Abstracts: Eating Disorders

J Obes 2014; 2014:249–315

Objective: To investigate the relationship between binge eating behavior and weight loss maintenance over a two-year period in adults. Design: Secondary data analysis using the Keep It Off study, a randomized trial evaluating an intervention to promote weight loss maintenance. Participants: 419 men and women (ages: 20 to 70 y; BMI: 20–44c kg/m²) who had intentionally lost ≥10% of their weight during the previous year. Measurements: Body weight was measured and binge eating behavior over the past 6 months was reported at baseline, 12 months, and 24 months. Height was measured at baseline. Results: Prevalence of binge eating at baseline was 19.4% (N=76). Prevalence of binge eating at any time point was 30.1% (N=126). Although the rate of weight regain did not differ significantly between those who did or did not report binge eating at baseline, binge eating behavior across the study period (additive value of presence or absence at each time point) was significantly associated with different rates of weight regain. Conclusion: Tailoring weight loss maintenance interventions to address binge eating behavior is warranted given the prevalence and the different rates of weight regain experienced by those reporting this behavior.

Lancet 2014; 383(9912):127–137

Background: Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of two manual-based outpatient treatments for anorexia nervosa: focal psychodynamic therapy and enhanced cognitive-behavioral therapy versus optimized treatment as usual. Methods: The ANTOP study is a multicentre, randomized controlled efficacy trial in adults with anorexia nervosa. We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either focal psychodynamic therapy, enhanced cognitive-behavior therapy, or optimized treatment as usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was weight gain, measured as increased body mass index (BMI) at the end of treatment. A key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology). Analysis was by intention to treat. This trial is registered at http://isrctn.org, number ISRCTN72809357. Results: Of 727 adults screened for inclusion, 242 underwent randomization: 80 to focal psychodynamic therapy, 80 to enhanced cognitive-behaviortherapy, and 82 to optimized treatment as usual. At the end of treatment, 54 patients (22%) were lost to follow-up, and at 12-month follow-up, a total of 73 (30%) had dropped out. At the end of treatment, BMI had increased in all study groups (focal psychodynamic therapy 0·73 kg/m², enhanced cognitive-behavior therapy 0·93 kg/m², optimized treatment as usual 069 kg/m²); no differences were noted between groups (mean difference between focal psychodynamic therapy and enhanced cognitive-behavioral therapy −0·45, 95% CI −0·96 to 0·07; focal psychodynamic therapy versus optimized treatment as usual −0·14, −0·68 to 0·39; enhanced cognitive-behavior therapy versus optimized treatment as usual −0·30, −0·22 to 0·83). At 12-month follow-up, the mean gain in BMI had risen further (1·64 kg/m², 1·30 kg/m², and 1·22 kg/m², respectively), but no differences between groups were recorded (0·10, −0·56 to 0·76; 0·25, −0·45 to 0·95; and 0·15, −0·54 to 0·83, respectively). No serious adverse events attributable to weight loss or trial participation were recorded. Interpretation: Optimized treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive-behavioral therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology. Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches.

Eat Disord 2013; 21(3):275–282

Background: Surgical treatment for morbid obesity can be very effective in terms of weight loss and reduction of psychopathology. But the (re)emergence of eating problems after surgery is still poorly understood and may be underreported. We describe three cases in which eating disorder symptoms developed after bariatric surgery. The accelerated weight loss and heightened dieting restraint, as well as the systematic reminders to control the amount of food eaten which are crucial for treatment success, might trigger the development of eating disorders after surgery. Implications for presurgery assessment and preparation are discussed.

Psychol Med 2013; 43(12):2477–2500

Background: Anorexia nervosa is a potentially deadly psychiatric illness that develops predominantly in females around puberty but is increasingly being recognized as also affecting boys and men, and women across the lifespan. The aim of this environmental scan is to provide an overview of best practices in anorexia nervosa treatment across the age spectrum. Method: A triangulation approach was used. First, a detailed review of randomized controlled trials (RCTs) for anorexia nervosa published between 1980 and 2011 was conducted; second, clinical practice guidelines were consulted and reviewed; third, information about RCTs currently underway was sourced. This approach facilitated a comprehensive overview, which addressed the extant evidence base, recent advances in evidence and improvements in treatment, and future directions. Results: The evidence base for the treatment of anorexia nervosa is advancing, albeit unevenly. Evidence points to the benefit of family-based treatment for youth. For adults, no specific approach has shown superiority and, presently, a combination of renourishment and psychotherapy such as specialist supportive clinical management, cognitive-behavioral therapy, or interpersonal psychotherapy is recommended. RCTs have neither sufficiently addressed the more complex treatment approaches seen in routine practice settings, such as multidisciplinary treatment or level of care, nor specifically investigated treatment in ethnically diverse populations. Methodological challenges that hinder progress in controlled research for anorexia nervosa are explained. Conclusions: The review highlights evidence-based and promising treatment modalities for anorexia nervosa and presents a triangulated analysis including controlled research, practice guidelines, and emerging treatments to inform and support clinical decision making.

Am J Psychiatry 2013; 170(8):917–925

Objective: Although anorexia nervosa has a high mortality rate, our understanding of the timing and predictors of mortality in eating disorders is limited. The authors investigated mortality in a long-term study of patients with eating disorders. Method: Beginning in 1987, 246 treatment-seeking female patients with anorexia nervosa or bulimia nervosa were interviewed every 6 months for a median of 9.5 years to obtain weekly ratings of eating disorder symptoms, comorbidity, treatment participation, and psychosocial functioning. From January 2007 to December 2010 (median follow-up of 20 years), vital status was ascertained with a National Death Index search. Results: Sixteen deaths (6.5%) were recorded (lifetime anorexia nervosa, N=14; bulimia nervosa with no history of anorexia nervosa, N=2). The standardized mortality ratio was 4.37 (95% CI=2.4–7.3) for lifetime anorexia nervosa and 2.33 (95% CI=0.3–8.4) for bulimia nervosa with no history of anorexia nervosa. Risk of premature death among patients with lifetime anorexia nervosa peaked within the first 10 years of follow-up, resulting in a standardized mortality ratio of 7.7 (95% CI=3.7–14.2). The standardized mortality ratio varied by duration of illness and was 3.2 (95% CI=0.9–8.3) for patients with lifetime anorexia nervosa for 0 to 15 years (4/119 died), and 6.6 (95% CI=3.2–12.1) for those with lifetime anorexia nervosa for >15 to 30 years (10/67 died). Multivariate predictors of mortality included alcohol abuse, low body mass index, and poor social adjustment. Conclusions: These findings highlight the need for early identification and intervention and suggest that a long duration of illness, substance abuse, low weight, and poor psychosocial functioning raise the risk for mortality in anorexia nervosa.

Am J Psychiatry 2013; 170(5):477–484

Objective: In this review, based on recent advances in cognitive neuroscience, the author presents a formulation in which the marked persistence of anorexia nervosa can be usefully understood as a well-ingrained maladaptive habit. Method: The author reviewed the relevant literature on the development and course of anorexia nervosa and interpreted critical features in light of developments in cognitive neuroscience. Results: Anorexia nervosa is a well-characterized disorder with remarkable persistence both across history and among affected individuals. Food restriction, the salient behavioral feature of the disorder, often begins innocently but gradually takes on a life of its own. Over time, it becomes highly entrenched and resistant to change through either psychological or pharmacological treatment. Cognitive neuroscience has described two related but distinct processes that underlie the acquisition of new patterns of behavior, namely, action-outcome and stimulus-response learning. It is likely that both processes are engaged in the development of anorexia nervosa and that stimulus-response learning (that is, habit formation) is critical to the persistence of the dieting behavior. Conclusions: The formulation of the dieting behavior characteristic of anorexia nervosa as a well-entrenched habit provides a basis for understanding the striking persistence of this disorder. This model helps explain the resistance of anorexia nervosa to interventions that have established efficacy in related disorders and implies that addressing the dieting behavior is critical, especially early in the course of the illness, before it has become ingrained.