Lebow, Jocelyn

Eating disorders involve irregularities in eating behavior that may cause gastrointestinal (GI) symptoms. Consequently, many patients with eating disorders seek gastroenterological healthcare at some point in their illness, with many seeking this care even before they seek treatment for and/or diagnosed with their eating disorder. As such, the gastroenterology provider is in a unique position to identify, manage, and facilitate treatment for an eating disorder early in the course of the illness. Although assessing eating disorders is already a difficult task, the identification of eating disorders in patients with GI disease represents an even greater challenge. In particular, common GI symptoms, such as nausea, vomiting, and bloating, may disguise an eating disorder because these symptoms are often viewed as a sufficient impetus for dietary restriction and subsequent weight loss. In addition, the focus on identifying an organic etiology for the GI symptoms can distract providers from considering an eating disorder. During this prolonged diagnostic evaluation, the eating disorder can progress in severity and become more difficult to treat. Unfortunately, a misconception that hinders eating disorder detection is the notion that the rate or method of weight loss is associated with an eating disorder. Regardless of whether weight loss is slow or rapid, purposeful or accidental, eating disorder behaviors and thought patterns may be present. Unidentified eating disorders are not only dangerous in their own right but also can interfere with effective management of GI disease and its symptoms. As such, it is imperative for the GI provider to remain well versed in the identification of these diseases.

AbstractObjectivePsychotropic medication use in youth with eating disorders (EDs) is poorly understood despite high co‐occurrence of psychiatric disorders. This study examined characteristics associated with medication use in treatment‐seeking youth with EDs.MethodYouth up to age 18 reported on medication use when presenting to an academic medical center outpatient ED service in the United States. Data presented were collected between 1998–2015.ResultsThe sample (N = 604) was predominantly female (90.6%) with a mean age of 15.3 years (SD = 2.3). Approximately one‐third (30%, n = 173) were taking psychotropic medications (40%, n = 70, were taking multiple medications). Antidepressant use was most common (26%, n = 152), followed by atypical antipsychotics (8%, n = 43). Adjusting for co‐occurring psychiatric disorders, non‐Hispanic Whites who had received prior treatment (psychotherapy, hospitalization) were significantly more likely to be using medication. Longer illness duration and prior treatment were associated with greater antidepressant use. For atypical antipsychotics, prior hospitalization was associated with greater use.ConclusionsFindings confirm moderate psychotropic medication use among young patients with EDs despite a lack of clarity regarding optimally effective pharmacologic interventions in this population. Pharmacological trials examining the efficacy of medications for young patients with EDs are warranted to inform future prescribing practice.

Abstract Objective This study used mixed methods to evaluate caregiver perspectives on recovery from an eating disorder. Method Caregivers ( N = 387) completed an online survey about their child's weight history, treatment history, illness trajectory, and recovery. Results Children were predominantly females with adolescent onset anorexia nervosa and currently 18.4 years old on average. Qualitative analysis of caregivers' open‐ended definitions of recovery revealed seven distinct recovery domains, including (a) weight (45%); (b) body image, eating disorder cognitions, and related emotions (54%); (c) eating behavior (71%); (d) independence and responsibility in eating disorder management (28%); (e) physical health (21%); (f) psychological well‐being (31%); and (g) life worth living (27%). Most (72%) reported that their child had achieved partial or full recovery at some point in their lifetime. Only 20% reported that their child had ever achieved full recovery, but 93% of those had sustained recovery over time (i.e., no relapses since achieving recovery). Physical recovery occurred on average 2.7 years after eating disorder onset, followed shortly by social and emotional recovery (2.9 years), and finally behavioral (3.4 years) and cognitive (3.9 years) recovery, which occurred at weights 6–7 pounds higher than those at which physical recovery was achieved. Discussion Findings suggest that caregivers hold a multifaceted view of recovery that includes not only weight restoration and symptom reduction, but also full engagement in social and occupational activities, establishment of a meaningful life, cognitive flexibility, and emotional well‐being. These data support clinical observations that physical and behavioral recovery precede cognitive recovery.

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.