Lebow, Jocelyn

ABSTRACT: Objective: To examine the medical assessment and triage of pediatric patients with anorexia nervosa (AN) initially seen in primary care. Methods: A retrospective cohort study was conducted for all pediatric patients with AN who had eating/weight concerns and initially identified symptoms in primary care in a single health care system between January 1, 2010, and December 31, 2016. Information on presenting concern, medical assessment/laboratory tests, clinical diagnoses, treatment recommendations, and referrals were abstracted from the medical record. Results: Forty-one (mean age = 13.7 years; SD = 2.2) pediatric patients with AN had eating/weight concerns and initially identified symptoms in a primary care. Overall, only 5% (n = 2/41) of patients received an AN diagnosis during the index visit; a minority were assessed for electrolyte disturbance (n = 20), electrocardiogram abnormality (n = 18), hypothermia (n = 13), binge/purge behaviors (n = 13), orthostatic hypotension (n = 2), or dehydration (n = 1), and only 56% (n = 23) received triage consistent with practice recommendations. Although 61% (n = 25) met criteria for inpatient admission, inpatient hospitalization was recommended for only 2 patients. Patients who received triage consistent with practice recommendations received AN diagnosis and treatment significantly earlier than those who did not (p < 0.01 and p = 0.001, respectively). Conclusion: Findings suggest that pediatric patients with AN may not be receiving medical assessment and triage per practice recommendations in the primary care setting. Understanding barriers to evidence-based care for pediatric eating disorders may inform provider education and system-wide changes to enhance outcomes in these patients.

AbstractObjectiveGiven that weight gain patterns in adolescents receiving outpatient Family‐Based Treatment (FBT) have not been characterized, the purpose of this study was to examine trajectories of weight gain in a group of adolescent patients with a restrictive eating disorder [e.g., anorexia nervosa (AN) and atypical AN] receiving FBT. This study also examined the association of patient characteristics with weight gain trajectories, including age, diagnosis, weight suppression, presenting BMI‐for‐age percentile, and eating pathology.MethodLatent growth mixture modeling was used to identify distinct weight trajectories, as defined by change in BMI‐for‐age percentile, for 153 adolescents with AN or atypical AN, receiving FBT.ResultsThere were five distinct weight gain trajectory profiles for adolescents receiving FBT for a restrictive eating disorder. Younger age and greater weight suppression were associated with more rapid weight gain trajectories. A pattern of slow and consistent weight gain was associated with older age and less eating pathology.DiscussionThere was considerable variability in weight gain trajectories in youth receiving outpatient FBT for a restrictive eating disorder. This suggests that patients' presenting information can be used to inform expectations regarding weight gain trajectories.

Accessible summaryWhat is known on the subject? Weight suppression (WS) has been suggested to predict outcome following psychological treatment for an eating disorder (ED). Some findings are contradictory and have not been considered systematically. What the paper adds to existing knowledge? The review suggests that weight gain at post‐treatment is reliably predicted by pretreatment WS, but findings regarding other outcomes (e.g., treatment dropout) are less consistent. Approximate effect sizes for observed relationships are identified, alongside support for biobehavioural theories of metabolic adaptation to weight loss. What are the implications for practice? Degree of WS at pretreatment is associated with weight gain and is important for clinicians to consider before offering treatment to patients with EDs. Patients high in WS might benefit from further support (e.g., psychoeducation) prior to beginning treatment. AbstractIntroductionWeight suppression (WS—the difference between highest body weight and current body weight) has been proposed as a predictor of treatment outcome within eating disorders (EDs), although this hypothesis has not been consistently supported.Aim/QuestionReview the association between pretreatment WS and outcome following psychological treatment for EDs.MethodA comprehensive electronic database search for published and unpublished literature from 1979 to 2017. Reference lists were also inspected. Eligibility criteria were determined according to relevant guidelines and a quality appraisal was conducted.ResultsTwelve studies met inclusion criteria (one was subsequently excluded based on insufficient data). Greater WS was generally associated with weight gain at post‐treatment although not with other treatment outcomes.DiscussionThe existing evidence, with data from 1,566 participants, is summarized according to three main post‐treatment outcomes: weight change; treatment completion; and symptom abstinence. Patients with disordered eating and greater WS may need to gain more weight than others during treatment to achieve good outcomes. Recommendations for future studies are provided.Implications for practiceEvidence‐based treatments for EDs may benefit from considering WS when planning treatment, such as further psychoeducation on weight changes. Societal interventions regarding promotion of healthy eating may also draw on these findings.

CONTEXT: Although practice guidelines suggest that primary care providers working with children and adolescents incorporate BMI surveillance and counseling into routine practice, the evidence base for this practice is unclear. OBJECTIVE: To determine the effect of brief, primary care interventions for pediatric weight management on BMI. DATA SOURCES: Medline, CENTRAL, Embase, PsycInfo, and CINAHL were searched for relevant publications from January 1976 to March 2016 and cross-referenced with published studies. STUDY SELECTION: Eligible studies were randomized controlled trials and quasi-experimental studies that compared the effect of office-based primary care weight management interventions to any control intervention on percent BMI or BMI z scores in children aged 2 to 18 years. DATA EXTRACTION: Two reviewers independently screened sources, extracted data on participant, intervention, and study characteristics, z-BMI/percent BMI, harms, and study quality using the Cochrane and Newcastle-Ottawa risk of bias tools. RESULTS: A random effects model was used to pool the effect size across eligible 10 randomized controlled trials and 2 quasi-experimental studies. Compared with usual care or control treatment, brief interventions feasible for primary care were associated with a significant but small reduction in BMI z score (–0.04, [95% confidence interval, –0.08 to –0.01]; P = .02) and a nonsignificant effect on body satisfaction (standardized mean difference 0.00, [95% confidence interval, –0.21 to 0.22]; P = .98). LIMITATIONS: Studies had methodological limitations, follow-up was brief, and adverse effects were not commonly measured. CONCLUSIONS: BMI surveillance and counseling has a marginal effect on BMI, highlighting the need for revised practice guidelines and the development of novel approaches for providers to address this problem.

The Food and Drug Administration recently approved topiramate for migraine prevention in adolescents. Given the well-established appetite-suppressant side effects of topiramate, as well as data suggesting a potential comorbidity between migraine and eating disorders, susceptible young migraine patients may be at a greater risk for the development or worsening of eating disorder symptoms with topiramate therapy. This case series comprises 7 adolescent patients in whom serious eating disorders developed or were exacerbated after the initiation of topiramate therapy. Clinical characteristics of these patients are highlighted. In addition, this case series provides guidelines for providers to use in assessing eating disorders before prescribing topiramate for migraine prevention in adolescents.

Adolescent patients with obesity are at significant risk of developing an eating disorder (ED), yet due to their higher weight status their symptoms often go unrecognized and untreated. Although not widely known, individuals with a weight history in the overweight (BMI-for-age ≥85th percentile but &lt;95th percentile, as defined by Centers for Disease Control and Prevention growth charts) or obese (BMI-for-age ≥95th percentile, as defined by the Centers for Disease Control and Prevention growth charts) range, represent a substantial portion of adolescents presenting for ED treatment. Given research that suggests that early intervention promotes the best chance of recovery, it is imperative that these children’s and adolescents’ ED symptoms are identified and that intervention is offered before the disease progresses. This report presents 2 examples of EDs that developed in the context of obese adolescents’ efforts to reduce their weight. Each case shows specific challenges in the identification of ED behaviors in adolescents with this weight history and the corresponding delay such teenagers experience accessing appropriate treatment.