Prevalence of adverse childhood experiences and their co-occurrence in a large population of adolescents: a Young HUNT 3 study.

PURPOSE: Studies of adverse childhood experiences (ACEs) undertaken at the time of adolescence in the general population are not common. The aim of this study was to determine the prevalence and co-occurrence of the individual ACEs and sub-types of ACEs in a large population of adolescents. METHODS: Data were used from the Young Nord-Trøndelag Health (Young HUNT 3) study, a population-based study of young adolescents. ACEs were operational defined as sexual, physical and/or emotional abuse; physical and/or emotional neglect; and/or household dysfunction. Co-occurrence was measured as the accumulation of ACEs and as an overlap analysis. RESULTS: Of the 8199 evaluable adolescents, 65.8% had experienced at least one ACE and 28% of those had experienced more than one ACE. Household dysfunction was the most prevalent ACE subtype. The biggest overlaps among the three ACE sub-types were seen in those reporting neglect or abuse. CONCLUSION: There was a high degree of overlap between the three ACE sub-types and the individual ACEs, indicating that ACEs should be assessed together as a whole rather than separately. This study provides an opportunity to assess ACEs and their co-occurrences in relation to outcomes later in life.

The outcome at follow-up after inpatient eating disorder treatment: a naturalistic study.

BACKGROUND: Patients with eating disorders may experience a severe and enduring course of illness. Treatment outcome for patients provided with inpatient treatment is reported as poor. Research to date has not provided consistent results for predictors of treatment outcome. The aims of the study were to investigate rates of remission at follow-up after inpatient treatment, symptom change from admission to follow-up, and predictors of treatment outcome. METHODS: The follow-up sample consisted of 150 female adult former patients (69.4% of all eligible female patients) with eating disorders. Mean age at admission was 21.7 (SD = 4.9) years. Diagnostic distribution: 66% (n = 99) anorexia nervosa, 21.3% (n = 32) bulimia nervosa and 12.7% (n = 19) other specified feeding or eating disorder, including binge eating. Data were collected at admission, discharge and follow-up (mean 2.7 (SD = 1.9) years). Definition of remission was based on the EDE-Q Global score, body mass index and binge/purge behavior. Paired T-tests were performed to investigate change over time. Univariate and multivariate logistic regressions were estimated to investigate predictors of remission. RESULTS: At follow-up, 35.2% of the participants were classified as in remission. Significant symptom reduction (in all patients) (p <  0.001) and significant increase in body mass index (BMI) (in underweight participants at admission) (p <  0.001) was found. Increased BMI (p <  0.05), the level of core eating disorder symptoms at admission (p <  0.01) and reduced core eating disorder symptoms (p <  0.01) during inpatient treatment were found significant predictors of outcome in the multivariate model. CONCLUSIONS: All participants had an eating disorder requiring inpatient treatment. Approximately one-third of all participants could be classified as in remission at follow-up. However, most participants experienced significant symptom improvement during inpatient treatment and the improvements were sustained at follow-up. Increased probability of remission at follow-up was indicated by lower core ED symptoms at admission for all patients, raised BMI during admission for patients with AN, and reduced core ED symptoms during inpatient treatment for all patients. This finding contributes important information and highlights the importance of targeting these core symptoms in transdiagnostic treatment programs.

How to integrate physical activity and exercise approaches into inpatient treatment for eating disorders: fifteen years of clinical experience and research.

BACKGROUND: The importance of physical activity and exercise among patients with eating disorders (EDs) is acknowledged among clinicians and researchers. The lack of clinical guidelines, the differing attitudes towards exercise approaches in treatment, and the lack of specialized competence all influence the management of ED symptoms in specialist ED treatment units. The purpose of the study was to examine 15 years of clinical experience with exercise approaches as an integrated part our inpatients treatment program. METHODS: From January 2003 to December 2017, 244 patients were admitted to a specialist ED unit in Norway. The treatment program at the ED unit is multidisciplinary. It is based on psychodynamic theory, and designed to enhance patients' recovery and to enable them to adopt a lifestyle that is as healthy as possible. The authors describe the clinical management of patients with reference to practical examples and a case example. RECOMMENDATIONS AND EXPERIENCE: The treatment for exercise is not manualized, but adjusted to the specific symptoms and needs of individual ED patients. The treatment approaches to exercise are part of the body-oriented treatment at the Specialist eating disorder unit (Regionalt kompetansesenter for spiseforstyrrelser (RKSF)), and the therapy addresses the entire body and the relation between the body, emotions, and the patient's social situation. It covers a chain of approaches from admission to discharge, from rest and relaxation to regular exercise groups. CONCLUSIONS: Our experience and recommendations support earlier proposals for treatment approaches to exercise and exercise-related issues as a beneficial supplement to the treatment of ED inpatients. We have not experienced any adverse influences on patients' recovery processes, such as their rate of weight gain. Our intention is that this paper will be a contribution to the field of ED, the integration of exercise approaches in the inpatient treatment of ED and development of clinical guidelines.

Impact of eating disorders on obstetric outcomes in a large clinical sample: A comparison with the HUNT study.

OBJECTIVE: Current evidence from clinical studies suggests that having an active eating disorder (ED) during pregnancy is associated with unfavorable obstetric outcomes. However, the role of a lifetime diagnosis of ED is not fully understood. Variations in findings suggest a need for additional studies of maternal ED. This study aims to identify associations between a lifetime ED and obstetric outcomes. METHOD: Data from a hospital patient register and a population-based study (The HUNT Study) were linked to the Medical Birth Registry in Norway. Register based information of obstetric complications (preeclampsia, preterm birth, perinatal deaths, small for gestational age (SGA), large for gestational age (LGA), Caesarean sections, and 5-min Apgar score) were acquired for 532 births of women with ED and 43,657 births of non-ED women. Multivariable regression in generalized estimating equations was used to account for clusters within women as they contributed multiple births to the dataset. RESULTS: After adjusting for parity, maternal age, marital status, and year of delivery, lifetime history of anorexia nervosa was associated with increased odds of having offspring who were SGA (Odds ratio (OR) 2.7, 95% Confidence Interval (CI) 1.4-5.2). Women with a lifetime history of bulimia nervosa had higher odds of having a Caesarian section (OR 1.7 95% CI 1.1-2.5). Women with EDNOS/sub-threshold ED had a higher likelihood of having a low Apgar score at 5 min (OR 3.1, 95% CI 1.1-8.8). CONCLUSION: Our study corroborates available evidence on the associations between maternal ED and adverse obstetric outcomes.

Validation of the exercise and eating disorder questionnaire in males with and without eating disorders.

OBJECTIVE: The need to consider gender when studying exercise in eating disorder (ED) has been underscored. The study aimed to test the psychometric properties and factor structure of the exercise and eating disorder (EED) questionnaire for males with and without ED, to highlight gender differences, and to explore issues relevant for a male version of the EED questionnaire. METHOD: This cross sectional study included 258 male participants: 55 ED patients (inpatients and outpatients) and 203 student controls. The patient group consisted of 54.5% (n = 30) with AN, 18.2% (n = 10) with BN, 27.2% (n = 15) with unspecified ED. The ED sample was treated as transdiagnostic in all analyses. t Tests, chi-square test, correlations analyses, and a principal component analysis were conducted. RESULTS: The analyses confirmed that the EED questionnaire had adequate psychometric properties, and a four-factor solution: (a) compulsive exercise, (b) positive and healthy exercise, (c) awareness of bodily signals, and (d) weight and shape exercise. The questionnaire discriminated significantly (p < .01- < .001) between patients and controls on the global score, subscales, and 16 out of 18 individual items. Convergent validity was demonstrated by high correlations between the EED questionnaire and the eating disorder examination questionnaire (r = .65). DISCUSSION: The results indicated that the EED questionnaire is a valid and reliable tool for males. It is a clinically derived, self-report questionnaire to assess compulsive exercise among ED patients, regarding attitudes and thoughts toward compulsive exercise and identification of treatment targets and priorities.

Impact of female adult eating disorder inpatients' attitudes to compulsive exercise on outcome at discharge and follow-up.

BACKGROUND: The link between compulsive exercise and eating disorders is well known, but research with clinical samples has been limited. The purpose of the study was to investigate changes in attitudes towards compulsive exercise and its impact on outcome at follow-up in female adult hospitalised patients with eating disorders. METHODS: The sample consisted of 78 patients: Diagnostic distribution: anorexia nervosa 59 % (n = 46), approximately 22 % (n = 16) in bulimia nervosa, and Eating Disorder not Otherwise Specified respectively. The average follow-up period was 26 months (SD =15 months). Compulsive exercise was measured by the Exercise and Eating Disorder (EED) questionnaire. Other measures were the Eating Disorder Inventory (EDI-2), Body Attitude Test (BAT), Symptom Checklist (SCL-90), Inventory of Interpersonal Problems (IIP 64), Beck Depression Inventory (BDI), and body mass index (BMI). Outcome measures were EDI-2 and BMI (patients with admission BMI ≤ 18.5). Paired sample t-tests and mixed model regression analysis were conducted to investigate changes in compulsive exercise and predictors of outcome respectively. RESULTS: All measures revealed significant improvements (p < .01 - p < .001) from admission to follow-up. EED scores significantly predicted changes in EDI-2 scores and BMI (p < .01 and p < .001 respectively). Other significant predictors were BAT, SCL-90, IIP-64, BMI (p < .01-.001) (EDI-2 as outcome measure), and BAT and BDI (p < .001) (BMI as outcome measure). CONCLUSIONS: The results demonstrated significant improvements in attitudes towards compulsive exercise during treatment and follow-up. The change in compulsive exercise scores predicted the longer-term course of eating disorder symptoms and BMI.

Women's weight and disordered eating in a large Norwegian community sample: the Nord-Trøndelag Health Study (HUNT).

OBJECTIVES: An increasing part of the population is affected by disordered eating (DE) even though they do not meet the full eating disorder (ED) criteria. To improve treatment in the range of weight-related disorders, there is a need to improve our knowledge about DE and relevant correlates of weight problems such as underweight, overweight and obesity. However, studies investigating DE and weight problems in a wide range of ages in the general population have been lacking. This paper explores DE, weight problems, dieting and weight dissatisfaction among women in a general population sample. DESIGN: Cross-sectional study. SETTING: The third survey of the Nord-Trøndelag Health Study (HUNT3). PARTICIPANTS: The population included 27,252 women, aged 19-99 years, with information on DE outcomes and covariates. OUTCOMES: DE was assessed with an 8-item version of the Eating Attitude Test and the Eating Disorder Scale-5. Body mass index (BMI) was objectively measured. Data on dieting and weight dissatisfaction were collected from self-reported questionnaires and analysed across weight categories. Crude and adjusted logistic and multinomial logistic regression models were used. RESULTS: High rates of overweight (38%) and obesity (23%) were found. DE was associated with weight problems. In women aged <30 years, 11.8% (95% CI 10.3 to 13.1) reported DE, and 12% (95% CI 11.5 to 12.6) reported DE in women aged >30 years. In those of younger ages (19-29 years), lower weight predicted DE, while increasing weight predicted DE in older aged women (30-99 years). The majority of women were dissatisfied with their weight (58.8%), and 54.1% of the women reported dieting. Neither BMI status nor age was associated with dieting or weight dissatisfaction. CONCLUSIONS: A high prevalence of DE was observed, and findings suggest that weight problems and DE are not distinct from one another. Dieting was associated with women's weight dissatisfaction, rather than with actual weight. This requires further investigations about directionality of effects.

Validation of the exercise and eating disorders questionnaire.

OBJECTIVE: Compulsive exercise is a well-known feature in eating disorders. The Exercise and Eating Disorder (EED) self-report questionnaire was developed to assess aspects of compulsive exercise not adequately captured by existing instruments. This study aimed to test psychometric properties and the factor structure of the EED among women with eating disorders and a control group. METHOD: The study included 449 female participants, including 244 eating disorders patients and 205 healthy controls. The patient group consisted of 32.4% (n = 79) AN patients, 23.4% (n = 57) BN, 34.4% (n = 84) EDNOS and 9.8% (n = 24) with BED diagnosis. RESULTS: The analyses confirmed adequate psychometric properties of the EED, with a four-factor solution: (1) compulsive exercise, (2) positive and healthy exercise, (3) awareness of bodily signals, and (4) weight and shape exercise. The EED discriminated significantly (p < .001) between patients and controls on the global score, subscales, and individual items. Test-retest reliability was satisfactory (r = 0.86). Convergent validity was demonstrated by high correlations between the EED and the Eating Disorder Examination Questionnaire (EDE-Q; r = 0.79). DISCUSSION: The EED is the first clinically derived, self-report questionnaire to assess compulsive exercise among ED patients. The EED offers assessment that has broader clinical utility than existing instruments because it identifies treatment targets and treatment priorities.

Risk factors for suicidal thoughts in adolescence--a prospective cohort study: the Young-HUNT study.

OBJECTIVES: Examining the associations between health and lifestyle factors recorded in the participants' early teens and development of suicidal thoughts recorded 4 years later. DESIGN: Population-based prospective cohort study. SETTINGS: All students in the two relevant year classes in Nord-Trøndelag County were invited, 80% attended both waves of data collection. PARTICIPANTS: 2399 secondary school students who participated in the Young-HUNT1 study in 1995-1997 (13-15 years old) were included in a follow-up study 4 years later (17-19 years old). PRIMARY OUTCOME MEASURE: Suicidal thoughts reported at age 17-19 years. RESULTS: 408 (17%, 95% CI 15.5% to 18.5%) of the adolescents reported suicidal thoughts at follow-up, 158 (14.2%, CI 13.6% to 16.4%) boys and 250 (19.5%, CI 18.8% to 22.0%) girls. Baseline anxiety and depressive symptoms (adjusted OR (aOR) 1.9, CI 1.4 to 2.6), conduct problems (aOR 1.8, CI 1.3 to 2.6), overweight (aOR 1.9 CI 1.4 to 2.4), and muscular pain and tension (aOR 1.8, CI 1.4 to 2.4), were all associated with reporting suicidal thoughts at follow-up. CONCLUSIONS: One in six young adults experienced suicidal thoughts, girls predominating. Suicidal thoughts were most strongly associated with symptoms of anxiety/depression, conduct problems, pain/tension and overweight reported when participants were 13-15 years old. Specific preventive efforts in these groups might be indicated. Future research should investigate whether similar associations are seen with suicide/suicidal attempts as endpoints.

Psychological factors and weight problems in adolescents. The role of eating problems, emotional problems, and personality traits: the Young-HUNT study.

BACKGROUND: The associations between psychological factors and weight problems in adolescents are not conclusive. We studied associations between psychological factors, including personality and weight problems, in an adolescent population. In addition, we examined the same psychological factors as predictors for change in weight categories during adolescence. METHOD: From 1995 to 1997, 8,090 adolescents, aged 13-18 years, participated in the Young-HUNT-I study; of those, 1,619 also participated in a follow-up study in 2000-2001. They completed a questionnaire monitoring eating problems, self-esteem, personality, anxiety, and depression, and had their height and weight measured. Weight problems were defined using the international age-and sex-specific BMI-cut-offs defining underweight, overweight, and obesity. Psychological factors at baseline were studied both in relation to weight categories at baseline, and as predictors for weight change between baseline and the follow-up. RESULTS: Significant sex differences in mean values were found in all psychological factors, with higher scores in girls compared with boys. In the cross-sectional design, eating problems were associated with weight problems, and the two factors of oral control (EAT-A) and food preoccupation (EAT-B) showed an inverse association. Oral control was associated with underweight, while food preoccupation was associated with overweight and obesity in both sexes. Low self-esteem was associated with overweight and obesity in both sexes, but no association was found between emotional problems or personality traits, and weight problems. During the follow-up, oral control was a clear predictor of weight change during adolescence in both sexes. Oral control protected against unhealthy weight gain but also predicted unhealthy weight reduction in both sexes. CONCLUSIONS: Girls scored higher on all psychological factors compared with boys, but no sex differences were found with regard to the association between psychological factors and weight problems. Eating problems showed the strongest association with weight problems at baseline and were also the strongest predictor of weight change during adolescence.

Sex differences in time trends for overweight and obesity in adolescents: the Young-HUNT study.

AIMS: To investigate sex differences in the prevalence and extent of overweight and obesity in adolescents aged 14-18 years. METHODS: Standardized measurements of height and weight were collected from surveys of adolescents in the same geographical area in 1966-69 (n = 8378) and in 1995-97 (n = 6673). The prevalence rates of overweight and obesity were calculated using criteria approved by the International Obesity Task Force. The extents of overweight and obesity were assessed by computing age- and sex-specific body mass index (BMI) percentiles. RESULTS: In 1995-97, 17.2% met the criteria for either overweight or obesity, as compared with 10.7% in 1966-69. The prevalence of overweight and obesity combined was higher in girls (13.0%) than in boys (8.5%) in 1966-69 (difference 4.5%, 95% confidence interval (CI) 3.1-5.9), while no sex difference was found in 1995-97 (girls 16.9%, boys 17.5%, difference -0.6, 95% CI -2.3-1.1). The increase in overweight was greater in boys (6.2PP, 95% CI 4.7-7.6) than in girls (1.9PP, 95% CI 0.4-3.5), while the sex difference in increased obesity was smaller (boys 2.8PP, 95% CI 2.1-3.4, girls 2.0PP, 95% CI 1.3-2.6). The increase in extent of overweight and obesity was highest in boys. The values of the 85th percentile and the 95th percentile in boys increased by 1.3 and 3.0 BMI units, respectively. The corresponding increases in girls were 0.7 and 1.7 BMI units. CONCLUSIONS: A marked sex difference in time trends for both the prevalence and extent of overweight and obesity, with a more pronounced increase in boys than in girls, was demonstrated. This might have implications for preventive strategies.

Changes in BMI-distribution from 1966-69 to 1995-97 in adolescents. The Young-HUNT study, Norway.

BACKGROUND: The aim of this study was to explore changes in the BMI-distribution over time among Norwegian adolescents. METHODS: Height and weight were measured in standardised ways and BMI computed in 6774 adolescents 14-18 years who participated in the Young-HUNT study, the youth part of the Health-study of Nord-Trondelag County, Norway in 1995-97. The results were compared to data from 8378 adolescents, in the same age group and living in the same geographical region, collected by the National Health Screening Service in 1966-69. RESULTS: From 1966-69 to 1995-97 there was an increased dispersion and a two-sided change in the BMI-distribution. Mean BMI did not increase in girls aged 14-17, but increased significantly in 18 year old girls and in boys of all ages. In both sexes and all ages there was a significant increase in the upper percentiles, but also a trend towards a decrease in the lowest percentiles. Height and weight increased significantly in both sexes and all ages. CONCLUSION: The increased dispersion of the BMI-distribution with a substantial increase in upper BMI-percentiles followed the same pattern seen in other European countries and the United States. The lack of increase in mean BMI among girls, and the decrease in the lowest percentiles has not been acknowledged in previous studies, and may call for attention.

[Eating disorders in primary care]. / Spiseforstyrrelser i allmennpraksis.

Early diagnosis and treatment are important for the prognosis in eating disorders and will also reduce the burden on the patient as well as n his or her family. On the other hand, community studies show that less than half of clinical cases of eating disorders are identified in primary care; hence, better skills among general practitioners in this field are very important. On the basis of the literature and clinical experience, this article discusses various problems related to identifying, evaluating and treating patients with eating disorders in primary care. The most important tool for the general practitioner is an understanding of the nature of the disorder, but tools for identification and treatment are also useful. Attending the patient and collaboration with hospitals and outpatient clinics could be a challenge. There are guidelines for the treatment of eating disorders in specialised health care, including indications for hospitalisation, but no guidelines for referral to outpatient treatment or for the coordination between the general practitioner and specialised units. The proposed British guidelines might serve as a basis for Norwegian guidelines.