Treatment adherence and nasogastric tube use in hospitalized youth with anorexia nervosa and premorbid overweight/obesity.

Youth with restrictive-eating disorders (EDs) often experience significant distress and difficulty with treatment adherence during nutritional rehabilitation. This study assessed whether youth with restrictive EDs and premorbid overweight/obesity admitted for inpatient nutritional rehabilitation experience greater psychological distress and difficulty with treatment adherence than youth with premorbid BMI <85th percentile. A retrospective chart review examined 150 youth hospitalized for medical complications of restrictive EDs. Rates of nasogastric tube (NGT; used when youth could not complete meals), agitation medication use, and disposition recommendation were compared across premorbid BMI groups. Patients with premorbid overweight/obesity were three times more likely to require NGT feeds. These findings suggest greater challenges with nutritional rehabilitation, specifically consuming nutrition orally, in patients with premorbid overweight/obesity, highlighting the need for early and individualized psychological support for this vulnerable patient population.

Who gets treated for an eating disorder? Implications for inference based on clinical populations.

BACKGROUND: The minority of people with an eating disorder receive treatment. Little is known about predictors of receiving treatment. METHODS: Using data from the Growing Up Today Study we identified correlates of receiving treatment for an eating disorder among the 1237 U.S. women who answered questions on treatment history in 2013 and reported meeting criteria for subthreshold eating disorder in ≥ 1 year between 1996 and 2013. Logistic regression models using generalized estimating equations were used to estimate the relative odds of receiving treatment. RESULTS: Approximately 11% of the women reported receiving treatment for an eating disorder. Independent of type of eating disorder, those who had received a diagnosis of depression or anxiety were more likely (odds ratio (OR) = 3.05 95% confidence interval (CI) 1.87-4.97) to receive treatment for an eating disorder. Women with obesity were approximately 85% less likely to receive treatment (OR = 0.13, 95% CI 0.04-0.46) regardless of their type of eating disorder or history of depression of anxiety diagnosis. CONCLUSIONS: Most women meeting criteria for an eating disorder do not receive treatment. Women with BED or obesity are the least likely to receive treatment.

Sexual Debut in Early Adolescence and Individual, School, and Neighborhood Social Capital.

PURPOSE: Sexual debut in early adolescence is associated with poor health outcomes in adulthood. We examined the associations of social capital within families, schools, and neighborhoods with early sexual debut. METHODS: Using data from the Healthy Passages cohort, a longitudinal multilevel study of adolescents, we performed a series of cross-classified multilevel logistic regression models to examine (1) the relative contribution of schools and neighborhoods to the variance and (2) the association of markers of social cohesion/social capital in families, schools, and neighborhoods with sexual debut by 10th grade. RESULTS: There were 4,001 youth participants nested in 115 schools and 751 neighborhoods, with a high degree of cross-classification (1,340 unique combinations of school and neighborhoods). In models adjusting for individual demographics, neighborhoods contributed more to the variance (log odds U [95% confidence interval {CI}] [intra class correlation {ICC}%]) in sexual debut than schools: Uneighborhoods = 0.11 (0.02, 0.23) [3.2%] versus Uschools = 0.07 (0.01, 0.16) [2%]. Restriction of dating and family cohesion, markers of family social capital, were associated with reduced odds of sexual debut by 10th grade (odds ratio = 0.45 95% CI: 0.41-0.49 and 0.93, 95% CI: 0.86, 1.00). Neighborhood cohesion and education level were associated with early debut. Although reduced, there remained significant, unexplained variance in both the school and neighborhood level in the fully adjusted model (Uschool = 0.08 [0.01, 0.17] [2.3%], Uneighborhood = 0.08 [0.02, 0.17] [2.2%]). DISCUSSION: Markers of social capital at the family and neighborhood levels were associated with sexual debut by 10th grade. Developers of public health programs aiming to delay sexual debut should consider family-focused and neighborhood-focused interventions.

Assessing growth in children and adolescents with Avoidant/Restrictive Food Intake Disorder.

BACKGROUND: Although growth delays and disruption are a well described medical complication of restrictive eating disorders in children and young adolescents, this complication has received less attention in patients with Avoidant/Restrictive Food Intake Disorder (ARFID). Patients with ARFID have challenges with adequacy of food volume and variety that are not related to body image but are instead related to lack of interest in eating, sensory concerns, and/or fears of aversive consequences. Because onset of ARFID is commonly before puberty, concerns regarding growth adequacy may present an additional treatment challenge and a unique opportunity for support. REVIEW: Child and adolescent patients with other restrictive eating disorders are at risk of irreversible deleterious impact on growth and development, particularly when onset is before or around puberty. Although faltering growth is a defining feature of ARFID, less attention has been paid to methods for examining growth concerns in young patients with ARFID and training providers to assess growth adequacy when prepubertal and peripubertal patients present with this diagnosis. Providers working with patients under 18 years of age with eating disorders will benefit from the tools discussed in this narrative review to adequately assess growth and development against genetic potential, recognize alterations in growth that are a result of nutritional deficiencies, and support and maximize catch-up growth and development when it has been impaired. CONCLUSION: Established pediatric growth monitoring tools and techniques to assess adequacy of growth can be applied to child and adolescent patients presenting with ARFID. These tools can improve long term outcomes in linear height for these patients and allow for monitoring during and after treatment until growth and development is complete. Medical providers caring for patients presenting with ARFID will need to establish best practices for assessing and monitoring growth.

Variation in care for inpatients with avoidant restrictive food intake disorder leads to development of a novel inpatient clinical pathway to standardize care.

INTRODUCTION: There is limited evidence to guide management of patients with avoidant restrictive food intake disorder (ARFID) admitted for medical stabilization. We describe variations in inpatient care which led to the development of a multidisciplinary inpatient clinical pathway (ICP) to provide standardized management and examine differences after the ICP was implemented. METHODS: A retrospective review of patients with ARFID admitted to Adolescent Medicine, Gastroenterology, and General Pediatrics at a single academic center was conducted. We compare hospital utilization and use of consulting services during the pre-ICP (2015-2017) and post-ICP (2018-2020) periods. RESULTS: 110 patients were admitted with ARFID (n = 57 pre- vs. n = 53 post-ICP). Most presented with moderate/severe malnutrition (63% pre vs. 81% post; p = 0.11) and co-morbid anxiety and/or depression (74% pre vs. 92% post; p = 0.01). There was some variation in use of enteral tube feeding by service in both periods (p = 0.76 and p = 0.38, respectively), although overall use was consistent between periods (46% pre vs. 58% post; p = 0.18). Pre-ICP, use of the restrictive eating disorder protocol differed across services (p < 0.001), with only AM using it. Overall, utilization of the restrictive eating disorder protocol decreased from 16% pre-ICP to 2% post-ICP (p = 0.02). There was variation by service in psychiatry/psychology (range 82-100% by service; p = 0.09) and social work consultations (range 17-71% by service; p = 0.001) during the pre-ICP period, though variation was reduced in the post-ICP period (p = 0.99 and p = 0.05, respectively). Implementation of the ICP led to improvements in these consultative services, with all patients in the post-ICP period receiving psychiatry/psychology consultation (p = 0.05) and an increase in social work consults from 44 to 64% (p = 0.03). Nutrition consults were consistently utilized in both periods (98% pre vs. 100% post; p = 0.33). CONCLUSION: The ICP was developed to standardize inpatient medical stabilization for patients with ARFID. In this single center study, implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: there were improvements in the use of consulting services and a reduction in the use of the restrictive eating disorder protocol. The ICP demonstrates the potential to further standardize and improve care over time.

There is limited evidence to guide management of children and adolescents with Avoidant Restrictive Food Intake Disorder (ARFID) admitted for medical stabilization. The study describes the variation in inpatient care for ARFID, which led to the development of a multidisciplinary standardized inpatient clinical pathway (ICP). The ICP centers the experience of the patient and family with an emphasis on biopsychosocial support. Implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: There were improvements in the use of psychiatry/psychology and social work consulting services and a reduction in the use of the restrictive eating disorder protocol. Future research is needed to better understand the impact of the inpatient clinical pathway to improve care over time.

Associations between presenting weight and premorbid weight and the medical sequelae in hospitalized youth with anorexia nervosa or atypical anorexia nervosa.

PURPOSE: To identify unique treatment considerations for youth with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) and premorbid overweight or obesity, we examined unique relationships between premorbid and presenting weight status and medical sequelae in youth with AN/AAN requiring medical hospitalization. DESIGN AND METHODS: We performed a retrospective study of 150 youth aged mean [SD] of 14.1[2.3] years, hospitalized for AN/AAN. Independent t-tests and Fischer's exact tests assessed differences in demographic and clinical characteristics by premorbid weight status. Logistic regressions assessed associations between premorbid and presenting weight status and vital sign or laboratory abnormalities. RESULTS: Compared to youth with premorbid 'normal' weights, youth with premorbid overweight/obesity demonstrated greater percent (p = .042) and faster rate (p < .001) of weight loss and had 10.9 times the odds of having anemia (p = .025). Youth with AN (<5th percentile for body mass index [BMI]) were more likely to experience hypoglycemia (p < .018) than youth with AAN (≥5th percentile BMI). Greater percent of weight loss significantly predicted bradycardia (p < .001) and hypoglycemia (p = .002), independent of premorbid or presenting weight status. CONCLUSION: Acute medical management of AN/AAN should be commensurate for hospitalized patients, regardless of premorbid weight status. However, those with more significant weight loss and those presenting as underweight may warrant particular monitoring for complications such as bradycardia and hypoglycemia. PRACTICE IMPLICATIONS: In youth with AN/AAN, high percent of weight loss warrants closer monitoring for medical complications during hospitalization. Those with premorbid overweight/obesity may need additional monitoring for anemia, as there may be additional contributors to anemia aside from malnutrition.

Pediatric hospital utilization for patients with avoidant restrictive food intake disorder.

BACKGROUND: Avoidant restrictive food intake disorder (ARFID) is a relatively new feeding and eating disorder added to the DSM-5 in 2013 and ICD-10 in 2018. Few studies have examined hospital utilization for patients with ARFID specifically, and none to date have used large administrative cohorts. We examined inpatient admission volume over time and hospital utilization and 30-day readmissions for patients with ARFID at pediatric hospitals in the United States. METHODS: Using data from the Pediatric Health Information System (PHIS), we identified inpatient admissions for patients with ARFID (by principal International Classification of Diseases, 10th Revision, ICD-10 diagnosis code) discharged October 2017-June 2022. We examined the change over time in ARFID volume and associations between patient-level factors (e.g., sociodemographic characteristics, co-morbid conditions including anxiety and depressive disorders and malnutrition), hospital ARFID volume, and hospital utilization including length of stay (LOS), costs, use of enteral tube feeding or GI imaging during admission, and 30-day readmissions. Adjusted regression models were used to examine associations between sociodemographic and clinical factors on LOS, costs, and 30-day readmissions. RESULTS: Inpatient ARFID volume across n = 44 pediatric hospitals has increased over time (ß = 0.36 per month; 95% CI 0.26-0.46; p < 0.001). Among N = 1288 inpatient admissions for patients with ARFID, median LOS was 7 days (IQR = 8) with median costs of $16,583 (IQR = $18,115). LOS and costs were highest in hospitals with higher volumes of ARFID patients. Younger age, co-morbid conditions, enteral feeding, and GI imaging were also associated with LOS. 8.5% of patients were readmitted within 30 days. In adjusted models, there were differences in the likelihood of readmission by age, insurance, malnutrition diagnosis at index visit, and GI imaging procedures during index visit. CONCLUSIONS: Our results indicate that the volume of inpatient admissions for patients with ARFID has increased at pediatric hospitals in the U.S. since ARFID was added to ICD-10. Inpatient stays for ARFID are long and costly and associated with readmissions. It is important to identify effective and efficient treatment strategies for ARFID in the future.

Recent studies indicate that Avoidant Restrictive Food Intake Disorder (ARFID) is a complex feeding and eating disorder often diagnosed in younger children. To date, there are no large studies using administrative data to examine hospital utilization or costs among patients with ARFID. In a geographically diverse cohort of pediatric hospitals in the United States, we found inpatient admissions for ARFID have increased over time and that ARFID is associated with long, costly stays and readmissions which has important implications for identifying efficient treatment strategies. Future studies are needed to explore effective and efficient treatment strategies and prevent readmissions in this patient population.

Weight Stigma Associated With Mental Health Concerns Among College Students.

INTRODUCTION: Weight stigma is widespread and exists across numerous domains including health care, educational institutions, workplaces, mass media, and interpersonal relationships. Weight stigma experienced during the college years may be particularly consequential because the college years are a period of increased vulnerability for the development of mental health concerns. The purpose of the present study was to examine how experiences of weight stigma relate to mental health concerns, including symptoms of eating disorders, anxiety, and depression, among college students. METHODS: Prevalence of interpersonal and anticipated weight stigma was examined among 2,707 students participating in the 2018-2019 and 2019-2020 Healthy Minds Study and tested for differences in prevalence across student characteristics. Logistic regression was used to explore relationships between measures of weight stigma and student mental health. Analyses were conducted in 2021-2023. RESULTS: Interpersonal and anticipated weight stigma were reported by 12.3% and 15.3% of students, respectively. Experiences of interpersonal and anticipated weight stigma were generally lowest among cisgender male students, heterosexual students, those with the fewest financial concerns, and those who did not perceive themselves to be "overweight." Both interpersonal and anticipated weight stigma were associated with elevated odds of high weight concerns, past-month binge eating, past-month purging, high eating disorder risk, moderate/severe anxiety symptoms, and moderate/severe depressive symptoms. CONCLUSIONS: Findings implicate interpersonal and anticipated weight stigma as potential risk factors for a range of mental health concerns. Weight stigma is an under-recognized and under-funded public health problem.

International consensus on patient-centred outcomes in eating disorders.

The effectiveness of mental health care can be improved through coordinated and wide-scale outcome measurement. The International Consortium for Health Outcomes Measurement has produced collaborative sets of outcome measures for various mental health conditions, but no universal guideline exists for eating disorders. This Position Paper presents a set of outcomes and measures for eating disorders as determined by 24 international experts from professional and lived experience backgrounds. An adapted Delphi technique was used, and results were assessed through an open review survey. Final recommendations suggest outcomes should be tracked across four domains: eating disorder behaviours and cognitions, physical health, co-occurring mental health conditions, and quality of life and social functioning. Outcomes are collected using three to five patient-reported measures. For children aged between 6 years and 12 years, the measures include the Children's Eating Attitude Test (or, for those with avoidant restrictive food intake disorder, the Eating Disorder in Youth Questionnaire), the KIDSCREEN-10, and the Revised Children's Anxiety and Depression Screener-25. For adolescents aged between 13 years and 17 years, the measures include the Eating Disorder Examination Questionnaire (EDE-Q; or, for avoidant restrictive food intake disorder, the Nine-Item Avoidant Restrictive Food Intake Disorder Screener [NIAS]), the two-item Patient Health Questionnaire (PHQ-2), the nine-item Patient Health Questionnaire (PHQ-9), the two-item Generalised Anxiety Disorder (GAD-2), the seven-item Generalised Anxiety Disorder (GAD-7), and the KIDSCREEN-10. For adults older than 18 years, measures include the EDE-Q (or, for avoidant restrictive food intake disorder, the NIAS), the PHQ-2, the PHQ-9, the GAD-2, the GAD-7, the Clinical Impairment Assessment, and the 12-item WHO Disability Assessment Schedule 2.0. These questionnaires should be supplemented by information on patient characteristics and circumstances (ie, demographic, historical, and clinical factors). International adoption of these guidelines will allow comparison of research and clinical interventions to determine which settings and interventions work best, and for whom.

Eating disorders occur at high rates in adolescents with epilepsy and are associated with psychiatric comorbidities and suicidality.

OBJECTIVES: To assess the occurrence rate, characteristics, and impact of eating disorders (EDs) in adolescents with epilepsy. METHODS: In this observational study, adolescents with epilepsy seen in a single center between 2013 and 2022 who had comorbid EDs were compared to two control groups of adolescents with only epilepsy and only EDs. Patients with intellectual disability or autism spectrum disorder were excluded. Data retrieved included demographic and anthropometric details and clinical variables relating to seizure types, EDs, and psychiatric disorders and behaviors. RESULTS: A total of 376 subjects were included in the study: 84 adolescents with both epilepsy and eating disorders, 135 with only epilepsy, and 157 with only EDs. The rate of EDs in adolescents with epilepsy was 7.0% (95% confidence interval [CI] 5.6%-8.5%) overall, 11.3% (95% CI 8.8%-14.3%) in females, and 3.1% (95% CI 1.9%-4.8%) in males. The median (interquartile range [IQR]) time difference between the onset of epilepsy to an ED was 1.6 (.5-3.6) years. Among adolescents with epilepsy, those with an ED were more likely to be female (p = .001) and have a lower body mass index z-score (zBMI) percentile (p < .001). Epilepsy type, seizure frequency, or seizure duration were not specific for having or not having EDs. Among adolescents with EDs, those with epilepsy had a younger onset of their EDs (p < .001), included relatively more males (p = .007), and consisted of more cases of anorexia-nervosa-restrictive type (p < .001), and fewer cases of bulimia nervosa (p = .04) and binge eating disorder (p = .003). Adolescents with epilepsy and a comorbid ED were more likely to have psychiatric comorbidities such as depression, anxiety, and suicidality than adolescents with only epilepsy or EDs. SIGNIFICANCE: EDs should be suspected and screened for in intellectually intact female and male adolescents with epilepsy, irrespective of their epilepsy type. If disturbed eating behaviors or EDs are identified, further evaluation should be directed at detecting other psychopathologies, including suicidality.

Anorexia nervosa and the COVID-19 pandemic among young people: a scoping review.

BACKGROUND: The extent to which the recent global COVID-19 Pandemic has impacted young people with restrictive eating disorders [i.e., anorexia nervosa (AN) and atypical anorexia nervosa (AAN)] is unclear. We conducted a scoping review of the literature to identify how the pandemic has impacted this population and to identify gaps in the current literature to inform future research efforts. MAIN BODY: We searched PubMed, EMBASE, the Web of Science, The Cochrane Library, PsycInfo, ProQuest Dissertations and Theses Global, LitCovid, Google Scholar, and relevant agency websites from 2019 to 2022. We included studies that focused on young people with AN/AAN globally. Of the 916 unduplicated articles screened, 17 articles met the inclusion criteria, reporting on 17 unique studies including 4,379 individuals. Three key findings were identified. First, an increase in hospitalizations related to eating disorders was found during COVID-19 among young people with AN and AAN. Multiple studies cited increased medical instability, even though the overall duration of disease was shorter compared to pre-pandemic levels. Second, changes in eating disorder-related symptomology during the pandemic were reported in this population, as well as poorer overall behavioral and mental health. Suggested reasons behind changes included boredom or minimal distraction from pathological thoughts, increased social isolation, increased social media and online use (e.g., reading blogs or watching YouTube), gym and school closures, changes in routines due to lockdowns and quarantines, and worries over gaining the "Quarantine 15". Third, there was an increase in the use of telemedicine as a treatment modality for the treatment of AN. Challenges were reported by both clinicians and patients regardless of past experience using telemedicine. When compared to no treatment, telemedicine was recognized as the best option during COVID-19 lockdowns; however some individuals expressed the preference for in-person treatment and planned to return to it once it became available. CONCLUSION: The pandemic significantly impacted young people with restrictive eating disorders as seen by increased hospitalizations and requests for outpatient care. A primary driver of the changes in eating disorder symptomatology may be lockdowns and quarantines. Further research investigating how the series of lockdowns and re-openings impacted individuals with AN/AAN is warranted.

Data collected from a scoping review of published peer-reviewed literature during the first two years of the COVID-19 pandemic have highlighted the impact that the global pandemic has had on young people with anorexia nervosa and atypical anorexia nervosa. We found an increase in medical hospitalizations related to eating disorders, changes in eating disorder-related symptomology as well as overall poorer behavioral and mental health among this population as a result of COVID-19. We also found an increase in the use of telemedicine as treatment modality, particularly during lockdowns, which sheds light on more diverse modalities for treatment. Further research investigating how the series of lockdowns and re-openings impacted individuals with AN/AAN is warranted.

Adolescent individual, school, and neighborhood influences on young adult diabetes risk.

Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), this study examines the association between adolescent school and neighborhood contexts and the likelihood of diabetes in young adulthood. We apply cross-classified multi-level modeling (CCMM) techniques to examine the simultaneous influence of non-nested school and neighborhood contexts as well as individual, school, and neighborhood-level factors (N = 14,041 participants from 128 schools, 1933 neighborhoods). Our findings suggest that individual-level factors are most associated with young adult diabetes, with small contributions from school and neighborhood factors and a small proportion of the variation explained by school and neighborhood contexts.

Triggers for eating disorder onset in youth with anorexia nervosa across the weight spectrum.

To aid in more targeted eating disorder (ED) prevention efforts, we sought to identify sociodemographic and weight-related risk factors for identified triggers for the onset of anorexia nervosa (AN) in youth. We conducted a retrospective chart review of youth admitted for medical treatment of AN between January 2015 and February 2020. From multidisciplinary admission notes, we extracted patient-reported reasons for diet/exercise changes. We used qualitative thematic analysis to identify ED triggers, then categorized each trigger as binary variables (presence/absence) for logistic regression analysis of risks associated with each trigger. Of 150 patients, mean (SD) age was 14.1(2.3) years. A total of 129 (86%) were female and 120 (80%) were Non-Hispanic White. Triggers included environmental stressors (reported by 30%), external pressures of the thin/fit ideal (29%), internalized thin/fit ideal (29%), weight-related teasing (19%), and receiving health education (14%). Younger age was associated with higher odds of weight-related teasing (p = .04) and health education (p = .03). Males had greater odds of internalized thin/fit ideal than females (p = .04). Those with premorbid body mass indices ≥85th percentile for age and sex had greater odds of reporting positive reinforcement (p = .03) and weight-related teasing (p = .04) than those with weights <85th percentile. We use these findings to detail potential targets for advancing ED prevention efforts.

Assessment of Patients With ARFID Presenting to Multi-Disciplinary Tertiary Care Program.

There are no standard assessment approaches for Avoidant Restrictive Food Intake Disorder (ARFID). We describe our approach to multidisciplinary assessment after assessing more than 550 patients with ARFID. We collected online survey (ARFID-specific instruments, measures of anxiety, depression) measures. Electronic medical record data (mental health and gastrointestinal diagnoses, micronutrient and bone density assessments, and growth parameters) were extracted for the 239 patients with ARFID seen between 2018 and 2021 with both parent and patient responses to online surveys. We identified 5 subtypes/combinations of subtypes: low appetite; sensory sensitivity; fear + sensory sensitivity; fear + low appetite; fear + sensory sensitivity + low appetite. Those with appetite-only subtype had higher mean age (14.0 years, P < 0.01) and the lowest average body mass index z score (-1.74, P < 0.01) compared to other subtypes. Our experience adds to understanding of clinical presentations in patients with ARFID and may aid in assessment formulation.

Emergency Department Visits and Hospitalizations for Eating Disorders During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Recent studies have reported increasing eating disorder incidence and severity following the coronavirus disease 2019 (COVID-19) pandemic. In a diverse cohort of pediatric hospitals, we examined trends in the volume of emergency visits and inpatient admissions for eating disorders before and during the pandemic. METHODS: We examined monthly trends in volume of patients with eating disorders (identified by principal International Classification of Diseases, 10th Revision, diagnosis codes) across 38 hospitals in the Pediatric Health Information System pre- (January 2018-March 2020) and post-COVID-19 onset (April 2020-June 2022). Using interrupted time series analysis, we examined the pre- and post monthly trends in eating disorder emergency and inpatient volume. RESULTS: Before the pandemic, eating disorder emergency visit volume was increasing by 1.50 visits per month (P = .006), whereas in the first year postonset, visits increased by 12.9 per month (P < .001), followed by a 6.3 per month decrease in the second year postonset (P < .001). Pre-COVID-19, eating disorder inpatient volume was increasing by 1.70 admissions per month (P = .01). In the first year postonset, inpatient volume increased by 11.9 per month (P < .001), followed by a 7.6 per month decrease in the second year postonset (P < .001). CONCLUSIONS: The volume of patients seeking emergency and inpatient eating disorder care at pediatric hospitals has increased dramatically since the pandemic onset and has not returned to prepandemic levels despite a decline in the second year postonset, with important implications for hospital capacity.

Clinician perspectives on assessing for disordered eating and body image disturbance in adolescents and young adults with cystic fibrosis.

BACKGROUND: Maintaining a healthy weight is a focus of Cystic Fibrosis (CF) care. With the increased use of highly effective CFTR modulators, many people with CF are gaining weight more easily, which may affect eating habits and body image. This study investigates providers' understanding and current practices surrounding body image disturbance and disordered eating in people with CF. METHODS: We distributed a one-time web-based survey to United States (U.S.)-based CF healthcare providers via CF Foundation list servs. The survey investigated providers' understanding and perceived importance of issues surrounding disordered eating and body image disturbance in adolescent and young adults (AYA) with CF as well as current screening practices. We used descriptive statistics to analyze participants' characteristics and practices. RESULTS: A total of 232 healthcare providers completed the survey. While most participants felt that screening for both body image disturbance and disordered eating should be standardized in CF care (79% and 82%, respectively), fewer than one third felt comfortable screening, and only one quarter actually screened for various eating disordered behaviors in daily practice. Only 2.7% reported using a formal screening tool. Participants reported provider assessment tools (86%), standardized partnerships with eating disorder specialists (80%), and CFF or national guidelines (79%) would be helpful to improve screening and counseling. CONCLUSION: While most CF providers believe that body image disturbance and disordered eating are important topics in AYA with CF, few address these topics with their patients. The development of educational sessions and national guidelines may improve screening and counseling practices.

Adolescents with anorexia nervosa or atypical anorexia nervosa with premorbid overweight/obesity: What should we do about their weight loss?

Traditionally, anorexia nervosa (AN) was understood to exist exclusively among underweight individuals and weight was used to assess level of severity and course of treatment. Recent trends have found a growing number of individuals presenting with AN or atypical AN (AAN) (i.e., those who remain with weight in a "normal" or "healthy" range despite significant weight loss) have a premorbid history of overweight/obesity. Individuals with AN/AAN and premorbid overweight/obesity represent an especially metabolically vulnerable population as with either AN or AAN, there is marked weight loss. Patients with AAN present a specific challenge as healthcare professionals must identify a clinically significant eating disorder in adolescents of potentially "normal" weights and then must balance their knowledge and training of traditional treatment of AN with obesity treatment and prevention. Currently, there are no evidence-based treatments to guide medical and mental health professionals regarding weight restoration, medical stabilization, and psychological treatment in patients with AN/AAN with a history of overweight/obesity while also addressing risk prevention for obesity.

COVID-19 related familial economic disruptions and eating disorder patients' mental health concerns and motivation to recover.

BACKGROUND: Family support has been shown to be important for adolescents and young adults (AYA) in eating disorder (ED) treatment. Many families were impacted by the pandemic, potentially altering their ability to support individuals in ED treatment. This study examined the association of COVID-19 related familial economic change with self-reported mental health (MH) and ED concerns in AYA seeking treatment for ED. METHODS: AYA patients with EDs aged 10-27 years enrolled in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) completed an additional COVID-19-specific survey (n = 89) that assessed their perception of the effects of the pandemic on their lives and their ED. Participants self-reported on familial economic disruptions, measured through a composite score of four markers: (1) family member's work hours cut, (2) family member was required to stop working, (3) family member lost job permanently, and (4) family lost health insurance/benefits. In bivariate analyses, we examined the association between self-reporting any familial economic disruption and self-reported changes in intrusive ED thoughts, feelings of anxiety, feelings of depression, feelings of isolation, and motivation to recover from their ED. Logistic regression models were used to examine the association between familial economic disruptions on self-reported changes in ED/MH affect and motivation to recover adjusting for age and ED diagnosis. RESULTS: Forty-six percent of participants self-reported that the pandemic had resulted in at least one economic familial disruption. Of patients reporting any familial economic disruption, 29% reported decreased motivation for ED recovery, and over 75% reported worsening feelings of depression, anxiety, isolation, and/or intrusive eating disorder thoughts. Reporting any COVID-19 familial economic disruption was marginally associated with feelings of isolation (p = 0.05). Though the findings were only marginally significant, the odds of reporting worsening feelings of depression, anxiety, intrusive ED thoughts or motivation to recover were nearly twice in those who reported a COVID-19-related familial economic disruption compared to those who did not report such a disruption. CONCLUSIONS: Family-related economic disruptions are associated with ED/MH-related concerns and motivation to recover from an ED during the COVID-19 pandemic in AYA patients.

Following the adoption of stay-at-home regulations to curb the spread of the COVID-19 pandemic, children's hospitals and emergency rooms across the United States saw a tremendous uptick in adolescents and young adults with eating disorders (ED) and mental health (MH) concerns. COVID-19 related regulations had economic consequences, with family members reduction in work hours, temporary or permanent termination from work, and/or loss of their health insurance or benefits. This study sheds light on the association between COVID-19 related familial economic disruptions and mental health and eating disorders (MH/ED) concerns and motivation to recover from an ED in patients receiving care for ED (89 participants). Of patients reporting some economic familial disruption, three-fourths self-reported worsening mental health (i.e, worsening feelings of depression, anxiety, isolation, or intrusive eating disorder thoughts). Patients who perceived familial economic disruption due to the COVID-19 pandemic had almost a two-fold increased likelihood of worsening eating disorders and mental health (ED/MH) concerns and/or motivation to recover. Our study underscores the need to consider the economic effects of the pandemic on the well-being of adolescents/young-adults with ED, particularly those from financially vulnerable families.

Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume.

Importance: The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking. Objective: To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic. Design, Setting, and Participants: Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre- and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data. Exposures: Onset of the COVID-19 pandemic. Main Outcomes and Measures: Monthly number of patients seeking inpatient/outpatient ED-related care. Results: Aggregate total inpatient ED admissions were 81 in January 2018 and 109 in February 2020. Aggregate total new outpatient assessments were 195 in January 2018 and 254 in February 2020. Before the COVID-19 pandemic, the relative number of pooled inpatient ED admissions were increasing over time by 0.7% per month (95% CI, 0.2%-1.3%). After onset of the pandemic, there was a significant increase in admissions over time of 7.2% per month (95% CI, 4.8%-9.7%) through April 2021, then a decrease of 3.6% per month (95% CI, -6.0% to -1.1%) through December 2021. Prepandemic, pooled data showed relative outpatient ED assessment volume was stable over time, with an immediate 39.7% decline (95% CI, -50.4% to -26.7%) in April 2020. Subsequently, new assessments increased by 8.1% (95% CI, 5.3%-11.1%) per month through April 2021, then decreased by 1.5% per month (95% CI, -3.6% to 0.7%) through December 2021. The nonhospital-based ED program did not demonstrate a significant increase in the absolute number of admissions after onset of the pandemic but did see a significant increase of 8.2 (95% CI, 6.2-10.2) additional inquiries for care per month in the first year after onset of the pandemic. Conclusions and Relevance: In this study, there was a significant COVID-19 pandemic-related increase in both inpatient and outpatient volume of patients with EDs across sites, particularly in the first year of the pandemic. Given inadequate ED care availability prior to the pandemic, the increased postpandemic demand will likely outstrip available resources. Results highlight the need to address ED workforce and program capacity issues as well as improve ED prevention strategies.