Phillipa Hay

Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples

In order to examine the concurrent and criterion validity of the questionnaire version of the Eating Disorders Examination (EDE-Q), self-report and interview formats were administered to a community sample of women aged 18-45 (n = 208). Correlations between EDE-Q and EDE subscales ranged from 0.68 for Eating Concern to 0.78 for Shape Concern. Scores on the EDE-Q were significantly higher than those of the EDE for all subscales, with the mean difference ranging from 0.25 for Restraint to 0.85 for Shape Concern. Frequency of both objective bulimic episodes (OBEs) and subjective bulimic episodes (SBEs) was significantly correlated between measures. Chance-corrected agreement between EDE-Q and EDE ratings of the presence of OBEs was fair, while that for SBEs was poor. Receiver operating characteristic (ROC) analysis, based on a sample of 13 cases, indicated that a score of 2.3 on the global scale of the EDE-Q in conjunction with the occurrence of any OBEs and/or use of exercise as a means of weight control, yielded optimal validity coefficients (sensitivity = 0.83, specificity = 0.96, positive predictive value = 0.56). A stepwise discriminant function analysis yielded eight EDE-Q items which best distinguished cases from non-cases, including frequency of OBEs, use of exercise as a means of weight control, use of self-induced vomiting, use of laxatives and guilt about eating. The EDE-Q has good concurrent validity and acceptable criterion validity. The measure appears well-suited to use in prospective epidemiological studies.

A review of the association between obesity and cognitive function across the lifespan : implications for novel approaches to prevention and treatment

Recent research suggests that increased adiposity is associated with poor cognitive performance, independently of associated medical conditions. The evidence regarding this relationship is examined in this review article. A relatively consistent finding across the lifespan is that obesity is associated with cognitive deficits, especially in executive function, in children, adolescents and adults. However, as illustrated by contradictory studies, the relationship between obesity and cognition is uncertain in the elderly, partly because of inaccuracy of body mass index as a measure of adiposity as body composition changes with aging. This review further discusses whether obesity is a cause or a consequence of these cognitive deficits, acknowledging the possible bidirectional relationship. The possible effects of increased adiposity on the brain are summarized. Our investigations suggest that weight gain results, at least in part, from a neurological predisposition characterized by reduced executive function, and in turn obesity itself has a compounding negative impact on the brain via mechanisms currently attributed to low‐grade systemic inflammation, elevated lipids and/or insulin resistance. The possible role of cognitive remediation treatment strategies to prevent and/or treat obesity is discussed.

Eating disorder behaviors are increasing: findings from two sequential community surveys in South Australia

Background Evidence for an increase in the prevalence of eating disorders is inconsistent. Our aim was to determine change in the population point prevalence of eating disorder behaviors over a 10-year period. Methodology/Principal Findings Eating disorder behaviors were assessed in consecutive general population surveys of men and women conducted in 1995 (n = 3001, 72% respondents) and 2005 (n = 3047, 63.1% respondents). Participants were randomly sampled from households in rural and metropolitan South Australia. There was a significant (all p<0.01) and over two-fold increase in the prevalence of binge eating, purging (self-induced vomiting and/or laxative or diuretic misuse) and strict dieting or fasting for weight or shape control among both genders. The most common diagnosis in 2005 was either binge eating disorder or other “eating disorders not otherwise specified” (EDNOS; n = 119, 4.2%). Conclusions/Significance In this population sample the point prevalence of eating disorder behaviors increased over the past decade. Cases of anorexia nervosa and bulimia nervosa, as currently defined, remain uncommon.

Assessing quality of life in eating disorder patients

Objective: To examine quality of life among subgroups of eating disorder patients. Method: Self-report questionnaires which included two quality of life measures were completed by 87 individuals referred for treatment to the Australian Capital Territory Eating Disorders Day Program. Health-related quality of life, as measured by the Medical Outcomes Study 12-item Short Form Mental Component Summary scale, and subjective quality of life, as measured by subscales of the World Health Organization Brief Quality of Life Assessment Scale (WHOQOL-BREF), were compared among individuals who received the diagnosis of anorexia nervosa purging subtype (n=15), anorexia nervosa restricting subtype (n=19), bulimia nervosa (n=40) and binge eating disorder (n=10), and among a general population sample of young adult women employed as a control group (n=495). Results: Eating disorder patients, when considered together, showed marked impairment in both health-related and subjective quality of life relative to normal control subjects. However, in both domains, restricting anorexia nervosa patients reported significantly better quality of life than other patient groups, after controlling for levels of general psychological distress. Scores on the Social Relationships subscale of the WHOQOL-BREF among individuals in this subgroup were similar to those of normal control subjects. Conclusions: Reliance on any one instrument is likely to be misleading in assessing the quality of life of eating disorder patients. Careful consideration needs to be given to the assessment of restricting anorexia nervosa patients in particular.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

Objectives: This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013–2014. Methods: The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008–2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified. Results: In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice. Conclusions: Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management. Expert reviewers Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

The validity of the DSM‐IV scheme for classifying bulimic eating disorders

OBJECTIVE This study was designed to assess the validity of the DSM-IV scheme for classifying recurrent binge eating. METHOD A general population sample of 250 young women with recurrent binge eating was recruited using a two-stage design. Information on their eating habits and associated psychopathology was obtained by personal interviews. Subjects were reassessed 1 year later. RESULTS The diagnosis of bulimia nervosa had good descriptive and predictive validity. On present state features it was not possible to distinguish binge-eating disorder from the nonpurging subtype of bulimia nervosa. However, these groups differed in their outcome at 1 year. Within eating disorder not otherwise specified (EDNOS), there was a subgroup of subjects with milder symptoms which were relatively unstable over time. DISCUSSION The findings suggest that bulimic eating disorders exist on a continuum of clinical severity, from bulimia nervosa purging type (most severe), through bulimia nervosa nonpurging type (intermediate severity), to binge-eating disorder (least severe). The data on outcome support retaining a distinction between nonpurging bulimia nervosa and binge-eating disorder.

Anorexia nervosa: aetiology, assessment, and treatment

Anorexia nervosa is an important cause of physical and psychosocial morbidity. Recent years have brought advances in understanding of the underlying psychobiology that contributes to illness onset and maintenance. Genetic factors influence risk, psychosocial and interpersonal factors can trigger onset, and changes in neural networks can sustain the illness. Substantial advances in treatment, particularly for adolescent patients with anorexia nervosa, point to the benefits of specialised family-based interventions. Adults with anorexia nervosa too have a realistic chance of achieving recovery or at least substantial improvement, but no specific approach has shown clear superiority, suggesting a combination of re-nourishment and anorexia nervosa-specific psychotherapy is most effective. To successfully fight this enigmatic illness, we have to enhance understanding of the underlying biological and psychosocial mechanisms, improve strategies for prevention and early intervention, and better target our treatments through improved understanding of specific disease mechanisms.

Treating severe and enduring anorexia nervosa: a randomized controlled trial

BACKGROUND There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN. METHOD Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes. RESULTS Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM. CONCLUSIONS Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.

Treatment for severe and enduring anorexia nervosa: A review

Objective: Many patients with anorexia nervosa develop an intractable and debilitating illness course. Our aims were to (i) conduct a systematic review of randomised controlled trials (RCTs) of treatment for chronic anorexia nervosa participants, and (ii) identify research informing novel therapeutic approaches for this group. Methods: Systematic search (SCOPUS plus previous reviews date 2011) of literature for (i) RCTs of treatment that included anorexia nervosa participants with a mean duration of illness of at least 3 years, (ii) studies reporting new treatments addressing factors associated with chronicity. Results: Evidence of efficacy for treatment approaches in severe and enduring anorexia nervosa is limited. Only one unpublished RCT designed to test a specific psychological approach for these patients was identified. There is a probable advantage for specialist psychotherapy over treatment as usual, and a promising study of relapse prevention with cognitive behaviour therapy (CBT) for anorexia nervosa (CBT-AN). Open trials have, however, reported developments in psychological therapies that warrant further specific evaluation. These include forms of CBT modified for anorexia nervosa, cognitive remediation therapy with emotion skills training, the Maudsley Model for Treatment of Adults with Anorexia Nervosa, the Community Outreach Partnership Program, Specialist Supportive Clinical Management and the approach of Strober with its emphasis on therapeutic alliance and flexible goals. Conclusions: Treatment trials need to move beyond targeting core eating disorder pathology (primarily weight restoration) and examine efficacy and effectiveness in minimising harm and reducing personal and social costs of chronic illness. There is also a need to develop better definitions of chronicity, with or without treatment ‘resistance’ specifiers.

Associations between obesity and developmental functioning in pre-school children: a population-based study

Objective:To examine associations between obesity and impairment in developmental functioning in a general population sample of pre-school children.Method:Standardized medical examinations were conducted in nine consecutive cohorts of male and female children (n=9415) aged between 4.4 and 8.6 years (mean=6.0, s.d.=0.37) residing in the Lower Bavaria region of Germany. Tests designed to assess performance in subdivisions representing four broad developmental domains, namely, motor development, speech development, cognitive development and psycho-social development, were completed by all participants.Results:Boys had significantly higher rates of impairment than girls. The prevalence of obesity in boys was 2.4%, whereas in girls it was 4.3% (χ 2=21.51, P< 0.01). After controlling for age, gender, year of recruitment and other potential covariates, the prevalence of impairment in gross motor skills was higher among obese male children than normal-weight male children (adjusted odds ratio=1.76, 95% confidence interval (CI)=1.02, 3.01, P< 0.05), whereas the prevalence of impairment in the ability to focus attention was higher in obese female children than normal-weight female children (adjusted odds ratio=1.86, 95% CI=1.00, 3.44, P< 0.05).Conclusions:The findings suggest that gender-specific associations between obesity and impairment in specific aspects of developmental functioning may be evident in younger children.