Weight Recovery in an Outpatient Medical Eating Disorders Clinic: A Retrospective Review.

BACKGROUND: The purpose of this study was to identify rates of weight recovery among adolescents and young adults with restrictive eating disorders (RED) as part of a quality improvement assessment in an Adolescent Medicine outpatient clinic in Rhode Island. METHODS: A retrospective chart review was completed on 94 randomly selected patients ages 10-21 years old. Demographics, descriptors, time to weight recovery, and participation in other care were recorded. RESULTS: The average age of participants was 15 years; most were female, cis-gender, White, had private insurance, and had one or more co-morbid psychiatric diagnosis. At intake, 81% were <95% treatment goal weight (TGW), with 27% at <80% TGW. Among participants who started at <95% of TGW, 51% achieved ≥95% of TGW; participants who engaged in a higher level of care were more successful. CONCLUSIONS: This study identifies outcomes and highlights the challenge of weight recovery among patients with RED, even when managed by an expert clinical team.

Multi-electrolyte disturbance and supplementation in severely malnourished hospitalized adolescents with restrictive eating disorders.

BACKGROUND: This study describes the prevalence of hypophosphatemia, hypokalemia, and/or hypomagnesemia and resulting electrolyte supplementation during refeeding in severely malnourished youths hospitalized for restrictive eating disorders. METHODS: Hospitalized patients between 11-26y (N = 81) at < 75% treatment goal weight (TGW) were assessed through retrospective chart review. Outcomes were compared between participants < 70% TGW and those 70-75% TGW. Nutritional rehabilitation started at 1750 kcals/day and advanced by 500 kcal every other day until target intake was achieved. Associations between %TGW on admission; hypophosphatemia, hypokalemia, and/or hypomagnesemia; and electrolyte supplementation were examined. RESULTS: Of the 24 (29.6%) participants with hypophosphatemia, hypokalemia, and/or hypomagnesemia, 7 (8.6%) received supplementation; the remainder corrected without supplementation. Participants < 70% TGW did not differ from those 70-75% TGW on rates of these conditions or need for supplementation. CONCLUSIONS: Hospital-based nutritional rehabilitation did not confer increased rates of hypophosphatemia, hypokalemia, and/or hypomagnesemia or need for electrolyte supplementation in patients < 70% TGW compared to those 70-75% TGW. While additional research is needed to establish clinical practice guidelines on electrolyte management in this population, our findings suggest that nutritional rehabilitation may be reasonably undertaken without prophylactic electrolyte supplementation, even in patients < 70% TGW.

Identifying safe management methods for nutritional rehabilitation among severely malnourished hospitalized adolescents and young adults with restrictive eating disorders can expedite discharge planning and improve treatment outcomes. In contrast to past studies on inpatient nutritional rehabilitation, this study describes the prevalence and management of multiple-electrolyte disturbance (hypophosphatemia, hypokalemia, and/or hypomagnesemia) during refeeding among hospitalized severely malnourished youths with restrictive eating disorders. We found that in this population, with experienced, close medical supervision, nutritional rehabilitation may be reasonably undertaken without prophylactic electrolyte supplementation, even in patients < 70% goal treatment weight. These findings can inform hospital-based refeeding protocols for adolescents and young adults with restrictive eating disorders, where the practice around prophylactic supplementation is variable.

Adapting family-based treatment for adolescent anorexia nervosa delivered in the home: A novel approach for improving access to care and generalizability of skill acquisition.

BACKGROUND: Anorexia nervosa (AN) is a serious mental illness associated with high rates of morbidity and mortality. Family-based treatment (FBT) is a well-established treatment for adolescent AN, yet it is underutilized in community settings and is unavailable to many families, particularly those from lower income and racial and ethnic minority backgrounds. Furthermore, some families do not respond optimally to FBT, possibly because of challenges translating skills acquired in office-based treatment settings to naturalistic settings. Home-based treatment could reduce barriers to access and enhance generalization of newly learned treatment skills. Home-based models demonstrate initial feasibility, acceptability, and efficacy for adolescent AN, however, FBT principles have yet to be applied as a stand-alone intervention in a home-based level of care. This paper describes the rationale for and process of adapting FBT principles/interventions to improve fit within a home-based model delivered in the context of community mental health, and discusses potential strengths and opportunities associated with this approach. RESULTS: Adaptations were made through consultation with collaborating community agencies and were guided by the complex interventions framework. The primary modifications included: (1) altered dose; (2) multiple family meals; (3) additional support for meal preparation and supervision; (4) clinician attendance at medical appointments; (5) cultural adaptation; and (6) introduction of distress tolerance and emotion regulation skills. CONCLUSIONS: Implementing FBT in the home may present one promising and novel approach to enhance engagement and treatment outcomes for adolescents with restrictive eating disorders, particularly those who are underserved, but evaluation of efficacy/effectiveness is needed.

Comparison of eating disorder characteristics and depression comorbidity in adolescent males and females: An observational study.

Depression comorbid with eating disorders is common and can worsen the severity of both disorders. Little is published regarding depression and eating disorders in male adolescents. This retrospective observational study compared eating disorder presentation and depression comorbidity between medically-hospitalized male and female adolescents. Standardized chart abstraction was performed for 148 subjects (n=127 females, =21 males). Male adolescents had significantly greater pre-hospitalization weight loss and longer eating disorder duration, and were 1.6 times more likely to have comorbid depression compared to female patients. These findings suggest increased detection and treatment of both disorders in adolescent males is warranted.

Disseminating Education and Treatment for Children and Adolescents with Eating Disorders Across Levels of Care.

BACKGROUND: Eating disorders (EDs) are psychiatric illnesses with high rates of morbidity and mortality. Healthcare providers often receive inadequate training in evidence-based ED assessment and treatment. DESIGN: Project CORE (Creating Opportunities for Rhode Island Eating Disorders Professionals) was developed to disseminate ED training/education and treatment approaches to the healthcare workforce. An interdisciplinary research team partners with pediatric healthcare professionals/trainees and supports them to better understand how to diagnose, manage, and collaborate across disciplines in the care of patients with EDs. METHODS: Phase I involves a needs assessment of pediatric healthcare professionals' knowledge, attitudes and needs in treating EDs. Phase II involves the development of training/education approaches, and therapeutic interventions for patients with EDs. In Phase III approaches/interventions are further developed and disseminated across RI. PRINCIPAL CONCLUSIONS: Project CORE's goals will address barriers to effective ED treatment in RI and broaden the workforce of interdisciplinary providers trained to recognize and treat patients with EDs across multiple healthcare settings.

Multidisciplinary care considerations for gender nonconforming adolescents with eating disorders: A case series.

Gender nonconforming youth are at risk for body dissatisfaction and disordered eating. Currently, only a small body of literature addresses this high-risk group. The five cases in this series highlight important themes for this patient population from an interdisciplinary perspective. Identified themes include increased risk for self-harm/suicide, complex psychiatric, and medical implications of delay to treatment for either gender dysphoria or disordered eating, and the importance of collaborative management to maximize care and facilitate healthy development to adulthood. The purpose of this case series is to expand the interdisciplinary discussion regarding the breadth of presentation and management considerations for gender nonconforming adolescents with disordered eating. An interdisciplinary approach to care might enhance access to comprehensive, collaborative treatment for disordered eating, and gender dysphoria in this unique population.

Daily Laboratory Monitoring is of Poor Health Care Value in Adolescents Acutely Hospitalized for Eating Disorders.

PURPOSE: This study investigates how the clinical practice guideline-recommended laboratory monitoring for refeeding syndrome impacts management and outcomes of adolescents with eating disorders hospitalized for acute medical stabilization and examines the value of laboratory monitoring (defined as the patient health outcomes achieved per dollar spent). METHODS: A retrospective chart review of medical admissions in a children's hospital between October 2010 and February 2014 was performed. Encounters were identified using International Classification of Diseases, Ninth Revision codes of eating disorders as primary or secondary diagnoses. Exclusion criteria included systemic diseases associated with significant electrolyte abnormalities. Chart abstraction was performed using a predetermined form. Costs were estimated by converting hospital-fixed Medicaid charges using a statewide cost-to-charge ratio. RESULTS: Of the 196 patient encounters, there were no cases of refeeding syndrome. A total of 3,960 key recommended laboratories were obtained; 1.9% were below normal range and .05% were critical values. Of these, .28% resulted in supplementation; none were associated with a change in inpatient management. Total laboratory costs were $269,250.85; the calculated health care value of this monitoring is 1.04 × 10(-8) differential outcomes per dollar spent. CONCLUSIONS: This study provides evidence to suggest that daily laboratory monitoring for refeeding syndrome is a poor health care value in the management of adolescents hospitalized for acute medical stabilization with eating disorders. This initial analysis suggests that starting at a relatively low caloric level and advancing nutrition slowly may negate the need for daily laboratory assessment, which may have important implications for current guidelines.

Skeletal complications of eating disorders.

Anorexia nervosa (AN) is a psychiatric illness with profound medical consequences. Among the many adverse physical sequelae of AN, bone health is impacted by starvation and can be permanently impaired over the course of the illness. In this review of skeletal complications associated with eating disorders, we discuss the epidemiology, neuroendocrine changes, adolescent vs. adult skeletal considerations, orthopedic concerns, assessment of bone health, and treatment options for individuals with AN. The focus of the review is the skeletal sequelae associated with anorexia nervosa, but we also briefly consider other eating disorders that may afflict adolescents and young adults. The review presents updates to the field of bone health in AN, and also suggests knowledge gaps and areas for future investigation.

Spinal Bone Texture Assessed by Trabecular Bone Score in Adolescent Girls With Anorexia Nervosa.

CONTEXT: Trabecular bone score (TBS) is a bone assessment tool that offers information beyond that afforded by dual-energy x-ray absorptiometry (DXA) bone mineral density (BMD) measurements. Adolescents with anorexia nervosa (AN) are known to exhibit compromised bone density and skeletal strength. OBJECTIVES: This study aimed to determine TBS among adolescents with AN and evaluate the correlation with anthropometric, clinical and densitometric variables. DESIGN: Areal BMD spinal measures were analyzed for TBS. Findings were compared with clinical (height, weight, body mass index [BMI], age, pubertal development, 25-hydroxyvitamin D) and self-reported data (illness duration, amenorrhea, exercise, fracture, family history of osteoporosis, and antidepressant use), and BMD measures by DXA and peripheral quantitative computed tomography (pQCT). SETTING AND PARTICIPANTS: This was an urban adolescent program consisting of 57 females with AN, age 11-18 y. INTERVENTIONS: Interventions included DXA (absolute BMD and Z-score), pQCT (volumetric BMD [vBMD] and stress-strain index [SSI]), laboratory evaluation, and questionnaire administration. MAIN OUTCOME MEASURES: Main outcome measures included TBS, areal and vBMD, SSI, fracture history, disease duration. RESULTS: The TBS of six participants (11%) showed degraded and 19 (33%) partially degraded microarchitecture. Spinal TBS was correlated (P < .05) with age, height, weight, BMI, pubertal stage, BMD, and body composition by DXA, and BMD and SSI by pQCT. TBS was not correlated with disease duration, fracture, vitamin D status, race, or ethnicity, and self-reported health data. CONCLUSIONS: TBS showed evidence of degraded microarchitecture in over 40% of this study sample, and strongly correlated with anthropometric data and measures of BMD and skeletal strength. TBS is a novel tool that captures another dimension of bone health in adolescents with AN.

Using the hospital as a venue for reproductive health interventions: a survey of hospitalized adolescents.

BACKGROUND AND OBJECTIVES: Less than one-half of sexually active adolescents have received counseling regarding contraception and sexually transmitted disease (STD) from their health care provider. We hypothesized that hospitalized adolescents would be interested in receiving reproductive health education and/or STD testing. In addition, we assessed the opinion of female adolescents on initiation of contraception during hospitalization. METHODS: A convenience sample of 13- to 18-year-old male and female adolescent patients hospitalized at a tertiary pediatric hospital were approached for inclusion. Consenting patients completed a self-administered anonymous questionnaire. RESULTS: Questionnaires from 49 female adolescents and from 51 male adolescents were collected. Based on their answers, 37% of female adolescents and 44% of male adolescents want to learn more about contraception and/or abstinence in the hospital independent of sexual activity. Thirty percent of respondents reported a desire for STD testing in the hospital. Fifty-seven percent of female subjects answered that adolescents should be offered contraception while in the hospital. CONCLUSIONS: Among hospitalized adolescents in this study, there was an interest in reproductive health education and contraception even among those with a primary care provider and without sexual experience. Thus, hospital-based pediatricians can play a pivotal role in expanding critical sexual health services by discussing and offering sexual health care to hospitalized adolescents. We recommend that hospitals make a brochure available to all admitted adolescents, with opportunity for follow-up discussions with their hospitalist.

Screening juvenile justice-involved females for sexually transmitted infection: a pilot intervention for urban females in community supervision.

Little is known about Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) rates in community-supervised juvenile justice-involved (CSJJI) females, or how to best provide screening for sexually transmitted infections in this population. A pilot intervention allowed case managers to offer optional CT/GC screening to CSJJI females during mandated visits. Anonymous satisfaction surveys and discussion groups assessed intervention acceptability. Case managers met with 514 CSJJI females; 102 (20%) agreed to screening and 117 tests were completed. Among those screened, 21 (18%) had CT and 3 (3%) had GC. Intervention feedback from case managers and clients was positive, but there were barriers to recruitment. Lessons learned from this case manager-facilitated intervention may increase the acceptability and effectiveness of future screening methods in this setting.

Receipt of sexual health information from parents, teachers, and healthcare providers by sexually experienced U.S. adolescents.

OBJECTIVE: To describe the extent to which sexually experienced adolescents in the United States receive sexual health information (SHI) from multiple of three sources: parents, teachers, and healthcare providers. DESIGN: Descriptive analysis. SETTING: 2006-2010 National Survey of Family Growth. PARTICIPANTS: Heterosexually experienced, unmarried/non-cohabiting females (n = 875) and males (n = 1,026) ages 15-19 years. MAIN OUTCOME MEASURES: Self-reported receipt of birth control, sexually transmitted infection/human immunodeficiency virus (STI/HIV), and condom information from parents, teachers, and healthcare providers. RESULTS: Parent and teacher SHI sources were reported by 55% and 43% of sexually experienced female and male adolescents, respectively, for birth control information; and by 59% and 66%, respectively, for STI/HIV information. For sexually experienced adolescents reporting both parent and teacher sources, about one-third also reported healthcare provider as a source of birth control information, and one-quarter of females and one-third of males reported a healthcare provider as a source of STI/HIV information, respectively. For sexually experienced adolescents reporting no SHI from either parent or teacher sources, only one in ten reported healthcare providers as a source of birth control information, with a similar proportion reporting healthcare providers as a source of STI/HIV information. SHI receipt was found to vary by gender with more females than males reporting birth control information receipt from parents and teachers, and about one in six males reporting no birth control or condom information receipt from either source. CONCLUSIONS: Study findings highlight gaps in sexual health information receipt from parents, teachers, and healthcare providers among sexually experienced adolescents, as well as gender differences across information sources.