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Current approach to eating disorders: a clinical update

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Current approach to eating disorders: a clinical update

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In this article, advances and the current status of evidence‐based treatment and outcomes for anorexia nervosa, bulimia nervosa, and binge eating disorder are discussed with focus on first‐line psychological therapies. In today’s society, eating disorders are becoming more common due to the emphasis on body image and “beauty”. A major challenge in improving treatment outcomes is to close the ‘treatment gap’. The treatment gap is the fact that the majority of patients with bulimia nervosa and anorexia nervosa wait around a decade to seek treatment. When they do seek treatment, in children and adolescents, an atheoretical family‐based treatment (FBT) is the leading modality of care. FBT is important because it helps build the support system for the patient seeking care. Recovery from an eating disorder is highly likely, as shown by research, but it is a slow process. A study of 228 women over 22 years with anorexia nervosa or bulimia found that 66% of patients recovered over the study, with the majority recovering within 9 years. This study is important because we need to verify that the way we are treating patients is working and creating positive outcomes. Much more research is needed in the field of eating disorders treatments to increase these patients quality of life.

Hay P. (2020). Current approach to eating disorders: a clinical update. Internal medicine journal, 50(1), 24–29. https://doi.org/10.1111/imj.14691

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Affiliations

¹ Translational Health Research Institute (THRI), School of Medicine, Western Sydney University, Sydney, New South Wales, Australia.

² Campbelltown Hospital, SWSLHD, Sydney, New South Wales, Australia.

Free PMC article

Free PMC article

Affiliations

¹ Translational Health Research Institute (THRI), School of Medicine, Western Sydney University, Sydney, New South Wales, Australia.

² Campbelltown Hospital, SWSLHD, Sydney, New South Wales, Australia.

Abstract

This article presents current diagnostic conceptualisations of eating disorders, including new disorders such as binge eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). This is followed by contemporary findings in the epidemiology of eating disorders, their broad sociodemographic distribution and the increases in community prevalence. Advances and the current status of evidence-based treatment and outcomes for the main eating disorders, anorexia nervosa, bulimia nervosa and BED are discussed with focus on first-line psychological therapies. Deficits in knowledge and directions for further research are highlighted, particularly with regard to treatments for BED and ARFID, how to improve treatment engagement and the management of osteopenia.

Keywords: anorexia nervosa; binge eating disorder; bulimia nervosa; epidemiology; treatment.

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[Consensus document about the nutritional evaluation and management of eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder, and others. Executive abstract].

Gómez Candela C, Palma Milla S, Miján-de-la-Torre A, Rodríguez Ortega P, Matía Martín P, Loria Kohen V, Campos Del Portillo R, Virgili Casas MªN, Martínez Olmos MÁ, Mories Álvarez MT, Castro Alija MJ, Martín-Palmero Á. Gómez Candela C, et al. Nutr Hosp. 2018 Jan 31;35(2):489-494. Nutr Hosp. 2018. PMID: 29756985 Review. Spanish. No abstract available.

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Frank GKW, Shott ME, DeGuzman MC. Frank GKW, et al. Child Adolesc Psychiatr Clin N Am. 2019 Oct;28(4):629-640. doi: 10.1016/j.chc.2019.05.007. Epub 2019 Jul 4. Child Adolesc Psychiatr Clin N Am. 2019. PMID: 31443880 Free PMC article. Review.

References

American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM‐5). Washington, DC: American Psychiatric Association; 2013.

World Health Organization . International Statistical Classification of Diseases and Related Health Problems, 11th Revision (ICD‐11). Geneva: World Health Organization; 2019.

Hay P, Mitchison D, Lopez Collado AE, González‐Chica DA, Stocks N, Touyz S. Burden and health‐related quality of life of eating disorders, including avoidant/restrictive food intake disorder (ARFID), in the Australian population. J Eat Disord 2017; 5: 21. - PMC - PubMed

Galmiche M, Déchelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000-2018 period: a systematic literature review. Am J Clin Nutr 2019; 109: 1402-13. - PubMed

Udo T, Grilo CM. Prevalence and correlates of DSM‐5-defined eating disorders in a nationally representative sample of US adults. Biol Psychiatry 2018; 84: 345-54. - PMC - PubMed

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avoidant restrictive food intake disorder

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feeding and eating disorders / classification

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feeding and eating disorders / diagnosis*

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feeding and eating disorders / epidemiology

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national center for biotechnology information

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Current approach to eating disorders: a clinical update - PubMed

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This article presents current diagnostic conceptualisations of eating disorders, including new disorders such as binge eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). This is followed by contemporary findings in the epidemiology of eating disorders, their broad sociodemo ...

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Diagnosis of Eating Disorders Among College Students: a Comparison of Military and Civilian Students - Dierra Doaks 

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Diagnosis of Eating Disorders Among College Students: a Comparison of Military and Civilian Students - Dierra Doaks 

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The article I chose this week is about eating disorders in the military. Eating disorders are often under-detected. People in the military are a subpopulation that may be extremely vulnerable to being undiagnosed. The study used a large college-aged sample with military and civilian students. The study used questionnaires. Ultimately, the results were interesting. The prevalence of eating disorders was high for both military and civilian students. The prevalence for military students was 14.4% while the prevalence for civilian students was 20.4%. There was also a higher prevalence for female civilian students than female military students. It’s also important to note that the prevalence of diagnosis of an eating disorder was low in both groups. The prevalence of diagnosis was 10.8% for military involved college students and 16.4% for civilian college students. This study is really important because it shows that the under diagnosis of eating disorders is very common and certain groups can be left out of the conversation.

Reports Summarize Military Medicine Findings from University of Michigan (Diagnosis of Eating Disorders Among College Students: a Comparison of Military and Civilian Students). NewsRX LLC, 2022. Print.

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Richard Adefioye: Psychiatric comorbidity in binge-eating disorder as a function of smoking history

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Richard Adefioye: Psychiatric comorbidity in binge-eating disorder as a function of smoking history

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Various factors (including biological, social and psychosocial) have been reported to induce eating disorders. But for this paper, the authors looked at the possible role smoking plays in the development of eating disorders, which I think is interesting.

For this study, the researchers interviewed 103 obese women using the DSM-IV diagnosis of BED and the participants were categorized as either daily smokers or never smokers. The correlation between this smoking choice was then regressed against the the lifetime rates of some comorbid psychopathologies.

The results of this study showed that the smokers had a significantly higher chance of developing panic disorder, major depressive disorder, post traumatic stress disorder and substance abuse.

However the authors concluded that it is still unclear whether smoking played a role in inducing BED in these women or they just reach out to cigarettes for comfort just like food during stress. However, smoking does greatly increase their chances of developing more mental illnesses.

White, M. A., and C. M. Grilo. 2006. Psychiatric comorbidity in binge-eating disorder as a function of smoking history. J. Clin. Psychiatry 67(4):594-599. (Article) doi: 10.4088/JCP.v67n0410

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Cinematherapy in the day hospital treatment of patients with eating disorders: Post by Jaida Garrett 

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Cinematherapy in the day hospital treatment of patients with eating disorders: Post by Jaida Garrett 

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The article I chose is an intensive case study done in the hospital for patients with eating disorders. The therapy that is being tested on patients in this intensive day study is cinematherapy. This therapy includes a therapist selecting specific commercial films for patients to view. What is important to note is that they studied a patient who has had an eating disorder from 17 to their current age, 40.

The study is important because it allows researchers to help patients with ED receive a more therapeutic treatment. The treatment allows for patients to feel more vulnerable to accepting treatment rather than the standard talk-oriented therapies such as CBT. It is also important because it allows for patients to overcome a lack of insight relating to their mind and body. So in the study, the patient was able to gain awareness of her emotions properly instead of associating them with "I feel overweight". Instead, she learned about aggressiveness and fear of relationships. The therapy helped with her self-discovery and self-expression in which not only the physicians understand but she as the patient understands as well. A key finding I believe is knowing how this therapy allows for patients to slip into a state of half wakefulness which loosens the fantasies and ideas to interact with the screen. It is the key to a patient accepting their thoughts and emotions. Clinically this therapy can be used well in addition to CBT for patients with mild to severe eating disorders. It is important to have more than one way of treatment because not all patients are the same. The number one priority is for the patient to become knowledgeable and aware of their disease as well as allow them to be comfortable in their treatment.

Gramaglia, C., Abbate-Daga, G., Amianto, F., Brustolin, A., Campisi, S., De-Bacco, C., & Fassino, S. (2011, August 12). Cinematherapy in the day hospital treatment of patients with eating disorders. case study and clinical considerations. The Arts in Psychotherapy. Retrieved March 2, 2022, from https://www.sciencedirect.com/science/article/abs/pii/S0197455611000712

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Vitamin D status in young Swedish women with anorexia nervosa during intensive weight gain therapy

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Vitamin D status in young Swedish women with anorexia nervosa during intensive weight gain therapy

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-Clarisa Williams

This study, published through the European Journal of Nutrition, was conducted to evaluate vitamin d status along with BMI, body composition of fat mass, and bone mineral density on patients with severe anorexia nervosa that were receiving an intensive nutritional therapy via high energy diet.  Reduced bone mass is associated with anorexia nervosa and can develop to osteoporosis and an increase risk of fractures. Nutrition and vitamin D are two factors that determine bone modeling and remodeling in adolescence. Vitamin D deficiency leads to a reduction in bone mass and decreased bone mineralization. Patients with anorexia nervosa can have decreased bone mass density and have seen 38%-50% prevalence of osteoporosis. The Endocrine Society suggests children and adults maintain Serum 25-hydroxyvitamin D levels above 50 nmol/L to prevent osteomalacia and above 75nmol/L to maximize the effect on calcium bone and muscle metabolism. The researchers found that even with the high energy diet, patient Vitamin D levels decreased overall. At the start of the study, the median Serum 25 levels were adequate at 84nmol/L but decreased after the nutritional intervention. There findings could indicate the need to increase vitamin D in patients with severe anorexia nervosa who are undergoing intensive nutritional therapy to prevent the decrease of levels.

Svedlund, A., Pettersson, C., Tubic, B., Magnusson, P., & Swolin-Eide, D. (2017). Vitamin D status in young Swedish women with anorexia nervosa during intensive weight gain therapy. European journal of nutrition, 56(6), 2061-2067.

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Tamunoerenomie Inimgba: An Evolutionary Genetic Perspective of Eating Disorders.

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Tamunoerenomie Inimgba: An Evolutionary Genetic Perspective of Eating Disorders.

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This article focuses on trying to create a framework that could possibly explain interactions between genetic risk and cultural influences in the development of eating disorders. Previous studies show that heritability estimates for eating disorders range from 28 to 83%., however no genetic risk factors have been conclusively found or any associations detected through genome-wide association studies. A key finding in the article was a possible genetic explanation fir the overlap of phenotypes since in anorexia nervosa and binge eating disorder could be presence of mutations or structural gene variants in the same gene that would cause opposite effects or mutations in nearby genes leading to a partial disequilibrium for the genes causing anorexia nervosa and binge eating disorder. This relates to nutritional sciences as understanding possible genes underlying eating disorders may bring to light better and more effective methods of treating these disorders. The clinical implications of the study is that this can provide a new perspective for research into new biological mechanisms and genetic roots for eating disorders.

Mayhew, A. J., Pigeyre, M., Couturier, J., & Meyre, D. (2018). An evolutionary genetic perspective of eating disorders. Neuroendocrinology, 106(3), 292-306.

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Rhoda Inimgba: Associations between physical activity and eating‐disorderpsychopathology among individuals categorised withbinge‐eating disorder and bulimia nervosa,

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Rhoda Inimgba: Associations between physical activity and eating‐disorderpsychopathology among individuals categorised withbinge‐eating disorder and bulimia nervosa,

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Participation in physical activity has been shown to improve the health of individuals but in the case of eating disorders, physical exercise can be said to be not effective. This is because it could be described as a purging behavior such as inducing vomiting or taking laxatives in order to lose weight. However, this study focuses on the relationship between non-compensatory physical exercise and eating disorders. This study is important because this non-compensatory exercise can prove to have psychological benefits and thereby improve the overall health of the individual. A key finding of the study was that individuals who actively participated in non-compensatory physical activity showed lower eating disorder psychopathology and also had a lower BMI. This finding relates to nutritional science as it provides nutritionist with a way to advise individuals with eating disorder how to carry out physical activity and also being able to control their weight loss. The clinical implications of this study is that this gives nutritionist a physical activity option to give to individuals seeing that it brings about a lower psychopathology unlike compulsive exercise which shows to be related to high eating disorder.

Kerrigan, S. G., Lydecker, J. A., & Grilo, C. M. (2019). Associations between physical activity and eating‐disorder psychopathology among individuals categorised with binge‐eating disorder and bulimia nervosa. International Journal of Clinical Practice, 73(11). https://doi.org/10.1111/ijcp.13401.

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Yoga in the treatment of eating disorders within a residential program: A randomized controlled trial

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Yoga in the treatment of eating disorders within a residential program: A randomized controlled trial

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I found this clinical study very interesting and helped contribute to my understanding of eating disorders that I have gotten from this class. Many diagnosis of eating disorders incorporate yoga into the treatment plan of patients. This study explored how yoga actually affects the patients. The yoga explored in this study was centered around meal times to have a more direct affect on the subjects. An assessment was given to each subject to complete before and after each meal post-yoga. It was found that the subjects of the trial had much lower negative effect before their meals. However, the effects of the yoga post-meal were not significant. I think this study showed how important it is to get the timing right on the treatments of patients. The more thorough a treatment is, the more effective it will be. This study gives doctors and nutritionist a better understanding of how the treatment of yoga should be prescribed to a patient.

https://pubmed.ncbi.nlm.nih.gov/27723416/

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Affiliations

¹ a Department of Behavioral Health and Nutrition, College of Health Sciences , University of Delaware , Newark , Delaware , USA.

² b The Emily Program , St. Paul , Minnesota , USA.

³ c The Neuropsychiatric Research Institute , Fargo , North Dakota , USA.

⁴ d The University of North Dakota School of Medicine and Health Sciences , University of North Dakota , Fargo , North Dakota , USA.

⁵ e Division of Epidemiology & Community Health, School of Public Health , University of Minnesota , Minneapolis , Minnesota , USA.

Free PMC article

Randomized Controlled Trial

Free PMC article

Affiliations

¹ a Department of Behavioral Health and Nutrition, College of Health Sciences , University of Delaware , Newark , Delaware , USA.

² b The Emily Program , St. Paul , Minnesota , USA.

³ c The Neuropsychiatric Research Institute , Fargo , North Dakota , USA.

⁴ d The University of North Dakota School of Medicine and Health Sciences , University of North Dakota , Fargo , North Dakota , USA.

⁵ e Division of Epidemiology & Community Health, School of Public Health , University of Minnesota , Minneapolis , Minnesota , USA.

Abstract

To investigate the effect of yoga on negative affect (an eating disorders risk factor), 38 individuals in a residential eating disorder treatment program were randomized to a control or yoga intervention: 1 hour of yoga before dinner for 5 days. Negative affect was assessed pre- and post-meal. Mixed-effects models compared negative affect between groups during the intervention period. Yoga significantly reduced pre-meal negative affect compared to treatment as usual; however, the effect was attenuated post-meal. Many eating disorders programs incorporate yoga into treatment. This preliminary evidence sets the stage for larger studies examining yoga and eating disorder treatment and prevention.

Conflict of interest statement

The authors have no conflicts of interest to report with this funding.

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Implementation of transdiagnostic treatment for emotional disorders in residential eating disorder programs: A preliminary pre-post evaluation.

Thompson-Brenner H, Boswell JF, Espel-Huynh H, Brooks G, Lowe MR. Thompson-Brenner H, et al. Psychother Res. 2019 Nov;29(8):1045-1061. doi: 10.1080/10503307.2018.1446563. Epub 2018 Mar 19. Psychother Res. 2019. PMID: 29553881

Effects of yoga on eating disorders-A systematic review.

Ostermann T, Vogel H, Boehm K, Cramer H. Ostermann T, et al. Complement Ther Med. 2019 Oct;46:73-80. doi: 10.1016/j.ctim.2019.07.021. Epub 2019 Jul 31. Complement Ther Med. 2019. PMID: 31519291

Randomized controlled clinical trial of yoga in the treatment of eating disorders.

Carei TR, Fyfe-Johnson AL, Breuner CC, Brown MA. Carei TR, et al. J Adolesc Health. 2010 Apr;46(4):346-51. doi: 10.1016/j.jadohealth.2009.08.007. Epub 2009 Nov 3. J Adolesc Health. 2010. PMID: 20307823 Free PMC article. Clinical Trial.

Effectiveness and clinical response rates of a residential eating disorders facility.

Twohig MP, Bluett EJ, Cullum JL, Mitchell PR, Powers PS, Lensegrav-Benson T, Quakenbush-Roberts B. Twohig MP, et al. Eat Disord. 2016 May-Jun;24(3):224-39. doi: 10.1080/10640266.2015.1064279. Epub 2015 Jul 27. Eat Disord. 2016. PMID: 26214231

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national center for biotechnology information

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Yoga in the treatment of eating disorders within a residential program: A randomized controlled trial - PubMed

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To investigate the effect of yoga on negative affect (an eating disorders risk factor), 38 individuals in a residential eating disorder treatment program were randomized to a control or yoga intervention: 1 hour of yoga before dinner for 5 days. Negative affect was assessed pre- and post-meal. Mixed ...

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Joe Devine: Are the Gut Bacteria Telling Us to Eat or Not to Eat? Reviewing the Role of Gut Microbiota in the Etiology, Disease Progression and Treatment of Eating Disorders

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Joe Devine: Are the Gut Bacteria Telling Us to Eat or Not to Eat? Reviewing the Role of Gut Microbiota in the Etiology, Disease Progression and Treatment of Eating Disorders

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For this weeks weekly wall post I am posting a study that looked at the link between gut microbiome and eating disorders. During this weeks lectures there were 3 main factors that were determined to causal in the development of eating disorders, and when I saw that biological factors were one of them, I became intrigued as I had always assumed social factors were the main ones. The study looks at the causality in the gut-brain axis and the development of eating disorders due to things like appetite control, and transformed brain function. The study highlights that there is an associative relationship between dysregulated food intake and the microbiome. The paper calls this dysbiosis, which is when the gut microbiome is not flourishing within the host which, within the paper, supports its role in the overall picture of health. While this is not a catchall treatment and more research is needed, the microbiome has very interesting relationships to almost everything.

Lam, Y. Y., Maguire, S., Palacios, T., & Caterson, I. D. (2017). Are the Gut Bacteria Telling Us to Eat or Not to Eat? Reviewing the Role of Gut Microbiota in the Etiology, Disease Progression and Treatment of Eating Disorders. Nutrients, 9(6), 602. https://doi.org/10.3390/nu9060602

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Impact of the Coronavirus Pandemic on Anorexia Nervosa and Atypical Anorexia Nervosa Presentations -Lydia Duncan 

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Impact of the Coronavirus Pandemic on Anorexia Nervosa and Atypical Anorexia Nervosa Presentations -Lydia Duncan 

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This article looks into the impact of the Covid-19 pandemic on Anorexia Nervosa (AN), including Atypical AN. Specifically, this study took place in an Australian tertiary paediatric(pediatric) hospital.The data was collected using a four year chart review (2017-2020) of 457 patients, to see which patients used the hospital's children's eating disorder service, as well as the severity of those cases. This study is important because it can help us see some more of the health complications and mental health issues that have arisen from the pandemic.
The biggest finding from this study was that the number of cases of AN & Atypical AN increased from 2017-2020. For example, the average number of presenting eating disorders (ED's) for 2017-2019 was 98.7. In 2020, the number of presenting ED's was 161 (a 63% increase). Another interesting result that I want to mention is that the presentation of eating disorders increased almost 10% specifically for females (% of patients w/ED who were also female in 2017= 80.6; % of patients w/ED who were also female in 2020= 90.1). These results are important to nutritional sciences because we want the number of ED's to decrease, not increase like they might have in the pandemic. It is also important because it could imply that other nutritional difficulties are occurring that should be further looked into.
A clinical implication of this study is that more individuals may have developed one of these ED's throughout the pandemic, and therefore it could be beneficial to discuss possible new eating habits to determine if they may have developed an ED over this stressful period of time. While it was interesting to see the relation between Covid-19 and ED's like AN or Atypical AN, further research with larger (and more diverse) cohorts are needed.

Springall, G., Cheung, M., Sawyer, S.M. and Yeo, M. (2022), Impact of the coronavirus pandemic on anorexia nervosa and atypical anorexia nervosa presentations to an Australian tertiary paediatric hospital. Journal of Paediatric Child Health. https://doi.org/10.1111/jpc.15755

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Cassie Craig: Vitamin D Level Trajectories of Adolescent Patients withAnorexia Nervosa at Inpatient Admission, during Treatment, and at One Year Follow Up: Association with Depressive Symptoms

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Cassie Craig: Vitamin D Level Trajectories of Adolescent Patients withAnorexia Nervosa at Inpatient Admission, during Treatment, and at One Year Follow Up: Association with Depressive Symptoms

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This study is important because it focuses on the prominence of potential comorbidities of Anorexia nervosa (AN), such as depression and vitamin D deficiency. Patients with AN were assessed at admission, discharge, and one year post-admission for vitamin D levels and depressive symptoms. These levels were compared to see if there was correlation between the comorbidities. This study found that vitamin D levels did not show deficiency as frequently at admission, as it did at discharge and follow up. This shows that vitamin D levels dropped during treatment without supplementation. This relates to nutritional sciences because it emphasizes the importance of employing supplements in AN treatments due to the high levels of nutrient deficiency. Although the study did not find a correlation between vitamin D levels and depressive systems, it highlights the importance of physicians to consistently observe vitamin D levels in AN patients. Vitamin D supplements should be utilized by physicians when treating AN patients to lower their chance of vitamin D deficiency when they are discharged and one year post-admission.

Föcker, Manuel et al. “Vitamin D Level Trajectories of Adolescent Patients with Anorexia Nervosa at Inpatient Admission, during Treatment, and at One Year Follow Up: Association with Depressive Symptoms.” Nutrients vol. 13,7 2356. 9 Jul. 2021, doi:10.3390/nu13072356

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The Relationship between Anorexia and Body Dysmorphia- Cole Cincinelli

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The Relationship between Anorexia and Body Dysmorphia- Cole Cincinelli

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As discussed in this week's module Anorexia Nervosa is defined by the DSM-5 as patients “severely underweight, characterized by an intense fear of gaining weight or becoming fat, and experience a disturbance in body image, undue influence of body shape on self-evaluation, or denial of the seriousness of the current low body weight.”(Hartmann et al., 2013). Similarly body dysmorphia is a distressing or impairing feeling of one's physical appearance. While two discrete conditions, anorexia and body dysmorphia share common psychopathological traits(Hartmann et al.,2013). As a physician it is important to be able to distinguish between the two because treatment can be different. These conditions together are highly comorbid (Hartmann et al., 2013). Considering both of these conditions are related to mental illness, it validates the enhanced distressing effect these have on an individual. If not corrected by a physician early on, these conditions can become extremely impairing to the patient. Also the patient could be deterred to seek treatment from the related stigma with mental illness. As a physician, understanding that anorexia and body dysmorphia are highly comorbid is important for the treatment and prevention of these conditions.

Hartmann, A. S., Greenberg, J. L., & Wilhelm, S. (2013). The relationship between anorexia nervosa and body dysmorphic disorder. Clinical psychology review, 33(5), 675–685. https://doi.org/10.1016/j.cpr.2013.04.002

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Cole Zetter: Micronutrient Deficiencies and Supplementation in Anorexia and Bulimia Nervosa: A Review of Literature

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Cole Zetter: Micronutrient Deficiencies and Supplementation in Anorexia and Bulimia Nervosa: A Review of Literature

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For this weeks module, I decided to read an article titled  Micronutrient Deficiencies and Supplementation in Anorexia and Bulimia Nervosa: A Review of Literature. I found this article to be important because it started out by describing and characterizing what anorexia and bulimia nervosa are. The article stated these eating disorders are characterized by unbalanced eating patterns that include inadequate dietary intake of various nutrients. The article went on to state how electrolyte and micronutrient values could be low but within acceptable laboratory reference ranges whenever rehydration and refeeding begins, but noted that their status must be closely monitored. One key finding I found within this study was that the article noted that the most acutely dangerous micronutrient deficiencies generally result from purging methods such as forced vomiting and abuse of laxatives, which should be assessed in all eating disordered patients, regardless of diagnosis. This would be due to the levels of sodium, phosphorus, magnesium, and potassium being critically important to a patient's health. The article later went on to describe the affects of malnutrition of vitamins and minerals. These included calcium, iron, zinc, vitamin A, thiamin, riboflavin, vitamin B6, vitamin B12, and more. This is very important because for example, when a patient is calcium deficient for a long time, the body leeches calcium from the bones in order to supplement the levels of calcium in the blood, thus causing lower bone density which is detrimental to overall health. I would say the clinical implications to this study would be to know how to treat anorexia and bulimia nervosa patients, including familiarizing yourself with normal laboratory test reference ranges for electrolytes, vitamins and minerals that all relate to nutrition and overall health. If you can see lab tests reporting low or abnormal values, that may be able to help with a diagnoses and or healthcare plan for the patients recovery. - Cole Zetter

Setnick, Jessica. “Micronutrient Deficiencies and Supplementation in Anorexia and Bulimia Nervosa: A Review of Literature.” Nutrition in clinical practice 25.2 (2010): 137–142. Web.

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Seonwook Kim: Adherence to the Mediterranean dietary pattern and incidence of anorexia and bulimia nervosa in women: The SUN cohort

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Seonwook Kim: Adherence to the Mediterranean dietary pattern and incidence of anorexia and bulimia nervosa in women: The SUN cohort

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My selected article this week is adherence to the Mediterranean dietary pattern and incidence of anorexia and bulimia nervosa in women. From the previous lectures in modules 1 and 2, Mediterranean diets improve many diseases states. However, as we learned in this lecture, orthorexia may cause unhealthy problems. So, I was wondering if adherence to the Mediterranean might cause a problem, and that is why I think this study is important. This study aimed to assess the association between adherence to the Mediterranean Dietary Pattern and incident risk of anorexia (AN) and bulimia nervosa (BN). The key finding in this study is that adherence to the Mediterranean diet was associated with a lower risk of AN and BN. Cereals and olive oil consumptions were associated with a lower risk. From the nutritional point of view, this type of diet may have a protective role against the incident risk of eating. Clinically, a Mediterranean diet plan can be added to eating disorder patients.

Leone A, Martínez-González MÁ, Lahortiga-Ramos F, Molero Santos P, Bertoli S, Battezzati A, Bes-Rastrollo M. Adherence to the Mediterranean dietary pattern and incidence of anorexia and bulimia nervosa in women: The SUN cohort. Nutrition. 2018 Oct;54:19-25. doi: 10.1016/j.nut.2018.02.008. Epub 2018 Mar 21. PMID: 29704863.

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doi: 10.1016/j.nut.2018.02.008.

Affiliations

¹ International Center for the Assessment of Nutritional Status, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy. Electronic address: Alessandro.leone1@unimi.it.

² Department of Preventive Medicine and Public Health, School of Medicine, University of Navarra, Pamplona, Spain; CIBERobn, Instituto de Salud Carlos III, Madrid, Spain; Navarra's Health Research Institute, Pamplona, Spain.

³ Department of Psychiatry and Medical Psychology, University Clinic of Navarra, Pamplona, Spain.

⁴ International Center for the Assessment of Nutritional Status, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy.

Free article

Free article

doi: 10.1016/j.nut.2018.02.008.

Affiliations

¹ International Center for the Assessment of Nutritional Status, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy. Electronic address: Alessandro.leone1@unimi.it.

² Department of Preventive Medicine and Public Health, School of Medicine, University of Navarra, Pamplona, Spain; CIBERobn, Instituto de Salud Carlos III, Madrid, Spain; Navarra's Health Research Institute, Pamplona, Spain.

³ Department of Psychiatry and Medical Psychology, University Clinic of Navarra, Pamplona, Spain.

⁴ International Center for the Assessment of Nutritional Status, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy.

Abstract

Objective: To our knowledge, no study has yet assessed the association between dietary patterns and incidence of eating disorders. This study aimed to assess the association between adherence to the Mediterranean dietary pattern (MDP) and incident risk of anorexia (AN) and bulimia nervosa (BN).

Methods: We conducted a prospective cohort study of 11 800 women from the Seguimiento Universidad de Navarra follow-up project. Participants were classified as having incident AN or BN if they were free of AN or BN at baseline and reported a physician-made diagnosis of AN or BN during the follow-up period. Nutritional status, lifestyle, and behavioral variables were investigated and used as covariates. A validated 136-item food frequency questionnaire and the Trichopoulou score were used to assess adherence to the MDP.

Results: After a median follow-up time of 9.4 y, 100 new cases of AN and BN were identified. The multivariate hazard ratio of AN and BN for the two upper categories of adherence to the MDP were 0.39 (95% CI: 0.20-0.75) and 0.32 (95% CI: 0.14-0.70; P trend = 0.021). Inverse dose-response relationships were found for the consumption of cereals and olive oil and marginally for polyunsaturated fatty acid intake. To address reverse causation, multivariable linear regressions were run using a cross-sectional approach between adherence to the MDP and risk of AN and BN at baseline. No difference in adherence was found between participants with and without eating disorders.

Conclusions: Our results suggest a potential inverse association between the MDP and the risk of AN and BN. Additional longitudinal studies and trials are needed.

Keywords: Anorexia nervosa; Bulimia nervosa; Cohort study; Eating disorder; Epidemiology; Mediterranean diet.

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mediterranean / statistics & numerical data*

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patient compliance / statistics & numerical data*

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national center for biotechnology information

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Adherence to the Mediterranean dietary pattern and incidence of anorexia and bulimia nervosa in women: The SUN cohort - PubMed

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doi: 10.1016/j.nut.2018.02.008. 1 International Center for the Assessment of Nutritional Status, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy. Electronic address: Alessandro.leone1@unimi.it. 2 Department of Preventive Medicine and Public Health, School of Medicine, University of Navarra, Pamplona, Spain; CIBERobn, Instituto de Salud Carlos III, Madrid, Spain; Navarra's Health Research Institute, Pamplona, Spain.

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Ivana Djuricic: Autoantibodies and the gut microbiome in Eating Disorders

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Ivana Djuricic: Autoantibodies and the gut microbiome in Eating Disorders

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Smitka K, Prochazkova P,
Roubalova R, Dvorak J, Papezova H,
Hill M, Pokorny J, Kittnar O, Bilej M and
Tlaskalova-Hogenova H (2021)
Current Aspects of the Role
of Autoantibodies Directed
Against Appetite-Regulating
Hormones and the Gut
Microbiome in Eating Disorders.
Front. Endocrinol. 12:613983.
doi: 10.3389/fendo.2021.613983

Not to harp on the gut microbiome, but it's just interesting to see how its makeup has the ability to affect things that don't seem related to me. So I picked this review because it brought up a subject I hadn’t ever thought about—a possible gut microbiome related contribution to eating disorders. Eating disorders are complex and require a team of healthcare providers to tackle, but at the core of it, I always thought of it as a psychological disorder.

This study is important because it tries to shed light on possible triggers of eating disorders that are rooted in changes in physiological systems and could be mitigated by other methods besides cognitive behavioral therapy alone. They are difficult disorders to treat and have a significant relapse rate, so it seems worthwhile to explore every avenue for treatment.

Although there are many interesting findings, like different types of stressors (infectious, mental stress, etc) can change the gut (“leaky gut”) and blood-brain barrier functions causing your body to make antibodies against microbial compounds which then cross-react with human neuropeptides and neurotransmitters regulating appetite and eating behaviors, I will focus on the changes in the gut microbiome they discussed.
They found significant microbiota changes in patients with anorexia nervosa (AN) and bulimia nervosa (BN). Since the microbiota produce neuroactive compounds like serotonin, dopamine, and GABA, they are important for mood regulation. In this review they pointed out a study that found lower levels of serotonin, dopamine, and GABA in fecal samples of women with AN compared to healthy women (among changes in the makeup of the gut flora). It’s relation to nutritional science is that maybe by utilizing pre-or-probiotics as part of a nutritional plan for AN patients, it can make a difference in mood and depressive-like behaviors that are part of what keeps AN patients in the cycle of disordered eating.

Clinically, it provides another way to look at the mechanisms that underlie AN, or other eating disorders. It is interesting to think that adding on a therapy focused modulating the gut microbiome, in addition to the multi-disciplinary treatment courses for AN, could make a difference in the success rate of existing treatments.

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Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial

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Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial

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Mitchell Watts

This article compares current inpatient standard treatment for anorexia nervosa with low-calorie feeding (LCR) compared to a new approach with high-calorie feeding (HCR). The LCR begins at 1200-1400 kcal/d and increases slowly by 200 kcal every other day. The HCR begins at 1400-2000 kcal with a faster increase at 200 kcal/d. The standard care has been used to minimize risk of refeeding syndrome. The researchers hypothesized that medical stability would be accomplished more quickly for patients receiving HCR without increased incidence of refeeding syndrome and with significant cost savings with a shorter length of stay. Their randomized clinical trial included 120 adolescents and young adults with anorexia nervosa (AN) and atypical anorexia (AAN). What they found is that electrolyte abnormalities and other adverse events did not differ by group, and hospital stay was 4.0 days shorter among the HCR group, which was associated with a savings of $19,056. This is important, because despite lengthy hospitalizations, 45% of patients are readmitted, and only 18% to 55% meet criteria for clinical remission at 1 year. Findings from this trial support the development of evidence-based recommendations for HCR.

I found this article to be interesting as I have had several of my own patients who presented with a high risk of refeeding syndrome due to severe protein-calorie malnutrition, though not specifically due to anorexia nervosa. ASPEN guidelines for refeeding include providing 10 to 20 kcal/kg for the first 24 hours and advancing by 33% of goal every 1 to 2 days. This is a relatively slow advancement and could take 3 to 5 days to achieve goal caloric intake. This does not include the initial time while feeding is held until electrolytes are normalized, and advancement might be slowed if their electrolytes are difficult to correct or drop quickly. I would be curious if an HCR approach could be used safely in these patients.

Garber, A. K., Cheng, J., Accurso, E. C., Adams, S. H., Buckelew, S. M., Kapphahn, C. J., Kreiter, A., Le Grange, D., Machen, V. I., Moscicki, A. B., Sy, A., Wilson, L., & Golden, N. H. (2021). Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial. JAMA pediatrics, 175(1), 19–27. https://doi.org/10.1001/jamapediatrics.2020.3359

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Affiliations

¹ Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco.

² Department of Preventive and Restorative Dental Sciences, University of California, San Francisco.

³ Department of Psychiatry and Behavioral Medicine, University of California, San Francisco.

⁴ Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California.

⁵ Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois (emeritus).

⁶ Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles.

⁷ Department of Clinical Pharmacy, University of California, San Francisco.

Free PMC article

Randomized Controlled Trial

Free PMC article

Affiliations

¹ Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco.

² Department of Preventive and Restorative Dental Sciences, University of California, San Francisco.

³ Department of Psychiatry and Behavioral Medicine, University of California, San Francisco.

⁴ Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California.

⁵ Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois (emeritus).

⁶ Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, Los Angeles.

⁷ Department of Clinical Pharmacy, University of California, San Francisco.

Abstract

Importance: The standard of care for refeeding inpatients with anorexia nervosa, starting with low calories and advancing cautiously, is associated with slow weight gain and protracted hospital stay. Limited data suggest that higher-calorie refeeding improves these outcomes with no increased risk of refeeding syndrome.

Objective: To compare the short-term efficacy, safety, and cost of lower-calorie vs higher-calorie refeeding for malnourished adolescents and young adults with anorexia nervosa.

Design, setting, and participants: In this multicenter randomized clinical trial with prospective follow-up conducted at 2 inpatient eating disorder programs at large tertiary care hospitals, 120 adolescents and young adults aged 12 to 24 years hospitalized with anorexia nervosa or atypical anorexia nervosa and 60% or more of median body mass index were enrolled from February 8, 2016, to March 7, 2019. The primary analysis was a modified intent-to-treat approach.

Interventions: Higher-calorie refeeding, beginning at 2000 kcal/d and increasing by 200 kcal/d vs lower-calorie refeeding, beginning at 1400 k/cal and increasing by 200 kcal every other day.

Main outcomes and measures: Main outcomes were end-of-treatment outcomes; the primary end point of this trial will be clinical remission over 12 months. Short-term efficacy was defined a priori as time to restore medical stability in the hospital, measured by the following 6 indices: 24-hour heart rate of 45 beats/min or more, systolic blood pressure of 90 mm Hg or more, temperature of 35.6 °C or more, orthostatic increase in heart rate of 35 beats/min or less, orthostatic decrease in systolic blood pressure of 20 mm Hg or less, and 75% or more of median body mass index for age and sex. The prespecified safety outcome was incidence of electrolyte abnormalities; cost efficacy was defined as savings associated with length of stay.

Results: Because 9 participants withdrew prior to treatment, the modified intention-to-treat analyses included 111 participants (93%; 101 females [91%]; mean [SD] age, 16.4 [2.5] years). Higher-calorie refeeding restored medical stability significantly earlier than lower-calorie refeeding (hazard ratio, 1.67 [95% CI, 1.10-2.53]; P = .01). Electrolyte abnormalities and other adverse events did not differ by group. Hospital stay was 4.0 days shorter (95% CI, -6.1 to -1.9 days) among the group receiving higher-calorie refeeding, which was associated with a savings of $19 056 (95% CI, -$28 819 to -$9293) in hospital charges per participant.

Conclusions and relevance: In the first randomized clinical trial in the US to compare refeeding approaches in patients with anorexia nervosa and atypical anorexia nervosa, higher-calorie refeeding demonstrated short-term efficacy with no increase in safety events during hospitalization.

Trial registration: ClinicalTrials.gov Identifier: NCT02488109.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Buckelew reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Kapphahn reported receiving grants from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) during the conduct of the study. Dr Le Grange reported receiving grants from the NIH during the conduct of the study, personal fees from Training Institute of Child and Adolescent Eating Disorders LLC outside the submitted work, and royalties from Guilford Press and Routledge. Dr Golden reported receiving grants from the NIH/NICHD during the conduct of the study. No other disclosures were reported.

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national center for biotechnology information

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Short-term Outcomes of the Study of Refeeding to Optimize Inpatient Gains for Patients With Anorexia Nervosa: A Multicenter Randomized Clinical Trial - PubMed

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1 Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco. 2 Department of Preventive and Restorative Dental Sciences, University of California, San Francisco. 3 Department of Psychiatry and Behavioral Medicine, University of California, San Francisco. 4 Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California.

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Interactions between nutrition and immunity in anorexia nervosa: a 1-y follow-up study

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Interactions between nutrition and immunity in anorexia nervosa: a 1-y follow-up study

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Ellen Reusch

For this week's wall, I found this somewhat older article on the relationships between nutrition and immunity in patients with anorexia nervosa. The study, published in 1997, followed 15 patients with anorexia nervosa and 15 control patients for one year. After 1 year, leukocyte levels and lymphocyte levels were found to be lower in patients who suffered from anorexia nervosa than in the control subjects. This is an interesting study to consider alongside this week's lecture topic, as we all are well aware that immune cells play a key role in our overall immune health and ability to fight off infections or pathogens. This study suggests that patients suffering from anorexia nervosa may be at increased risk for more infections due to depleted white blood cell counts. This information could be important to clinicians who treat patients with anorexia nervosa, as it may provide some motivation for them to more closely monitor the patients for any signs or symptoms of infection, or to respond sooner with treatment if infection is suspected. This study also shows another reason why healthy nutrition is crucial to our overall health, and not just for weight management or energy levels.

Citation: Marcos, Ascension, et al., Interactions between nutrition and immunity in anorexia nervosa: a 1-y follow-up study. American Society for Clinical Nutrition. Published 1997. https://watermark.silverchair.com/485s.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAsQwggLABgkqhkiG9w0BBwagggKxMIICrQIBADCCAqYGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMrdiJniHKYbdIBmZOAgEQgIICdw5Hpm7uEZgcg-1PikK0Jh9fbfh8NGMszyMIBqJoiRlRcZi84bDsQ82FcJF0v719PgqCV7i2kWCZCnX0UWwU_fuvVsJmTx4PSkkOaaHgdf6u4YzJqsee-T5WYRv7JkAoDUh1p6G3B7ehFM1sarMgKP7Kp2q8o50krw9I56rBy-o8ST66duUQcxQ_c-iMmynxX4D-G6V9hOlgfip5nrFmBxp0XavFd5zVKuDdSt1sD0Aaw3t4U5sUAFZwCEa2osbMSZ48om3AlpfeRoKXNugTtxz_A5Sh-neB1FMcmPP60XSHhr052-jfUhcOopyz4ZqzfKEbjrupXwUBP9FYWlT4tgapMwXrnkSzaLImeQXH_pZgObl5bTcw9-8VNRuoY-dgjrn4wHbZg1eKE_39y2CfgWsYuOvgWORzvycMVeSGCtxkU-Ee9szUK3AnjJCIcO861p1VOxEVLZf2_nsftzO3W3P85nUTN6Moxm7kI_zZfIw49h0G_eXn7203X6CyGAZHG9XsJzALy4s1SjxWE-Vlprl4eYxq5qpj3kHt_byRaia6HNXlsaf3y55YWG1VH7zIRv5u3vVduWp4b_Elu4Ozq0ZaBuw-KYqL86Ibb_PsOk1QxqcLU7Jnh_djxeJeuiofjylWhSD9VsEG8UYeJ-P_3PdmjCZxvnI2H6zmIcyjSNEnCLSw9R97DzXRSxIPRz69aIXZu_U2KW_G8FZGUjft3vhENhG4koIBvPT0x6s9PUADJhW4x0w5_rM0-62bMA8KRNVYu-U_Nazlh7FeITYeY9fDwySWRhS4Qeq98q4K3eecv0S3uL7KFIIZV9kc5_Hfl-vKT16sSV0

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Julie Rees: Food Insecurity and Bulimia Nervosa in the United States

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Julie Rees: Food Insecurity and Bulimia Nervosa in the United States

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Food insecurity is a major issue facing many children and adults especially in financially challenging times.  Previous studies have linked food insecurity to overeating.  This study looked at a possible link between food insecurity binge-eating disorder, and bulimia nervosa.  They found that participants who had lower quality and variety of foods (low food security) and those who did not inadequate food either in nutritional value or quantity (very low food security) were more likely to binge-eat than those who were food secure.  There was not a significant difference in the food insecure participants being classified in binge-eating disorder or the bulimia nervosa groups.  This suggests that although food insecurity or even just food restriction can lead to binge behaviors, other factors play a role in who develops bulimia nervosa.  With that in mind, we know that binge behavior is not healthy.  Clinically, food insecurity can play a role in many conditions including eating disorders and should be considered during treatment.

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Abstract

Keywords: food insecurity, binge-eating disorder, bulimia nervosa, overeating, binge eating, weight

Introduction

Food insecurity is "limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially-acceptable ways" ( Bickel, Nord, Price, Hamilton, & Cook, 2000). Food insecurity can change dietary patterns because of perceptions of the amount or quality of food available to members of a household. Food insecurity may also have a cyclical pattern where access to food is limited and then abundant (e.g., due to paycheck or food stamp timing; Bruening, MacLehose, Loth, Story, & Neumark-Sztainer, 2012). The cycle of dietary restriction and overconsumption is also characteristic of binge eating in both bulimia nervosa (BN) and binge-eating disorder (BED), although dietary restriction is traditionally conceptualized as internally-motivated for weight loss ( Fairburn, 2008). We recently reported, in a survey study of 1251 US adults, that food insecurity was associated with BED and obesity (without comorbid eating disorders) ( Rasmusson, Lydecker, Coffino, White, & Grilo, 2018). A previous study of 503 adults seeking food from food pantries reported that food-insecurity severity was associated with binge-eating frequency, eating-disorder psychopathology, and compensatory-behavior frequency (vomiting, laxative/diuretic use, and excessive exercise) ( Becker, Middlemass, Taylor, Johnson, & Gomez, 2017).

Despite the potential overlap in function between restriction related to food insecurity and internally-motivated restriction for weight loss, and research reporting associations with BED ( Rasmusson et al., 2018) and weight-compensatory behaviors ( Becker et al., 2017), no research has investigated whether food insecurity is related to BN as defined by the Diagnostic and Statistical Manual for Mental Health Disorders, 5 edition (DSM-5) ( American Psychiatric Association, 2013). Thus, the current study aimed to extend our previously published work ( Rasmusson et al., 2018) by examining the relation between food insecurity and BN. We hypothesized that food insecurity would be associated with membership in the BN study group compared with HW and further hypothesized that this relation would persist after adjusting for demographic characteristics (age, sex, education, race/ethnicity). We also sought to explore whether food-security status was associated with membership in BN compared with BED study groups.

Methods

Participants

Survey respondents ( N=873) were English- and Spanish-speaking individuals from the US who responded to an advertisement to "share your opinions about eating, weight, and health" ("encuesta sobre la alimentación, el peso y la salud") on Mechanical Turk and completed measures in English or Spanish. All participants were assessed concurrently. Mechanical Turk yields data with comparable reliability and validity as other recruitment sources such as psychology student subject pools ( Buhrmester, Kwang, & Gosling, 2011) and has been used in many studies, including those focusing on food security ( Darling, Sato, van Dulmen, Flessner, & Putt, 2018; Leung, Musicus, Willett, & Rimm, 2017). The current study was restricted to US respondents due to potentially contrasting food environments between the US and other countries. The study was approved by the institutional review board. All participants provided informed consent prior to the online survey.

Measures

Algorithms

Study groups were created using QEWP-5 and body mass index (BMI) weight categories (calculated from self-reported height and weight). depicts the flow and creation of study groups. BED study group criteria were: at least weekly binge-eating episodes (eating an unusually large amount of food and perceiving eating to be out of control) over the past three months ("1 episode per week" through "14 or more episodes per week"), at least moderate distress about overeating and feeling out of control ("moderately" through "extremely"), and denial of weekly compensatory behaviors over the past three months. Individuals in the BED group did not have BMI limitations. BN study group criteria were: at least weekly binge-eating episodes over the past three months ("1 episode per week" through "14 or more episodes per week"), at least weekly compensatory behaviors over the past three months (vomiting, laxative misuse, diuretic misuse, fasting, excessive exercise, diet pill misuse; "1 episode per week" through "14 or more episodes per week"), at least moderate overvaluation of weight and shape ("among the main things" or "the most important things"), and BMI >18.5 kg/m ². Individuals in the healthy-weight group denied weekly binge eating ("no" or "less than 1 episode per week"), compensatory behaviors, and had a BMI 18.5-24.9 kg/m ². The majority of participants in the BN study group reported distress about binge eating ( n=69 of 78), although this was not an exclusion factor in algorithms because it is not in DSM-5 diagnostic criteria.

Statistical Analysis

Differences in participant characteristics by group (HW, BED, BN) were examined using chi-square tests for categorical variables (sex, education level, race/ethnicity) and analyses of variance (ANOVAs) for continuous variables (age and BMI). Chi-square tests assessed associations between study groups and food-security status (food security, low food security, very low food security). Hierarchical logistic regressions evaluated associations between food-security status (food security, low food security, very low food security) and study groups (HW vs. BN group and BED vs. BN group) after adjusting for variance due to age, sex, education, and race/ethnicity. Reference groups for categorical variables were male (sex), high school (education), non-Hispanic White (race/ethnicity) and food security (food-security status).

Results

The participant group had 873 individuals categorized as HW ( n=710), BED ( n=85) and BN ( n=78). Data on HW and BED groups were previously published ( Rasmusson et al., 2018) but are used here to provide relevant comparison groups for analyses of food security and BN. summarizes differences across HW, BED, and BN groups.

Table 1.

Both low and very low food security were significantly more common in the BN study group than HW but did not differ significantly from BED. Within the BN study group, 28.2% ( n=22) of respondents had low food security and 25.6% ( n=20) of respondents had very low food security.

Overall, individuals with very low food security ( M=2.20, SD=5.65; p=.032) and low food security ( M=2.56, SD=5.25; p=.001) had greater binge-eating frequency than individuals with food security ( M=1.24, SD=4.06), F(2,870)=6.48, p=.002, η p ²=.015. Binge-eating frequency did not differ significantly by food-security status within the BN study group ( p s>.05).

Hierarchical logistic regressions evaluated the extent to which low and very low food security contributed to study group classification and are summarized in (BN vs. HW; BN vs. BED). Sex, age, education, and race/ethnicity were entered in Step 1. Food-security status was entered in Step 2 (reference group: food security). Low food security (OR 2.48, CI 1.39-4.42) and very low food security (OR 3.06, CI 1.64-5.70) were associated with BN compared with HW, and made a significant contribution beyond demographic variables entered in Step 1, χ ²(2)=16.20, p<.001. Neither low food security (OR 1.05, CI 0.48-2.27) nor very low food security (OR 1.77, CI 0.75-4.16) was associated with increased likelihood of BN group membership compared with BED.

Table 2.

Discussion

Previous studies, conducted with different participant groups in the US, reported that food insecurity was associated with binge eating ( Becker et al., 2017; Bruening et al., 2012) and was unexpectedly associated with weight-compensatory behaviors ( Becker et al., 2017). Our previous study extended this new emerging literature by finding that low and very low food security were significantly associated with both BED and obesity versus a healthy-weight comparison group ( Rasmusson et al., 2018). Findings from the current study extend earlier work further by showing that food insecurity is associated with BN as well as greater binge-eating frequency. Our findings that food-security status did not distinguish between BN and BED study groups, together with previous findings that food-security status for BED versus HW had effect sizes that were similar to those for food-security status and BN versus HW in the current study, suggest that the association of food insecurity with BN is similar to its association with BED.

Individuals with low and very low food security were more likely to be classified in the BN study group compared with the HW but not BED comparison group. Our findings extend the previous study by Becker et al. (2017) that reported associations between food insecurity severity and weight-compensatory behaviors among food pantry users that were contrary to their hypotheses; specifically, our findings suggest significant associations with BN relative to a HW control. Interestingly, our analyses revealed that neither low nor very low food security was associated with BN relative to the BED comparison group. This suggests that food insecurity may not necessarily contribute to the presence/absence of compensatory behaviors, and other factors may distinguish those who binge from those who binge and purge. Future research should investigate how patients perceive the function of weight-compensatory behaviors.

Our findings here suggest that restriction, even when stemming from food insecurity, might play a role in increasing or maintaining binge eating and BN psychopathology. We emphasize, however, that our findings are cross-sectional and preclude statements about directionality or causality and that longitudinal research is needed to better understand these associations. Moreover, study groups contained respondents who reported core features of BN and BED on established self-report questionnaires, but diagnoses were not confirmed with a clinical interview. Eating-disorder psychopathology and food insecurity were self-reported; however, research suggests that the current study's measures converge reasonably well with clinician assessments ( Berg et al., 2012; Elder & Grilo, 2007; Keenan, Olson, Hersey, & Parmer, 2001). Moreover, there are relative strengths and limitations to both self-report and interview assessments for capturing different aspects of eating behaviors ( Udo & Grilo, 2018). Notably, generalizability to those outside of the US is uncertain, and generalizability to the US population is limited because our sample was an internet community sample and not nationally-representative.

With the above caveats in mind, we cautiously suggest that food insecurity has the potential to complicate treatment for BN or BED. Indeed, the "food-stamp cycle" as a potential mechanism for the association between food insecurity and binge eating suggests that cyclical access to food may inadvertently help to maintain disordered eating by impeding regular eating patterns ( Cook, 2002; Dinour, Bergen, & Yeh, 2007). Future clinical research should address prevention and intervention for food-insecure individuals who might be vulnerable to BN and BED, as well as whether current treatments for BN and BED need to be adapted beyond assessing for food insecurity (e.g., additional problem-solving around regular access to meals).

In summary, our findings suggest that low and very low food security are associated with BN but do not distinguish between BN and BED study groups. These findings emphasize food insecurity as a pressing public health issue with the potential to harm the mental health of low-income Americans. Therefore, policy-makers and health-care professionals should be aware of food insecurity and its potential to complicate prevention and intervention efforts with individuals with eating disorders; these findings contribute to the ongoing and increasing dialogue about the global burden of food insecurity ( Perez-Escamilla, 2017). Development of preventative interventions and evaluation of the effectiveness of psychiatric treatments for eating disorders in this vulnerable group of individuals facing food insecurity is a key clinical-research and health-care priority.

Acknowledgments

This research was supported, in part, by National Institutes of Health grant K24 DK070052.

Footnotes

The authors report no conflicts of interest.

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Food Insecurity and Bulimia Nervosa in the United States

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Keywords: food insecurity, binge-eating disorder, bulimia nervosa, overeating, binge eating, weight Food insecurity is "limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially-acceptable ways" ( Bickel, Nord, Price, Hamilton, & Cook, 2000).

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Sidney Harm: Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial

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Sidney Harm: Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial

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I decided to look further into the types of therapy an individual diagnosed with anorexia nervosa could undergo and which has been shown to be the most effective. It sometimes can be difficult to determine what the best treatment approach is because treatment is very individualized in every medical diagnosis case. But it is important to know and understand the types of treatment options and which ones have shown to be the most impactful, even though it might not be for one or more patients but it could give a solid starting point in treatments. This study looked into three different types of treatment; in-patient, out-patient specialist, and general child and adolescent mental health services. They included individuals both male and female between the ages of 12-18 years old. Overall their findings did not support their hypothesis of in-patient treatment being more effective than out-patient. Even though this doesn’t directly connect with nutritional sciences by looking at nutrients or drug metabolism, it does help study treatments for a diagnosis that can have an impact on how the body reacts when it is not given the adequate nutrition to function properly.

References:

Gowers, Clark, A., Roberts, C., Griffiths, A., Edwards, V., Bryan, C., Smethurst, N., Byford, S., & Barrett, B. (2007). Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial. British Journal of Psychiatry, 191(5), 427–435. https://doi.org/10.1192/bjp.bp.107.036764

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Andrea Ballinger: Presence of Orthorexia Nervosa in yoga practitioners

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Andrea Ballinger: Presence of Orthorexia Nervosa in yoga practitioners

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This week, I chose a pilot study examining the relationship between ashtanga yoga practitioners and the development of orthorexia nervosa. This article is interesting in that other studies include yoga practice as an additional recovery measure for those with an already established eating disorder. Particularly important, is yoga's focus on a mind-body connection, which can help encourage body acceptance. However, this paper suggests that a long-term yoga practice may be associated with developing disordered eating habits.

Participants were surveyed about their yoga practice, beliefs about their appearance, perfectionist traits, and healthy orthorexia vs. orthorexia nervosa.  The study concluded that the main predictors for orthorexic behavior was a drive for thinness, (compulsive) interest in a healthy diet , and depth of immersion in yoga. This conclusion is important because yoga could unknowingly cause more harm than good when added to a treatment plan for someone recovering from disordered eating. Clinicians should learn the additional risk factors for ON development and offer alternatives if their patients already have an established yoga practice. Also, being that orthorexia nervosa is still an emerging diagnosis, it is important for clinicians to be vigilant in distinguishing between healthy orthorexia and orthorexia nervosa.

Domingues, R.B., Carmo, C. Orthorexia nervosa in yoga practitioners: relationship with personality, attitudes about appearance, and yoga engagement. Eat Weight Disord 26, 789–795 (2021). https://doi.org/10.1007/s40519-020-00911-w

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Funding

Funded by Fundação para a Ciência e a Tecnologia with Contract number DL57/2016/CP1361/CT0017.

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Affiliations

1. Centre for Marine and Environmental Research (CIMA), Universidade do Algarve, Campus de Gambelas, 8005-139, Faro, Portugal

Rita B. Domingues

2. Psychology Research Centre (CIP/UAL), Universidade do Algarve, Campus de Gambelas, 8005-139, Faro, Portugal

Cláudia Carmo

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Correspondence to Rita B. Domingues.

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The authors declare that they have no conflict of interest.

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Since this was a non-experimental, anonymous, voluntary survey, no ethical approval was required.

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Informed consent was obtained from all individual participants included in the study.

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Domingues, R.B., Carmo, C. Orthorexia nervosa in yoga practitioners: relationship with personality, attitudes about appearance, and yoga engagement. Eat Weight Disord 26, 789-795 (2021). https://doi.org/10.1007/s40519-020-00911-w
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Keywords

Orthorexia nervosa

Yoga

Risk factors

Perfectionism

Body image

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Orthorexia nervosa in yoga practitioners: relationship with personality, attitudes about appearance, and yoga engagement - Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity

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Purpose Disordered eating symptoms and a high prevalence of orthorexia nervosa can be found in yoga practitioners. Given that yoga is increasingly used as a complementary treatment for eating disorders (ED), understanding the relationship between yoga practice and the development of disordered eating is crucial to guide treatment recommendations.

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Katelyn Spain: Self-induced vomiting and dental erosion – a clinical study

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Katelyn Spain: Self-induced vomiting and dental erosion – a clinical study

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Patients that suffer from Bulimia Nervosa have gastric juices regularly reach the oral cavity, which increases the risk of dental erosion. Dental erosion is defined as the chemical loss of mineralized tooth substance caused by exposure to acids not derived from oral bacteria; this leads to dental caries and other oral diseases. This purpose of this study was to assess the occurrence, distribution and severity of dental erosions in a group of patients experiencing self-induced vomiting, from Bulimia Nervosa. Out of 66 patients, diagnosed with Bulimia Nervosa, 46 presented with dental erosion. About 26% of those patients with dental erosion had ten or more teeth affected. Of all the erosions, roughly 41% were found on palatal/lingual surfaces, which are the surfaces of the teeth that are found closest to the tongue. For patients that had been suffering from Bulimia Nervosa for a longer period of time, they were found to have more dental erosions. The clinical implications for this study, would be for doctors that diagnose and treat patients with Bulimia Nervosa to refer the patients to a dentist to address dental needs.

Uhlen, M. M., Tveit, A. B., Stenhagen, K. R., & Mulic, A. (2014). Self-induced vomiting and dental erosion--a clinical study. BMC oral health, 14, 92. https://doi.org/10.1186/1472-6831-14-92

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Abstract

Background

In individuals suffering from eating disorders (ED) characterized by vomiting (e.g. bulimia nervosa), the gastric juice regularly reaches the oral cavity, causing a possible risk of dental erosion. This study aimed to assess the occurrence, distribution and severity of dental erosions in a group of Norwegian patients experiencing self-induced vomiting (SIV).

Methods

The individuals included in the study were all undergoing treatment at clinics for eating disorders and were referred to a university dental clinic for examinations. One calibrated clinician registered erosions using the Visual Erosion Dental Examination (VEDE) system.

Results

Of 72 referred patients, 66 (63 females and three males, mean age 27.7 years) were or had been experiencing SIV (mean duration 10.6 years; range: 3 - 32 years), and were therefore included in the study. Dental erosions were found in 46 individuals (69.7%), 19 had enamel lesions only, while 27 had both enamel and dentine lesions. Ten or more teeth were affected in 26.1% of those with erosions, and 9% had ≥10 teeth with dentine lesions. Of the erosions, 41.6% were found on palatal/lingual surfaces, 36.6% on occlusal surfaces and 21.8% on buccal surfaces. Dentine lesions were most often found on lower first molars, while upper central incisors showed enamel lesions most frequently. The majority of the erosive lesions (48.6%) were found in those with the longest illness period, and 71.7% of the lesions extending into dentine were also found in this group. However, despite suffering from SIV for up to 32 years, 30.3% of the individuals showed no lesions.

Conclusions

Dental erosion commonly affects individuals with ED experiencing SIV, and is more often found on the palatal/lingual surfaces than on the buccal in these individuals, confirming a common clinical assumption.

Keywords: Dental erosion, Eating disorders, Vomiting

Background

Eating disorders (ED) are conditions characterized by restricted food intake or binge eating, and often by self-induced vomiting (SIV). In addition to having the potential to impair both physical health and psychosocial functioning [ 1], these disorders could also have an impact on oral health. Among oral complications is dental erosion, an irreversible loss of tooth substance as a consequence of exposure to acids that do not involve bacteria [ 2]. Such acids may enter the oral cavity from extrinsic (e.g. acidic foodstuff), as well as from intrinsic sources (gastric acid).

The prevalence of ED has been studied in different countries. A nationally representative survey from the U.S. estimated that the lifetime prevalence of ED ranged from 0.6 - 4.5% among adults [ 3] and from 0.3 - 0.9% among adolescents [ 4]. According to questionnaire-based, epidemiological studies in Norway, the lifetime prevalence of any ED among adolescents was found to be 12.5% [ 5], and of anorexia nervosa (AN) and bulimia nervosa (BN) among adult females 0.4% and 1.6%, respectively [ 6]. A recent study in Finland reported that the lifetime prevalence of AN among young adults was 1.3% and of BN 1.1% [ 7], whereas a large German study found the prevalence of AN and BN among children and adolescents to be 0.14% and 0.11%, respectively [ 8].

Significant higher values of erosive tooth wear have been found in patients suffering from ED compared to control groups [ 9- 15]. Johansson et al. [ 15] found that patients with ED had an 8.5-times increased risk of having dental erosion compared to healthy controls, and that individuals with a longer history of ED had lesions more frequently.

An obvious risk factor considering dental health in individuals suffering from BN, certain forms of AN or other EDs, is repeated vomiting. The stomach content, which can have a pH close to 1 [ 16, 17], repeatedly reach the mouth and may be destructive to the tooth substance [ 11]. Recent studies have shown more dental erosive wear among adolescents reporting vomiting [ 15, 18], and that these individuals have a 5.5-times higher risk of dental erosions than those without such behaviour [ 15].

As emphasized by Hellstrom [ 19], eating disorders are serious and potentially fatal conditions, where the implications on dental health are reasonably not considered among the most important. However, although many of the physical manifestations of these disorders are reversible, those affecting the teeth's hard tissue are not [ 20, 21]. Dentists play a significant role in identifying, preventing and treating dental erosion, and it is therefore important to be aware of risk indicators associated with this condition. A common apprehension among clinicians is that dental erosions are typically localized on the palatal surfaces of the upper front teeth in patients with vomiting or regurgitation, while erosions on the buccal or facial surfaces may be a result from high consumption of highly acidic foods and drinks. Although there is some support for this in the literature, [ 9, 10, 17, 19, 22- 25], several of these studies have limitations. Three of the studies have a low number of participants included [ 19, 22, 24], and calibration of examiners prior to onset of the studies was performed in only one study [ 23]. In addition, two of the studies did not distinguish between enamel and dentine lesions, making the severity assessment of the erosions difficult [ 10, 25]. This complicates the examiners' ability to monitor the progression of the lesions.

It is often assumed by clinicians and researchers that ED patients have an increased risk of developing dental erosion. However, more information about dental erosions in this risk group is required in order to adequately prevent and treat them. Therefore, the aim of this study was to assess the occurrence, distribution and severity of dental erosions in patients suffering from eating disorders characterized by self-induced vomiting, and the possible association between dental erosions and the duration of the eating disorder.

Methods

Participants

The individuals included in the study were all undergoing psychiatric and/or medical outpatient treatment at clinics for eating disorders during 2005 - 2013. Because of the assumed relation between eating disorders and dental problems, all patients at these clinics were offered a referral for a dental examination. The patients who were interested were then offered a dental examination at a university dental clinic (University of Oslo, Norway). The eating disorder diagnoses were made by the professional team at the eating disorder clinics. Of 72 referred patients examined at the university dental clinic, 62 had been diagnosed with BN, eight with AN, one with binge-eating disorder (BED) and one with an unspecific eating disorder. Self-induced vomiting was, or had been, a part of the eating disorder for 67 patients, and only these individuals were further studied. After the examination, one additional individual was excluded from the study because of crowns and onlays on all lower molars and upper front teeth.

Interview

Prior to the dental examination, each patient was interviewed by one examiner. The standardized interview was based on questions from a previously tested questionnaire [ 26, 27], and discussed the patient's present medical condition, other diseases/diagnoses and medical history. In addition, the examiner asked each patient about their dietary habits, such as consumption of acidic beverages and foods. This consumption was assessed by frequency questions with five possible responses: several times daily, once daily, 3-5 times weekly, 1-2 times weekly and less than once weekly. The participants were also asked if they vomited after eating, and if so, how often (daily, several times weekly, monthly and occasionally) and how long time since the last episode of vomiting.

The duration of self-induced vomiting was recorded during the interview, with three possible responses: 3-7 years, 8-10 years and more than 10 years duration of self-induced vomiting. Only a few participants specified the time of last episode of vomiting, and because this ranged from weeks to years, it was therefore not further considered in the study. The frequency of SIV was registered as times of vomiting per week, and ranged from two to 210 times per week.

Calibration and clinical examination

The intra-oral clinical examination was performed by one previously calibrated clinician (AM). The examiner was calibrated with four other clinicians (intra- and inter-examiner agreement values of mean κ w = 0.95 and mean κ w = 0.73; range 0.71 - 0.76, respectively). For more details see Mulic et al. [ 28].

The clinical examination was performed in a dental clinic with standard lighting, using mirrors and probes. Access saliva was removed from the teeth with compressed air and cotton rolls. The lingual/palatal and buccal surfaces of all teeth, and the occlusal surface of premolars and molars, were examined. For severity grading of dental erosion, a well established scoring system with the ability to diagnose early stages, as well as more advanced stages of erosion, was required. Scoring of dental erosion was therefore performed according to the Visual Erosion Dental Examination (VEDE) system [ 27- 29]: Score 0: No erosion; score 1: Initial loss of enamel, no dentine exposed; score 2: Pronounced loss of enamel, no dentine exposed; score 3: Exposure of dentine, < 1/3 of the surface involved; score 4: 1/3-2/3 of the dentine exposed; score 5: > 2/3 of dentine exposed. The number and distribution of affected teeth and surfaces were also registered. When surfaces were either filled, repaired with a crown or a veneer, affected by attrition or abrasion, or the tooth had been extracted, the surfaces and teeth were recorded as missing and excluded.

Ethical considerations

The study was approved by the local Regional Committee for Medical Research Ethics and The Norwegian Social Science Data Services. Written, informed consent was obtained from all participants.

Statistical analysis

The statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS, Chicago, IL, USA, version 20). Presence of dental erosive wear was used as the dependent variable. Frequency distributions, descriptive and bivariate analyses (Chi-square test) were conducted to provide summary statistics and preliminary assessment of the associations between independent variables and the outcome.

The level of significance was set at 5%.

Results

Participants

Of the 66 individuals included, 63 were female and three were male, with a mean age of 27.7 years (range: 20 - 48). Two participants did not answer the question regarding the duration of their eating disorder, but for the remaining 64 participants, the mean duration of the disorder was 10.6 years (range: 3 - 32 years).

Prevalence, severity and distribution of dental erosions

Of the 66 individuals included in the study, 20 (30.3%) showed no signs of dental erosions. The mean age of these individuals was 27.7 years (range: 20 - 48) and the duration of ED ranged from 3 to 32 years (mean: 10.6). Of the 46 individuals with dental erosion, only 43 answered the question of the duration of SIV.

Dental erosions were found in 46 individuals (69.7%), 43 women and three men. Of these, 19 individuals had enamel lesions only, while 27 had both enamel and dentine lesions. Of the individuals with erosions, 35 participants (76.1%) had five or more teeth affected, while 12 (26.1%) had 10 or more teeth with erosive lesions. Four individuals (9%) had ≥10 teeth with dentine lesions. Erosions grade 4 or 5 (severe erosion) were found in only six of the individuals, three of these had been suffering from ED for 16, 21 and 28 years, while two had been diagnosed six and nine years ago.

Dentine lesions appeared most frequently on occlusal surfaces (n = 66, 58.4%), followed by palatal surfaces on front teeth (n = 22, 19.5%). Of the 66 surfaces with dentine erosions on occlusal surfaces (Table ), lower first molars had most often dentine involvement (n = 28), while enamel lesions were most frequently found on upper central incisors (n = 58).

Table 1

Duration of SIV and dental erosions

The group of individuals (n = 16) with the longest duration of SIV (>10 years) had 71.7% of the dentine lesions and 40.4% of the enamel lesions (Table ).Of the individuals included in the study, eight (17.4%) had five or more teeth with dentine lesions. Only seven of these individuals answered the question of the duration of SIV, and for those who did, the mean duration was 17.1 years (range: 6 - 28). Ten participants (21.7%) had five or less surfaces with erosions (Figure ). Seven of the individuals had lesions on occlusal surfaces only. Eight of those with five or less involved tooth surfaces had been suffering from ED for 5 - 10 years, while two patients reported duration of 26 and 28 years, respectively.

The distribution of the total number of surfaces with erosive lesions (n = 432) according to the duration of SIV is presented in Table . The palatal surfaces were most frequently affected (41.6%), followed by occlusal surfaces (36.6%), regardless of the duration of SIV (Table ). However, the longer the duration of SIV, the more lesions were recorded on the palatal surfaces of the front teeth and in the lateral segments (Table ). The same was found on the buccal surfaces; though the prevalence was lower (Table ).

The individuals who had been suffering from ED for more than 10 years had significantly more buccal lesions in the lateral segments than those with a shorter duration of the disorder (p = 0.02). This group did also have significantly more palatal lesions in the lateral segments than those who had been suffering from ED for 3 - 7 years (p < 0.01) and 8 - 10 years (p = 0.04). Nine individuals who had induced vomiting for more than 10 years showed no signs of dental erosions, and in two individuals less than five teeth were affected.

Consumption of acidic beverages

Of the 54 individuals who answered the questionnaire, 24 reported a high daily intake of acidic beverages (≥0.5 liters per day), 30 participants reported a low consumption (<0.5 liters per day), and of these 17 (70.8%) and 23 persons (76.7%) showed dental erosions, respectively. The mean age in these groups was 28.4 (range: 21 - 48) and 27.5 years (range 20 - 43), and the mean duration of SIV was 12.0 (range: 3 - 28) and 9.9 years (range: 3 - 21). The mean number of teeth with erosions was 4.3 in the high consumption group and 5.8 in the low consumption group. Only one person in the high consumption group showed erosions grade 4 and 5, and no more than 9 teeth were affected, while in the low consumption group 3 individuals showed erosions grade 4 or 5, and six participants had 10 or more teeth affected with dental erosions.

Discussion

In this study, dental erosions were found in 69.7% of the individuals having a history of self-induced vomiting (SIV). This is in the lower range of previously reported prevalence (47 - 93%) among bulimic patients [ 11, 12, 30]. Although all the individuals included in the current study had a history of SIV, and thereby were at risk of developing dental erosions, 30.3% of the participants did not display any signs of erosion lesions. Previous studies have reported different findings. All patients with ED in the study by Robb et al. [ 10] had significantly more abnormal tooth wear (erosion) than the healthy control group, this finding being most prominent in the SIV group. None of the 23 women with AN in the study by Shaughnessy et al. [ 31] showed dental erosions, even though 26% of the participants reported a history of binge-eating/purging activity. Rytomaa et al. [ 11] found that 13 of 35 bulimics did not suffer from dental erosions. The observation that not all bulimic patients show a pathological level of tooth wear has also been reported by Milosevic and Slade [ 9] and Touyz et al. [ 30]. Although vomiting has been related to the occurrence of erosive wear, the study by Robb et al. [ 10] showed that those who suffered from AN, but did not vomit, also showed more erosions than the control population.

Dental erosions can be caused by acids from extrinsic (e.g. acidic foodstuff) as well as from intrinsic sources (gastric acid). In the present study, one of the inclusion criteria was self-induced vomiting, a challenge to the enamel due to exposure to gastric acid. Nearly half (n = 24) of the participants who completed the questionnaire also reported a high daily intake of acidic beverages. It is likely that individuals who induce vomiting up to several times per day have a higher risk of developing dental erosion than those who never, or more seldom, practice this behaviour. It is reasonable to assume that individuals who, in addition to exposing their teeth to gastric acids several times per day, often consume acidic beverages, have a greater risk of developing dental erosion than those who do not. However, in the present study, there were more erosions and more severe lesions in the group with low consumption of acidic beverages than in the group with high consumption. Bartlett and Coward [ 16] compared the erosive potential of gastric juice and a carbonated beverage in vitro and found that gastric juice had greater potential to cause dental erosions in enamel and dentine than a carbonated drink. The authors pointed out that the result reflects the lower pH and titratable acidity of gastric juice. This could be a reason why more lesions were not found in those individuals who consumed large amounts of acidic beverages in addition to SIV.

For patients with ED it is difficult to evaluate the risk of various dietary factors, vomiting and/or unfavourable saliva factors. Information about the frequency and duration of SIV is associated with uncertainties, because ED often are associated with shame and denial. It is often a general finding that these individuals are well-educated and well-informed about the condition. Many of them normally choose healthy diets devoid of sweets and sugary soft drinks. In contrast, when they have episodes of binge-eating they select "junk food", which is high in fat, sugar, salt and calories [ 12].

The results from the present study showed that the participants who had been practicing SIV for more than 10 years showed more erosions and more severe lesions (with exposed dentine). Frequent acid exposures may have a detrimental effect on the teeth's hard tissue, and particularly if the exposures continue over a long period of time. This finding is in accordance with results from Johansson et al. [ 15] and Altshuler et al. [ 25], who found a significant association between the duration of the ED and the prevalence of dental erosions. In addition, Dynesen et al. [ 14] showed that the duration of the ED had a significant influence on the severity grade of the erosive lesions. However, other studies did not find any association between frequency, duration of vomiting and dental erosion [ 9, 10]. In the present study nine individuals who had induced vomiting for more than 10 years showed surprisingly no signs of dental erosions, and in two individuals less than five teeth were affected.

The different results from the studies mentioned, and the fact that one third of the individuals in the present study did not show any erosive lesions despite regular vomiting, might be explained by individual differences in the susceptibility to erosion. It is still not clear what factors are relevant for the development and progression of erosion in these patients. Saliva factors, salivary flow rate, the pellicle and the composition of the enamel may be as important as the frequency of acid exposures [ 10].

It has often been speculated that differences in the composition of saliva could be responsible for the rapidly progressing erosive substance loss in patients with vomiting-associated ED [ 32]. A lower salivary pH in ED patients than in healthy controls has been documented by Touyz et al. [ 30], but in contrast Milosevic et al. [ 33] did not find any differences between BN patients and controls. Schlueter et al. [ 34] suggested that enhanced proteolytic activity in the saliva of bulimic patients might contribute to an altered buffering capacity of the saliva, as well as development and progression of dental erosion through degradation of dentine and the pellicle. Levels of amylase, immunoglobulin and electrolytes have also been investigated, but the findings differ substantially [ 32]. Several studies have shown a significantly lower unstimulated salivary flow in bulimic patients than in controls [ 11, 14, 19]. Many ED patients are prescribed antidepressants or other psychopharmaceutical medication, that are known to reduce salivary flow, and Dynesen et al. [ 14] showed that xerogenic medication significantly lowered unstimulated flow rate in this patient group.

The assumption that dental erosions caused by vomiting or regurgitations are typically localized on the palatal surfaces of the upper front teeth, and that erosions caused by high consumption of acidic foods and drinks are found on buccal surfaces, has led to efforts to relate the location of erosive lesions to the etiology of the condition [ 17, 22, 23]. From a clinical point of view, it is important to investigate whether it is possible to differentiate between erosions caused by SIV and erosions caused by consumption of acidic foodstuff. Hellstrom [ 19] reported that while lingual erosions were a frequent finding in individuals experiencing SIV, such lesions did not appear in individuals without this behaviour. Lussi et al. [ 23] found that chronic vomiting appeared to be the variable most indicative for lingual erosions. The present results showed that the majority of the lesions were found on the palatal surfaces and that the individuals with the longest duration of SIV had significantly more buccal and palatal lesions in the lateral segments than those with a shorter duration of the disorder. The more severe lesions (with exposed dentine) appeared most frequently on the occlusal surfaces of the lower first molars, followed by the palatal surfaces on the upper incisors. These results were consistent with work previously reported by Mulic et al. [ 18] in a study of healthy adolescents, and can partly be explained by the position of these teeth in the mouth and partly by their early time of eruption. The lower first molars are the first permanent teeth to erupt, they have an important function concerning occlusion and chewing, and acidic liquids naturally gravitate towards the floor of the mouth. The upper incisors also erupt at an early age, and as the rough surface of the tongue serves as a short-time reservoir for acids from foodstuff and liquids, the movements of the tongue have the potential to cause both an abrasive and an erosive effect (perimylolysis) on the palatal surface of the upper front teeth [ 35]. The rinsing effect of saliva is weaker on the upper teeth than on the lower, and the saliva clearance and buffer capacity are even lower in individuals with reduced saliva secretion [ 17].

Vigorously and frequent tooth brushing is a common habit in ED patients, and in combination with the repeated exposure to stomach acid, this could also contribute to the increased erosive tooth wear in this group [ 15, 19]. However, a study concerning oral hygiene habits did not ascertain why some of the vomiting bulimic patients suffered from severe erosions and others did not [ 36].

As expected, the prevalence of dental erosion in the individuals experiencing SIV was high. In addition, the duration of SIV seemed to influence the number of palatal and buccal lesions.

However, the present study does have some limitations: The proportion of male participants versus females was small. This, however, reflects the gender distribution shown in the study by Jaite et al. [ 8], where as much as 92.7% of individuals with bulimia nervosa were female, and seems to reflect the population prevalence of ED. Information on e.g. the exact duration of disease, frequency of SIV, oral hygiene habits and eating habits is unfortunately difficult to obtain, as it is based exclusively on the participants' subjective memory and their willingness to share. One might consider using standardized questionnaires instead of interviews, but these have approximately the same limitations in this matter. Another possible limitation of this study is that the participants were all undergoing treatment at clinics for eating disorders. Thus, the study does not include individuals who do not receive treatment for their disease, and the results might have been different if corresponding information from such individuals was obtained. Saliva secretion was not measured in this study. Considering that one third of the participants with EDs in a study by Rytomaa et al. [ 11] had decreased unstimulated saliva secretion, and hence decreased protection against dental erosion, this might have been an interesting addition to the study. However, Dynesen et al. [ 14] found that although individuals with vomiting had a significantly lower unstimulated salivary flow rate compared to a control group, this did not significantly influence dental erosion.

Conclusion

In the present study, dental erosions frequently affected individuals with ED experiencing SIV, and erosions were more often found on the palatal than on the buccal surfaces in these individuals, supporting a common clinical assumption. However, an interesting finding was that nearly one third of the individuals who had been experiencing SIV presented no visual signs of dental erosion. This emphasizes the necessity of further investigation concerning the etiology of the condition, and of communicating the increasing knowledge of ED and dental erosion to clinical practitioners. Since dentists often are the first health care professionals to whom persons with previously undiagnosed ED may present [ 32], and as dental care is an important part of the overall treatment for these patients, it is of imperative importance that dentists have an adequate knowledge regarding such disorders and how to prevent and treat the resulting oral consequences.

Competing interests

The authors declare that they have no competing interest. The authors alone are responsible for the content and writing of the paper.

Authors' contributions

MMU and AM carried out the data collection; MMU did the data analysis and writing of the article. ABT initiated the idea and along with KRS and AM supervised the project and assisted in writing/editing of the article. All authors have read and approved the final manuscript.

Acknowledgements

The authors would like to thank the participants for cooperation during the date collection.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Association; 2013. pp. 329-354. [Google Scholar]

Pindborg J. Pathology of the Dental Hard Tissues. Copenhagen: Munksgaard; 1970. p. 445. [Google Scholar]

Altshuler BD, Dechow PC, Waller DA, Hardy BW. An investigation of the oral pathologies occurring in bulimia nervosa. Int J Eat Disord. 1990;Volume 9(Issue 2):191-199. [Google Scholar]

Sovik JB, Tveit AB, Storesund T, Mulic A. Dental erosion: a widespread condition nowadays? A cross-sectional study among a group of adolescents in Norway. Acta Odontol Scand. 2014. [PubMed]

Shaughnessy BF, Feldman HA, Cleveland R, Sonis A, Brown JN, Gordon CM. Oral health and bone density in adolescents and young women with anorexia nervosa. J Clin Pediatr Dent. 2008;33(2):87-92. [[PMC free article] [PubMed] Google Scholar]

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Self-induced vomiting and dental erosion - a clinical study

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In individuals suffering from eating disorders (ED) characterized by vomiting (e.g. bulimia nervosa), the gastric juice regularly reaches the oral cavity, causing a possible risk of dental erosion. This study aimed to assess the occurrence, distribution and severity of dental erosions in a group of Norwegian patients experiencing self-induced vomiting (SIV).

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Facebook Use and Disordered Eating in College-Aged Women

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Facebook Use and Disordered Eating in College-Aged Women

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https://doi.org/10.1016/j.jadohealth.2015.04.026
Emalee Haynes

Social media use is increasing in today’s society. This study looked at Facebook use specifically in relation to potential connection between use and eating disorders or behaviors. From this study it was concluded that there was an association between using Facebook and having some form of disordered eating and/or mental health difficulties through appearance comparison and online bullying. This can relate to nutrition because it can be a barrier to treatment or trigger for patients experiencing a form or eating disorder. The study specifically studied college-aged women, but this could be concluded to have an effect on other age groups who use Facebook. When you have a patient that is struggling with social media relating to their eating disorder changing the talk to a more positive light can be helpful or suggesting a social media cleanse for a period of time. The clinical implications of this study are being able to relate or understand more causes of triggers or problems patients may face relating to eating disorders, and their mental health. Making sure to always ask patients more questions to potentially pull out this trigger can be beneficial in starting treatment sooner and getting to the source of potential problems. Additionally, this can affect those who may not have been diagnosed with an eating disorder, thus serving as a screening tool of asking about social media use when meeting with patients.

Walker, M., Thornton, L., De Choudhury, M., Teevan, J., Bulik, C. M., Levinson, C. A., & Zerwas, S. (2015). Facebook Use and Disordered Eating in College-Aged Women. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 57(2), 157–163. https://doi.org/10.1016/j.jadohealth.2015.04.026

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Yoga in the treatment of eating disorders within a residential program: A randomized controlled trial

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Yoga in the treatment of eating disorders within a residential program: A randomized controlled trial

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Esraa Zamzami

The study I chose for this week's wall is a pilot study that examines the influence of introducing yoga practices prior to mealtime to reduce anxiety and negative emotions. Although yoga is not a nutrition intervention, it does affect an individual's nutritional status. The importance of this study is its primary goal is to decrease the negative thoughts and anxiety that are causing the negative behaviors in patients with eating disorders. The yoga practices in this study were specifically designed and developed to target eating disorders symptomatology. The key finding of this pilot study is that yoga could significantly reduce the adverse effects prior to mealtime; however, this effect started to diminish after meal consumption. The intervention lasted only for five days which is a very short period, and that may be the reason why the post-meal effect was not seen. This strongly relates to nutrition because when improving the mental state of these patients, the eating disorder symptoms may decrease and could positively affect their nutritional status. More research must be done to have strong recommendations to include yoga as therapy for eating disorders as a clinical implication.

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Affiliations

¹ a Department of Behavioral Health and Nutrition, College of Health Sciences , University of Delaware , Newark , Delaware , USA.

² b The Emily Program , St. Paul , Minnesota , USA.

³ c The Neuropsychiatric Research Institute , Fargo , North Dakota , USA.

⁴ d The University of North Dakota School of Medicine and Health Sciences , University of North Dakota , Fargo , North Dakota , USA.

⁵ e Division of Epidemiology & Community Health, School of Public Health , University of Minnesota , Minneapolis , Minnesota , USA.

Free PMC article

Randomized Controlled Trial

Free PMC article

Affiliations

¹ a Department of Behavioral Health and Nutrition, College of Health Sciences , University of Delaware , Newark , Delaware , USA.

² b The Emily Program , St. Paul , Minnesota , USA.

³ c The Neuropsychiatric Research Institute , Fargo , North Dakota , USA.

⁴ d The University of North Dakota School of Medicine and Health Sciences , University of North Dakota , Fargo , North Dakota , USA.

⁵ e Division of Epidemiology & Community Health, School of Public Health , University of Minnesota , Minneapolis , Minnesota , USA.

Abstract

To investigate the effect of yoga on negative affect (an eating disorders risk factor), 38 individuals in a residential eating disorder treatment program were randomized to a control or yoga intervention: 1 hour of yoga before dinner for 5 days. Negative affect was assessed pre- and post-meal. Mixed-effects models compared negative affect between groups during the intervention period. Yoga significantly reduced pre-meal negative affect compared to treatment as usual; however, the effect was attenuated post-meal. Many eating disorders programs incorporate yoga into treatment. This preliminary evidence sets the stage for larger studies examining yoga and eating disorder treatment and prevention.

Conflict of interest statement

The authors have no conflicts of interest to report with this funding.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Yoga in the treatment of eating disorders within a residential program: A randomized controlled trial - PubMed

# data[].attributes.attachment_link.description
To investigate the effect of yoga on negative affect (an eating disorders risk factor), 38 individuals in a residential eating disorder treatment program were randomized to a control or yoga intervention: 1 hour of yoga before dinner for 5 days. Negative affect was assessed pre- and post-meal. Mixed ...

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Strict health-oriented eating patterns (orthorexic eating behaviours) and their connection with a vegetarian and vegan diet-Ashley Wahlman

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Strict health-oriented eating patterns (orthorexic eating behaviours) and their connection with a vegetarian and vegan diet-Ashley Wahlman

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This was a very interesting study because it discussed how following a vegetarian diet can lead to the onset of an eating disorder.  As we know different diets fade in and out and it's interesting to see the potential effects that it may have on our body. A key finding of this study is that individuals who followed a vegetarian diet experienced a higher level of orthorexic eating behavior than individuals who consumed meat. This indicates that food, our diet specifically, does play a role in our eating behavior and could possibly induce orthorexic eating. So, it may be better idea to stay away from certain diets, but ketogenic diets have been seen to make a difference in patients with certain eating disorders.  Overall, if you are recovering from anorexia or you are at high risk possibly staying away from a vegetarian diet may be a good idea to lessen the potential of taking on orthorexic eating behavior. This is important for clinicians to keep in mind to when offering diet plans to patients with eating disorders.   Works Cited:
Brytek-Matera, A., Czepczor-Bernat, K., Jurzak, H., Kornacka, M., & Kołodziejczyk, N. (2019). Strict health-oriented eating patterns (orthorexic eating behaviours) and their connection with a vegetarian and vegan diet. Eating and weight disorders : EWD, 24(3), 441–452. https://doi.org/10.1007/s40519-018-0563-5

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Affiliations

¹ Katowice Faculty of Psychology, SWPS University of Social Sciences and Humanities, Technikow 9, 40-326, Katowice, Poland. abrytek-matera@swps.edu.pl.

² Interdisciplinary Doctoral Studies, Wroclaw Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wroclaw, Poland.

³ Katowice Faculty of Psychology, SWPS University of Social Sciences and Humanities, Technikow 9, 40-326, Katowice, Poland.

⁴ Faculty of Psychology, SWPS University of Social Sciences and Humanities, Warsaw, Poland.

Free PMC article

Free PMC article

Affiliations

¹ Katowice Faculty of Psychology, SWPS University of Social Sciences and Humanities, Technikow 9, 40-326, Katowice, Poland. abrytek-matera@swps.edu.pl.

² Interdisciplinary Doctoral Studies, Wroclaw Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wroclaw, Poland.

³ Katowice Faculty of Psychology, SWPS University of Social Sciences and Humanities, Technikow 9, 40-326, Katowice, Poland.

⁴ Faculty of Psychology, SWPS University of Social Sciences and Humanities, Warsaw, Poland.

Abstract

Purpose: Although research on vegetarianism is becoming more prevalent, to date, only a few research has been conducted on relationship between vegetarian diet and orthorexia nervosa (ON). The objective of the present study was to examine the orthorexic dietary patterns and eating behaviours among individuals following a vegetarian, vegan, and meat diet. We examined the moderating role of ethical and health reasons for following a meat-free diet on the relation between vegan versus vegetarian diet and eating behaviours and ON. The study aimed to determine the predictors of ON in individuals with differential food preferences.

Methods: Seventy-nine individuals following a meat-free diet and 41 individuals following an omnivore diet completed the EHQ and the TFEQ-R18.

Results: Our findings indicated that individuals following a vegan diet showed a higher level of knowledge of healthy eating than those who followed a vegetarian diet and those who followed an omnivore diet. Participants maintaining a vegan diet for health reasons were more likely to have greater knowledge about healthy eating. Cognitive restraint was a predictor of ON among a sample following a meat-free diet.

Conclusions: Our results could contribute to identify potential risk factors for strict health-oriented eating patterns and to gain a better insight into ON.

Level of evidence: Level V, descriptive study.

Keywords: Eating behaviours; Orthorexia nervosa; Vegan diet; Vegetarian diet.

Conflict of interest statement

The authors declare that they have no conflict of interest.

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References

Ruby MB. Vegetarianism. A blossoming field of study. Appetite. 2012;58:141-150. - PubMed

Barthels F, Meyer F, Pietrowsky R. Orthorexic and restrained eating behaviour in vegans, vegetarians, and individuals on a diet. Eat Weight Disord. 2018;23:159-166. - PubMed

Bardone-Cone A, Fitzsimmons-Craft E, Harney M, Maldonado C, Lawson M, Smith R, et al. The inter-relationships between vegetarianism and eating disorders among females. J Acad Nutr Diet. 2012;112:1247e1252. - PMC - PubMed

Barnett MJ, Dripps WR, Blomquist KK. Organivore or organorexic? Examining the relationship between alternative food network engagement, disordered eating, and special diets. Appetite. 2016;1(105):713-720. - PubMed

Varga M, Thege BK, Dukay-Szabo S, Túry F, van Furth EF. When eating healthy is not healthy: orthorexia nervosa and its measurement with the ORTO-15 in Hungary. BMC Psychiatry. 2014;14:59. - PMC - PubMed

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feeding and eating disorders / psychology*

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national center for biotechnology information

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Strict health-oriented eating patterns (orthorexic eating behaviours) and their connection with a vegetarian and vegan diet - PubMed

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1 Katowice Faculty of Psychology, SWPS University of Social Sciences and Humanities, Technikow 9, 40-326, Katowice, Poland. abrytek-matera@swps.edu.pl. 2 Interdisciplinary Doctoral Studies, Wroclaw Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wroclaw, Poland. 3 Katowice Faculty of Psychology, SWPS University of Social Sciences and Humanities, Technikow 9, 40-326, Katowice, Poland.

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Posted by Richard Proudfoot
The research paper selected for this week is titled: “Remission from Chronic Anorexia Nervosa With Ketogenic Diet and Ketamine: Case Report”

This research paper is a 2020 case report from 5 various practitioners at Internal Medicine & Addiction Medicine, Waban, MA, United States; Consultant-Ketogenic Diet Therapy LLC, Elm Grove, WI, United States; Innovative Psychiatry, South Windsor, CT, United States; Center for Neural Sciences, New York University, New York, NY, United States; The Neuroscience Institute, NYU Langone Medical Center, New York, NY, United States; Center of Excellence in Eating and Weight Disorders, Icahn School of Medicine at Mount Sinai, New York, NY, United States. The authors report the case of a 29-year-old woman who struggled with severe and enduring anorexia nervosa for 15 years, and experienced a complete recovery following a novel treatment of adopting a ketogenic diet followed by ketamine infusions. Her remission has persisted for over 6 months.

This study is important because complete and sustained remission of chronic anorexia nervosa is quite rare, and the novel use of a ketogenic diet and IV ketamine treatment in this potentially lethal condition suggests avenues for further research, and hope for patients and their families.

The key findings from this study is the treatment paradigm essentially involved three modalities, and not just two treatment arms: first the patients adoption and reconsideration of anorexia nervosa as a disorder whose symptoms are predominately metabolically driven, which was an enormous paradigm shift for the patient; secondly adopting the ketogenic diet and contextualizing ketosis as helpful for her brain rather than as a weight loss or weight control method for her body; and third IV ketamine infusions at a dose and titration schedule not previously reported.

Clinical implication from of this study is a reminder that the ketogenic diet has an impressive record of safety and efficacy for treating seizure disorders in children and has been used continuously since the 1920s. It is an emerging therapy for treatment of other neurological and psychiatric disorders such as Parkinson’s, early Alzheimer’s, and bipolar disorder. Ketogenic diet use in combination with new paradigm, such as “Adaptation to Flee Famine Hypothesis” and the dissociation effect of an old medicine, Ketamine, may be able to reverse the unrelenting suffering and lethality of eating disorders, particularly anorexia nervosa.1

Scolnick B, Zupec-Kania B, Calabrese L, Aoki C, Hildebrandt T. Remission from Chronic Anorexia Nervosa With Ketogenic Diet and Ketamine: Case Report. Front Psychiatry. 2020;11:763. Published 2020 Jul 30. doi:10.3389/fpsyt.2020.00763

Posted by Richard Proudfoot