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1.  Couple-Based Interventions for Adults with Eating Disorders 
Eating disorders  2015;23(4):356-365.
A significant number of adults with eating disorders fail to achieve relief from the disorder, with many dropping out from treatment or relapsing. Standard treatment remains individual therapy despite partners being negatively affected and typically wanting to help in an effective and loving way. We propose that couple-based interventions, which leverage the support of a partner and the relationship in treatment, may improve outcome and recovery rates for adults with eating disorders. In this paper, we survey the empirical literature supporting the treatment of adults in a couple context and describe our existing and emerging couple-based interventions for eating disorders.
PMCID: PMC4700507  PMID: 26010371
2.  Is childhood bullying involvement a precursor of eating disorder symptoms? A prospective analysis 
Bullying is a common childhood experience with enduring psychosocial consequences. The aim of this study was to test whether bullying increases risk for eating disorder symptoms.
Ten waves of data on 1420 participants between ages 9 and 25 were used from the prospective population-based Great Smoky Mountains Study. Structured interviews were used to assess bullying involvement and symptoms of anorexia nervosa and bulimia nervosa as well as associated features. Bullying involvement was categorized as not involved, bully only, victim only, or both bully and victim (bully-victims).
Within childhood/adolescence, victims of bullying were at increased risk for symptoms of anorexia nervosa and bulimia nervosa as well as associated features. These associations persisted after accounting for prior eating disorder symptom status as well as preexisting psychiatric status and family adversities. Bullies were at increased risk of symptoms of bulimia and associated features of eating disorders, and bully-victims had higher levels of anorexia symptoms. In terms of individual items, victims were at risk for binge eating and bully-victims had more binge eating and use of vomiting as a compensatory behavior. There was little evidence in this sample that these effects differed by sex. Childhood bullying status was not associated with increased risk for persistent eating disorder symptoms into adulthood (ages 19, 21, and 25).
Bullying predicts eating disorder symptoms for both bullies and victims. Bullying involvement should be a part of risk assessment and treatment planning for children with eating problems.
PMCID: PMC4715551  PMID: 26337405
Eating behavior; Body Image; Bullying; Epidemiology; Childhood; Adolescence; Psychosocial; Stress
3.  Treatment-seeking patients with binge-eating disorder in the Swedish national registers: clinical course and psychiatric comorbidity 
BMC Psychiatry  2016;16:163.
We linked extensive longitudinal data from the Swedish national eating disorders quality registers and patient registers to explore clinical characteristics at diagnosis, diagnostic flux, psychiatric comorbidity, and suicide attempts in 850 individuals diagnosed with binge-eating disorder (BED).
Cases were all individuals who met criteria for BED in the quality registers (N = 850). We identified 10 controls for each identified case from the Multi-Generation Register matched on sex, and year, month, and county of birth. We evaluated characteristics of individuals with BED at evaluation and explored diagnostic flux across eating disorders presentations between evaluation and one-year follow-up. We applied conditional logistic regression models to assess the association of BED with each comorbid psychiatric disorder and with suicide attempts and explored whether risk for depression and suicide were differentially elevated in individuals with BED with or without comorbid obesity.
BED shows considerable diagnostic flux with other eating disorders over time, carries high psychiatric comorbidity burden with other eating disorders (OR 85.8; 95 % CI: 61.6, 119.4), major depressive disorder (OR 7.6; 95 % CI: 6.2, 9.3), bipolar disorder (OR 7.5; 95 % CI: 4.8, 11.9), anxiety disorders (OR 5.2; 95 % CI: 4.2, 6.4), and post-traumatic stress disorder (OR 4.3; 95 % CI: 3.2, 5.7) and is associated with elevated risk for suicide attempts (OR 1.8; 95 % CI: 1.2, 2.7). Depression and suicide attempt risk were elevated in individuals with BED with and without comorbid obesity.
Considerable flux occurs across BED and other eating disorder diagnoses. The high psychiatric comorbidity and suicide risk underscore the severity and clinical complexity of BED.
PMCID: PMC4880842  PMID: 27230675
Binge-eating disorder; Comorbidity; Suicide; Eating disorders
5.  The Intestinal Microbiota in Acute Anorexia Nervosa and During Renourishment: Relationship to Depression, Anxiety, and Eating Disorder Psychopathology 
Psychosomatic medicine  2015;77(9):969-981.
The relevance of the microbe-gut-brain axis to psychopathology is of interest in anorexia nervosa (AN), as the intestinal microbiota plays a critical role in metabolic function and weight regulation.
We characterized the composition and diversity of the intestinal microbiota in AN, using stool samples collected at inpatient admission (T1) (n=16) and discharge (T2) (n=10). At T1, participants completed the Beck Depression and Anxiety Inventories and the Eating Disorder Examination-Questionnaire. Patients with AN were compared to healthy individuals who participated in a previous study (healthy comparison group; HCG). Genomic DNA was isolated from stool samples, and bacterial composition was characterized by 454 pyrosequencing of the 16S rRNA gene. Sequencing results were processed by the Quantitative Insights Into Microbial Ecology pipeline. We compared T1 vs. T2 samples, samples from both points were compared to HCG (n=12), and associations between psychopathology and T1 samples were explored.
In patients with AN, significant changes emerged between T1 and T2 in taxa abundance and beta (between-sample) diversity. Patients with AN had significantly lower alpha (within-sample) diversity than HCG at both T1 (p=0.0001) and T2 (p=0.016), and differences in taxa abundance were found between AN patients and HCG. Levels of depression, anxiety, and eating disorder psychopathology at T1 were associated with composition and diversity of the intestinal microbiota.
We provide evidence of intestinal dysbiosis in AN and an association between mood and the enteric microbiota in this patient population. Future directions include mechanistic investigations of the microbe-gut-brain axis in animal models and association of microbial measures with metabolic changes and recovery indices.
PMCID: PMC4643361  PMID: 26428446
eating disorders; anorexia nervosa; intestinal microbiota; gut-brain axis; depression; anxiety
6.  Using ancestry-informative markers to identify fine structure across 15 populations of European origin 
European Journal of Human Genetics  2014;22(10):1190-1200.
The Wellcome Trust Case Control Consortium 3 anorexia nervosa genome-wide association scan includes 2907 cases from 15 different populations of European origin genotyped on the Illumina 670K chip. We compared methods for identifying population stratification, and suggest list of markers that may help to counter this problem. It is usual to identify population structure in such studies using only common variants with minor allele frequency (MAF) >5% we find that this may result in highly informative SNPs being discarded, and suggest that instead all SNPs with MAF >1% may be used. We established informative axes of variation identified via principal component analysis and highlight important features of the genetic structure of diverse European-descent populations, some studied for the first time at this scale. Finally, we investigated the substructure within each of these 15 populations and identified SNPs that help capture hidden stratification. This work can provide information regarding the designing and interpretation of association results in the International Consortia.
PMCID: PMC4169539  PMID: 24549058
population stratification; AIMs; principal component analysis
7.  Sex- and Age-Specific Incidence of Healthcare-Register-Recorded Eating Disorders in the Complete Swedish 1979–2001 Birth Cohort 
To investigate the sex- and age-specific incidence of healthcare-register-recorded anorexia nervosa (AN) and other eating disorders (OED) in a complete birth cohort, and assess whether incidence varies by diagnostic period and (sub-) birth cohort.
We used the actuarial method and Poisson models to examine the incidence of AN and OED from 1987–2009 (when individuals were 8–30 years) for a cohort of 2.3 million individuals (48.7% female) born from 1979–2001 in Sweden, identified using Swedish registers.
For both sexes, incidences of AN and OED increased considerably for diagnostic periods after 2000, but differed little by birth cohort. In 2009, AN incidence in the peak age category was 205.9 cases/100,000 persons (95% CI: 178.2, 233.5) for females (14–15 years), versus 12.8 cases/100,000 (95% CI: 5.6, 20.1) for males (12–13 years). OED incidence in the peak age category was 372.1 cases/100,000 (95% CI: 336.4, 407.9) for females (16–17 years), versus 22.2 cases/100,000 (95% CI: 13.3, 31.1) for males (14–15 years).
Our finding of an increase in healthcare register-recorded eating disorders for diagnostic periods after 2000 likely reflects improved detection and expanded register coverage in Sweden. The peak of eating disorder incidence in adolescence, which began unexpectedly early for AN in males, suggests the importance of vigilance for signs of AN in young boys and early primary prevention efforts. Waiting until later could miss critical windows for intervention that could prevent disorders from taking root.
PMCID: PMC5028825  PMID: 26769444
eating disorders; anorexia nervosa; men; incidence; epidemiology; Sweden
8.  The Intestinal Microbiome in Bariatric Surgery Patients 
With nearly 39% of the worldwide adult population classified as obese, much of the globe is facing a serious public health challenge. Increasing rates of obesity, coupled with the failure of many behavioral and pharmacological interventions, have contributed to a rise in popularity of bariatric surgery as a treatment for obesity. Surgery-mediated weight loss was initially thought to be a direct result of mechanical alterations causing restriction and calorie malabsorption. However, the mounting evidence suggests that indirect factors influence the accumulation and storage of fat in patients that have undergone this procedure. Given the established impact the intestinal microbiota has on adiposity, it is likely that this complex enteric microbial community contributes to surgery-mediated weight loss and maintenance of weight loss post-surgery. In this review, we discuss the physiological and psychological traits exhibited by bariatric surgery candidates that can be influenced by the intestinal microbiota. Additionally, we detail the studies that investigated the impact of bariatric surgery on the intestinal microbiota in humans and mouse models of this procedure.
PMCID: PMC5022764  PMID: 26426680
9.  Psychosocial Factors Associated with Bulimia Nervosa during Pregnancy: An Internal Validation Study 
The aim of this paper was to internally validate previously reported relations (1) between psychosocial factors and bulimia nervosa (BN) outcomes during pregnancy.
This study is based on the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Participants were women enrolled during pregnancy (N = 69,030). Internal validity was evaluated by way of bootstrapped parameter estimates using the overall sample and a split sample calibration approach.
Bootstrap bias estimates were below the problematic threshold, and extend earlier findings(1) by providing support for the validity of the models at the population level of all pregnant women in Norway. Bootstrap risk ratios indicated that prevalence, incidence, and remission of BN during pregnancy were significantly associated with psychosocial factors. The split sample procedure showed that the models developed on the training sample did not predict risks in the validation sample.
This study characterizes associations between psychosocial exposures and BN outcomes among pregnant women in Norway. Women with lifetime and current self-reported psychosocial adversities were at a much higher risk for BN during pregnancy. Psychosocial factors were associated with BN remission during pregnancy, inviting the prospect of enhancing therapeutic interventions. We consider the findings in the context of reproducibility in science.
PMCID: PMC4411202  PMID: 25346291
bulimia nervosa; course; eating disorders; incidence; internal validation; MoBa; pregnancy; The Norwegian Mother and Child Cohort Study
10.  Risk for self-reported anorexia or bulimia nervosa based on drive for thinness and negative affect clusters/dimensions during adolescence: A three-year prospective study of the TChAD cohort 
The present study explored the cross-sectional and predictive effect of drive for thinness and/or negative affect scores on the development of self-reported anorexia nervosa (AN) and bulimia nervosa (BN).
K-means were used to cluster the Eating Disorder Inventory-Drive for Thinness (DT) and Child Behavior Checklist Anxious/Depressed (A/D) scores from 615 unrelated female twins at age 16–17. Logistic regressions were used to assess the effect of these clusters on self-reported eating disorder diagnosis at ages 16–17 (n=565) and 19–20 (n=451).
DT and A/D scores were grouped into four clusters: Mild (scores lower than 90th percentile on both scales), DT (higher scores only on DT), A/D (higher scores only on A/D), and DT-A/D (higher scores on both the DT and A/D scales). DT and DT-A/D clusters at age 16–17 were associated cross-sectionally with AN and both cross-sectionally and longitudinally with BN. The DT-A/D cluster had the highest prevalence of AN at follow-up compared with all other clusters. Similarly, an interaction was observed between DT and A/D that predicted risk for AN.
Having elevated DT and A/D scores may increase risk for eating disorder symptomatology above and beyond a high score on either alone. Findings suggest that cluster modeling based on DT and A/D may be useful to inform novel and useful intervention strategies for AN and BN in adolescents.
PMCID: PMC4543580  PMID: 26013185
Drive for thinness; anxiety; depression; negative affect; subtyping; eating disorders; anorexia; bulimia; risk
11.  Facebook Use and Disordered Eating in College-Aged Women 
Disordered eating behavior—dieting, laxative use, fasting, binge eating—is common in college-aged women (11–20%). A documented increase in the number of young women experiencing psychopathology has been blamed on the rise of engagement with social media sites such as Facebook. We predicted that college-aged women’s Facebook intensity (e.g., the amount of time spent on Facebook, number of Facebook friends, and integration of Facebook into daily life), online physical appearance comparison (i.e., comparing one’s appearance to others’ on social media) and online “fat talk” (i.e., talking negatively about one’s body) would be positively associated with their disordered eating behavior.
In an online survey, 128 college-aged women (81.3% Caucasian, 6.7% Asian, 9.0% African-American, and 3.0% Other) completed items, which measured their disordered eating, Facebook intensity, online physical appearance comparison, online fat talk, body mass index, depression, anxiety, perfectionism, impulsivity, and self-efficacy.
In regression analyses, Facebook intensity, online physical appearance comparison, and online fat talk were significantly and uniquely associated with disordered eating and explained a large percentage of the variance in disordered eating (60%) in conjunction with covariates. However, greater Facebook intensity was associated with decreased disordered eating behavior whereas both online physical appearance comparison and online fat talk were associated with greater disordered eating.
College-aged women who endorsed greater Facebook intensity were less likely to struggle with disordered eating when online physical appearance comparison was accounted for statistically. Facebook intensity may carry both risks and benefits for disordered eating.
PMCID: PMC4514918  PMID: 26206436
disordered eating; fat talk; physical appearance comparison; media exposure; social media; Facebook
12.  Nociceptin receptor antagonist SB 612111 decreases high fat diet binge eating 
Behavioural brain research  2016;307:25-34.
Binge eating is a dysregulated form of feeding behavior that occurs in multiple eating disorders including binge-eating disorder, the most common eating disorder. Feeding is a complex behavioral program supported through the function of multiple brain regions and influenced by a diverse array of receptor signaling pathways. Previous studies have shown the overexpression of the opioid neuropeptide nociceptin (orphanin FQ, N/OFQ) can induce hyperphagia, but the role of endogenous nociceptin receptor (NOP) in naturally occurring palatability-induced hyperphagia is unknown. In this study we adapted a simple, replicable form of binge eating of high fat food (HFD). We found that male and female C57BL/6J mice provided with daily one-hour access sessions to HFD eat significantly more during this period than those provided with continuous 24 hour access. This form of feeding is rapid and entrained. Chronic intermittent HFD binge eating produced hyperactivity and increased light zone exploration in the open field and light-dark assays respectively. Treatment with the potent and selective NOP antagonist SB 612111 resulted in a significant dose-dependent reduction in binge intake in both male and female mice, and, unlike treatment with the serotonin selective reuptake inhibitor fluoxetine, produced no change in total 24-hour food intake. SB 612111 treatment also significantly decreased non-binge-like acute HFD consumption in male mice. These data are consistent with the hypothesis that high fat binge eating is modulated by NOP signaling and that the NOP system may represent a promising novel receptor to explore for the treatment of binge eating.
PMCID: PMC4896639  PMID: 27036650
nociceptin; high fat; binge eating; intermittent access; fluoxetine; hyperphagia
13.  The Incidence of Eating Disorders in a Danish Nationwide Register Study Associations with Suicide Risk and Mortality 
Our aim was to characterize the incidence rates and cumulative incidence of anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS), and examine associations among eating disorder diagnoses, suicide attempts, and mortality. Individuals born in Denmark between 1989 and 2006 were included (N=966,141, 51.3% male). Eating disorders diagnoses (AN, Broad AN, BN, EDNOS) were drawn from the Danish Psychiatric Central Research Register (PCRR) and Danish National Patient Register (NPR). Suicide attempts and deaths were captured in the NPR, the PCRR, and the Danish Civil Registration System (CRS). In females, AN had a peak hazard at approximately age 15 years, BN at 22 years, and EDNOS had an extended peak that spanned 18 years to 22 years. Eating disorder diagnoses predicted a significantly higher hazard for death and suicide attempt compared with the referent of individuals with no eating disorders. In males, peak hazard for diagnosis was earlier than in females. The present study represents one of the largest and longest studies of eating disorder incidence and suicide attempts and death in both females and males. Eating disorders are accompanied by increased hazard of suicide attempts and death even in young adults.
PMCID: PMC4482129  PMID: 25958083
eating disorders; anorexia nervosa; bulimia nervosa; incidence; suicide; mortality
14.  Self-Image and Suicide in a Swedish National Eating Disorders Clinical Register 
Comprehensive psychiatry  2013;55(3):439-449.
Using a prospective design, to examine the relation between self-image (assessed using the Structural Analysis of Social Behavior) and suicide attempts/completions in women with anorexia nervosa-restricting type (ANR), anorexia nervosa-binge/purge type (ANBP), bulimia nervosa (BN), binge eating disorder, and eating disorder not otherwise specified (EDNOS); and to assess whether these self-image variables add unique predictive value to suicide when considering other baseline predictors.
Women (N=2,269) age 12 to 45 (M=22.1) presenting to specialist eating disorders clinics in Sweden between 2005 and 2009 were identified through the Stepwise Eating Disorders Quality Register. Data on age, body mass index, eating disorder severity (Eating Disorder Examination-Questionnaire scores), psychiatric comorbidity, global assessment of functioning, and self-image were abstracted from Stepwise and included as baseline predictors or covariates. Suicide information (prior attempt and attempt/completion after Stepwise registration) was obtained from the National Patient Register and Cause of Death Register.
Prevalence of detected suicide attempts/completions over the study period was 9.2%. Negative self-image variables were associated with prior suicide attempts in ANR and EDNOS and later suicide attempts/completions in women with BN. In a stepwise Cox proportional hazards model, only low self-affirmation predicted time to suicide attempts/completions in women with BN when accounting for age and prior suicide attempt.
Assessing self-image might assist with identifying women with BN at elevated risk for suicide.
PMCID: PMC3965622  PMID: 24332388
SASB; self-image; suicide; eating disorders; anorexia; bulimia; binge eating disorder
15.  Partner distress in the context of adult anorexia nervosa: The role of patients’ perceived negative consequences of AN and partner behaviors 
Romantic partners can play an important role in the recovery from anorexia nervosa (AN). It is important to understand partners’ behaviors and variables associated with their own distress. The aim was to examine associations of patients’ perceived negative consequences of AN, behavioral strategies employed by partners, and partner distress.
We used a cross-sectional design to assess associations between self-reports of patients’ perceived negative consequences of AN, partners’ caregiver distress, negative affect, relationship satisfaction, and observational coding measures of partners’ behavioral strategies of change promotion and acceptance/validation. Sixteen adult patient-partner dyads in committed relationships were assessed at baseline of a couple-based intervention for AN.
Partners’ change promotion moderated the association between patients’ perceived negative consequences of AN and partners’ caregiver distress. Partners’ acceptance/validation was associated with partners’ negative affect.
This report represents the first description of specific partner behaviors in the context of AN. Partners who reported the least distress were those who were trying to promote changes in AN behaviors in patients who reported high negative consequences of AN, and partners who were trying to show understanding of the patients’ experience. Future studies should examine the impact of partner behaviors on AN treatment outcome.
PMCID: PMC4342417  PMID: 25087574
16.  Can Attention to the Intestinal Microbiota Improve Understanding and Treatment of Anorexia Nervosa? 
Anorexia nervosa (AN) is characterized by severe dietary restriction or other weight loss behaviors and exhibits the highest mortality rate of any psychiatric disorder. Therapeutic renourishment in AN is founded primarily on clinical opinion and guidelines, with a weak evidence base. Genetic factors do not fully account for the etiology of AN, and non-genetic factors that contribute to the onset and persistence of this disease warrant investigation. Compelling evidence that the intestinal microbiota regulates adiposity and metabolism, and more recently, anxiety behavior, provides a strong rationale for exploring the role of this complex microbial community in the onset, maintenance of, and recovery from AN. This review explores the relationship between the intestinal microbiota and AN and a potential role for this enteric microbial community as a therapy for this severe illness.
PMCID: PMC4861228  PMID: 27003627
Anorexia nervosa; intestinal microbiota; behavior; refeeding; adiposity; metabolism
17.  Eating Disorders, Pregnancy, and the Postpartum Period: Findings from the Norwegian Mother and Child Cohort Study (MoBa) 
This review summarizes studies on eating disorders in pregnancy and the postpartum period that have been conducted as part of the broader Norwegian Mother and Child Cohort Study (MoBa). Prior to the 2000s, empirical literature on eating disorders in pregnancy was sparse and consisted mostly of studies in small clinical samples. MoBa has contributed to a new era of research by making population-based and large-sample research possible. To date, MoBa has led to 19 studies on diverse questions including the prevalence, course, and risk correlates of eating disorders during pregnancy and the postpartum. The associations between eating disorder exposure and pregnancy, birth and obstetric outcomes, and maternal and offspring health and well-being, have also been areas of focus. The findings indicate that eating disorders in pregnancy are relatively common and appear to confer health risks to mother and her child related to sleep, birth outcomes, maternal nutrition, and child feeding and eating.
PMCID: PMC4838406  PMID: 27110061
eating disorders; pregnancy; MoBa; The Norwegian Mother and Child Cohort Study
18.  Developmental Trajectories of Postpartum Weight 3 Years After Birth: Norwegian Mother and Child Cohort Study 
Maternal and child health journal  2015;19(4):917-925.
This study explored the developmental trajectories of postpartum weight from 0.5 to 3 years after childbirth, and aimed to determine the associations between postpartum weight trajectories and pre-pregnancy body mass index and adequacy of gestational weight gain (GWG). Data from the Norwegian Mother and Child Cohort study were used, following 49,528 mothers 0.5, 1.5, and 3 years after childbirth. Analyses were performed using latent growth mixture modeling. Three groups of developmental trajectories of postpartum weight were found, with most women (85.9 %) having a low level of weight retention initially and slight gain over 3 years, whereas 5.6 % of women started at a high postpartum weight retention (on average 7.56 kg) at 0.5 years but followed by a marked weight loss over time (2.63 kg per year on average), and the third trajectory represented women (8.5 %) who had high weight retention high initially (on average 4.67 kg at 0.5 years) and increasing weight over time (1.43 kg per year on average). Pre-pregnancy overweight and obesity and excessive GWG significantly predicted a high postpartum weight trend. Women had substantial variability in postpartum weight development—both initially after birth and in their weight trajectories over time. Early preventive interventions may be designed to assist women with pre-pregnancy overweight and obesity and excessive GWG, which helps to reduce the increasing trend for postpartum weight.
PMCID: PMC4482124  PMID: 25081240
Postpartum weight; MoBa; Developmental trajectory; Prepregnancy BMI; Gestational weight gain
19.  Genetics and Epigenetics of Eating Disorders 
Eating disorders (EDs) are serious psychiatric conditions influenced by biological, psychological, and sociocultural factors. A better understanding of the genetics of these complex traits and the development of more sophisticated molecular biology tools have advanced our understanding of the etiology of EDs. The aim of this review is to critically evaluate the literature on the genetic research conducted on three major EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). We will first review the diagnostic criteria, clinical features, prevalence, and prognosis of AN, BN, and BED, followed by a review of family, twin, and adoption studies. We then review the history of genetic studies of EDs covering linkage analysis, candidate gene association studies, genome-wide association studies, and the study of rare variants in EDs. Our review also incorporates a translational perspective by covering animal models of ED-related phenotypes. Finally, we review the nascent field of epigenetics of EDs and a look forward to future directions for ED genetic research.
PMCID: PMC4803116  PMID: 27013903
eating disorders; anorexia nervosa; bulimia nervosa; binge eating disorder; genetics; epigenetics
21.  Habitual Starvation and Provocative Behaviors: Two Potential Routes to Extreme Suicidal Behavior in Anorexia Nervosa 
Behaviour research and therapy  2010;48(7):634-645.
Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.
PMCID: PMC4731222  PMID: 20398895
anorexia; suicide; restricting; purging; self-injury
22.  Characteristics of Women with Body Size Satisfaction at Midlife: Results of the Gender and Body Image Study (GABI) 
Journal of women & aging  2013;25(4):10.1080/08952841.2013.816215.
This study characterizes the profile of women (N = 1,789) ages 50 and over who report body size satisfaction on a figure rating scale. Satisfied women (12.2%) had a lower body mass index and reported fewer eating disorder symptoms, dieting behaviors, and weight and appearance dissatisfaction. Interestingly, satisfied women exercised more than dissatisfied women and weight and shape still played a primary role in their self-evaluation. Weight monitoring and appearance altering behaviors did not differ between groups. Body satisfaction was associated with better overall functioning. This end point appears to represent effortful body satisfaction rather than passive contentment.
PMCID: PMC3816007  PMID: 24116991
body satisfaction; body image; aging; eating disorders; silhouette; women
23.  Malnutrition among Cognitively Intact, non-Critically Ill Older Adults in the Emergency Department 
Annals of emergency medicine  2014;65(1):85-91.
We estimate the prevalence of malnutrition among older patients presenting to an emergency department (ED) in the southeastern United States and identify subgroups at increased risk.
We conducted a cross-sectional study with random time block sampling of cognitively intact patients aged 65 years and older. Nutrition was assessed using the Mini Nutritional Assessment Short-Form (0–14 scale) with malnutrition defined as a score of 7 or less and at-risk for malnutrition defined as a score of 8–11. The presence of depressive symptoms was defined as a Center for Epidemiological Studies Depression-10 score of 4 or more (0–10 scale).
Among 138 older adults, 16% (95% Confidence Interval [CI], 10%–22%) were malnourished and 60% (95% CI, 52%–69%) were either malnourished or at-risk for malnutrition. Seventeen of the 22 malnourished patients (77%) denied previously being diagnosed with malnutrition. The prevalence of malnutrition was not appreciably different between males and females, across levels of patient education, or between those living in urban and rural areas. However, the prevalence of malnutrition was higher among patients with depressive symptoms 52%, those residing in assisted living 50%, those with difficulty eating 38%, and those reporting difficulty buying groceries 33%.
Among a random sample of cognitively intact older ED patients, more than half were malnourished or at-risk for malnutrition, and the majority of malnourished patients had not previously been diagnosed. Higher rates of malnutrition among those with depression, difficulty eating, and difficulty buying groceries suggest the need to explore multifaceted interventions.
PMCID: PMC4275371  PMID: 25129819
Geriatrics; Emergency Medicine; Malnutrition
24.  Maternal eating disorder and infant diet. A latent class analysis based on the Norwegian Mother and Child Cohort Study (MoBa) 
Appetite  2014;84:291-298.
Knowledge of infant diet and feeding practices among children of mothers with eating disorders is essential to promote healthy eating in these children. This study compared the dietary patterns of 6-month-old children of mothers with anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified - purging subtype, to the diet of children of mothers with no eating disorders. The study was based on 53,879 mothers in the Norwegian Mother and Child Cohort Study (MoBa). Latent class analysis (LCA) was used to identify discrete latent classes of infant diet based on the mothers’ responses to questions about 16 food items. LCA identified five classes, characterized by primarily homemade vegetarian food (4% of the infants in the sample), homemade traditional food (8%), commercial infant cereals (35%), commercial jarred baby food (39%), and a mix of all food groups (11%). We then estimated the association between the different latent dietary classes and maternal eating disorders using a multinomial logistic regression model. Infants of mothers with bulimia nervosa had a lower probability of being in the homemade traditional food class compared to the commercial jarred baby food class, than the referent without an eating disorder (O.R. 0.59; 95% CI 0.36–0.99). Infants of mothers with binge eating disorder had a lower probability of being in the homemade vegetarian class compared to the commercial jarred baby food class, than the referent (O.R. 0.77; 95% CI 0.60–0.99), but only before controlling for relevant confounders. Anorexia nervosa and eating disorder not otherwise specified-purging subtype were not statistically significant associated with any of the dietary classes. These results suggest that in the general population, maternal eating disorders may to some extent influence the child’s diet as early as 6 months after birth; however, the extent to which these differences influence child health and development remain an area for further inquiry.
PMCID: PMC4482116  PMID: 25453594
Eating disorder; Child feeding; Dietary patterns; Latent class analysis; MoBa; Norwegian Mother and Child Cohort Study
25.  Prevalence of Screening-Detected Eating Disorders in Chinese Females and Exploratory Associations with Dietary Practices 
China is undergoing dramatic Westernization, hence may be able to provide unique insights into the role of sociocultural factors in disease. The purpose of this exploratory study was two-fold: to describe the prevalence of screening-detected eating disorders and disordered eating in China at the first occasion of assessment in the large-scale China Health and Nutrition Survey (CHNS) and to explore the associations between dietary practices and disordered eating. Regarding the first objective, participants are provincially representative and in subsequent waves will be followed longitudinally.
CHNS participants were recruited using multistage, cluster random sampling, beginning in 1989. In this study, participants comprised 259 female adolescents (12–17 years) and 979 women (18–35 years) who participated in the CHNS 2009 survey, which is the first CHNS survey to assess disordered eating. Dietary practice-disordered eating associations were investigated with logistic regression adjusting for age, body mass index, and urbanization.
Of the participants, 6.3% (95% CI: 4.8, 8.2) of adults and 7.8% (95% CI: 5.0, 12.0) of adolescents had a screening-detected eating disorder. Dietary practices had non-significant associations with disordered eating at the general population level, except for protein consumption among women. There was evidence that skipping meals and a high-fat diet may confer risk.
Screening-detected eating disorders in China are lower in prevalence than in developed countries. Dietary practices had fairly limited associations with disordered eating at the general population level; protein consumption, skipping meals, and a high-fat diet are candidate dietary practice exposures for disordered eating.
PMCID: PMC4314345  PMID: 25407415
China; China Health and Nutrition Survey; dietary practices; disordered eating; screening; overweight; SCOFF

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