospitalized patients; and (2) to compare patients' scores before and after weight restoration to scores from healthy participants (HPs). METHOD: The FPQ was completed by 88 patients and 115 HPs. RESULTS: Compared with HPs, patients had significantly lower fat preference scores before (74.03 ± 32.03 vs. 102.93 ± 16.89, P < 0.001) and after (81.51 ± 26.89 vs. 102.92 ± 16.89, P < 0.001) weight restoration. Fat preference scores increased with weight gain (74.03 + 32.03 vs. 81.51 + 26.89, P < 0.01) but did not normalize in AN. DISCUSSION: Acutely weight restored patients continue to endorse decreased preference for high fat foods. The FPQ may be a useful metric by which to assess improvements in diet during treatment. Further study is warranted to validate the FPQ against observed food intake in AN. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:148-151).

Assessment of the motivation to use artificial sweetener among individuals with an eating disorder.

Eating disorders are associated with a range of abnormalities in eating behavior. Some individuals consume large amounts of non-caloric artificial sweeteners, suggesting abnormalities in appetitive responding. The current study aimed to quantify hedonic and motivating effects of artificial sweetener in individuals with and without an eating disorder. Two laboratory studies were conducted. Hedonic preference was estimated using the number of artificial sweetener packets (0-10) added to unsweetened cherry flavored Kool-Aid (study 1). Motivation to obtain sweetener was assessed by a progressive ratio (PR) work task (study 2). Ninety-three participants (25 anorexia nervosa restricting type (AN-R), 23 AN binge/purge type (AN-B/P), 20 bulimia nervosa (BN), and 25 normal controls (NC)) completed the study. No significant difference in hedonic preference was found among participant groups. Work completed at the PR task ranged from 0 to 9500 key-board presses. The AN-B/P group had a significantly higher breakpoint and performed significantly more work for sweetener compared to the BN and NC groups. Among AN-B/P and AN-R participants, the preferred number of Equal packets was significantly correlated with the breakpoint and total work. The increased amount of work for sweetener among individuals with AN-B/P supports an enhanced reward value of sweet taste in this population, and suggests that the characteristic food avoidance in AN cannot be accounted for by decreased reward value of all taste-related stimuli. This study also supports the novel application of a PR ratio task to quantify the motivating effect of sweet taste among individuals with an eating disorder.

Assessment of fat taste in individuals with and without anorexia nervosa.

OBJECTIVE: Avoidance of dietary fat is a highly characteristic eating behavior of individuals with anorexia nervosa (AN). To date, no study has determined whether these individuals are better able to perceive the fat content of foods than individuals without AN. The goal of this study was to compare blinded taste ratings of fat-free, low fat, and regular cream cheese in patients with AN and in normal controls (NC). METHOD: AN (n = 25) and control (NC; n = 25) participants were presented with a series of nine cream cheese samples of three differing fat contents and asked to taste and rate each sample from very low to very high fat. RESULTS: Repeated measures ANOVA found no significant main effect of fat content and no interaction between fat content and diagnosis; however, a significant three-way interaction between fat content, diagnosis, and trial was observed. Post hoc analysis revealed a significant fat content by trial interaction within the AN group, suggesting a significant trial effect for the fat-free samples only with improving ability to detect fat-free samples over repeated trials. DISCUSSION: The current study suggests that individuals with AN do not have a markedly greater ability to taste fat than NC, and that; therefore, fat avoidance is likely primarily based on cognitive factors.

Envisioning the Future of Well-Being Efforts for Health Care Workers-Successes and Lessons Learned From the COVID-19 Pandemic.

Importance: The National Academy of Medicine's National Plan for Health Workforce Well-Being provides recommendations for supporting the mental health and well-being of health care workers. This article aims to guide implementation of National Academy of Medicine recommendations by describing 2 programs at Columbia University Irving Medical Center and the University of California, San Francisco (UCSF), designed early in the COVID-19 pandemic to respond to the behavioral health needs of the health care workforce. The development of these programs, their similarities and differences, and the key lessons learned are discussed. Observations: The well-being programs, CopeColumbia and UCSF Cope, shared key elements. Both efforts were led by their respective departments of psychiatry and used similar frameworks. Teams created strategic cross-university partnerships to share difficulties and successes across both programs. Moreover, both programs addressed compounding stressors of racial and political unrest, evaluated program components, and created resources for employee self-management. CopeColumbia and UCSF Cope differed in approaches to identifying high-risk employees and formal assessment and treatment pathways. From the authors' experience implementing these programs and having knowledge regarding health care workforce burnout, this article offers recommendations for the development of well-being programs. These include structural changes and resources to promote group and individual well-being emphasizing equity and justice, intentional involvement of psychiatry on well-being leadership teams, and bold efforts to destigmatize mental health care alongside clear paths to mental health treatment. Conclusions and Relevance: The impact of the COVID-19 pandemic revealed a need for institutions to support the mental health and emotional well-being of health care workers. By outlining the development and implementation of 2 well-being programs in large academic health care settings and making recommendations to promote workforce well-being, it is the authors' hope that leaders will be empowered to carry forward critical changes. Most importantly, implementing plans now will provide the resilience needed both for the long shadow of the pandemic and future crises.

Dietary energy density and diet variety as risk factors for relapse in anorexia nervosa: a replication.

OBJECTIVE: To replicate our previous findings of an association between energy density and diet variety in recently weight-restored patients with anorexia nervosa (AN) and clinical outcome in the year following treatment. METHOD: Nineteen hospitalized, weight-restored women with AN completed a food record, from which a diet energy density score (DEDS) and a diet variety score (DVS) were calculated. After hospital discharge, patients were contacted regularly; at the end of one year, clinical outcome was determined using modified Morgan-Russell criteria. As in our previous study, outcome was dichotomized into "full, good, or fair" and "poor" groups. RESULTS: Data from 16 subjects were available. The DEDS was significantly lower (p < .05) in the poor outcome group (0.7 ± 1) compared with the "full, good, or fair" outcome group (0.9 ± 1). Although the DVS was also lower in the poor outcome group (13.9 ± 2) compared with the "full, good or fair" outcome group (15.7 ± 1.8), this difference was not statistically significant. DISCUSSION: In recently weight-restored patients with AN, a lower DEDS, but not DVS, is associated with poor clinical outcome after inpatient treatment. This finding may be important in the assessment of risk for relapse in patients with AN.

Eating behavior in anorexia nervosa: before and after treatment.

OBJECTIVE: The purpose of this study was to assess eating behavior in patients with anorexia nervosa before and after weight normalization and healthy controls using a standardized, multiple-item lunch meal paradigm. METHOD: Eighteen patients were studied shortly after inpatient admission and again after gaining to a BMI ≥ 19.5 kg m(-2) . Fifteen healthy controls were studied twice, ∼2-3 months apart. RESULTS: When underweight, patients with AN consumed fewer total calories (364 ± 208 kcal) and a lower percentage of calories from fat (18% ± 10%) compared to controls (775 ± 228 kcal, p = 0.001; 38% ± 7%, p = 0.001). After weight normalization, despite a modest increase in total calories (364 ± 208 kcal vs. 516 ± 273 kcal, p = 0.04) and in percent of calories from fat (18% ± 10% vs. 23% ± 9%, p = 0.04), patients continued to consume fewer total calories and a reduced percent of calories from fat compared to controls (758 ± 346 kcal, p = 0.03; 38% ± 18%, p = 0.004). DISCUSSION: Patients with AN, even after acute treatment, consume fewer total calories and fewer calories from fat, compared to healthy controls. The reduced overall intake and persistent avoidance of fat may contribute to relapse, and therefore are potential therapeutic targets.

Accuracy of self-reported energy intake in weight-restored patients with anorexia nervosa compared with obese and normal weight individuals.

OBJECTIVE: To compare self-reported and measured energy intake in weight-restored patients with anorexia nervosa (AN), weight-stable obese individuals (OB), and normal weight controls (NC). METHOD: Forty participants (18 AN, 10 OB, and 12 NC) in a laboratory meal study simultaneously completed a prospective food record. RESULTS: AN patients significantly (p = .018) over-reported energy intake (16%, 50 kcal) and Bland-Altman (B-A) analysis indicated bias toward over-reporting at increasing levels of intake. OB participants significantly (p = .016) under-reported intake (19%, 160 kcal) and B-A analysis indicated bias toward under-reporting at increasing levels of intake. In NC participants, NS (p = .752) difference between reported and measured intake was found and B-A analysis indicated good agreement between methods at all intake levels. DISCUSSION: Self-reported intake should be cautiously interpreted in AN and OB. Future studies are warranted to determine if over-reporting is related to poor outcome and relapse in AN, or under-reporting interferes with weight loss efforts in OB.

Percent body fat is a risk factor for relapse in anorexia nervosa: a replication study.

OBJECTIVE: We aimed to replicate and extend our previous findings of an association between percent body fat in recently weight-restored patients with Anorexia Nervosa (AN) and clinical outcome in the year following treatment. METHOD: Twenty-two hospitalized, weight-restored women with AN underwent whole body MRI to determine percent adipose tissue. Following hospital discharge, patients were contacted regularly, and at the end of the year, clinical outcome was determined using modified Morgan-Russell (MR) criteria: full, good, fair or poor. Identical to our previous study, outcome was dichotomized into "full, good or fair" and "poor" groups. RESULTS: Data from 21 subjects were available for analysis. Percent body fat was significantly lower in the poor outcome group (22% ± 5%) compared to the "full, good or fair" outcome group (27 % ± 4%)(p < 0.035). To further examine the relationship, we combined data from the current study with data from the 26 subjects on whom we had previously reported. Univariate analysis of variance (ANOVA) demonstrated a significant difference in percent adipose tissue across the four MR outcome groups (F = 3.416, df = 3, p<0.03). DISCUSSION: Lower percent adipose tissue after short-term weight normalization is associated with poor clinical outcome in the year following inpatient treatment. These findings may be important in the assessment of risk for relapse in patients with AN.

Brain tissue volume changes following weight gain in adults with anorexia nervosa.

OBJECTIVE: To measure brain volume deficits among underweight patients with anorexia nervosa (AN) compared to control participants and evaluate the reversibility of these deficits with short-term weight restoration. METHOD: Brain volume changes in gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) were examined in 32 adult women with AN and compared to 21, age and body mass index-range matched control women. RESULTS: Patients with AN had a significant increase in GM (p = .006, η(2) = 0.14) and WM volume (p = .001, η(2) = 0.19) following weight restoration. Patients on average had lower levels of GM at low weight (647.63 ± 62.07 ml) compared to controls (679.93 ± 53.31 ml), which increased with weight restoration (662.64 ± 69.71 ml), but did not fully normalize. DISCUSSION: This study suggests that underweight adult patients with AN have reduced GM and WM volumes that increase with short-term weight restoration.

Supporting the well-being of health care providers during the COVID-19 pandemic: The CopeColumbia response.

OBJECTIVE: COVID-19 is an international public health crisis, putting substantial burden on medical centers and increasing the psychological toll on health care workers (HCW). METHODS: This paper describes CopeColumbia, a peer support program developed by faculty in a large urban medical center's Department of Psychiatry to support emotional well-being and enhance the professional resilience of HCW. RESULTS: Grounded in evidence-based clinical practice and research, peer support was offered in three formats: groups, individual sessions, and town halls. Also, psychoeducational resources were centralized on a website. A Facilitator's Guide informed group and individual work by including: (1) emotional themes likely to arise (e.g., stress, anxiety, trauma, grief, and anger) and (2) suggested facilitator responses and interventions, drawing upon evidence-based principles from peer support, stress and coping models, and problem-solving, cognitive behavioral, and acceptance and commitment therapies. Feedback from group sessions was overwhelmingly positive. Approximately 1/3 of individual sessions led to treatment referrals. CONCLUSIONS: Lessons learned include: (1) there is likely an ongoing need for both well-being programs and linkages to mental health services for HCW, (2) the workforce with proper support, will emerge emotionally resilient, and (3) organizational support for programs like CopeColumbia is critical for sustainability.

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic.

OBJECTIVE: The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic. METHODS: This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th-April 24th 2020) at a large medical center in NYC (n = 657). RESULTS: Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest. CONCLUSIONS: NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.

Differential glucose metabolism in weight restored women with anorexia nervosa.

Women with anorexia nervosa (AN) develop visceral adiposity associated with insulin resistance after partial weight restoration, but little is known about the glucose homeostasis after full weight restoration. In this investigation, we studied glucose homeostasis in twenty-four women with AN before (AN) and after weight restoration (WR) at a single institution, with both restricting and binge-purge subtypes (>70% binge-purge), compared to gender-, age- and BMI-matched healthy controls (HC). Participants underwent fasting plasma hormone analysis, oral glucose tolerance test (OGTT), and body composition analysis. Glucose homeostasis was assessed by the homeostasis model assessment (HOMA) and OGTT, and parameters were analyzed for association with body composition. We observed that a subset of the WR patients (21%) had metabolically unhealthy HOMA insulin resistance estimates (HOMA-IR), while this was not seen in the control group. Overall mean HOMA-IR between groups were not significantly different. Mean glucose reactivity was higher in the WR group than HC women (p = 0.008, Hedges' g = 0.811), and time-adjusted glucose reactivity in the WR group was inversely associated with visceral adiposity (r = -0.559, p = 0.006), but not with fat mass (r = -273, p = 0.208) or lean mass (r = -0.002, p = 0.994). Our findings suggest that glucose response during the OGTT in women with AN is altered in association with visceral adiposity acutely after full weight restoration, but that they do not develop overt insulin resistance. Glucometabolic profiling could offer novel insights to energy homeostasis acutely after weight restoration.

The FTO Gene and Measured Food Intake in 5- to 10-Year-Old Children Without Obesity.

OBJECTIVE: Genetic variation in the first intron of FTO (e.g., single-nucleotide polymorphism [SNP] rs9939609) is strongly associated with adiposity. This effect is thought to be mediated (at least in part) via increasing caloric intake, although the precise molecular genetic mechanisms are not fully understood. Prior pediatric studies of FTO have included youth with overweight and obesity; however, they have not informed whether a genotypic effect on ingestive behavior is present prior to obesity onset. Therefore, this study investigated the association between FTO and caloric intake in children aged 5 to 10 years without obesity (adiposity ≤ 95th percentile). METHODS: A total of 122 children were genotyped for rs9939609 and ate ad libitum from a laboratory lunch buffet following a standardized breakfast. Linear regressions, adjusting for body mass, were used to examine the association between FTO "dose" (number of copies of SNP rs9939609) and intake variables. RESULTS: There was a significant association between FTO and total intake. Each risk allele predicted an additional 64 calories, accounting for 3% of the variance. There were no associations between FTO and macronutrient preference, energy density, or diet variety. Results were influenced by race. CONCLUSIONS: Results corroborate and extend prior work by showing a dose-dependent effect on food intake in children without obesity.

The clinical significance of amenorrhea as a diagnostic criterion for anorexia nervosa.

OBJECTIVE: Amenorrhea is a DSM-IV criterion for the diagnosis of anorexia nervosa (AN). Several studies have reported few differences between patients who meet the full DSM-IV criteria for AN and those who meet all but the amenorrhea criterion. Although this suggests that the absence of menses does not provide critical diagnostic information, many of these studies are limited by small sample sizes. This study aims to examine the clinical utility of amenorrhea as a criterion for the diagnosis of AN. METHOD: A chart review was conducted of 240 consecutive patients admitted for inpatient treatment at the NY State Psychiatric Institute from 1993 to 2006. Menstrual data were collected from the Eating Disorder Examination conducted upon admission. Independent samples t-tests were performed to evaluate differences in clinical variables, including age, lifetime lowest body mass index (BMI), admission and discharge BMI, previous number of hospitalizations, duration of illness, Beck Depression Inventory total score, Beck Anxiety Inventory total score, and Eating Disorder Examination subscale scores. RESULTS: The amenorrheic and menstruating groups differed significantly only on lowest lifetime BMI and admission BMI, with individuals with amenorrhea having lower BMIs on both measures. CONCLUSION: These results indicate that amenorrhea does not distinguish between groups on a number of important measures of clinical severity. It may be that amenorrhea reflects weight and nutritional status, rather than providing useful diagnostic information. Future studies are needed to examine the potential prognostic value of menstrual status.

Does percent body fat predict outcome in anorexia nervosa?

OBJECTIVE: The goal of this study was to investigate the relationship of body composition and neuroendocrine levels with clinical outcome in women with anorexia nervosa in a relapse-prevention trial. METHOD: Body composition and fasting cortisol and leptin levels were assessed before random assignment in 32 weight-recovered subjects with anorexia nervosa from the New York site of the Fluoxetine to Prevent Relapse in Women With Anorexia Nervosa trial. Clinical outcome at the end of study participation was defined using modified Morgan-Russell criteria (full, good, fair, poor), then dichotomized into treatment "success" or "failure." RESULTS: In a binary logistic regression model examining the effect of percent body fat, body mass index, anorexia nervosa subtype, waist-to-hip ratio, and serum cortisol and leptin levels on treatment outcome, only percent body fat was significantly associated with outcome. CONCLUSIONS: In recently weight-restored women with anorexia nervosa, lower percent body fat was associated with poor long-term outcome.