Eating disorders in persons with type 1 diabetes: A focus group investigation of early eating disorder risk.

Through focus groups, we examined the development and maintenance of an eating disorder in 16 females with type 1 diabetes and an eating disorder. The quotes and qualitative data summaries provide rich insights into understanding why those with type 1 diabetes are at increased risk for eating disorders. Content analyses revealed five themes pertinent to the dual diagnosis (feeling different, difficulty with control/coping, body image, feelings, and quality of life) of which four themes were relevant to eating disorder development. Findings support early identification of those at risk and inform interventions to mitigate development of an eating disorder.

Do symptom-specific stages of change predict eating disorder treatment outcome?

PURPOSE: Interview methods to assess stages of change (SOC) in eating disorders (ED) indicate that SOC are positively correlated with symptom improvement over time. However, interviews require significant time and staff training and global measures of SOC do not capture varying levels of motivation across ED symptoms. This study used a self-report, ED symptom-specific SOC measure to determine prevalence of stages across symptoms and identify if SOC predict treatment outcome. METHODS: Participants [N = 182; age 13-58 years; 92% Caucasian; 96% female; average BMI 21.7 (SD = 5.9); 50% ED not otherwise specified (EDNOS), 30.8% bulimia nervosa (BN), 19.2% anorexia nervosa (AN)] seeking ED treatment at a diverse-milieu multi-disciplinary facility in the United States completed stages of change, behavioral (ED symptom use and frequency) and psychological (ED concerns, anxiety, depression) measures at intake assessment and at 3, 6 and 12 months thereafter. Descriptive summaries were generated using ANOVA or Kruskal-Wallis (continuous) and χ (2) (categorical) tests. Repeated measures linear regression models with autoregressive correlation structure predicted treatment outcome. RESULTS: At intake assessment, 53.3% of AN, 34.0% of BN and 18.1% of EDNOS patients were in Preparation/Action. Readiness to change specific symptoms was highest for binge-eating (57.8%) and vomiting (56.5%). Frequency of fasting and restricting behaviors, and scores on all eating disorder and psychological measures improved over time regardless of SOC at intake assessment. Symptom-specific SOC did not predict reductions in ED symptom frequency. Overall SOC predicted neither improvement in Eating Disorder Examination Questionnaire (EDE-Q) scores nor reduction in depression or trait anxiety; however, higher overall SOC predicted lower state anxiety across follow-up. CONCLUSIONS: Readiness to change ED behaviors varies considerably. Most patients reduced eating disorder behaviors and increased psychological functioning regardless of stages of change, indicating the benefits of treatment and effectiveness of treatment-as-usual for overall psychiatric improvement.

Poor outcome and death among youth, young adults, and midlife adults with eating disorders: an investigation of risk factors by age at assessment.

OBJECTIVE: Eating disorders (EDs) present across a broad age range, yet little is known about the characteristics and outcome of midlife patients compared to younger patients. Among patients seeking ED treatment who were stratified by age at initial assessment (IA), this study aimed to (1) discern sociodemographic and clinical differences, (2) determine outcome rates, and (3) identify predictors of poor outcome including death. METHOD: Participants [219 females (12 years or older, 94.1% Caucasian) who completed outcome assessment and 31 known decedents] were stratified by age at IA (<18 as youth, 18-39 as young adult, and ≥40 years as midlife adult). Analyses of variance and chi-square tests identified group differences; ordered logistic regression with stepwise selection identified factors predicting outcome. RESULTS: Midlife adults were more significantly compromised at follow-up compared to youths and young adults, including psychological and physical quality of life, ineffectiveness, interpersonal concerns, and general psychological maladjustment. Midlife adults had the highest rates of poor outcome or death; good outcome was achieved by only 5.9% of midlife adult compared to 14.0% of young adult and 27.5% of youth patients. Older age at IA, alcohol and/or drug misuse, endocrine concerns, and absence of family ED history predicted poor outcome or death. DISCUSSION: Midlife adults seeking ED treatment have more complex medical and psychological concerns and poorer outcomes than youths and young adults; further exploration is needed to improve treatment outcome. Specialized treatment focusing on quality of life, comorbid medical concerns, interpersonal connection, and emotion regulation is encouraged.

What does remission tell us about women with eating disorders? Investigating applications of various remission definitions and their associations with quality of life.

OBJECTIVE: To compare remission rates, determine level of agreement and identify quality of life (QoL) distinctions across a broad spectrum of remission definitions among patients with eating disorders (ED). METHODS: Women (N=195; 94 AN, 24 BN, and 77 EDNOS) from inpatient and partial hospital ED programs participated in a study of treatment outcomes. Remission rates were evaluated with percentages, kappa coefficients identified level of agreement and Mann-Whitney-Wilcoxon tests with Bonferroni corrections determined differences in quality of life between remitted and not remitted patients by remission definition. RESULTS: Depending on remission definition used, the percent of remitted patients varied from 13.2% to 40.5% for AN, 15.0% to 47.6% for BN and 24.2% to 53.1% for EDNOS. Several definitions demonstrated "very good" agreement across diagnoses. Remission was associated with higher quality of life in psychological, physical/cognitive, financial and work/school domains on a disease-specific measure, and in mental but not physical functioning on a generic measure. CONCLUSIONS: Remission rates vary widely depending on the definition used; several definitions show strong agreement. Remission is associated with quality of life, and often approximates scores for women who do not have an eating disorder. The ED field would benefit from adopting uniform criteria, which would allow for more accurate comparison of remission rates across therapeutic interventions, treatment modalities and facilities. We recommend using the Bardone-Cone criteria because it includes assessment of psychological functioning, was found to be applicable across diagnoses, demonstrated good agreement, and was able to distinguish quality of life differences between remitted and not remitted patients.

The meaning of (quality of) life in patients with eating disorders: a comparison of generic and disease-specific measures across diagnosis and outcome.

OBJECTIVE: Compare general and disease-specific health-related quality of life (HRQoL) among female patients with an eating disorder (ED). METHOD: Female patients (n = 221; 95.3% Caucasian; 94.0% never married) completed the Medical Outcome Short Form Health Survey (SF-36) and Eating Disorders Quality of Life (EDQoL) as part of a study of treatment outcomes. Multivariate regression models were used to compare HRQoL differences across initial ED diagnosis (85 AN-R, 19 AN-B/P, 27 BN, 90 EDNOS) and ED diagnostic classification at time of outcome assessment (140 no ED, 38 subthreshold ED, 43 full threshold ED). RESULTS: There were no significant differences across ED diagnosis at initial assessment on either of the SF-36 Component Summary scores. However, patients with AN-B/P scored poorer on the work/school EDQoL subscales than other ED diagnoses, and on the psychological EDQoL subscale compared to AN-R and EDNOS. At outcome assessment, comparisons across full threshold, subthreshold and no ED classification indicated that those with no ED reported better HRQoL than those with full threshold ED on the SF-36 Mental Components Summary and three of four EDQoL subscales. Furthermore, those with no ED reported better psychological HRQoL than those with subthreshold ED. DISCUSSION: Disease-specific HRQOL measures are important to use when comparing HRQoL in ED patients across treatment and outcome, and may have the sensitivity to detect meaningful differences by diagnosis more so than generic instruments. EDQoL scores from patients remitted from symptoms approach but do not reach scores for unaffected college females; thus, treatment should continue until quality of life is restored.

Eating disorder treatment among women forty and older: increases in prevalence over time and comparisons to young adult patients.

OBJECTIVES: There is limited information on the prevalence of middle-aged women seeking specialized treatment for an eating disorder and whether middle-aged patients are significantly different from young-adult patients. This two-part study sought to identify changes in the past two decades in the prevalence of middle-aged (MA; 40+ years) and young-adult (YA; 18-39 years) women seeking treatment for an eating disorder (ED) and to identify differences and similarities between both groups. METHODS: For study 1, all unique female inpatient admissions from 1989 to 2006 were reviewed (n=1,040). For study 2, women admitted to any treatment level from January-May 2007 were compared, based on age at intake admission, on psychological questionnaires and factors relevant to an eating disorder. RESULTS: In study 1, the overall percent of MA women who presented for inpatient ED treatment increased significantly from an average of 4.7% (1989-2001) to an average of 11.6% (2002-2006). In study 2, at intake, MA women were more likely than YA to be married, be older at ED onset and report a longer duration of illness. Self-esteem, depression, anxiety, ED psychopathology, and BMI were not significantly different between groups. CONCLUSIONS: Findings indicate an increase in the prevalence of inpatient admissions among middle-aged women, but few differences between middle-aged and younger-aged women at treatment admission. However, the longer duration of illness among MA warrants in-depth investigation of factors related to resistance to seeking treatment and to existing treatments failing patients, and consideration of tailoring treatment to course of illness.

Number of different purging behaviors used among women with eating disorders: psychological, behavioral, self-efficacy and quality of life outcomes.

The objective of this study was to examine differences between a number of different purging behaviors used and outcome measures among eating disorder patients. Among 211 females who received inpatient or partial hospitalization eating disorder treatment, analyses of covariance and cross-tabulations identified associations among a number of different purging behaviors (vomiting, laxative use, diuretic use) used and psychological, behavioral, self-efficacy and quality of life measures at follow-up. Most patients (80.1%) reported purging for weight control. Use of different purging behaviors was significantly associated at follow-up with lower self-esteem, greater depression, higher state and trait anxiety, higher BMI, poorer self-efficacy for normative eating and body image, compromised quality of life, greater dietary restraint, and eating, shape and weight concerns. Furthermore, a higher percentage of those who used purging behaviors met criteria for a subthreshold or threshold eating disorder at follow-up compared to their non-purging peers. Eating disorder patients who use different purging behaviors are more compromised at follow-up than patients who do not purge. Due to the severe medical complications associated with different purging behaviors, future research should address best practices for clinical intervention and prevention.