Dasha Nicholls

Body mass index cut offs to define thinness in children and adolescents: international survey

Objective To determine cut offs to define thinness in children and adolescents, based on body mass index at age 18 years. Design International survey of six large nationally representative cross sectional studies on growth. Setting Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States. Subjects 97 876 males and 94 851 females from birth to 25 years. Main outcome measure Body mass index (BMI, weight/height2). Results The World Health Organization defines grade 2 thinness in adults as BMI <17. This same cut off, applied to the six datasets at age 18 years, gave mean BMI close to a z score of −2 and 80% of the median. Thus it matches existing criteria for wasting in children based on weight for height. For each dataset, centile curves were drawn to pass through the cut off of BMI 17 at 18 years. The resulting curves were averaged to provide age and sex specific cut-off points from 2-18 years. Similar cut offs were derived based on BMI 16 and 18.5 at 18 years, together providing definitions of thinness grades 1, 2, and 3 in children and adolescents consistent with the WHO adult definitions. Conclusions The proposed cut-off points should help to provide internationally comparable prevalence rates of thinness in children and adolescents.

Academy for Eating Disorders Position Paper: The Role of the Family in Eating Disorders

Position It is the position of the Academy for Eating Disorders (AED) that whereas family factors can play a role in the genesis and maintenance of eating disorders, current knowledge refutes the idea that they are either the exclusive or even the primary mechanisms that underlie risk. Thus, the AED stands firmly against any etiologic model of eating disorders in which family influences are seen as the primary cause of anorexia nervosa or bulimia nervosa, and condemns generalizing statements that imply families are to blame for their child’s illness. The AED recommends that families be included in the treatment of younger patients, unless doing so is clearly ill advised on clinical grounds. The position articulated in this article is in line with the World Wide Charter for Action on Eating Disorders.

Childhood eating disorders: British national surveillance study

BACKGROUND The incidence of eating disorders appears stable overall, but may be increasing in younger age groups. Data on incidence, clinical features and outcome of early-onset eating disorders are sparse. AIMS To identify new cases of early-onset eating disorders (<13 years) presenting to secondary care over 1 year and to describe clinical features, management and 1-year outcomes. METHOD Surveillance over 14 months through the established British Paediatric Surveillance System, and a novel child and adolescent psychiatry surveillance system set up for this purpose. RESULTS Overall incidence was 3.01/100,000 (208 individuals). In total, 37% met criteria for anorexia nervosa; 1.4% for bulimia nervosa; and 43% for eating disorder not otherwise specified. Nineteen per cent showed determined food avoidance and underweight without weight/shape concerns. Rates of comorbidity were 41%; family history of psychiatric disorder 44%; and early feeding difficulties 21%. Time to presentation was >8 months. A total of 50% were admitted to hospital, typically soon after diagnosis. Outcome data were available for 76% of individuals. At 1 year, 73% were reported improved, 6% worse and 10% unchanged (11% unknown). Most were still in treatment, and seven were hospital in-patients for most of the year. CONCLUSIONS Childhood eating disorders represent a significant clinical burden to paediatric and mental health services. Efforts to improve early detection are needed. These data provide a baseline to monitor changing trends in incidence.

Selective Eating: Symptom, Disorder or Normal Variant

Selective eating is the little studied phenomenon of eating a highly limited range of foods, associated with an unwillingness to try new foods. Common in toddlers, it can persist into middle childhood and adolescence in a small number of children, most commonly boys. When this happens social avoidance, anxiety and conflict can result. This article describes a sample of 20 children with selective eating who presented for help to a specialist eating clinic. We outline the presenting features and associated phenomena for the group, suggest an approach to treatment, and explore from a theoretical point of view where this symptom, disorder or normal variant fits into the spectrum of childhood eating difficulties.

Family-based behavioural treatment of obesity: acceptability and effectiveness in the UK

Objective:To assess the acceptability and impact of family-based behavioural treatment (FBBT) for childhood obesity in a clinical setting in the UK.Design:Pre- and post-treatment assessment for four consecutive treatment groups.Setting:Treatment groups took place at Great Ormond Street Hospital, London.Patients:Participants were 33 families with obese (BMI ⩾98th centile for age and sex) children aged 8–13 years.Intervention:FBBT was delivered over 12 sessions.Main outcome measures:Overweight (percentage BMI), self-esteem, mood and eating attitudes were assessed before and after treatment; overweight was re-assessed at 3-month follow-up for those who completed treatment.Results:The FBBT programme materials translated easily to the UK setting and the programme was well-liked by participants. Twenty-seven out of 33 families (82%) completed the sessions. Children lost 8.4% BMI over the time of treatment, and this was maintained at 3-month follow-up. Self-esteem and depression improved significantly and there was no change in food pre-occupation, anorexia or bulimia on the ChEAT.Conclusions:These results establish that FBBT is feasible and acceptable in a clinical setting in Britain. They indicate that significant loss of overweight can be achieved using the programme without adverse psychological consequences.

Family-based behavioural treatment of childhood obesity in a UK national health service setting: randomized controlled trial

Background:The best outcomes for treating childhood obesity have come from comprehensive family-based programmes. However there are questions over their generalizability.Objective:To examine the acceptability and effectiveness of ‘family-based behavioural treatment’ (FBBT) for childhood obesity in an ethnically and socially diverse sample of families in a UK National Health Service (NHS) setting.Methods:In this parallel group, randomized controlled trial, 72 obese children were randomized to FBBT or a waiting-list control. Primary outcomes were body mass index (BMI) and BMI s.d. scores (SDSs). Secondary outcomes were weight, weight SDSs, height, height SDSs, waist, waist SDSs, FM index, FFM index, blood pressure (BP) and psychosocial measures. The outcomes were assessed at baseline and after treatment, with analyses of 6-month data performed on an intent-to-treat (ITT) basis. Follow-up anthropometric data were collected at 12 months for the treatment group.Results:ITT analyses included all children with baseline data (n=60). There were significant BMI SDS changes (P<0.01) for the treatment and control groups of −0.11 (0.16) and −0.10 (1.6). The treatment group showed a significant reduction in systolic BP (−0.24 (0.7), P<0.05) and improvements in quality of life and eating attitudes (P<0.05), with no significant changes for the control group. However the between-group treatment effects for BMI, body composition, BP and psychosocial outcomes were not significant. There was no overall change in BMI or BMI SDSs from 0–12 months for the treatment group. No adverse effects were reported.Conclusions:Both treatment and control groups experienced significant reductions in the level of overweight, but with no significant difference between them. There were no significant group differences for any of the secondary outcomes. This trial was registered at http://www.controlled-trials.com/ under ISRCTN 51382628.

Comparison of specialist and nonspecialist care pathways for adolescents with anorexia nervosa and related eating disorders

OBJECTIVE To explore the role of specialist outpatient eating disorders services and investigate how direct access to these affects rates of referral, admissions for inpatient treatment, and continuity of care. METHOD Services beyond primary care in Greater London retrospectively identified adolescents who presented with an eating disorder over a 2-year period. Data concerning service use were collected from clinical casenotes. RESULTS In areas where specialist outpatient services were available, 2-3 times more cases were identified than in areas without such services. Where initial outpatient treatment was in specialist rather than nonspecialist services, there was a significantly lower rate of admission for inpatient treatment and considerably higher consistency of care. DISCUSSION Developing specialist outpatient services with direct access from primary care is likely to lead to improvements in treatment and reduce overall costs.

Investigating autism spectrum disorder and autistic traits in early onset eating disorder

OBJECTIVE To investigate whether young people (8-16 years) with an eating disorder have a higher prevalence of autism spectrum disorder (ASDs) and elevated autistic traits compared to typically developing (TD) peers. METHOD Twenty-two participants with early onset eating disorder (EOED) were assessed using standardized ASD measures and compared to IQ matched TD (n = 24) and ASD (n = 20) controls. RESULTS An ASD diagnosis was no more common in EOED than in TD controls. However, repetitive and stereotyped behavior was more often observed in the EOED group and, compared to TD controls, there was a trend (p = .07) toward greater autistic social impairment in EOED. DISCUSSION Whilst participants with EOED did not show increased ASD prevalence, they did have elevated autistic traits of clinical significance, particularly repetitive and stereotyped behavior. Further work is required to determine whether inflexibility and social difficulties in EOED have identical phenomenology and etiology to those seen in ASD.

Managing anorexia nervosa

Clinical confidence and coordinated multidisciplinary care can influence the course of anorexia nervosa in children and adolescents. Sicker and younger patients with anorexia nervosa often present first to a paediatrician, requiring early recognition and appropriate management. Paediatric knowledge and skills are also needed to manage the impact of eating disorders on growth and development. This review provides practical guidance on the management of anorexia nervosa for paediatricians, in the areas of assessment, acute management and re-feeding, and long-term monitoring. In the absence of a strong evidence base for some of these recommendations, local protocols based on best practice guidelines can reduce anxiety, increase cooperation and reduce risk.

Body composition in early onset eating disorders

Background: Body mass index (BMI) or equivalent weight for height indices are the most widely used measures of body composition in early onset and adolescent eating disorders. Although of value as screening instruments the limitation in disease states is their inability to discriminate fat and fat-free components of body weight.Objective: To compare height-adjusted fat and fat-free components of body composition in children and young adolescents with different types of eating disorders with those of age matched reference children.Design: Weight, height, triceps and subscapular skinfold thickness were measured in 172 children (aged 7–16 y) with eating disorders receiving specialist treatment. Fat mass index (FMI) and fat-free mass index (FFMI) were calculated using Slaughters and Deurenbergs equations and normalisation for height. Using data from 157 normal children, representative of the UK 1990 growth reference data, reference curves for FMI and FFMI±2 s.d. were derived. Results for patient groups were superimposed on these reference curves.Results: FMI and FFMI were both reduced in eating disorders associated with malnutrition, including anorexia nervosa (AN). AN subjects did not differ from other subjects with comparable degrees of malnutrition. Children with eating disorders of normal weight, such as bulimia nervosa and selective eating, did not differ significantly from reference children in their relative FM and FFM.Conclusions: FM and FFM merit independent consideration in disorders of malnutrition in children, rather than expressing data as percentage body fat or percentage BMI. The implications of loss of FFM on growth and development merit further investigation.