Association between depressive symptoms and objectively measured daily step count in individuals at high risk of cardiovascular disease in South London, UK: a cross-sectional study.

OBJECTIVES: Depressive symptoms are common but rarely considered a risk factor for unhealthy lifestyles associated with cardiovascular disease (CVD). This study investigates whether depressive symptoms are associated with reduced physical activity (PA) in individuals at high risk of developing CVD. DESIGN: Secondary analysis of the cross-sectional baseline data from a randomised controlled trial of an intensive lifestyle intervention. SETTING: 135 primary care practices in South London, UK. PARTICIPANTS: 1742 adults, 49-74 years, 86% male at high (≥20%) risk of developing CVD in the next 10 years as defined via QRISK2 score. OUTCOME MEASURES: The main explanatory variable was depressive symptoms measured via the Patient Health Questionnaire-9 (PHQ-9). The main outcome was daily step count measured with an accelerometer (ActiGraph GT3X) stratified by weekdays and weekend days. RESULTS: The median daily step count of the total sample was 6151 (IQR 3510) with significant differences (P<0.001) in mean daily step count between participants with low (PHQ-9 score: 0-4), mild (PHQ-9 score: 5-9) and moderate to severe depressive symptoms (PHQ-9 score: ≥10). Controlling for age, gender, ethnicity, education level, body mass index (BMI), smoking, consumption of alcohol, day of the week and season, individuals with mild depressive symptoms and those with moderate to severe depressive symptoms walked 13.3% (95% CI 18.8% to 7.9%) and 15.6% (95% CI 23.7% to 6.5%) less than non-depressed individuals, respectively. Furthermore, male gender, white ethnicity, higher education level, lower BMI, non-smoking, moderate alcohol intake, weekdays and summer season were independently associated with higher step count. CONCLUSIONS: People at high risk of CVD with depressive symptoms have lower levels of PA. TRIAL REGISTRATION: ISRCTN84864870; Pre-results.

Mental health problems in Austrian adolescents: a nationwide, two-stage epidemiological study applying DSM-5 criteria.

This is a nationwide epidemiological study using DSM-5 criteria to assess the prevalence of mental disorders in a large sample of Austrian adolescents between 10 and 18 years including hard-to-reach samples. A sample of 3615 adolescents from four cohorts (school grades 5, 7, 9, 11; age range 10-18 years) was recruited from 261 schools, samples of unemployed adolescents (n = 39) and adolescents from mental health institutions (n = 137) were added. The Youth Self-Report and SCOFF were used to screen for mental health problems. In a second phase, the Childrens' Diagnostic Interview for Mental Disorders was used to make point and lifetime psychiatric diagnoses. Mental health service use was also assessed. Point prevalence and lifetime prevalence rates for at least one psychiatric disorder were 23.9% and 35.8%. The highest lifetime prevalence rates were found for anxiety disorders (15.6%), neurodevelopmental disorders (9.3%; ADHD 5.2%) and depressive disorders (6.2%). Forty-seven percent of adolescents with a lifetime psychiatric disorder had a second diagnosis. Internalising disorders were more prevalent in girls, while neurodevelopmental disorders and disruptive, impulse control and conduct disorders were more prevalent in boys. Of those with a lifetime psychiatric disorder, 47.5% had contacted mental health services. Of the residual 52.5% who had not contacted mental health services, 18.1% expressed an interest in treatment. DSM-5 mental health disorders are highly prevalent among Austrian adolescents. Over 50% had or were interested in accessing treatment. Early access to effective interventions for these problems is needed to reduce burden due to mental health disorders.

Are obesity risk genes associated with binge eating in adolescence?

OBJECTIVE: Cognitions and behaviors characteristic of binge eating are associated with a polymorphism in the FTO gene, robustly related to body mass index (BMI) and obesity risk. We investigated the association between binge eating and the individual and combined effect of 32 SNPs robustly associated with BMI in a population-based sample. We hypothesized that higher BMI and binge eating might share a common genetic etiology. METHODS: Binge eating was assessed in adolescents from the Avon Longitudinal Study of Parents and Children at age 14 (n = 5,958) and 16 years (n = 4,948). We tested associations between 32 BMI-related SNPs and binge eating in crude and BMI-, age-, and gender-adjusted regression models. RESULTS: Crude analyses showed an association between binge eating and rs1558902 (FTO) that persisted after adjustment for BMI (OR = 1.20, P = 8 × 10(-3) ). A weighted allelic score consisting of all 32 BMI-related SNPs was associated with binge eating (P = 8 × 10(-4) ); this association attenuated (P = 0.08) when rs1558902 was removed from the weighted allelic score. CONCLUSIONS: BMI-related genes are associated with adolescent binge eating, in particular an FTO polymorphism. Although replication is needed, our findings have biological plausibility and are consistent with a postulated effect of FTO on appetite and food intake. Future studies should aim to understand the mechanisms underlying the relationship between FTO, binge eating, and obesity.

Parent skills training treatment for parents of children and adolescents with eating disorders: a qualitative study.

OBJECTIVE: This study examined the experience of parents of children with eating disorders after having participated in a skills-based training intervention. METHOD: Eleven parents were interviewed and transcripts were analysed using inductive thematic analysis. RESULTS: Parent responses were organised around key themes of (1) effectiveness and acceptability of the intervention; (2) interpersonal experience of the group process; and (3) feedback on intervention content. Overall, the transfer of specialist skills was highly valued by parents and applied within the home and hospital setting. DISCUSSION: This study contributes preliminary evidence that skills-based training may improve parent self-efficacy,psychological distress, anxiety, and burden.This intervention can also be a cost-effective method for supporting carers,and future research is required to contribute data on treatment efficacy for patients in addition to parents.

Social rank and symptom change in eating disorders: a 6-month longitudinal study.

BACKGROUND: Following previous cross-sectional research adopting an evolutionary approach to social rank and eating disorders, the present study explored the predictive value of social rank for changes in eating disorder symptoms in a 6-month longitudinal study. METHODS: Seventy-three women and men with a history of eating disorders were followed up over 6 months. A broad range of measures of social rank were used to determine whether social rank at baseline predicted residual changes in eating disorder symptoms. RESULTS: Low social rank (in terms of perceived external entrapment and submissive behaviour) predicted an increase in symptoms of anorexia but not symptoms of bulimia. The predictive value of low social rank was not mediated by changes in depressive symptoms. CONCLUSION: Perceived low rank predicts an increase in anorexic symptoms. However, further research is required to determine the precise nature of how social rank exerts its influence on the development of eating disorder symptoms. KEY PRACTITIONER MESSAGE: Self-perceived low social rank predicts an increase in anorexic symptoms but not bulimic symptoms. The effect of low social rank on changes in anorexic symptoms was not mediated by changes in depressive symptoms. Interventions for anorexia nervosa may need to incorporate techniques for increasing status and/or self-compassion.

The incidence of eating disorders in the UK in 2000-2009: findings from the General Practice Research Database.

OBJECTIVES: Few studies have investigated the incidence of eating disorders (EDs). Important questions about changes in the incidence of diagnosed disorders in recent years, disorder and gender-specific onset and case detection remain unanswered. Understanding changes in incidence is important for public health, clinical practice and service provision. The aim of this study was to estimate the annual (age-specific, gender-specific and subtype-specific) incidence of diagnosed ED: anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) in primary care over a 10-year period in the UK (2000-2009); to examine the changes within the study period; and to describe peak age at diagnosis. DESIGN: Register-based study. SETTING: Primary care. Data were obtained from a primary care register, the General Practice Research Database, which contains anonymised records representing about 5% of the UK population. PARTICIPANTS: All patients with a first-time diagnosis of AN, BN and EDNOS were identified. PRIMARY OUTCOME: Annual crude and age-standardised incidence rates were calculated. RESULTS: A total of 9072 patients with a first-time diagnosis of an ED were identified. The age-standardised annual incidence rate of all diagnosed ED for ages 10-49 increased from 32.3 (95% CI 31.7 to 32.9) to 37.2 (95% CI 36.6 to 37.9) per 100 000 between 2000 and 2009. The incidence of AN and BN was stable; however, the incidence of EDNOS increased. The incidence of the diagnosed ED was highest for girls aged 15-19 and for boys aged 10-14. CONCLUSIONS: The age-standardised incidence of ED increased in primary care between 2000 and 2009. New diagnoses of EDNOS increased, and EDNOS is the most common ED in primary care.

Is attention to detail a similarly strong candidate endophenotype for anorexia nervosa and bulimia nervosa?

OBJECTIVES: To investigate whether attention to detail is a similarly strong candidate endophenotype of anorexia (AN) and bulimia nervosa (BN), and to explore the incidence and clinical correlates of attention to detail. METHODS: A total of 266 women (including AN, BN, recovered AN, unaffected sisters of AN/BN & control women) undertook a thorough clinical assessment and were administered two neuropsychological measures of attention to detail (Group Embedded Figure Test; Rey-Osterrieth Complex Figure). RESULTS: Superior attention to detail was found across all AN groups including recovered AN and unaffected AN sisters. Those with BN and their unaffected sisters showed a profile more consistent with poor global integration. The combined effect of superior attention to detail and poor global integration ("weak coherence") was present in 42.3% of active cases and corresponded with a more severe illness, elevated obsessive-compulsive symptoms, and a higher likelihood of comorbid clinical anxiety and self-harm. CONCLUSIONS: Attention to detail is a stronger candidate endophenotype of AN compared to BN, where poor global integration may be more relevant. The unique contribution of both aspects of weak coherence (superior attention to detail/poor global integration) requires further exploration and understanding in both eating disorders. Integrating cognitive remediation of these traits into treatment for the subset of patients it is relevant for may improve outcome.

Nutritional intake and dietary patterns in pregnancy: a longitudinal study of women with lifetime eating disorders.

There is limited knowledge about dietary patterns and nutrient/food intake during pregnancy in women with lifetime eating disorders (ED). The objective of the present study was to determine patterns of food and nutrient intake in women with lifetime ED as part of an existing longitudinal population-based cohort: the Avon Longitudinal Study of Parents and Children. Women with singleton pregnancies and no lifetime psychiatric disorders other than ED (n 9723) were compared with women who reported lifetime (ever) ED: (anorexia nervosa (AN, n 151), bulimia nervosa (BN, n 186) or both (AN+BN, n 77)). Women reported usual food consumption using a FFQ at 32 weeks of gestation. Nutrient intakes, frequency of consumption of food groups and overall dietary patterns were examined. Women with lifetime ED were compared with control women using linear regression and logistic regression (as appropriate) after adjustment for relevant covariates, and for multiple comparisons. Women with lifetime ED scored higher on the 'vegetarian' dietary pattern; they had a lower intake of meat, which was compensated by a higher consumption of soya products and pulses compared with the controls. Lifetime AN increased the risk for a high ( ≥ 2500 g/week) caffeine consumption in pregnancy. No deficiencies in mineral and vitamin intake were evident across the groups, although small differences were observed in macronutrient intakes. In conclusion, despite some differences in food group consumption, women with lifetime ED had similar patterns of nutrient intake to healthy controls. Important differences in relation to meat eating and vegetarianism were highlighted, as well as high caffeine consumption. These differences might have an important impact on fetal development.

Perception of autonomy and connectedness prior to the onset of anorexia nervosa and bulimia nervosa.

OBJECTIVE: This study examines retrospective correlates of nonshared family environment prior to onset of disease, by means of multiple familial informants, among anorexia and bulimia nervosa patients. METHODS: A total of 332 participants was included (anorexia nervosa, restrictive type (AN-R): n = 41 plus families); bulimic patients (anorexia nervosa, binge-purging type; bulimia nervosa: n = 59 plus families). The EATAET Lifetime Diagnostic Interview was used to establish the diagnosis; the Subjective Family Image Test was used to derive emotional connectedness (EC) and individual autonomy (IA). RESULTS: Bulimic and AN-R patients perceived significantly lower EC prior to onset of disease compared to their healthy sisters. Bulimic patients perceived significantly lower EC prior to onset of disease compared to AN-R patients and compared to their mothers and fathers. A low family sum - sister pairs sum comparison - of EC had a significant influence on the risk of developing bulimia nervosa. Contrary to expectations, AN-R patients did not perceive significantly lower levels of IA compared to their sisters, prior to onset of disease. Findings of low IA in currently ill AN-R patients may represent a disease consequence, not a risk factor. CONCLUSIONS: Developmental child psychiatrists should direct their attention to disturbances of EC, which may be present prior to the onset of the disease.

Development and validation of the Detail and Flexibility Questionnaire (DFlex) in eating disorders.

Whilst neuropsychological testing provides the most accurate profile of cognitive functioning, the time consuming nature of individual assessment deems it impossible for many research and clinical settings. This paper presents the development and validation of the Detail and Flexibility Questionnaire (DFlex), a 24-item self-report scale measuring two aspects of neurocognitive functioning; cognitive rigidity (difficulty with set-shifting/flexibility) and attention to detail (weak coherence). Exploratory factor analysis extracted two subscales, further confirmed and refined by item response analysis. Both subscales showed high internal reliability, construct validity (as compared to relevant subscales of the Autistic-Spectrum Quotient) and strong discriminant validity with large effect sizes found between both lifetime eating disorder and healthy control groups, and between current and recovered anorexia nervosa. We suggest using the cognitive rigidity and attention to detail subscales independently to give a rough approximation of these two aspects of cognitive style as they manifest in the context of everyday life.

Exploring the neurocognitive signature of poor set-shifting in anorexia and bulimia nervosa.

Poor set-shifting has been implicated as a risk marker, maintenance factor and candidate endophenotype of eating disorders (ED). This study aimed to add clarity to the cognitive profile of set-shifting by examining the trait across ED subtypes, assessing whether it is a state or trait marker, and whether it runs in families. A battery of neuropsychological tasks was administered to 270 women with current anorexia (AN) and bulimia nervosa (BN), women recovered from AN, unaffected sisters of AN and BN probands, and healthy control women. Set-shifting was examined using both individual task scores and a composite variable (poor/intact/superior shifting) calculated from four neuropsychological tasks. Poor set-shifting was found at a higher rate in those with an ED particularly binge/purging subtypes. Some evidence for poor set-shifting was also present in those recovered from AN and in unaffected sisters of AN and BN. Clinically, poor set-shifting was associated with a longer duration of illness and more severe ED rituals but not body mass index. In sum, poor set-shifting is a transdiagnostic feature related to aspects of the illness but not to malnutrition. In part it is a familial trait, and is likely involved in the maintenance of the illness.

Models as a high-risk group: the health implications of a size zero culture.

The size zero culture of the fashion industry is damaging not only to the general public but also to the models themselves. This editorial explores mechanisms unique to this population that increase the risk of developing an eating disorder, and discusses the potential for successful intervention by the fashion and beauty industries in the modelling world.

Shame in women with a history of eating disorders.

OBJECTIVE: Several studies have investigated shame in eating disorders but most have used non-clinical samples examined only one type of eating disorder or included only a limited range of shame measures. The current study explored shame from multiple perspectives in women who report a range of eating disorder diagnoses and who are at different stages of illness and recovery. METHOD: In a postal questionnaire study, 224 women with a history of an eating disorder completed measures of anorexic and bulimic symptoms, depression and shame. RESULTS: After controlling for levels of depression, shame was associated with eating disorder symptoms. Specifically, shame as a measure of 'perceived involuntary subordination' (external shame) was uniquely associated with severity of anorexia nervosa symptoms, while shame as a measure of 'feelings' (internal shame) was uniquely associated with severity of bulimia nervosa symptoms. DISCUSSION: Different types of shame are related to different eating disorder symptoms and this may have implications for the aetiology and presentation of these disorders. These affective states may need to be addressed explicitly in therapy.

Getting beneath the phenotype of anorexia nervosa: the search for viable endophenotypes and genotypes.

Treatment for anorexia nervosa has changed little from that described by Gull over a century ago. To focus merely on symptomatic relief from "not eating," as occurs with some forms of hospital care, is primitive. The evidence base to guide treatment is thin. Nevertheless, there is hope that better understanding of the causes and maintaining factors may translate into more sophisticated treatments. This review aims to look beyond the overt and startling "not eating" phenotype of anorexia nervosa and consider eating disorder endophenotypes. The first part of the review sets the eating behaviour, clinical, and psychopathological features into the context of what is now understood about the central control of appetite. The evidence base for a framework of potential eating disorder endophenotypes follows. Finally, ideas about how to translate endophenotypes into treatment are introduced.

Cognitive flexibility in anorexia nervosa and bulimia nervosa.

The aim of this study was to determine if there are differences in cognitive flexibility in anorexia nervosa and bulimia nervosa. Fifty-three patients with an eating disorder (34 with anorexia nervosa and 19 with bulimia nervosa) and 35 healthy controls participated in the study. A battery of neuropsychological tests for cognitive flexibility was used, including Trail Making B, the Brixton Test, Verbal Fluency, the Haptic Illusion Test, a cognitive shifting task (CatBat) and a picture set test. Using exploratory factor analysis, four factors were obtained: 1: Simple Alternation; 2: Mental Flexibility; 3: Perseveration; and 4: Perceptual Shift. Patients with anorexia nervosa had abnormal scores on Factors 1 and 4. Patients with bulimia nervosa showed a different pattern, with significant impairments in Factors 2 and 4. These findings suggest that differential neuropsychological disturbance in the domain of mental flexibility/rigidity may underlie the spectrum of eating disorders.

Social comparison and submissive behaviour in eating disorder patients.

Animal analogues of anorexia nervosa suggest that submissive behaviour and social defeat may be implicated in the onset of wasting diseases. Data from human sufferers of anorexia nervosa and bulimia nervosa are also consistent with the presence of submissive behaviours and perceived low social rank (e.g. low self-esteem, helplessness, and feelings of shame). A total of 101 patients with eating disorders completed the Submissive Behaviour Scale and the Social Comparison Rating Scale, and their responses were compared with 101 age- and sex-matched student controls. Patients with eating disorders reported significantly higher levels of submissive behaviour and a more unfavourable social comparison than did student controls. Furthermore, levels of submissive behaviour and unfavourable social comparison were significantly related to severity of eating disorder symptoms, even after taking account of depressive symptoms and other psychopathology. These preliminary results suggest that ranking theory may have some application to eating disorders. Further research is required to determine whether rank plays a specific role in eating disorders (beyond the increased rates of depression which also occur in eating disorders) and, if so, what is its precise role.

Evidence for metabolic and endocrine abnormalities in subjects recovered from anorexia nervosa.

Subjects with anorexia nervosa (AN) at low weight display metabolic, endocrine, and behavioral abnormalities. Whether these various differences are a consequence of the condition and persist after recovery is unclear. We tested the hypothesis that abnormalities in the insulin and leptin axes and in the desire to eat persisted in subjects who had recovered from AN in terms of body mass index (BMI) and menstrual function. Endocrine, metabolic, and psychological parameters were assessed by sampling under fasting conditions and serially in response to a standard meal. Subjects included 18 females recovered from AN and 18 female controls and measures included plasma insulin, leptin, glucose and beta-hydroxybutyrate (beta-HBA) concentrations together with desire to eat. Fasting glucose concentrations were normal in both groups, but fasting insulin concentrations were significantly lower and the fasting glucose/insulin ratio significantly higher in the recovered subjects. The glucose concentration was significantly higher at the end of the meal period in the recovered group. The peak increase of insulin during the meal was significantly less in the recovered group and in response to the meal, glucose/insulin ratios were significantly higher for the first 45 minutes indicating a delayed insulin response. Fasting beta-HBA concentrations were not significantly different between groups, but postmeal decreases were significant and larger in the recovered AN group. Fasting and meal-related leptin concentrations were not significantly different between the groups and in both groups were correlated with BMI. In controls, but not in recovered subjects, the reported desire to eat was correlated with plasma glucose and leptin concentrations. The insulin, glucose and beta-HBA data indicated the presence of insulin hypersensitivity in the recovered subjects. As the insulin response to the meal was blunted and apparently delayed, there may be a persistent alteration in pancreatic function as a long-term pathological consequence of the anorexia. Alternatively, these data indicate a possible trait marker for AN.

Personality disorders and personality dimensions in anorexia nervosa.

Information on the relationship between anorexia nervosa (AN) and personality disorders (PDs) and dimensions of temperament and character (measured by the Temperament and Character Inventory [TCI; Cloninger, Przybeck Svrakic, & Wetzel, 1994]) is limited. This study examines the predictive validity of the TCI for PD diagnoses assessed by the International Personality Disorder Examination-ICD-10 (IPDE-ICD-10; Loranger, Janca, & Sartorius, 1997) interviews of 46 women with DSM-IV-defined AN. Patients with a PD reported higher levels of harm-avoidance and lower levels of self-directedness than those without a PD. Scores on the TCI were predictive of the number of PD features present, particularly for those PDs in the anankastic, anxious, and dependent groups accounting for 40% to 51% of the variance. Cluster analysis based on scores on the TCI identified a subgroup of patients characterized by low levels of novelty seeking, self-directedness, and cooperativeness and high levels of harm avoidance. This cluster included the majority of those with avoidant, anxious, or dependent PDs. Assessment of particular personality dimensions was able to predict PDs in an anorexic sample. Since normal personality dimensions have greater validity than the categorical PDs, a consideration of normal temperament and character may assist in clinical decisionmaking and considerations concerning treatment.